Journal of the Royal Society of Medicine Volume 85 April 1992
235
Case reports
Squamous cell carcinoma complicating lichen planus of the lip
Case presented to Section of Dermatology, 20 June 1991
C C Harland MRCP1 A R Phipps FRCS2 R A Marsden FRCP3 C A Holden MD MRCP' 'Department of Dermatology, St Helier Hospital, Carshalton SM5 1AA and Departments of 2Reconstructive Surgery and 3Dermatology, St George's Hospitc4, London SW17 OQT Keywords: lichen planus; squamous cell carcinoma
The premalignant potential of oral lichen planus (OLP) is debatable'. More than 200 cases of oral cancer and OLP have been reported, but rarely has this- association been adequately substantiated by good clinical and histological data. Case report A 23-year-old Irishman of fair complexion presented in 1988 with a clinically documented eight year history of cutaneous lichen planus with lip and buccal involvement. There was no history of alcohol abuse or excessive sun exposure, but he had smoked 10 years earlier. Examination revealed annular lichen planus on the arms, lacy white patches on the buccal mucosa and white areas on the side of the lower lip. His dentition was in good condition. A hyperkeratotic nodule on the left lower lip was biopsied, and was reported as hypertrophic lichen planus. The nodule regressed with topical potent corticosteroid cream, after which the patient defaulted from the clinic. He returned in May 1990 with a new lesion on the right side of the lower lip. Clinical examination revealed a large fungating tumour (Figure 1), which histologically proved to be an invasive well differentiated squamous cell carcinoma. Adjacent lip showed classical features of lichen planus: a lymphocytic infiltrate applied to the epidermis, basal
..:.... ..
... ...'.:
.....
...'-
'...
Figume2. Lichen planus of the lip adjacent to squamous cell carcinoma (H&E, x2.84). Note vacuolar degeneration of basal cell layer and saw-tooth appearance of epidermis
cell vacuolar degeneration, hypergranulosis, Civatte bodies and resultant saw-tooth appearance of the epidermis (Figure 2) A vermilionectomy was performed in order to remove potentially dysplastic epithelium. Two months later he required suprahyoid and right neck lymph node dissection and radiotherapy for metastatic disease. Discussion The malignant transformation of OLP was first reported by Hallopeau in 19102. Subsequently there have been numerous reviews and case reports about this putative association, some suggesting that 10% of patients developed oral cancer-. Lichen planus is characterized microscopically by chronic erosion and regeneration of the basal keratinocyte layer5. This, coupled with the fact that the mouth is exposed to various carcinogens such as smoking, alcohol and poor dentition, may account for this increased incidence. A more recent and larger series of225 cases indicates that the incidence for malignant transformation is less than 1%4, suggesting that the relationship between OLP and cancer has been overestimated. Indeed, both are relatively common diseases and would be expected to coexist by chance. Furthermore, there may have been diagnostic difficulties. Leukoplakia is sometimes clinically misinterpreted as OLP, and lichenoid dysplasia may be confused histologically with OLP5. Also, a precise anatomical correlation between OLP and squamous cell carcinoma is seldom defined in previous reports, thus allowing spurious associations to be made. Squamous cell carcinoma of the lip predominantly affects 50-70-year-old patients, particularly those who have fair skin and a history of chronic sun exposure7. Risk factors in our patient include ultraviolet irra4iation and smoking. However, he was remarkably young to have developed oral cancer. In view of the patient's age and clear clinical and histological documentation of squamous cell carcinoma arising within an area of longstandinglichen planus of the lip, this case supports the -notion that OLPs a premalignant condition. Other recognized risk factors may be important in promoting malignant transormation. Patients with OLP should be advised to avoid preventable tanding active disease risk factors such as smoking, merits follow-up in order to dete early cancerous changes.
.,L -|i IS! L~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ S~ M.X.1.... References
-7
I Krutchkoff DJ, Cutler L, Laskowski S. Oral lichen planus: the Figure 1. Squamous cell carcinoma arising from longstanding lichen planus of the lip
evidence regarding potential malignant transformation. J Oral Pathol 1978;7:1-7
0141-0768/92/
040235-02/$02.00/0 i 1992 The Royal Society of Medicine
236
Journal of the Royal Society of Medicine Volume 85 April 1992
2 Hallopeau H. Sur un cas de lichen de Wilson gingival avec neoplasie voisine dans la region maxillaire. Bull Soc Fr Dermatol Syphiligr 1910;17:33 3 Dechaume M, Payen J, Piriou J. Le lichen plan isole de la muquese buccale: considerations anatomocliniques d'apres 50 observations dont 30 avec examen histologique. Presse Med 1957;65:2133-5 4 Fulling H-J. Cancer development in oral lichen planus. Arch Dermatol 1973;108:667-9 5 Marks R, Black M, Wilson Jones E. Epidermal cell kinetics in lichen planus. Br J Dermatol 1973;88:37-45
6 Krutchkoff DJ, Eisenberg E. Lichenoid dysplasia: a distinct histopathologic entity. Oral Surg Oral Med Oral Pathol 1985; 60:308-15 7 Krolls SO, Hoffman S. Squamous cell carcinoma of the soft tissues: a statistical analysis of 14,253 cases by age, sex, and race of patients. J Am Dent Assoc 1976;92:571-4
(Accepted 24 September 1991)
Squamous cell carcinoma arising in rhinophyma
Case presented to Section of Plastic Surgery, 8 January 1991
D A Ross BSc FRCS M P Davies FRCS Regional Plastic Surgery Unit, Queen Mary's University Hospital, Roehampton, London SW15 Keywords: rhinophyma; malignant change
We present a case of squamous cell carcinoma arising in a long-standing rhinophyma. This association is rare and the literature is reviewed. The extensive invasion of the tumour is emphasized.
Case report A 54-year-old man presented with an ulcer arising in a rhinophyma of approximately 10 years standing. The ulcer had been present for 3 years, but had grown markedly in the 12 months preceding admission, and it had been this and not the large rhinophyma which had led him to seek the advice of his GP (Figure 1). The initial attempt to resect the ulcer and shave the rhinophyma was abandoned when it became apparent that the ulcer represented the tip of the iceberg of a tumour which extended deeply into the nasal septum and laterally under an obscuring layer of rhinophymatous tissue into the skin over the maxillae. Histology confirmed a poorly differentiated squamous cell carcinoma with dysplastic areas in the rhinophymatous skin at the lateral margins. A CT scan showed no evidence of bony invasion but at a second, wider excision, the entire nose and majority of the bony nasal septum were removed in order to gain tumour
-, :8.
...
, , ....
..
Figure 1. Pre-operative view, showing the patient's rhinophyma and ulcer
Figure 2. Postoperative view, showing the extent of resection
clearance (Figure 2). A split skin graft was applied to the defect and a prosthesis fitted. He was subsequently referred for adjuvant radiotherapy and showed no sign of recurrence 6 months later. Discussion
Rhinophyma is seen mainly in men in their 5th-6th decades. Wolfe reviewed 60 cases occurring over 20 years and found only two cases in women'. The aetiology remains obscure with putative factors including alcohol, diet and vitamin deficiency1. In one report Freeman found 33% of patients with rhinophyma to have a history of alcohol abuse. Two cases were noted to follow prolonged steroid therapy2. Macroscopically it appears as a form of acne rosacea, with proliferation and hyperplasia of sebaceous glands. Acanthosis, manifested by hyperplasia of all the layers of the epidermis, has also been noted to be a common feature3. Acute and chronic inflammation is superimposed upon this along with intermittent areas of fibrosis. Malignant change (squamous cell carcinoma in particular), is a well rognized complication of chronic inflammation as seen mi ulcers, osteomyelitis and even burn scars. It is also seen in association with the chronic inflammatory dermatoses such as lupus vulgaris, discoid lupus erythematosus and hypertrophic lichen planus. However, despite te mked level of cellular activity and inflammtion seen in rhinophyma the association between it and malignant change is rare; until 1966 only five cases were reported in the literature. Broadbent described two cases of squamous cell carcinoma arising in longstanding rhinophyma, however the tumours were well defined with no evidence of occult spread so strikingly seen in our case4. In 1967 Acker and Helwig reported five cases of basal cell carcinoma arising in 47 patients with long-standing rhinophyma3. The authors concluded that basal cell carcinoma is more likely to arise in rhinophymatous than 'normal' skin, this argument being based on comparison between the incidence of basal cell
0141^0768/92/ 040236-0402.00/0 © 1992 The Royal Society of Medicine
235
Case reports
Squamous cell carcinoma complicating lichen planus of the lip
Case presented to Section of Dermatology, 20 June 1991
C C Harland MRCP1 A R Phipps FRCS2 R A Marsden FRCP3 C A Holden MD MRCP' 'Department of Dermatology, St Helier Hospital, Carshalton SM5 1AA and Departments of 2Reconstructive Surgery and 3Dermatology, St George's Hospitc4, London SW17 OQT Keywords: lichen planus; squamous cell carcinoma
The premalignant potential of oral lichen planus (OLP) is debatable'. More than 200 cases of oral cancer and OLP have been reported, but rarely has this- association been adequately substantiated by good clinical and histological data. Case report A 23-year-old Irishman of fair complexion presented in 1988 with a clinically documented eight year history of cutaneous lichen planus with lip and buccal involvement. There was no history of alcohol abuse or excessive sun exposure, but he had smoked 10 years earlier. Examination revealed annular lichen planus on the arms, lacy white patches on the buccal mucosa and white areas on the side of the lower lip. His dentition was in good condition. A hyperkeratotic nodule on the left lower lip was biopsied, and was reported as hypertrophic lichen planus. The nodule regressed with topical potent corticosteroid cream, after which the patient defaulted from the clinic. He returned in May 1990 with a new lesion on the right side of the lower lip. Clinical examination revealed a large fungating tumour (Figure 1), which histologically proved to be an invasive well differentiated squamous cell carcinoma. Adjacent lip showed classical features of lichen planus: a lymphocytic infiltrate applied to the epidermis, basal
..:.... ..
... ...'.:
.....
...'-
'...
Figume2. Lichen planus of the lip adjacent to squamous cell carcinoma (H&E, x2.84). Note vacuolar degeneration of basal cell layer and saw-tooth appearance of epidermis
cell vacuolar degeneration, hypergranulosis, Civatte bodies and resultant saw-tooth appearance of the epidermis (Figure 2) A vermilionectomy was performed in order to remove potentially dysplastic epithelium. Two months later he required suprahyoid and right neck lymph node dissection and radiotherapy for metastatic disease. Discussion The malignant transformation of OLP was first reported by Hallopeau in 19102. Subsequently there have been numerous reviews and case reports about this putative association, some suggesting that 10% of patients developed oral cancer-. Lichen planus is characterized microscopically by chronic erosion and regeneration of the basal keratinocyte layer5. This, coupled with the fact that the mouth is exposed to various carcinogens such as smoking, alcohol and poor dentition, may account for this increased incidence. A more recent and larger series of225 cases indicates that the incidence for malignant transformation is less than 1%4, suggesting that the relationship between OLP and cancer has been overestimated. Indeed, both are relatively common diseases and would be expected to coexist by chance. Furthermore, there may have been diagnostic difficulties. Leukoplakia is sometimes clinically misinterpreted as OLP, and lichenoid dysplasia may be confused histologically with OLP5. Also, a precise anatomical correlation between OLP and squamous cell carcinoma is seldom defined in previous reports, thus allowing spurious associations to be made. Squamous cell carcinoma of the lip predominantly affects 50-70-year-old patients, particularly those who have fair skin and a history of chronic sun exposure7. Risk factors in our patient include ultraviolet irra4iation and smoking. However, he was remarkably young to have developed oral cancer. In view of the patient's age and clear clinical and histological documentation of squamous cell carcinoma arising within an area of longstandinglichen planus of the lip, this case supports the -notion that OLPs a premalignant condition. Other recognized risk factors may be important in promoting malignant transormation. Patients with OLP should be advised to avoid preventable tanding active disease risk factors such as smoking, merits follow-up in order to dete early cancerous changes.
.,L -|i IS! L~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ S~ M.X.1.... References
-7
I Krutchkoff DJ, Cutler L, Laskowski S. Oral lichen planus: the Figure 1. Squamous cell carcinoma arising from longstanding lichen planus of the lip
evidence regarding potential malignant transformation. J Oral Pathol 1978;7:1-7
0141-0768/92/
040235-02/$02.00/0 i 1992 The Royal Society of Medicine
236
Journal of the Royal Society of Medicine Volume 85 April 1992
2 Hallopeau H. Sur un cas de lichen de Wilson gingival avec neoplasie voisine dans la region maxillaire. Bull Soc Fr Dermatol Syphiligr 1910;17:33 3 Dechaume M, Payen J, Piriou J. Le lichen plan isole de la muquese buccale: considerations anatomocliniques d'apres 50 observations dont 30 avec examen histologique. Presse Med 1957;65:2133-5 4 Fulling H-J. Cancer development in oral lichen planus. Arch Dermatol 1973;108:667-9 5 Marks R, Black M, Wilson Jones E. Epidermal cell kinetics in lichen planus. Br J Dermatol 1973;88:37-45
6 Krutchkoff DJ, Eisenberg E. Lichenoid dysplasia: a distinct histopathologic entity. Oral Surg Oral Med Oral Pathol 1985; 60:308-15 7 Krolls SO, Hoffman S. Squamous cell carcinoma of the soft tissues: a statistical analysis of 14,253 cases by age, sex, and race of patients. J Am Dent Assoc 1976;92:571-4
(Accepted 24 September 1991)
Squamous cell carcinoma arising in rhinophyma
Case presented to Section of Plastic Surgery, 8 January 1991
D A Ross BSc FRCS M P Davies FRCS Regional Plastic Surgery Unit, Queen Mary's University Hospital, Roehampton, London SW15 Keywords: rhinophyma; malignant change
We present a case of squamous cell carcinoma arising in a long-standing rhinophyma. This association is rare and the literature is reviewed. The extensive invasion of the tumour is emphasized.
Case report A 54-year-old man presented with an ulcer arising in a rhinophyma of approximately 10 years standing. The ulcer had been present for 3 years, but had grown markedly in the 12 months preceding admission, and it had been this and not the large rhinophyma which had led him to seek the advice of his GP (Figure 1). The initial attempt to resect the ulcer and shave the rhinophyma was abandoned when it became apparent that the ulcer represented the tip of the iceberg of a tumour which extended deeply into the nasal septum and laterally under an obscuring layer of rhinophymatous tissue into the skin over the maxillae. Histology confirmed a poorly differentiated squamous cell carcinoma with dysplastic areas in the rhinophymatous skin at the lateral margins. A CT scan showed no evidence of bony invasion but at a second, wider excision, the entire nose and majority of the bony nasal septum were removed in order to gain tumour
-, :8.
...
, , ....
..
Figure 1. Pre-operative view, showing the patient's rhinophyma and ulcer
Figure 2. Postoperative view, showing the extent of resection
clearance (Figure 2). A split skin graft was applied to the defect and a prosthesis fitted. He was subsequently referred for adjuvant radiotherapy and showed no sign of recurrence 6 months later. Discussion
Rhinophyma is seen mainly in men in their 5th-6th decades. Wolfe reviewed 60 cases occurring over 20 years and found only two cases in women'. The aetiology remains obscure with putative factors including alcohol, diet and vitamin deficiency1. In one report Freeman found 33% of patients with rhinophyma to have a history of alcohol abuse. Two cases were noted to follow prolonged steroid therapy2. Macroscopically it appears as a form of acne rosacea, with proliferation and hyperplasia of sebaceous glands. Acanthosis, manifested by hyperplasia of all the layers of the epidermis, has also been noted to be a common feature3. Acute and chronic inflammation is superimposed upon this along with intermittent areas of fibrosis. Malignant change (squamous cell carcinoma in particular), is a well rognized complication of chronic inflammation as seen mi ulcers, osteomyelitis and even burn scars. It is also seen in association with the chronic inflammatory dermatoses such as lupus vulgaris, discoid lupus erythematosus and hypertrophic lichen planus. However, despite te mked level of cellular activity and inflammtion seen in rhinophyma the association between it and malignant change is rare; until 1966 only five cases were reported in the literature. Broadbent described two cases of squamous cell carcinoma arising in longstanding rhinophyma, however the tumours were well defined with no evidence of occult spread so strikingly seen in our case4. In 1967 Acker and Helwig reported five cases of basal cell carcinoma arising in 47 patients with long-standing rhinophyma3. The authors concluded that basal cell carcinoma is more likely to arise in rhinophymatous than 'normal' skin, this argument being based on comparison between the incidence of basal cell
0141^0768/92/ 040236-0402.00/0 © 1992 The Royal Society of Medicine
