Squamous cell carcinoma arising in an oral lichenoid lesion

BACKGROUND: Oral lichen planus, or OLP, is a chronic inflammatory mucocutaneous disease that frequently involves the oral mucosa. Lichenoid dysplasia, or LD, refers to lesions that could be mistaken clinically for OLP but have histologic features of dysplasia and a true malignant predisposition. Published case reports of OLP conversion to squamous cell carcinoma, or SCC, have created a great deal of controversy about the true nature of OLP, highlighting the need to verify its clinical diagnosis histologically. CASE DESCRIPTION: The authors document the development of SCC in a 58-year-old woman with an oral lesion diagnosed clinically as OLP and described histologically as having lichenoid features with dysplastic changes. The time from the initial diagnosis of oral lichenoid lesions to the patient's return visit to the medical center with clinically evident cancer was three years and eight months. The SCC developed in the labial mucobuccal fold and left mandibular edentulous ridge, which had undergone multiple biopsy procedures. CLINICAL IMPLICATIONS: This case does not provide answers to the ongoing controversy about the innate propensity of OLP to become malignant. However, in view of both the common occurrence of OLP and unresolved issues regarding its premalignant potential, this case report illustrates the need for histologic confirmation and close follow-up of patients with clinical lesions that have lichenoid features.     

Dysplasia in oral lichen planus: relevance,controversies and challenges. A position paper

Background Patients with oral lichen planus (OLP) have an increased risk of oral cancer. For this reason, OLP is classified as an oral potentially malignant disorder. However, the precise personal (or individual) risk is unknown. Recent meta-analytical studies have reported that dysplastic OLP may transform to cancer in around 6% of cases, while the rate of transformation is lower (<1.5%) in non-dysplastic cases. The presence of epithelial dysplasia has emerged as the most powerful indicator for assessing cancer risk in oral potentially malignant disorders in routine practice. However, the general acceptance of epithelial dysplasia as an accompanying histologic feature in OLP is subject to great controversy. Many pathologists consider the presence of dysplasia as a criterion to exclude OLP when routinely reporting on this disease. This practice, widespread among oral pathology professionals, has resulted in the underestimation of the potential for malignancy of OLP.Material and Methods A review of the literature was carried out in order to critically analyze the relevance, controversies and challenges encountered across the diagnosis of epithelial dysplasia in OLP.Results 12 studies have been published examining dysplastic changes in OLP, reporting Figures ranging from 0.54% to 25% of cases with dysplasia in the first diagnostic biopsy. The diagnosis of dysplasia in the OLP poses an additional difficulty due to the fact that the affected oral epithelium per se develops changes related to autoimmune aggression. Among the most frequent histological features of OLP that develops dysplasia are basal cell hyperplasia with basaloid appearance, loss of basal cells polarity, cellular and nuclear pleomorphism and irregular stratification.Conclusions Epithelial dysplasia should not be considered an exclusion criterion for OLP; its evaluation requires experienced pathologists in this field. Key words:Oral lichen planus, epithelial dysplasia, oral cancer.     

Oral lichen planus: Malignant potential and diagnosis

Oral lichen planus (OLP) is one of the most common diseases of the oral mucosa. Clinically, it has specific and clearly identifiable features; bilateral symmetric presentation showing a lace-like network of fine white lines (known as Wickham's striae) is an essential element of OLP even if the lesion exhibits a mainly atrophic and erosive pattern. There are various lesions that resemble OLP clinically and histologically. These lesions are widely referred to as lichenoid reactions or lichenoid lesions (OLLs). OLLs include contact hypersensitivity to dental materials, drug-induced lichenoid lesions, lichenoid reactions in chronic graft-versus-host disease, and other lesions that resemble OLP. The risk of malignant transformation of OLP is the subject of ongoing debate in the literature. Some authors have suggested that only OLLs, but not OLP, are of a premalignant nature and thus, should be categorized as “other dysplastic conditions.” Contrary to this suggestion, many cases of oral squamous cell carcinoma (OSCC) developing in patients with OLP presenting with no epithelial dysplasia have been reported. In addition, it has been reported that multiple events including multifocal dysplasia and/or OSCC subsequently occurred in some patients with OLP, suggesting possible field cancerization in OLP. In this paper, differential diagnosis between OLP and OLLs and their malignant potential are reviewed.     

Oral lichenoid dysplasia: a clinicopathologic analysis

Three women had a diagnosis of oral lichen planus (OLP), which was made on the basis of clinical and histologic features. All three had persistent burning pain associated with large mucosal lesions. Changes in the color (red, red and white, white), configuration, and severity of the lesions were unpredictable and did not correlate well with topical corticosteroid therapy. Only one patient used tobacco (cigarettes)--this patient had recurrent oral candidiasis and was receiving multiple medications. One of the two nonsmokers was a denture wearer with a single episode of candidiasis. After 63, 32, and 56 (mean 50) months, carcinoma developed in all three. In retrospect, the initial biopsy specimens of two patients exhibited lichenoid dysplasia, whereas that of the third showed only lichenoid mucositis. Although speckled erythroplakia was the earliest clinical sign of a classic, nonregressing premalignant lesion, it already signaled the presence of invasive carcinoma. Some early epithelial dysplasias appear to have a robust inflammatory/immunologic response to the antigenically (but as yet not histologically) altered dysplastic epithelium and a high probability of at least temporary resolution. Mucosal erythema of obscure origin displaying spontaneous, usually temporary, partial to complete regression may be common to both purely inflammatory conditions like lichen planus and early epithelial dysplasia. We contend that some, if not most, cases of apparent malignant transformation of OLP likely represent red and white lesions that were dysplastic from their inception but that mimic OLP both clinically and histologically.     

Oral mucocutaneous diseases: clinicopathologic analysis and malignant transformation

Oral mucocutaneous diseases (MCDs) are a heterogeneous group of disorders that could involve oral mucous membrane frequently. The purpose of this study was analysis of clinicopathologic features and relative frequency of MCDs with emphasize on malignant transformation of oral lichen planus (OLP). In this retrospective study, clinical data regarding to site of involvement, patient's age and sex, and accompanied symptoms were noted, and pathologic slides of OLP were reviewed for the detection of dysplastic changes. Among 309 patients, OLP and pemphigus vulgaris were the first and second most common MCDs. Buccal mucosa was the most frequent affected site. Female predominance (70.23%) and mean age of 45.3 years were seen. Approximately 12.4% of OLPs showed dysplastic and neoplastic changes. In conclusion, MCD with oral manifestation is most probably to be OLP and pemphigus vulgaris rather than other rare disorders. Malignant transformation may occur in all forms of OLP, and hence, regular, exact follow-up of the patient is necessary for enhancing quality of life.     

Oral lichen planus and malignant transformation: a retrospective follow-up study of clinical and histopathologic data.

OBJECTIVE: Patients in the stomatology service of the Department of Oral Surgery and Stomatology who were clinically and histopathologically diagnosed with oral lichen planus (OLP) in the years 1995 to 2001 were examined for a possible malignant transformation of a previously biopsied OLP site. METHOD AND MATERIALS: For the 145 patients included, the recordings were searched for initial localization and type of OLP lesion, potential noxious agents, distribution between symptomatic and asymptomatic OLP types, and for a malignant transformation of a known OLP site during the follow-up period up to December 2003. RESULTS: The group comprised 47 men and 98 women with a mean age of 56.3 years. Of the 497 lesions, almost half were classified as reticular or papular, predominantly located on the buccal mucosa, gingiva, and borders of the tongue. Four patients did not adhere to their scheduled control visits and were dropped from the study. During the follow-up period 4 patients developed malignant transformation of OLP. In 3 of these cases, dysplasia was present at the initial diagnosis of OLP. This results in a malignant transformation rate of 2.84% among the remaining 141 patients; if the 3 patients with initial dysplasia are excluded, the rate drops to 0.71%. CONCLUSIONS: Until further knowledge is derived from large prospective studies, the data supporting or negating a potential malignant character of OLP lesions remains inconclusive. Special emphasis has to be directed toward unified inclusion and exclusion criteria regarding clinical and histologic findings and identifiable risk factors to allow the comparison of different studies.     

Oral lichen planus: causes,diagnosis and management

Oral lichen planus (OLP) is a chronic inflammatory disease of unknown etiology. In this paper we review the clinical and histological features of OLP, process of OLP diagnosis, causes of OLP, management of OLP patients and medical treatment of OLP lesions. Approximately 0.2 per cent OLP patients develop intra-oral carcinoma each year compared with approximately 0.005 per cent Australian adults. Possible mechanisms of increased oral cancer risk in OLP patients are presented. The aims of current OLP therapy are to eliminate mucosal erythema and ulceration, alleviate symptoms and reduce the risk of oral cancer. Patient education may improve the outcomes of OLP therapy and further reduce the risk of oral cancer in OLP patients. Although OLP may be diagnosed clinically, appropriate specialist referral is required for: (i) histological diagnosis; (ii) assessment of causative/exacerbating factors, associated diseases and oral cancer risk; (iii) patient education and management; (iv) medical treatment; and (v) long-term review and re-biopsy as required.     

Genetics/epigenetics of oral premalignancy: current status and future research

Squamous cell carcinoma (SCC) of the oral and oropharyngeal region is the sixth most common malignancy in the world today. Despite numerous advances in treatment, long-term survival from this disease remains poor. Early detection can decrease both morbidity and mortality associated with this neoplasm. However, screening for potentially malignant disease is typically confounded by difficulty in discriminating between reactive/inflammatory lesions vs those lesions that are premalignant in nature. Furthermore, the histologic diagnosis of dysplasia can be subjective and is thus prone to a considerable range of interpretation. Similarly, no definitive, validated criteria exist for predicting which dysplastic lesions are most likely to progress to cancer over time. Given this state of science, the presence of dysplasia can only be used to indicate that an oral lesion may have an increased risk of malignant transformation. Molecular biomarkers capable of identifying the subset of lesions likely to progress to cancer are required to eliminate this clinical diagnostic dilemma. The purpose of this review is to assess the current state of knowledge regarding genetic/epigenetic alterations observed in oral mucosal premalignancy. In addition, recommendations for future research studies directed at defining the predictive capacity of specific biomarkers in this modeling are presented.     

Oral lichen planus: controversies surrounding malignant transformation

Studies of the malignant potential of oral lichen planus (OLP) have been hampered by inconsistencies in the diagnostic criteria used for OLP, the criteria adopted to identify a true case of malignant transformation in OLP, the risk factors for malignant transformation and the optimum management of patients to ensure the early diagnosis of transformation. Consensus remains elusive, and leading workers in this field have recently published conflicting reports on the malignant potential of OLP and on the important question of the advisability of excluding patients with epithelial dysplasia or a tobacco habit from studies on this issue. The present review outlines these debates and proposes a possible a molecular basis for the malignant transformation in this disease.     

Evaluation on Malignant Transformation of Oral Lichen Planus

目的：口腔扁平苔藓（oral lichen planus,OLP)是否属于癌前病变，至今仍存在较大的争论。本文的目的在于评估OLP的癌变性质。方法：报告1995－2002年之间9例OLP的癌变病例。结果：5例OLP患者同时或继发为口腔鳞状细胞癌，1例为疣状癌，3例为上皮异常增生。其中7例发生在原OLP存在的部位，1例发生在其它部位，1例在同一部位同时存在OLP和鳞状细胞癌。OLP的癌变常发生在糜烂型和萎缩型，发生于颊粘膜，舌或牙龈。根据所制定的OLP的诊断及癌变标准，4例OLP患者发生了癌变。结论：OLP具有一定的癌变潜力，对OLP患者应每年随访2－4次，尤其是对发生在颊粘膜，舌或牙龈的糜烂型和萎缩型的患者。     

Number V Oral lichen planus: clinical features and management

Oral lichen planus (OLP) is a relatively common chronic inflammatory disorder affecting stratified squamous epithelia. Whereas in the majority of instances, cutaneous lesions of lichen planus (LP) are self-limiting and cause itching, oral lesions in OLP are chronic, rarely undergo spontaneous remission, are potentially premalignant and are often a source of morbidity. Current data suggest that OLP is a T cell-mediated autoimmune disease in which auto-cytotoxic CD8+ T cells trigger apoptosis of oral epithelial cells. The characteristic clinical aspects of OLP may be sufficient to make a correct diagnosis if there are classic skin lesions present. An oral biopsy with histopathologic study is recommended to confirm the clinical diagnosis and mainly to exclude dysplasia and malignancy. The most commonly employed and useful agents for the treatment of lichen planus (LP) are topical corticosteroids but other newer agents are available.     

口腔扁平苔藓中人乳头瘤病毒的检测

为研究口腔扁平苔藓（OLP）与人乳头瘤病毒（HPV）的关系．作者采用聚合酶链（PCR）技术，对22例OLP中的HPV低危型──11型以及高危型—16型DNA分别进行了检测，并以10例正常口腔粘膜（NOM）作为对照。结果表明：PCR是检测OLP中HPV较为理想的方法。OLP中的HPV与NOM相比较，11型相对升高。OLP各临床分型中，网纹型的HPV阳性百分比最高，该型的病程迁延．治疗后易复发，可能与HPV的潜伏和感染有关，4例糜烂型，即有2例含有HPV16，提示糜烂型与癌变的关系。HPV在NOM中的存在。表明HPV可以无症状或以潜伏的形式存在于口腔粘膜。     

Malignant transformation in a cohort of patients with oral epithelial dysplasia

Oral epithelial dysplasia (OED) is often diagnosed in oral potentially malignant disorders (OPMD) and carries an increased risk of malignant transformation. Currently, the reported risk of malignant transformation for OED varies. Here we present the risk in a cohort of 150 patients with OED at a specialist centre. In this cohort 2.6%, 4.1%, and 29.2% cases of mild, moderate, and severe OED, respectively, progressed to oral squamous cell carcinoma at the dysplastic site, while a small number developed a malignant lesion elsewhere. Moreover, 17 patients experienced an increase in grade of dysplasia and two showed histological resolution of their lesions.     

口腔扁平苔藓免疫学因素的研究现状

口腔扁平苔藓(OLP)是一种严重影响患者身心健康的发生于口腔黏膜的非传染性炎症性疾病.OLP的病因尚不明确,可能与多种因素有关.目前的研究表明,OLP的发病与免疫因素密切相关,它是一种以T淋巴细胞介导的免疫应答为特征的慢性疾病.抗原特异性机制和非特异性机制可能参与OLP的免疫过程.首先由树突状细胞摄取、处理未知抗原触发...     

口腔扁平苔藓诊疗指南(修订版)

口腔扁平苔藓是一种临床常见的口腔黏膜慢性炎性疾病,以中年女性多见,大多数患者有疼痛、粗糙不适等症状,部分病例还有癌变风险,对患者身心造成较大危害。积极预防、准确诊断和规范治疗对有效防治口腔扁平苔藓具有重要意义。本指南是在2012年试行版基础上进行修订,主要涵盖口腔扁平苔藓的病因及病史采集、临床表现、病理表现、诊断、鉴别诊断、治疗前检查、疾病治疗及预防等8个方面,为该病的临床诊疗提供科学依据和指导。     

Detecting oral cancer: a new technique and case reports

The VELscope is an important aid in patient assessment, and when added to a well-thought out clinical assessment process that takes into consideration the age of the patient and risk factors that include tobacco, alcohol, and immunologic status, it increases the clinician's ability to detect oral changes that may represent premalignant or malignant cellular transformation. False positive findings are possible in the presence of highly inflamed lesions, and it is possible that use of the scope alone may result in failure to detect regions of dysplasia, but it has been our experience that use of the VELscope improves clinical decision making about the nature of oral lesions and aids in decisions to biopsy regions of concern. Where tissue changes are generalized or cover significant areas of the mouth, use of the scope has allowed us to identify the best region for biopsy. As with all clinical diagnostic activities, no single system or process is enough, and all clinicians are advised to use good clinical practice to assess patients and to recall and biopsy lesions that do not resolve within a predetermined time frame. Lesions that are VELscope-positive and absorb light need to be followed with particular caution, and if they do not resolve within a 2-week period, then further assessment and biopsy are generally advised. It is much better to occasionally sample tissue that turns out to be benign than to fail to diagnose dysplastic or malignant lesions. In our fight to protect patients from cancer, the VELscope improves our odds for early detection, hopefully resulting in fewer deaths from oral cancer.     

口腔扁平苔藓、白斑及鳞癌棘细胞形态计量学分析

目的:从形态计量学角度探讨口腔扁平苔藓(OLP)癌变的可能性,并为口腔黏膜良恶性病变的鉴别诊断提供客观参考资料。方法:采用多功能图象分析系统对取自口腔黏膜的正常、口腔扁平苔藓(OLP)、伴轻、中度上皮异常增生白斑(LK)、鳞癌(SCC)的上皮棘层细胞及胞核进行形态计量学研究分析,选择表示细胞及细胞核大小和形状的二维参数9个,体视学参数10个,并比较这些参数在各组间的变化趋势及差异。结果:无论从二维或三维的各项形态学指标,OLP的测量值都处于正常与LK和鳞癌之间,与正常组相比,各参数值多无显著性差异,而与鳞癌组差异显著。结论:OLP是一种介于正常与轻、中度上皮异常增生之间的病变,具有一定的癌变倾向,但癌变潜能低于癌前白斑。二维定量和三维定量结合可更全面地反映口腔黏膜癌变过程中细胞及细胞核的量变质变过程;核质比值、细胞核体积密度可作为鉴别良恶性病变的参考指标。     

The configuration of clinics and the use of biopsy and photography in oral premalignancy: a survey of consultants of the British Association of Oral and Maxillofacial Surgeons

Oral dysplastic lesions may have an increased chance of becoming oral squamous cell carcinoma, but to date their management remains controversial. The aim of this survey was to explore the current practical aspects of the management of patients with dysplasia by oral and maxillofacial consultants in the UK. In the survey we asked consultants about the numbers of patients they see with oral premalignant lesions, the frequency and specialty of designated hospital clinics, their use of photographs and biopsy, factors that influence their decision whether to biopsy a lesion at the first appointment, the procedure for treatment and follow-up and their use (if any) of chemopreventive agents. We found a wide variation in the practical aspects of managing patients with dysplasia, and the lack of consistency among clinicians supports the idea of an initiative to establish more robust national guidelines to use as a gold standard in the future.