A review of common pediatric lip lesions: herpes simplex/recurrent herpes labialis, impetigo, mucoceles, and hemangiomas

Lip lesions are a common presentation to the pediatrician's office. These lesions are often benign in children, without significant functional morbidity. However, owing to the prominent placement of lips and their role in communication, lip lesions can be alarming to patients as well as to their parents. For these reasons the pediatrician has an important role in recognizing, diagnosing, and treating the various types of labial dermatoses that commonly present to a pediatric practice. Four of the most common lip lesions a pediatrician will see are herpes simplex/recurrent herpes labialis, impetigo, mucoceles, and hemangiomas. This paper reviews the current literature on the diagnosis, treatment, and management of these 4 lesions.

[Squamous cell carcinoma of the lip. Retrospective analysis of 42 cases]

BACKGROUND

To examine to what extent physicians follow a regional guidelines for the diagnosis, staging, treatment and follow-up of patients with squamous cell carcinoma of the lower and upper lip.

METHODS

DESIGN

retrospective analysis of data from the medical records of 42 patients diagnosed with squamous cell carcinoma of the lower and upper lip during the period 1990-2000.

SETTING

Department of head and neck pathology, oral cavity and audio-verbal communication of Naples University.

PARTICIPANTS

the data were collected by this Department.

RESULTS

In accordance with the TNM system, the 50% of cases was in stage T1, 33% in T2, 14% in T3. In few cases (3%) the lesion was in stage T4. All cases were in M0 and only 8% of cases presented nodal disease at diagnosis (N1). The type of treatment in relation to age was in agreement with the guidelines in 34% of cases. Of the 42 surgically-treated patients, only 4 showed, after 12 months, a local recurrence.

CONCLUSIONS

Prognosis is good if squamous carcinoma is diagnosed early.

[Delayed deltoid-pectoral flap]

Delayed flaps include surgical techniques performed in order to diminish the blood supply of a flap before placing it at the definitive location. The purpose is to improve the irrigation of the distal region of the flap. Three cases of head and neck reconstructions with delayed deltopectoral flaps are reported. Literature about anatomic and physiologic phenomenon occurred during the delay period is reviewed, as well as the different surgical techniques described to delay a flap. We think that the deltopectoral flap remains an adequate technique, being indicated when the reconstruction is impossible with local flaps. That is the case of defects or irradiated regions. In our opinion, if the deltoid region of the flap is necessary to the reconstruction it is recommended to delay the flap, to increase the probability of complete survival at the distal region. In our cases the delay period has been one week, obtaining a complete survival of the flap in all of them.

Desmoplastic malignant melanoma of the lip: a report of 6 cases and review of the literature

Desmoplastic malignant melanoma is a rare neoplasm consisting primarily of spindle-shaped melanoma cells embedded in a fibrous stroma, with approximately 6% of cases occurring in the lip. A literature search revealed that most reported cases occur in sun-exposed areas in older men. Few cases of desmoplastic malignant melanoma of the lip in young people (in their mid-twenties) have been described. We report 6 previously undocumented cases of labial desmoplastic malignant melanoma occurring in young individuals and review 20 cases from the literature. Physicians should consider the possibility of desmoplastic malignant melanoma in young people who present with atypical lip lesions, which on histopathologic analysis demonstrate spindle-cell hyperplasia. Although this diagnosis is rare and there have not been reports of such patients in the literature thus far, our findings should alert clinicians to the possibility of desmoplastic malignant melanoma as a diagnosis for lip lesions in young people.

Carney complex: report of a Japanese case associated with cutaneous superficial angiomyxomas, labial lentigines, and a pituitary adenoma

We report the case of a 12-year-old female patient who manifested multiple cutaneous angiomyxomas and labial pigmented lesions. Although the familial history was not confirmed in the present case, autosomal dominant inheritance has been reported to be involved in the pathogenesis of this condition. In addition to the cutaneous complications, magnetic resonance (MR) images revealed the presence of a pituitary adenoma, which provoked an elevation of serum growth hormone (GH) level. On the other hand, no significant symptoms such as cardiac myxoma, myxoid fibroadenoma of the breast, or adrenocortical complaints suggesting Cushing syndrome, were detected. In the Japanese literature, only a few cases of this disorder have been described in the form of brief reports. There have been only a few similar cases described in the dermatological field, except for one report diagnosed as Carney complex in 1990. Therefore, the present case seems to be the first Japanese case of typical Carney complex manifesting major clinical complications, including angiomyxomas, lentigines, and a pituitary adenoma, which induced endocrine overactivity.

[Angiomatous lips]

After defining vascular malformations and tumors, the authors approach specific problems of these lesions involving the lips. Careful planning and assessment are necessary throughout the clinical course and evolution. Therapeutic management concern the vascular anomaly but the functional, cosmetic and psychological repercussions as well. The rules of surgical treatment are discussed in this labial location. Capillary malformations can be treated by pulsed dye laser for the skin involvement, but sometimes by reconstructive surgery in case of soft tissue and bony overgrowth. Venous malformations require percutaneous sclerotherapy, partial or total removal surgery, reconstructive surgery, with or without previous embolization, according to the size and functional repercussions. Lymphatic malformations involving the lip are based upon conservative and observing treatment or surgery according to impairment and psychological impact. There is a strong tendency for these lymphatic microcystic malformations to invade and to recur after surgery. The new lasers (diode, Nd Yag) have to be assessed in this area. Arterio-venous malformations are the most severe anomaly. When the lesion is cosmetically and functionally acceptable, the authors propose conservative management waiting for therapeutic progress expected from genetics research. Otherwise management require embolization and complete surgical treatment with lip reconstruction. The first-line treatment of hemangiomas is medical and pharmacological (local medical care, corticosteroids, interferon, vincristine) but surgery may be indicated in three situations. In urgent cases with severe complications surgery is performed after failure of medical management. Early surgery is recommended to prevent functional or cosmetic disturbance or serious psychological distress. Ultrasound dissection (Dissectron) an significantly contribute to the surgical outcome. Late surgery retains its classical cosmetic and functional indications and techniques to treat the residual after-effects. Three key-words dominate the rules of therapeutic management of all types of vascular anomalies: multidisciplinary approach, experience and carefulness.

Desmoplastic melanoma of the lip

BACKGROUND

This retrospective study looks at the prognosis of desmoplastic melanoma of the lip, correlating it with the clinical course, treatment, and patterns of failure.

METHOD

Twenty-two patients with desmoplastic melanoma of the lip were seen at the University of Texas M. D. Anderson Cancer Center from 1965 to 1998.

RESULTS

Three disease groups: (I) untreated tumor (3 patients), (II) excisional scar (10 patients), and (III) locoregional recurrence (9 patients). Group I had two cures and one failure. In group II six had no recurrences, and there were four failures. In group III, all patients failed. Ten patients (45%) had no evidence of disease, of which three (30%) had an initial misdiagnosis. Twelve patients (55%) died of disease or were living with disease, of which eight (67%) had an initial misdiagnosis.

CONCLUSIONS

Desmoplastic melanoma of the lip is often misdiagnosed and, therefore, inappropriately treated with multiple recurrences and poor prognosis. Accurate diagnosis and combined treatment may improve local control and survival.

[Malignant non-Hodgkin's lymphoma of the lip: a case report]

The non Hodgkin's lymphoma of the lip is rare. A 3-year-old child with non-Hodgkin's lymphoma of the upper lip (stage I in the Ann Harbor system) was reported. An immunodeficiency, been in correspondence with a food deficiency, was probably a causal factor. A post-chemotherapy residual lesion justified a surgery.

Squamous cell carcinoma of the lip. Patterns of relapse and outcome: Reporting the Westmead Hospital experience, 1980-1997

Australia has one of the highest rates of squamous cell carcinoma of the lip in the world. Despite a high cure rate, many studies report relapse rates of between 5% and 20% with an associated mortality of 5-10%. The aim of this study was to review the patterns of relapse and outcome for patients treated at Westmead Hospital, Sydney. Ninety-three eligible patients were identified in a retrospective review of all lip cancer patients referred to Westmead Hospital between 1980 and 1997. Relevant data were extracted from the treatment files and included contact with referring doctors and utilizing the Cancer Council Registry. Equal numbers of patients were treated with radiotherapy alone or surgery (+/- adjuvant radiotherapy). The majority of patients were male (78.5%) with T1N0 cancers (64.5%) of the lower lip. A minority (5.4%) had nodal disease at diagnosis. Following treatment, 31 (33.3%) patients relapsed, 11 at the primary site, 18 at the regional nodes and two at both sites simultaneously. Patients treated with a combined approach (RTx/Sx) experienced a better outcome. Overall cancer-specific survival at 5 years was 85%. These findings highlight a disturbing relapse rate and mortality for a subgroup of patients diagnosed with a more aggressive form of lip cancer. Treatment and follow up of these patients should accordingly be more aggressive.

Regional guideline for diagnosis and treatment of squamous cell carcinoma of the lip: what is the level of compliance?

OBJECTIVE

To investigate to what extent physicians comply with a regional guideline for the diagnosis, staging, treatment and follow-up of patients with squamous cell carcinoma of the lower lip.

DESIGN

Retrospective analysis of data from the medical records of 248 patients diagnosed with squamous cell carcinoma of the lower lip during the period 1989-1997.

SETTING

Comprehensive Cancer Centre of the Northern region of the Netherlands.

STUDY PARTICIPANTS

The data were collected by this Centre for the regional population-based cancer registry.

RESULTS

Overall compliance with the separate guidelines varied between 4 and 80%. For diagnosis and staging, the guideline was followed for 4-70% of patients. The type of treatment in relation to age conformed to the guideline in 34% of cases. Of the 208 surgically-treated patients, treatment was performed in accordance with the guidelines in 92 (44%) patients, compared with seven out of 18 (39%) patients who received radiotherapy. Follow-up in accordance with the guideline was 11% in the first year, 9% in the second year and 21% in the third year.

CONCLUSION

Only a minority of patients with squamous cell carcinoma of the lower lip, a rare rumour, were managed according to the available regional guideline. Regular review of both the guideline and its implementation is necessary in order to optimize its use.

Expression of Rb, pRb2/p130, p53, and p16 proteins in malignant melanoma of oral mucosa

We previously reported that pRb2/p130 gene, one of the Rb family members, was immunohistochemically abundantly expressed in well-differentiated oral squamous cell carcinomas, whereas in undifferentiated ones the expression was low. Oral malignant melanoma is extremely rare, however the prognosis is poor because it tends to locally invade tissue or metastasize and its biological behavior appears to be different from cutaneous malignant melanoma. The present study dealt with the expression of pRb2/p130, Rb, p53, and p16 in 13 cases of malignant melanoma of oral mucosa as revealed by immunohistochemical staining. The stage classification of the 13 patients was as follows; stage II: eight patients, stage III: three patients, and stage IV: two patients. pRb2/p130 was expressed in only two stage II-cases, neither of which have shown any evidence of recurrence or metastasis for over 14 years. Positive staining for Rb was found in three cases consisting of one stage II-case, one stage III-case, and one stage IV-case. p53 was expressed in two cases, one a stage II and the other a stage IV. Positive staining for p16 was found in seven cases consisting of four stage II-cases, two stage III-cases, and one stage IV-case. pRb2/p130 may be inversely correlated with the malignancy of oral malignant melanoma, but further study is needed.

[Treatment methods for primary cancer of the lower lip]

The long-term results of treatment of primary cancer of a lower lip were studied in 954 patients. It was established that cryodestruction was the most effective method for treatment of I and IIA stage squamous cell keratinizing type cancer of a lower lip irrespective of its clinical form. In tumour spreading to the corner of a mouth, and in IIIA stage tumour, use of radiation methods of treatment as the independent ones (close-focus roentgenotherapy and long-focus gamma-therapy) has proved to be of low effectiveness.

[First experience with hypothermia in radiotherapy for locally advanced skin cancer of the face]

An original method of cryotherapy is presented. After each exposure during standard fractionation regimen tumor was cooled to 0-5 deg C in 20 patients with locoregional skin cancer of the face. Complete remission was registered in 18 cases of good cosmetic effect. Recurrence was reported in 2 cases during 9 month--10 year follow-up.

Hemangiomas in infants and children. An algorithm for intervention

Considerable confusion exists with the diagnosis and management of vascular birthmarks. For this article we reviewed charts for the diagnosis and recommended management of 208 new patients with vascular birthmarks presenting to the Albany Medical Center Vascular Malformation Clinic, Albany, NY, over a 26-month period from October 1995 through December 1997. Based on our patient population, data available, and the current literature, we concluded that an early evaluation and an accurate diagnosis in infants with a vascular birthmark are important. Furthermore, intervention by way of systemic steroids, laser therapy, or surgical debulking is appropriate and safe in a select group of patients presenting with a proliferating hemangioma and in patients with an involuting but disfiguring hemangioma. Also in this article we present an algorithm to assist the clinician with the management of the pediatric patient with a diagnosis of a hemangioma.

Risk of second primary cancer following treatment of squamous cell carcinoma of the lower lip

The risk of second primary cancers (excluding skin cancers) was evaluated among 56 patients who underwent treatment for a squamous cell carcinoma of the lower lip. The mean follow-up was 5.5 years. Ten patients (17.8%) developed at least one new primary cancer. The prevalence of second primary cancers within the respiratory and upper digestive tract, and elsewhere in the body, was 19.4 and 12.9 per 1000 person-years of follow-up, respectively. Patients were at risk for a second primary cancer at a steady rate of 2.7% per year during at least 5 years.

A comparison of results after radiotherapy and surgery for stage I squamous cell carcinoma of the lower lip

BACKGROUND

Controversy still exists as to whether radiotherapy or surgery is the preferable therapeutic modality for stage I squamous cell carcinoma of the lower lip. Therefore, a retrospective study was undertaken to compare the results of both treatment modalities.

METHODS

The results of 90 patients who received radiotherapy and 166 patients who underwent surgery as the primary form of treatment for their stage I primary squamous cell carcinoma of the lower lip were evaluated. Tumor size and histological grade of differentiation were assessed.

RESULTS

Local control rates were the same with radiotherapy or surgery. Overall survival rates for both groups of patients were similar as well. Disease-free survival rates in the patients who underwent radiotherapy were significantly lower compared with the surgically treated group. This was due to a higher occurrence of regional metastases in the patients who received radiotherapy. Univariate analysis showed that irradiated patients had a statistically significant greater tumor size. The difference of histological differentiation between the groups was also statistically significant, the poorly differentiated being more common in the irradiated group. Multivariate analysis showed that only tumor size carried significant independent prognostic information.

CONCLUSIONS

The cure rates of stage I squamous cell carcinoma of the lower lip are favorable whether treated by radiotherapy or surgery, and local control rates are similar. The radiotherapeutic treated group showed an increased incidence of cervical metastases, which was due to the more advanced tumor size in these patients.

Oral malignant melanoma: long-term follow up in three patients

Three patients with oral malignant melanoma, who survived for at least ten years after initial examination, are presented. The depth of tumor invasion was 5 mm or less in all patients. The first patient received surgery and postoperative immunotherapy and she had no recurrence more than 18 years after treatment. The second patient underwent surgery but had local recurrence after 11 years. He underwent resection and postoperative chemotherapy and was still alive more than 14 years after initial examination. The third patient received radiotherapy and had metastasis nine months after treatment. Resection and radiotherapy were performed and the patient was alive more than 14 years after first presentation.

Prognosis value of the expression of Ki-67 for squamous cell carcinoma of the oral cavity

Ki-67 is a nuclear antigen expressed in G1, S, G2 and M phase of cell cycle and absent in quiescent cells (G0). In some neoplasms, Ki-67 expression has a prognostic value. The purpose of this study was to determine the role of Ki-67 expression like prognostic factor in oral squamous cell carcinoma (OSCC). Monoclonal antibody MIB-1 that recognizes Ki-67 antigen was used. 74 OSCCs were analyzed. 49% of OSCCs did not express Ki-67 antigen. In the Ki-67 positive tumours, the expression was slight in 36.5%, moderate in 10.8% and intense in 10.8% of the cases. In all the positive OSCCs, the distribution of the marking was patchy in different zones of the tumour, moreover, in 65% of the lesions, the positive cells were located mainly in the proximity of intraoral blood vessels. A significantly more intense expression was noted on tumours that had not been differentiated (p < 0.05), with a larger nuclear pleomorphism (p < 0.05) and in lesions that invaded in the form of disassociated neoplastic cells of in small groups of neoplastic cells (p < 0.001). However, the expression of Ki-67 did not correlate with the mitosis count and it had no influence on survival.

Lip cancer: a review

Dental examinations should routinely include examination of the lips by visual inspection and palpation. The primary risk factor for lip cancer is actinic damage. Squamous cell carcinoma of the lip accounts for about nine per cent of all oral cancers, but there has been a downward trend in the number of cases reported from 1973 to 1984. This trend may be due to the increased use of sunscreens. The clinical presentation and management of lip cancer are discussed.

Squamous cell carcinoma of the lips in a northern Greek population. Evaluation of prognostic factors on 5-year survival rate--I

The purpose of this study was to determine the clinical features of squamous cell carcinoma (SCC) of the lips, along with its prognostic factors, in order to extend and update the information related to lip cancer in northern Greece and to provide a basis for international comparison. Records of 1510 patients with SCC of the oral cavity presented at the Theagenion Anticancer Institute of Thessaloniki, Greece from 1979 and 1989 were reviewed. The most common site for oral squamous cell carcinoma (OSCC) was found to be the lips (59.4%) as compared to 40.5% of intra-oral SCC. Males were affected more frequently, presenting a ratio of 9.2:1. The peak age of incidence was found to be the 6th decade for men and the 8th for women. Rural residents and outdoor workers were affected more than urban residents (79.9% versus 28.1%). Most of the patients were diagnosed in early categories and early clinical stages of the disease. Almost all (98.5%) were classified into T1 and T2 categories, and 92.9% into stages I and II. A total of 7.59% of patients presented with clinically-positive lymph-node involvement. Most of them were classified as an advanced stage of the disease. Primary surgical excision was performed on 60.14%, radiotherapy on 35.14%, a combination of these on 2.47%, and chemotherapy alone or in combination with the above regimens in 2.22% of the cases. The outcome was adequate for surgery, radiotherapy, and the combination of the two, since 91.3, 74, and 90%, respectively, survived for more than 5 years. An overall 5-year survival rate of 83.3% was found. Our findings showed that the survival rate was significantly influenced by the main prognostic factors, such as the size of the tumour, the lymph-node involvement, the clinical stage of the disease and the histologic differentiation. SCC of the lips continues to be the most common site of oral cancer development amongst the Greek population. The aetiologic significance of actinic radiation for SCC of the lips is confirmed by our findings. The main prognostic factors proved to significantly influence the survival of our patients. Our results support the fundamental principal of head and neck cancer, i.e. that early detection of the primary tumour is the best prognostic factor for increasing survival rates. Therefore, public awareness concerning the disease, and better education for health care workers which will provide a thorough knowledge for the prognosis of oral cancer and the factors influencing it, is necessary.