J Interdiscipl Histopathol Proliferative Verrucous Leukoplakia: A Case Report with Emphasis on Diagnosis and Treatment Journal Name : Journal of Interdisciplinary Histopathology Manuscript ID : JIHP-2016-05-032 Manuscript Type : Case Report Submission Date : 05-May-2016 Abstract : Proliferative verrucous leukoplakia(pvl) is characterized by development of multiple keratotic plaques with roughened surface projections. Since its introduction in 1985 by Hansen et al, PVL of the oral mucosa still remains an enigma and is difficult to define as a sub entity of leukoplakia. Although the lesion typically begins as simple, flat hyperkeratosis indistinguishable from ordinary leukoplakic lesion, PVL exhibits persistent growth and eventually becomes exophytic and verrucous in nature. As the lesion progresses, they may go through a stage indistinguishable from verrucous carcinoma, but may later develop dysplastic changes or transform into full-fledged squamous cell carcinoma usually within 8 years of initial PVL diagnosis. PVL is unusual among the leukoplakia variants in having a strong female predilection and minimal association with tobacco usage. Presenting here, a case of PVL transforming into verrucous carcinoma with areas of suspected malignancy, in a 53 year old male with habit of chewing tobacco quid and beedi smoking 4 to 6 times a day since 20 years. With a chief complaint of pain and burning sensation of the oral cavity and multiple oral lesions since one month. This paper will elaborate typical behaviour pattern of the lesion and will discuss this rare entity in light of current information. Keywords : Leukoplakia, Oral cancer, Proliferative verrucous leukoplakia, Squamous cell carcinoma, Verrucous carcinoma. For your questions please send message to editorialoffice.jihp@gmail.com
1 COVER LETTER 2 Date : 06 /5/2016 3 4 5 6 7 8 9 10 11 12 To, The Editor, Journal of Interdisciplinary Histopathology Respected Sir/Madam Subject: Submission of case report with brief review for publication We take the privilege of submitting a case report with brief review titled PROLIFERATIVE VERRUCOUS LEUKOPLAKIA- A CASE REPORT WITH EMPHASIS ON DIAGNOSIS AND TREATMENT. for publication to your esteemed journal. We have not sent this article anywhere else for publication. We promise to abide by the rules and regulations of the journal. We declare that there is no conflict of interest and there is no financial assistance gained. 13 Thanking you 14 15 16 17 18 Yours sincerely Dr Bhagyalaxmi Hongal MDS (Oral &Maxillofacial Pathology & Microbiology) Assistant professor, Vasantdada Patil Dental College & Hospital, Sangli 19 20 21 22 23 24 25 26 27 28 1
29 30 31 TITLE PAGE PROLIFERATIVE VERRUCOUS LEUKOPLAKIA: A CASE REPORT WITH EMPHASIS ON DIAGNOSIS AND TREATMENT 32 RUNNING TITLE: PROLIFERATIVE VERRUCOUS LEUKOPLAKIA- A CASE REPORT 33 AUTHOR DETAILS & AFFILIATIONS 34 35 36 37 38 1) Dr. Bhagyalaxmi Hongal. MDS (Oral &Maxillofacial Pathology & Microbiology) Assistant professor, Vasantdada Patil Dental College & Hospital, Sangli Email Id: drbhagyalaxmi@gmail.com Mobile no: 09860779991 39 2) Dr. Priya Shirish Joshi 40 MDS (Oral &Maxillofacial Pathology & Microbiology) 41 Professor & Head, Vasantdada Patil Dental College & Hospital, Sangli 42 43 44 45 46 47 48 Email Id: sangeetakov@yahoo.co.in Mobile no: 9890712016 3) Dr.Appasaheb Sanadi MDS (Oral &Maxillofacial Surgery) Associate Professor, Vasantdada Patil Dental College & Hospital, Sangli Email Id: dr.ans84@gmail.com Mobile no: 09975016819 49 50 51 2
52 CORRESPONDING AUTHOR: 53 54 55 56 57 Dr. Bhagyalaxmi Hongal. MDS (Oral &Maxillofacial Pathology & Microbiology) Senior lecturer, Vasantdada Patil Dental College & Hospital, Sangli drbhagyalaxmi@gmail.com Mobile no 09860779991 58 Dr. Priya Shirish Joshi 59 MDS (Oral &Maxillofacial Pathology & Microbiology) 60 Professor & Head, Vasantdada Patil Dental College & Hospital, Sangli 61 62 Email Id: sangeetakov@yahoo.co.in Mobile no: 9890712016 63 64 65 66 67 68 69 ADDRESS FOR CORRESPONDENCE Dr. Bhagyalaxmi Praveen Hongal Flat no 12, Swapnshilpi Residency, Gulmohar colony Beside nayantara eye hospital Near Mali Theatre, SANGLI, MAHARASHTRA, 416416 70 71 72 73 74 Word count Abstract 204 Manuscript- 1328 Total number of pages in manuscript- 8 Images 4 75 76 Conflicts of Interest: Nil 3
77 78 79 80 81 82 Funding source: None Declaration: The paper was presented orally as power point presentation at National OOO symposium held at Bangalore on 13 th 14 th 15th March 2015.. Contributors details: All authors have read the manuscript and consented for publication.. Dr.Bhagyalaxmi Hongal will act as guarantor and take all the responsibilities as contributing author. 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 4
98 MANUSCRIPT 99 100 PROLIFERATIVE VERRUCOUS LEUKOPLAKIA: A CASE REPORT WITH EMPHASIS ON DIAGNOSIS AND TREATMENT 101 ABSTRACT 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 Proliferative verrucous leukoplakia(pvl) is characterized by development of multiple keratotic plaques with roughened surface projections. Since its introduction in 1985 by Hansen et al, PVL of the oral mucosa still remains an enigma & is difficult to define as a sub entity of leukoplakia. Although the lesion typically begins as simple, flat hyperkeratosis indistinguishable from ordinary leukoplakic lesion, PVL exhibits persistent growth and eventually becomes exophytic and verrucous in nature. As the lesion progresses, they may go through a stage indistinguishable from verrucous carcinoma, but may later develop dysplastic changes or transform into full-fledged squamous cell carcinoma usually within 8 years of initial PVL diagnosis. PVL is unusual among the leukoplakia variants in having a strong female predilection and minimal association with tobacco usage. Presenting here a case of PVL transforming into verrucous carcinoma with areas of suspected malignancy in a 53 year old male with habit of chewing tobacco quid and beedi smoking 4 to 6 times a day since 20 years, with a chief complaint of pain and burning sensation of the oral cavity & multiple oral lesions since one month. This paper will elaborate typical behaviour pattern of the lesion and will discuss this rare entity in light of current information. 117 118 KEY WORDS: Leukoplakia, Oral cancer, Proliferative verrucous leukoplakia, Squamous cell carcinoma, Verrucous carcinoma. 119 120 121 5
122 123 124 125 126 127 128 129 130 INTRODUCTION: Hansen and collaborators (1985) described proliferative verrucous leukoplakia (PVL) as a distinct entity of leukoplakia, presenting as verrucous or exophytic lesion with progressive histological changes in sequential biopsies such as hyperkeratosis, different grades of dysplasia, verrucous carcinoma and squamous cell carcinoma (SCC) 1. In 2005, WHO defined PVL as a rare subtype of oral leukoplakia with unknown etiology, affecting more commonly women (men:women proportion of 1:4) in the 60 s, with a high risk of malignant transformation and diagnosis based on the association of clinical and histopathological features. 2 We are presenting here an interesting case of PVL in a male patient with a habit of chewing tobacco quid. 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 CASE REPORT: A 53 year old male patient reported to the department with a chief complaint of pain and burning sensation in the left back cheek region since one month. Patient was asymptomatic one month back. Initially the lesion was painless white patch which got ulcerated and was then associated with pain on eating hot and spicy food. Patient had a habit of chewing tobacco quid and beedi smoking 4 to 6 times a day since 30 years. Extra oral examination did not reveal any noticeable findings. On palpation left submandibular lymph nodes were found to be enlarged and fixed. Intra oral examination revealed multiple white patches on the oral mucosa involving right buccal mucosa (Fig.1.A), left labial mucosa (Fig.1.B), left side of the palate(fig.1.c) and left alveolous (Fig.1.D). The lesion for which the patient reported was ulcerative and verruca papillary and was extending from left mandibular canine to pterygomandibular area involving alveolous. The surrounding mucosa was pigmented. The surface was rough with a warty appearance with palpable multiple projections giving leathery feel on touch. Lesion on right buccal mucosa was present since last 3 years, extending anteroposteriorly from right first mandibular premolar to right pterygo-mandibular raphae and there 6
147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 was no change in the texture and size of the lesion over the years. On investigations OPG revealed ill defined irregular moth eaten radiolucency extending from left canine region anteriorly to pterygomandibular raphae posteriorly. (Figure 2) Provisional diagnosis of carcinoma of left alveolous and proliferative verrucous leukoplakia was established. Incisional biopsy of lesion related to patient s chief complaint (left labial mucosa and alveolous) was performed. Histopathology revealed hyperorthokeratotic epithelium with surface irregularity and exophytic verrucous or church spire like keratin cuffing with prominent granular cell layer. There was evidence of bulbous rete ridges with elephant foot like pushing margin. (Figure 3) Dysplastic changes, epithelial pearl, indistinct basement membrane and few atypical mitotic figures were noted in epithelium. (Figure 4) Connective tissue was dense fibrocellular with juxtaepithelial intense chronic inflammatory cell infiltration. Considering all the clinical and histopathologic features we confirmed the diagnosis as proliferative verrucous leukoplakia progressing to verrucous carcinoma with questionable invasion. Incisional biopsies from multiple sites were not performed as the case was referred to Sidhivinayak cancer hospital Miraj for further treatment and management. 162 163 DISCUSSION: 164 165 166 167 168 169 170 171 Proliferative verrucous leukoplakia was first defined in 1985 (Hensen) as a disease of unknown etiology, not always associated with known risk factors of oral cancer and exhibits a strong tendency to develop areas of carcinoma. 1 With the introduction of the term PVL the previously used term oral florid papillomatosis has disappeared from the literature. PVL is a disease of elderly females as given in original report by Hensen 1 with mean age of occurrence being 62 years in their patients and male to female ratio of 1:4. Human Papilloma virus appears to have a significant role in the etiology of PVL as reported by Eversole LR 3. 7
172 The alcohol and tobacco use has not been directly related to PVL etiology, although studies 173 report that at least 30% of the PVL patients are smokers. 2 But the case we are presenting 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 here is a 53 years old male patient with the habit of chewing tobacco quid. One of the hallmarks of PVL is its variable and progressive clinical presentation. PVL may appear on any soft tissue surface of the oral cavity and may present as a single distinct lesion or, less often, as scattered multifocal growths involving several oral sites. A case of PVL with cutaneous involvement has also been reported. 4 The most affected oral sites described in the literature are alveolar ridges, buccal mucosa and tongue, followed by labial mucosa and hard or soft palate. [5,6,7] Our findings are similar to that described in the literature expect for the involvement of tongue and soft palate. The natural history of PVL begins as a benign unifocal, homogenous leukoplakia that is persistent and slow growing. At this stage diagnosis of PVL is difficult because of its innocuous character but over a period of time this benign lesion soon acquires a verrucous or papillary surface, sometimes showing areas of erythematous change, becomes multifocal or widespread and at mean times become malignant. 8 Our case had similar findings. Many case series reported so far describe histopathology of PVL as a characteristic exophytic verruciform pattern with bulbous rete ridges and acanthosis but dysplasia seems to be a late feature. Absence of dysplasia in early lesions may lead to less aggressive form of treatment. 190 191 192 193 194 195 196 DIAGNOSTIC CRITERIAS FOR PVL GIVEN BY DIFFERENT AUTHORS Generally, diagnosis is made according to Hansen s 1 first definition of PVL in 1985. Ghazali et al. 8 established the following criteria and that all their proposed criteria should be met without exclusion. 1. The lesion starts as homogenous leukoplakia without evidence of dysplasia at the first visit. 2. With time, some areas of leukoplakia become verrucous. 8
197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 3. The disease progresses to the development of multiple isolated or confluent lesions at the same or different site. 4. With time, the disease progresses through the different histopathological stages reported by Hansen et al 1 (1985). 5. The appearance of new lesions after treatment. 6. A follow-up period of no less than one year. After analysing the results of 7 case series, Rocio CLet al 9 have proposed 5 major and 4 minor criteria as well as various combinations among them, to allow for a definitive diagnosis of PVL. Major Criteria: A. A leukoplakia lesion with more than two different oral sites, which is most frequently found in the gingiva, alveolar processes and palate. B. The existence of a verrucous area. C. That the lesions have spread or engrossed during development of the disease. D. That there has been a recurrence in a previously treated area. E. Histopathologically, there can be from simple epithelial hyperkeratosis to verrucous hyperplasia, verrucous carcinoma or oral squamous cell carcinoma, whether in situ or infiltrating. Minor Criteria: a. An oral leukoplakia lesion that occupies at least 3 cm when adding all the affected areas. b. That the patient be female. c. That the patient (male or female) be a non-smoker. d. A disease evolution higher than 5 years. They suggested one or two following combinations of the criteria should meet in order to make the diagnosis of PVL, that is 9
222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 1. Three major criteria (being E among them) or 2. Two major criteria (being E among them) + two minor criteria. Our case was fulfilling 4 major and one minor criteria and fitted well in the diagnosis of PVL. Malignant transformation rate of PVL can be higher than 70%, reaching up to 100% in some cases. 74.62% of the published cases reports give a mean malignant transformation rate of 6.08 years. Therefore, the early diagnosis of PVL can be beneficial in the prognosis of these patients. (1,9, 10) Distant metastasis and regional node involvement may be a late feature in this condition. 11 In our case left regional lymph node was involved similar to the reported findings. Treatment procedures employed for PVL are surgery, carbon dioxide laser therapy, and photodynamic therapy. 12 Photodynamic therapy would appear to offer the best prognosis as it will be able to cover the treatment of multiple sites with minimal morbidity. It is important to analyze any verruciform leukoplakic lesion carefully to have the earliest possible diagnosis. PVL is a persistent and progressive oral lesion that requires very close follow-up along with early and aggressive treatment to increase the chances of a favourable outcome. 238 239 240 241 242 243 244 245 246 247 248 249 10
250 251 252 253 254 255 256 257 258 259 260 261 262 REFERENCES: 1)Hansen LS, Olson JA, Silverman S Jr. Proliferative verrucous leukoplakia. A long-term study of thirty patients. Oral Surg Oral Med Oral Pathol Oral Radiol 1985; 60: 285 98. 2) Adriele Ferreira Gouveˆa, Pablo Agustin Vargas, Ricardo D. Coletta, Jacks Jorge, Ma rcio Ajudarte Lopes Clinicopathological features and immunohistochemical expression of p53, Ki-67, Mcm-2 and Mcm-5 in proliferative verrucous leukoplakia J Oral Pathol Med (2010) 39: 447 452 3)Eversole LR. Pappillary lesions of the oral cavity: relationship to humam pappillomaviruses. J Calif Dent Asso 2000 ;28(12) 922-7. 4)Robert J. Cabay, Thomas H. Morton Jr, Joel B. Epstein. Proliferative verrucous leukoplakia and its progression to oral carcinoma: a review of the literature. J Oral Pathol Med (2007) 36: 255 61 263 264 5) Jose V Bagan,Yolanda Jimenez, Jose M Sanchis Proliferative verrucous leukoplakia high incidence of gingival squamous cell carcinoma. J Oral Pathol Med 2003:32:379-82 265 266 267 6) Gandolfo S, Castellani R, Pentenero M. Proliferative verrucous leukoplakia: a potentially malignant disorder involving periodontal site. J Periodontol 2009; 80: 274 81. 268 269 270 271 7) Batsakis JG, Suarez P, El-Naggar AK. Proliferative verrucous leukoplakia and its related lesions. Oral Oncol 1999; 35: 354 9. 8)Ghazali N, Bakri M, Zain R. Aggressive, multifocal oral verrucous leukoplakia: Proliferative verrucous leukoplakia or not? J Oral Pathol Med (2002) 32: 383 92 272 273 274 9) Rocio CL, David BM, Luis-Alberto ML, Germán EG, Proliferative verrucous leukoplakia: A proposal for diagnostic criteria: Med Oral Patol Oral Cir Bucal. 2010 Nov 1;15 (6):e839-45. 11
275 276 277 278 279 10)Silverman S Jr, Gorsky M. Proliferative verrucous leukoplakia: a follow-up study of 54 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1997;84:154-7. 11).Joanna MZ, Victor lopez, Paul Speight, Colin Hopper. Proliferative verrucous leukoplakia- A report of ten cases; Oral Med Oral Pathol Oral Radiol Endod 1996 ;82: 396-401 280 281 12) Schoelch ML, Sekandari N, Regezi N, Silverman S. Laser management of oral leaukoplakias: A follow up study of 70 patients.laryngoscope 1999; 106(9): 949-53. 282 283 284 285 286 287 FIGURE LEGENDS Figure 1: A: Verrucous leukoplakia on right buccal mucosa B: Leukoplakia on left labial mucosa C: Leukoplakia on left side of the palate D: Ulcerative and verruca papillary lesion on left alveolous 288 289 290 291 292 293 294 295 Figure 2: Ill defined irregular moth eaten radiolucency extending from left canine region anteriorly to pterygomandibular raphae posteriorly. Figure 3: Hyper orthokeratotic epithelium and exophytic verrucous or church spire like keratin cuffing with prominent granular cell layer with bulbous rete ridges with elephant foot like pushing margin. Figure 4: Dysplastic changes, epithelial pearl, indistinct basement membrane and few atypical mitotic figures in epithelium. 296 297 298 12
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