Solar cheilosis: An ominous precursor

Immunoexpression of PD-L1, CD4+ and CD8+ cell infiltrates and tumor-infiltrating lymphocytes (TILs) in the microenvironment of actinic cheilitis and lower lip squamous cell carcinoma

Lower lip squamous cell carcinomas (LLSCC) could be associated with a previous history of potentially malignant oral diseases (PMOD), especially actinic cheilitis (AC), with high sun exposure being a well-described risk factor. Immune evasion mechanisms, such as the PD-1/PD-L1 (programmed cell death protein 1/programmed death-ligand 1) pathway has been gaining prominence since immunotherapy with immune checkpoint inhibitors showed a positive effect on the survival of patients with different types of neoplasms. Concomitant with the characterization of the tumor microenvironment, the expression of either or both PD-1 and PD-L1 molecules may estimate mutual relations of progression or regression of the carcinoma and prognostic values of the patient.

Assembling a consensus on actinic cheilitis: A Delphi study

AIMS

To discuss the terminology to define and classify actinic cheilitis (AC) and to build a consensus on the diagnostic and therapeutic approaches to AC.

METHODS

Two-round Delphi study using a questionnaire including 34 closed sentences (9 on terminology and taxonomy, 5 on potential for malignant transformation, 12 on diagnostic aspects, 8 on treatment) and 8 open questions. Experts' agreement was rated using a Likert scale (1-7).

RESULTS

A consensus was reached on 24 out 34 statements (73.5%) and on 5 out of 8 (62.5%) close-ended questions. The response rate was identical in both rounds (attrition of 0%). AC is the term with the highest agreement (median of 7 (strongly agree; IQR: 6-7)) and the lowest dispersion (VC = 21.33). 'Potentially malignant disorder' was the preferred classification group for AC (median of 7) and 85.6% of participants showing some level of agreement (CV < 50). Experts (66.75%) consider AC a clinical term (median: 7; IQR: 4-7) and believe definitive diagnosis can be made clinically (median: 6; IQR: 5-7), particularly by inspection and palpation (median: 5; IQR: 4-6). Histopathological confirmation is mandatory for the management of AC (median: 5; IQR: 2.5-7), even for homogeneous lesions (median: 5; IQR: 3.5-6). Consensus was reached on all treatment statements (VC < 50).

CONCLUSIONS

AC is a potentially malignant disorder with a significant lack of agreement on diagnostic criteria, procedures, biopsy indications and the importance of techniques to assist in biopsy. A consensus was reached on nomenclature and management of this disorder.

Use of topical anti-inflammatory and antineoplastic agents in the treatment of young-aged actinic cheilitis: A systematic review

INTRODUCTION

Several treatments have been used to reduce inflammation and to reverse epithelial alterations in actinic cheilitis (AC).

AIM

A systematic review was conducted to analyze the potential of topical treatments for remission and clinical improvement of AC as well as patient acceptability.

METHODS

A systematic review of clinical trials was conducted following the PICO strategy to answer the following question: Are topical anti-inflammatory and antineoplastic agents effective in the treatment of actinic cheilitis? The quality of the studies was assessed by ROB-2, and the certainty of evidence was rated by GRADE guidelines.

RESULTS

Eight clinical trials were selected, including four that investigated the use of anti-inflammatory drugs and four use of antineoplastic agents. The use of 3% diclofenac sodium was associated with partial remission of AC, while 5% imiquimod and ingenol mebutate promoted complete remission. Furthermore, 5% fluorouracil was the drug most associated with complications during treatment. Diclofenac sodium (3%) and fludroxycortide showed the best acceptance by the patients, especially in terms of symptom relief and comfort provided.

CONCLUSION

The anti-inflammatory and antineoplastic agents analyzed largely provided good clinical outcomes, with evidence of remission of AC lesions, development of few local adverse reactions during treatment, and good patient adherence.

Oral Medicine Considerations for Older Patients

With the projected increase to 1.3 billion people aged 65 years or older by 2040, healthcare professionals are faced with significant challenges in managing this population of patients. In the oral cavity, oral mucosal disease is a significant problem found in older populations. Several facial pain conditions are more likely to be seen in this cohort of patients. Although management of this group of patients may not always be appropriate in general practice, an awareness of the range of oral medicine conditions that may be encountered in older patients is essential to allow prompt referral and treatment.

Therapeutic approaches for actinic cheilitis: therapeutic efficacy and malignant transformation after treatment

Actinic cheilitis (AC) is a sun-induced premalignant lesion. AC is a clinical term housing a wide pathological spectrum ranging from hyperkeratosis to invasive squamous cell carcinoma. The aim of this systematic review was to examine the therapeutic efficacy of different approaches in clinical, histological, and cosmetic terms, and the malignization rate after treatment. A systematic search was undertaken in October 2016 and updated in April 2019 at MEDLINE (from 1966), Embase (from 1980), and Proceedings Web of Science (Conference Proceedings Citation Index-Science (CPCI-S) from 1990) databases. The search strategy was (("actinic" or "solar") AND ("cheilitis")) using both medical subject headings (MeSH) and freetext. A total of 392 potentially eligible reports were identified. After the selection procedure, 20 articles were included. It was concluded that surgical treatment is the first line of treatment for AC and has proved useful for the clinical and pathological control of the disorder. However, there was no evidence of effective treatment in preventing malignant transformations. Non-surgical procedures showed less consistent results, although drug therapy may improve the results obtained by other therapeutic approaches.

Can immunohistochemical biomarkers distinguish epithelial dysplasia degrees in actinic cheilitis? A systematic review and meta-analysis

BACKGROUND

Actinic cheilitis (AC) is a potentially malignant disorder of the lip, characterized by epithelial and connective tissue alterations caused by chronic exposure to ultraviolet radiation. In the past decades, diverse studies have been conducted in lip carcinogenesis and many biomarkers have been identified in lip lesions, yet there is no scientific evidence that determines its usefulness in the clinical setting or in histopathological routine. Therefore, we conducted the first systematic review in this field to summarize the results of published studies on immunohistochemical biomarkers in lip carcinogenesis, to evaluate if there is a marker than can distinguish the different histological grades of AC.

MATERIAL AND METHODS

Retrospective studies that investigated immunohistochemical biomarkers in AC defined on standardised histological assessment were gathered from five databases and evaluated. Each study was qualitatively evaluated using the Critical Appraisal Tools from SUMARI.

RESULTS

The proliferation marker Ki-67 was the most studied biomarker and we observed, through meta-analysis, that it was differently expressed between AC and lip cancer, but not in AC subgroups. Most articles had a high risk of bias.

CONCLUSIONS

In summary, the literature lacks quality follow up studies in actinic cheilitis. Multi-centre cohort studies, with patients stratified by treatment type and the use of image analysis software, could be the solution to further address the issues of investigating potentially malignant lesions and help change clinical practice, in terms of individualizing patients' treatment and prognosis prediction.

Proper management of suspicious actinic cheilitis

BACKGROUND

Actinic cheilitis (AC) is a variant of actinic keratosis which is known to be a premalignant condition that could develop into squamous cell carcinoma (SCC). Epimyoepithelial carcinoma (EC) is a very rare salivary gland (SG) neoplasm that has classical biphasic histologic findings of small tubules and glandular lumina surrounded by clear myoepithelial cells.

CASE PRESENTATION

We report a very rare case of AC occurring on the lower lip of a 70-year-old woman, which is developing to the EC later.

CONCLUSIONS

Diverse appearances of AC include edematous reddish in the acute stage and grey-whitish or dried hyperkeratotic wrinkled lesions in the chronic stage for several months or even years. Accurate treatment of AC in its initial stage could be recommended to avoid further malignant transformation; proper management of clinically suspicious AC is suggested.

Actinic cheilitis and lip squamous cell carcinoma: Literature review and new data from Brazil

Background

To investigate the prevalence of malignant and potentially malignant lesions of the lip in an oral pathology service and to compare these data with a literature review.

Material and Methods

A total of 3173 biopsy reports and histopathological records were analyzed. Cases with a histological diagnosis of actinic cheilitis (AC) with or without epithelial dysplasia, in situ carcinoma, or lip squamous cell carcinoma (LSCC) were included. A comprehensive literature review was conducted to investigate the prevalence of AC and/or LSCC.

Results

124 cases (3.91%) were included, 75 (60.5%) had some degree of epithelial dysplasia and 31 (25.0%) were LSCC. Clinically, most of the lesions were diagnosed as AC (50.8%); however, eight cases clinically reported as AC were histologically diagnosed as LSCC. Regarding clinical characteristics, most individuals were fair-skinned male, with mean age of 54.3±12.3 years, and with a history of long-term solar exposure. Furthermore, 18 articles were selected from the literature, showing that the lower lip was predominantly affected and that most individuals were males, fair-skinned, and older than 40 years.

Conclusions

Since most of the cases diagnosed clinically as AC presented some degree of epithelial dysplasia, it is important to emphasize the value of biopsy and the histological evaluation of this lesion.

Key words:Actinic cheilitis, Precancerous conditions, In situ carcinoma, Oral diagnosis, Mouth neoplasms.

Photodynamic Therapy: A Clinical Consensus Guide

BACKGROUND

The American Society of Dermatologic Surgery (ASDS) periodically develops consensus documents for its members concerning various aspects of dermatologic surgery. Advances in photodynamic therapy (PDT) have been many and PDT use has been established in a variety of skin conditions.

OBJECTIVE

The ASDS board of directors proposed a committee of experts in the field to develop consensus documents on different treatments. An expert panel reviewed the literature on PDT and discussed the findings. The consensus was reached with evidence-based recommendations on different clinical applications for PDT.

PATIENTS AND METHODS

This consensus document includes discussions regarding PDT, including different photosensitizers and various light source activators, historical perspective, mechanism of action, various therapeutic indications and expected outcomes, pre- and post-care, and management of adverse outcomes.

RESULTS

Photodynamic therapy is highly effective for pre-cancerous lesions, superficial nonmelanoma skin cancers, inflammatory acne vulgaris and other conditions. New protocols including laser mediated PDT significantly improve results for several indications.

CONCLUSION

The ASDS consensus document on PDT will be helpful for educating members on safe and effective PDT for a variety of indications.

Actinic cheilosis: early intervention prevents malignant transformation

Potentially malignant disorders (PMD) have a high risk of malignant transformation. Habits such as tobacco and alcohol use predispose to PMD and subsequently to an oral carcinoma. Oral squamous cell carcinoma (OSCC) can occur even without the usage of tobacco. Occupational exposure to actinic rays may predispose to the development of OSCC in the lip. People who are involved in farming or those exposed to an environmental background radiation, such as ultraviolet rays, develop a PMD called actinic cheilosis. A high proportion of patients with actinic cheilosis develop an oral carcinoma when not diagnosed and treated in early stages. This case depicts the clinical and histological changes in a 61-year-old Indian man with actinic cheilosis.

Non-melanoma Skin Cancer in Canada Chapter 3: Management of Actinic Keratoses

Background

Actinic keratosis (AK) and cheilitis (AC) are lesions that develop on photodamaged skin and may progress to form invasive squamous cell carcinomas (SCCs).

Objective

To provide guidance to Canadian health care practitioners regarding management of AKs and ACs.

Methods

Literature searches and development of graded recommendations were carried out as discussed in the accompanying introduction (chapter 1 of the NMSC guidelines).

Results

Treatment of AKs allows for secondary prevention of skin cancer in sun-damaged skin. Because it is impossible to predict whether a given AK will regress, persist, or progress, AKs should ideally be treated. This chapter discusses options for the management of AKs and ACs.

Conclusions

Treatment options include surgical removal, topical treatment, and photodynamic therapy. Combined modalities may be used in case of inadequate response. AKs are particularly common following the longterm immunosuppression in organ transplant patients, who should be monitored frequently to identify emerging lesions that require surgery.

Management of actinic cheilitis using ingenol mebutate gel: A report of seven cases

Actinic cheilitis (AC) can precede the development of squamous cell carcinoma of the lip, a location with high risk of invasiveness and metastasis. We communicate the good results that we obtained when treating seven patients suffering from AC with ingenol mebutate (IM) 0,015% concentration gel on three consecutive days. Three patients achieved complete clearance and four significant improvement. IM is a topical field treatment approved for actinic keratosis. To our knowledge, reported experience in the management of AC with IM is very limited. Local skin responses grade 3 were the main adverse event observed and they resolved in all patients without specific therapy within 1 to 2 weeks. IM is characterized by its rapid clinical effect, its favorable safety profile and its dosing period of only 3 days, shorter than with other field therapies. All these facts make it an attractive new therapy for AC, with need for further study.

Topical pharmacotherapy for skin cancer: part II. Clinical applications

The purpose of the paper is to provide an in-depth, evidence-based analysis of the clinical use of topical treatments for skin cancer. A comprehensive review of topical drugs has been performed, including 5-fluorouracil, imiquimod, diclofenac, ingenol mebutate, retinoids, resiquimod, piroxicam, dobesilate, and betulinic acid. The evaluated studies were rated according to their level of evidence level (I-V), as indicated by recent guidelines for evidence-based medicine, The Oxford 2011 Levels of Evidence. Therapeutic response is generally related to tumor type, extent, and localization, and also to patient compliance. Careful patient selection is required in order to achieve the desired goal of complete tumor clearance.

Actinic cheilitis: clinicopathologic profile and association with degree of dysplasia

BACKGROUND

Actinic cheilitis (AC) is a potentially malignant disorder of the lip caused by exposure to solar radiation.

OBJECTIVES

This study was conducted to evaluate the clinicopathologic profile of cases of AC and to verify associations with the degree of dysplasia.

METHODS

This retrospective study analyzed data for 40 patients with AC. Demographic, clinical, and histopathologic data were evaluated. Sections measuring 5 μm in thickness were cut, deparaffinized, and stained with hematoxylin and eosin for histologic examination. The degree of epithelial dysplasia was graded using the criteria defined by the World Health Organization. Two calibrated oral pathologists analyzed the slides.

RESULTS

Analysis of the AC patients sampled showed that 75.0% were male (P=0.002), 80.0% were aged≥40 years (P<0.001), 74.3% were Caucasian (P=0.004), and 68.6% had occupational exposure to sunlight (P=0.028). The most common clinical manifestation was white lesions (55.0%), and 40.0% of patients had no dysplasia. No significant associations emerged between the histologic grading of AC and gender (P=1.000), age (P=1.000), ethnicity (P=0.416), occupational exposure to sunlight (P=1.000), and clinical presentation (P=0.467).

CONCLUSIONS

The degree of dysplasia in AC was not statistically associated with gender, age, ethnicity, occupational exposure to sunlight, or clinical appearance. This study provides some support for the hypothesis that clinicopathologic features are not related to the degree of dysplasia in AC.