Kharidi U.A, Kodgi A, Biradar A, Kulkarni A

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1 Case Report Malignant Conversion of Oral Lichen Planus - A Case Report Kharidi U.A, Kodgi A, Biradar A, Kulkarni A Kharidi U.A, Kodgi A, Biradar A, Kulkarni A. Malignant Conversion of Oral Lichen Planus - A Case Report. J Periodontal Med Clin Pract 2015; 02: Affiliation 1. Dr. Usama A. Kharadi, Post graduate student, Department of Oral Medicine & Radiology, PDU Dental College & Hospital, Solapur. 2. Dr. Ashwin Kodgi, Assistant Professor, Department of Prosthodontics, Nanded Rural Dental College & Research Center, Nanded. 3. Dr. Ashwini Biradar, Assistant Professor, Department of Public health dentistry, MIDSR Dental College, Latur. 4. Dr. Abhay Kulkarni, Assistant Professor, Department of Oral Medicine & Radiology, PDU Dental College & Hospital, Solapur. Corresponding Author: Dr. Usama A. Kharadi Address: PDU Dental college & Hopsital, 19/1, Kegaon, Solapur Id: drosamakharadi@gmail.com ABSTRACT individuals may not have superfluous exposure to Lichen planus (LP) is a mucocutaneous disease. known risk factors such as alcohol and tobacco. Aim The exact etiology is still unidentified. It involves of presenting this case is to show the budding 1% to 2% of the population. The commonness of malignant transformation of oral lichen planus to lesions is 40% on both oral & cutaneous surfaces. oral SCC, chiefly in the erosive forms. The episode is 35% on cutaneous surfaces alone & Keywords : lichen planus, oral lesions, leukoplakia 25% on mucosa alone. There has been dispute INTRODUCTION: concerning malignant alteration in OLP. This Erasmus Wilson (1869) invented the term Lichen recommends to scrutinize the lesions two to four times annually. The threat of malignant transformation in oral lichen planus is real but not towering. Oral physicians must have high index of notion of the likelihood of malignancy mounting in OLP. The pretentious individuals are more likely to be women, comparatively young. All these 103 [1] Planus. It gives a hint of a flat fungal infection but the current substantiation imply it as a mucocutaneous disorder. Oral lichen planus (OLP) is a chronic inflammatory oral state. There is T-cell [2] mediated chronic immune response which leads to an intense destruction of basal layer of epithelium. OLP presents as white striations, papules, plaques, [3]

2 erythema, erosions or blisters affecting was present. The lesion was extending anteriorly predominantly the buccal mucosa, tongue and gingivae, although other sites too occasionally [4] involved. OLP occurs more in women than men and superiorly till the corner of mouth. Severe variant in the form of ulcerative lesion was present on the left side of lip. The lesion was surrounded by (1.4:1) & in adults. OLP lesions are typically continous white border & erosive areas were mixed bilateral, with mixture of subtypes. The OLP lesions are more repetitive than the dermal lesions and have been reported to carry a danger of malignant conversion to oral squamous cell carcinoma ( with white areas. The ulcer in the anterior area [FIGURE 3] was roughly oval shaped and approximately 1.5x2cm extending from buccal mucosa to lip on left side side. Ulcer was showing [5] %). The pathogenesis involves possible yellowish floor with indurated base. The ulcer was antigen presentation by the oral keratinocytes. This antigenic trigger go along with a mixed inflammatory response comprising mainly of T- cells, macrophages, and mast cells, as well as the [6] associated cytokines and cytotoxic molecules. WHO classifies OLP as a potentially malignant disorder with unspecified malignant conversion hazard and suggests that OLP patients should be [7] under close monitoring. CASE REPORT: 60 years female [FIGURE 1] reported with chief complaint of burning sensation in mouth since 1 year. She was under treatment of ENT surgeon, who had given first symptomatic treatment and as she did not respond to medication, he had started Dapsone tender on palpation, with no clinical discharge. A white, non tender, non scrapable patch of approximately 1x1cm surrounded by diffuse gryish white patch anteroposteriorly was seen on right buccal mucosa [FIGURE 4]. Bilaterally one on each side submandibular lymph nodes were palpable, soft in consistency, free & tender on left side. Provisional diagnosis of erosive lichen planus involving left buccal mucosa & homogenous leukoplakia on right buccal mucosa was considered. INVESTIGATIONS: After confirming routine blood investigation were within normal range incisional biopsy was taken from left side of lesion on buccal mucosa involving 300 mg daily therapy considering OLP for 6 weeks. anterior & middle part. The H & E section [FIGURE She was not relieved in spite of taking proper medications and was referred to our department. She was a chronic tobacco chewer since last 15 years but had completely stopped her habit since last one year. While having detailed clinical examinations she revealed no skin lesions & no systemic abnormality was found. Intraorally erosive lesions involving left buccal mucosa on left side corner of mouth, and white patch on right buccal mucosa was evident. An irregularly shaped erosive lesion on left buccal mucosa [FIGURE 2] starting from buccal vestibule in region of 34, 35, 36 & ], showed stratified sqamous epithelium overlying mature cellular connective tissue. The epithelium showed acanthosis, mild basal cell hyperplasia, open faced nuclei. Focal area of epithelial pearl formation and drop shaped rete ridges are seen. The basement membrane appears to be intact. The connective tissue consist of mature fibrocellular stroma & a band of subepithelial chronic inflammatory cell infiltrate which includes lymphocytes & plasma cells. The overall features were suggestive of mild epithelial dysplasia.

3 DIFFRENTIAL DIAGNOSIS: diabetes patient was referred to physician for Malignancy involving left side of buccal mucosa. control of hyperglycemia. The physician started antidiabetic treatment and the patient was recalled TREATMENT: for steroid tapering. The patient consulted Dapsone was discontinued as there was no oncosurgeon with fear of malignancy. The cutaneous & wide spread involvement. Topical oncosurgeon had planned for wide excision of lip antifungal agent [Candid] along with topical steroid lesion with abbey explander flap and surgical [Fluocinoline acetamide] was started. Systemic excision of buccal mucosa lesion. The patient didn't corticosteroid [Tablet Wysolone 20mg thrice daily turned up for the treatment and on follow up from for 15 days] was also prescribed. On follow up visit the relatives we comes to know history of patients blood investigations revealed marked increased in death in 8 months of reported time due to chronic blood sugar level & considering steroid induced illness. 105

4 Figure 4: White patch on right buccal mucosa Figure 5: Histopathologic picture DISCUSSION: OLP is a well accepted cell-mediated immune response, in which T lymphocytes assemble beneath the epithelium of the oral mucosa and amplify the rate of differentiation of the stratified squamous epithelium. The net result is hyperkeratosis, erythema & ulcerations. WHO manifestation in OLP is similar to that observed in dysplastic oral lesions and it is considered as a [14] indication of malignant potential. The transcription factor NF-kB is a major molecule associated with chronic inflammation and cancer. The expression of NF-kB has been reported higher in OLP & it play role in its malignant [15] transformation. The chronic and/or refractory lesions should be considered for a biopsy. The average time for a lichen planus to transfer into SCC is reported to be 7.2 years. This demands for defines OLP as a precancerous condition, long term, appropriate follow up and monitoring associated with an increase in the risk of oral cancer. [10] Six clinical forms of OLP are reticular, papular, plaque-like, erosive, atrophic and of OLP lesions. [16] CONCLUSION: [ 1 1 ] bullous. The reticular lesions are Oral physicians should have high index of asymptomatic, while erythematous and erosive suspicion of malignant conversion in OLP [12] ones provoke discomfort. The malignant particularly in erosive form. Steroid induced revolution is highest for erythematous and diabetes should be carefully evaluated even in [11,12] erosive lesions. The oral mucosa affected by initial phases of steroid regimen. OLP is compromised & becomes more sensitive to exogenous mutagens in tobacco, alcohol, betal REFERENCES: [13] quid & candida albicans. Inactivation of p53 is 1. Thomas P.Sollecito, Soft tissue a recurrent phenomenon in OSCC. The p53 [8] The Common presentations of OLP are bilateral lesions involving the buccal mucosa, gingivae, [9] and lateral borders of the tongue. The floor of the mouth is the least commonly affected. calcification; DENTAL CLINICS OF 106

5 N O R T H A M E R I C A ; J a n u a r y management; Oral Surg Oral Med Oral 2005:49(1). Pathol Oral Radiol Endod 2003: 96(1); 2. C. Scully and M. Carrozzo, Oral 32-7 mucosal disease: lichen planus, British 9. Gorsky M, Raviv M, Moskona D, Laufer Journal of Oral and Maxillofacial M, Bodner L. Clinical characteristics and Surgery, 2008:46(1); treatment of patients with oral lichen 3. Rajendran R. diseases of skin In. planus in Israel. Oral Surg Oral Med Oral Rajendran R, Sivapathasundhram B. Pathol Oral Radiol Endod 1996;82: th Shafers text book of oral pathology (6 edition). Elsevier: New Delhi, India 10. Pindborg JJ, Reichart PA, Smith CJ, van der Waal I. WHO International 2006; histological Clasification of Tumours. 4. PB Sugerman, NW Savage, Oral lichen Histological typing of cancer and planus: Causes, diagnosis and management; Australian Dental Journal Springer; precancer of the oral mucosa. Berlin: 2002;47: Ismail SB, Kumar SK, Zain RB. Oral 5. M. A. Gonzalez-Moles, C. Scully, and J. lichen planus and lichenoid 6. reactions: A. Gil-Montoya, Oral lichen planus: etiopathogenesis, diagnosis, management controversies surrounding malignant transformation, Oral Diseases, vol. 14, 2007;49: no. 3, pp , and malignant transformation. J Oral Sci 12. Einsen D. The clinical features, malignant 6. Eleni A. Georgakopoulou et al, Review potential, and systemic 7. associations of Article,Oral Lichen Planus as a oral lichen planus: a study of 723 patients. Preneoplastic Inflammatory Model; J Am Acad Dermatol 2002;46: J o u r n a l o f B i o m e d i c i n e a n d Biotechnology 2012, Article ID Sangeeta vanjari et al: Malignant transformation of oral lichen planus; 7. S. Warnakulasuriya, N. W. Johnson, and I. JIAOMR 2010;22(3): Van Der Waal, Nomenclature and classification of potentially malignant disorders of the oral mucosa, Journal of Oral Pathology and Medicine, vol. 36, no. 10, pp , M. Ebrahimi, K. Nylander, and I. van der Waal, Oral lichen planus and the p53 family: what do we know? Journal of Oral Pathology and Medicine2011:40(4); 8. Joel B. Epstein et al, Oral lichen planus: 15. N. L. Rhodus, B. Cheng, S. Myers, W. Progress in understanding its malignant Bowles, V. Ho, and F. Ondrey, A Potential and the implications for clinical comparison of the pro-inflammatory, NF 107

6 êbdependent cytokines: TNF-alpha, IL- management of oral lichen planus: 1-alpha, IL-6, and IL- 8 in different oral Northwest dentistry journal of the fluids from oral lichen planus patients, minnestoa dental association. March- Clinical Immunology, vol. 114, no. 3, pp. April 2003;82(2) , Rhodus N et al. Diagnosis and Competing interest / Conflict of interest The author(s) have no competing interests for financial support, publication of this research, patents and royalties through this collaborative research. All authors were equally involved in discussed research work. There is no financial conflict with the subject matter discussed in the manuscript. Source of support: NIL Copyright 2014 JPMCP. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 108