Interrelationships of calibre persistent artery, chronic ulcer and squamous cancer of the lower lip

A new approach to the management of caliber-persistent artery: A case report and analysis of previously reported cases

A caliber-persistent labial artery (CPLA) is an incipient arterial branch that penetrates near the submucosal tissue of the lip without dividing or reducing in diameter and often appears as a palpable lesion on the lip. It occurs at an incidence of approximately 3%. This study investigated the causes of swelling of the lips, focusing on CPLA, and reviewed the literature for past cases in order to inform the treatment of a 32-year-old man presenting with an asymptomatic, solitary, elevated lesion on the vermilion of the upper lip of seven months duration. Biopsy resulted in abundant bleeding. Histopathology showed fragments of connective tissue composed of spindle-shaped cells, fibroblasts, collagen fibers and sections of small blood vessels with lymphocytic infiltration of chronic inflammatory cells around the small vessels. A thick-walled section reminiscent of a major artery was apparent. In view of the size of the lesion and concern over the functional and esthetic impairment that might result from surgery, the patient was treated with triamcinolone (40 mg/ml) injected at low pressure into the lesion, which caused the formation of deposits of colloidal particles within the lesion. The procedure was repeated twice at 2-week intervals. Subsequently, the lesion was found to have completely regressed. The favorable therapeutic results achieved, and the findings of the present review, support the intralesional injection of triamcinolone as a first-line conservative treatment in CPLA rather than a surgical approach that can result in inordinate hemorrhaging.

Caliber-Persistent Artery

Caliber-persistent artery (CPLA) of the lip is a common vascular anomaly in which a main arterial branch extends to the surface of the mucous tissue with no reduction in its diameter. It usually manifests as pulsatile papule, is easily misdiagnosed, and is observed more frequently among older people, suggesting that its development may involve a degenerative process associated with aging; CPLA is also characterized by the loss of tone of the adjacent supporting connective tissue. Although the diagnosis is clinical, high-resolution Doppler ultrasound is a useful noninvasive tool for evaluating the lesion. This report describes the case of a 58-year-old male patient who complained of a lesion of the lower lip with bleeding and recurrent ulceration. The patient was successfully treated in our hospital after a diagnosis of CPLA and is currently undergoing a clinical outpatient follow-up with no complaints.

Calibre Persistent Labial Artery: Clinical Features and Immunohistochemistry Diagnosis

Calibre persistent labial artery (CPLA) usually presents as an asymptomatic papule on the lower lip and can be easily misdiagnosed as a mucocele, haemangioma, venous lake, varix or fibroma. When it is ulcerated, squamous cell carcinoma is the most usual differential diagnosis. Here, we report a case of a 25-year-old woman with no previous relevant medical history who presented with a complaint of an asymptomatic, non-ulcerated, progressively growing nodule (over the last 5 months) on the upper lip. In this case, the diagnosis was made clinically and confirmed by immunohistochemical analysis. We conclude that clinicians should be aware of CPLA and it should be included in the differential diagnosis of labial mucosal papules. Sometimes, the immunohistochemical analysis is necessary to make a correct diagnosis.

Caliber persistent artery of the eyelid

BACKGROUND

To report three cases of caliber persistent artery presenting in the eyelid.

METHODS

A case series describing three patients with vascular lesions of the eyelid that were biopsied. One case was bilateral.

RESULTS

All three patients presented with a painless red lesion on the eyelid. These were on the lower eyelid in two patients and the upper eyelid in one patient. For the bilateral case, the lesions were both on the lower eyelid. Histological examination of all four biopsies showed a large caliber artery within the dermis extending almost at right angles to the skin surface and consistent with caliber persistent artery.

CONCLUSIONS

These are the first reports of caliber persistent artery of the eyelids, an entity that is most commonly recognized on the lips. Clinicians should consider this entity in the differential diagnosis of patients presenting with a painless, vascular lesion of the eyelid.

Calibre-persistent labial artery: often misdiagnosed as a mucocoele

The authors present five cases of calibre-persistent labial artery (CPLA) all of which were diagnosed clinically as a labial mucocoele. The purpose of this article is to bring this rarely reported lesion to the attention of clinicians.

Intra-oral calibre persistent artery

Calibre persistent arteries (CPA) penetrate into submucosal tissue without division or reduction in calibre. Intraorally, these abnormalities have been predominantly reported in the lip. Here we report a case of CPA in the buccal vestibule. Misdiagnosis of this entity may result in profuse bleeding during surgical intervention.

Calibre persistent labial artery: clinical features and noninvasive radiological diagnosis

Calibre persistent labial artery (CPLA) is defined as a primary arterial branch that penetrates into the submucosal tissue without division or decrease in diameter. It usually presents as an asymptomatic papule on the lower lip and can be easily misdiagnosed as a varix, haemangioma, venous lake, mucocele or fibroma. When it is ulcerated, squamous cell carcinoma is the most usual differential diagnosis. The most frequently used method to confirm the diagnosis of CPLA has been excisional biopsy, which carries the risk of profuse bleeding. Angiography, another invasive method, has also been used. Here, we report a case of a 20-year-old woman with a 5-year history of multiple CPLA lesions involving both upper and lower lips. In this case, the diagnosis was made clinically and confirmed by Doppler ultrasonography, which is a noninvasive and simple diagnostic tool.

Ultrasonography: a noninvasive tool to diagnose a caliber-persistent labial artery, an enlarged artery of the lip

OBJECTIVE

Currently, practitioners use clinical and histopathologic examination to diagnose a caliber-persistent labial artery (CPLA). We illustrate the use of ultrasonography as a noninvasive diagnostic tool to visualize this enlarged artery of the lip.

METHODS

We examined the lips of 3 patients with a suspected CPLA. We localized and determined the extension of the intralabial artery with ultrasonography, including pulsed and color Doppler analysis. We compared the sonograms to the clinical and histopathologic findings.

RESULTS

Sonograms showed clear enlargement of the labial artery in the 3 cases. The course of the constant-diameter artery was either vertical or oblique from the depth of the lip to the surface of the mucosa. This vascular abnormality was confirmed by histopathologic examination.

CONCLUSIONS

Ultrasonography and color Doppler imaging may be useful noninvasive tools for the diagnosis and preoperative evaluation, as well as the follow-up, of labial lesions related to a CPLA, thus eliminating the need for diagnostic surgery in typical pulsatile nodules. Ultrasonography may help distinguish a CPLA from other vascular lesions of the lip such as an aneurysm. Atypical cases or chronic ulcerations mimicking a cancer should undergo biopsy so that a malignant process is not missed.

The potential peril from caliber-persistent arteries of the lips

The arteries supplying the lips are very tortuous so they can accommodate the movements of the mouth. Labial arteries taper only slightly and are usually caliber-persistent vessels. On rare occasions, older adults have a tumor-like lesion form on the vermilion of the upper or lower lip or have an ulcer of the lower lip. Cancer is the concern of the person and his or her physician and dentist. In surgical excision of this tumor-like lesion or removal of a specimen for biopsy, the treatment team needs to prepare for the possibility of brisk arterial bleeding and have proper materials to ligate the labial artery in the event it is inadvertently transected. It is also important to remember that both ends of a transected artery should be ligated. Could the tumor-like lesion or lip ulcer be a mucosal sign of a caliber-persistent artery of another area of the gastrointestinal tract? This question has not received adequate investigation. The relationship is unlikely but deserves consideration.

Caliber-persistent labial artery. A common vascular anomaly

Sixteen cases of caliber-persistent labial artery of the lips have been reported to date in the English literature. Six of these were clinically misdiagnosed as squamous cell carcinoma and treated with wedge resection. To date, we have seen 187 cases clinically and an additional 23 cases through our surgical oral pathology services. Careful clinical observation usually reveals a soft linear or papular bluish elevation above the labial mucosal surface. The unique feature is pulsation--not simply pulsation toward and away from the observer, which can be caused by an underlying artery, but lateral pulsation, which only an artery can exhibit. All but 2 of our 187 clinical cases were asymptomatic. To the best of our knowledge, this is the first report of caliber-persistent labial artery of the upper lip. The upper:lower lip ratio for the clinical cases was almost 2:1. Three times as many lower lip as upper lip lesions were biopsied. Males and females were almost equally affected (clinical cases, 76:86; histopathologic cases, 9:13). Although a vascular term (artery, hemangioma, phlebolith, varix, vascular malformation) was used on the biopsy form in one half of the clinical differential diagnoses, none of the clinical histories mentioned pulsation. In contrast to the cases of Miko et al. in 1980 and 1983, none of our cases manifested itself as an ulcer, nor was carcinoma ever mentioned in the clinical differential diagnosis. The purpose of this article is to familiarize clinicians and pathologists with the clinical and histopathologic features of this seldom reported but common vascular anomaly. Clinicians should carefully look for lateral pulsation in lip mucosal papules so as to avoid unnecessary surgery and intraoperative arterial bleeding. Pathologists should recognize that a relatively large-caliber superficial artery in a lip biopsy may not be an incidental finding but rather the clinical lesion that was biopsied.

Clinical diagnosis of caliber-persistent labial artery of the lower lip

Only 14 cases of caliber-persistent labial artery of the lower lip have been reported to date. Six of these were misdiagnosed and treated as squamous cell carcinoma, another as a mucocele. The correct diagnosis emerged only after the wedge resections were examined histopathologically. We report the first cases of caliber-persistent labial artery to be diagnosed clinically since the original description of the condition by Howell and Freeman in 1973. Our first case was a nonpulsatile hard, linear, "gooseneck lamp" submucosal nodule of the lower lip. On the basis of an initial misdiagnosis of sclerosing sialadenitis, a biopsy was attempted. Brisk pulsatile bleeding proved the lesion to be an artery, and the superficial location and large diameter of the vessel lead to the clinical diagnosis of caliber-persistent labial artery. The "gooseneck lamp" hardening is typical of Monckeberg's arteriosclerosis. The second case was a pulsatile blue linear submucosal nodule of the lower lip. The clinical diagnosis of caliber-persistent labial artery was confirmed when angiography showed the lesion to be an abnormally dilated labial artery. Both cases were successfully ligated with no complications at 16 and 10 months after surgery.

Oral caliber-persistent artery. Unusual presentations of unusual lesions

Two cases of oral caliber-persistent artery are reported. Both cases were different from the five previously reported oral examples of this unusual entity. One case is the first reported instance of a caliber-persistent artery not associated with spontaneous hemorrhage, inflammation, or ulceration. The clinical importance of this entity to the patient and the treating practitioner is stressed.

The caliber persistent artery of the stomach: a unifying approach to gastric aneurysm, Dieulafoy's lesion, and submucosal arterial malformation

The caliber persistent artery of the stomach is the most dangerous form of gastrorrhagias; the overall lethality rate is 60.5%. A literature review aimed at completeness, a study of the hitherto largest case material (24 cases), and a comparative analysis of the bleeding and normal gastric arteries gave the following results: (1) the walls of the pathologic arteries are of normal structure; (2) as submucous arteries, they are of normal diameter; (3) they are attached to the mucosa by virtue of Wanke's musculoelastic mantle; (4) at the level of the muscularis mucosae, they are definitely oversized; (5) in the area of the linkage of the artery to the mucosa, a vulnerable mucosal spot is created; (6) the artery is accompanied by a vein of similar caliber; and (7) perforation of the vein takes place before that of the artery. In addition to surgical pathology and pathogenesis, the pitfalls of its diagnosis and treatment are also discussed. Caliber persistent artery of the stomach is much more common than the literature indicates, necessitating an increased awareness of the condition.

Ulceration of the lip associated with a 'calibre-persistent artery'

A case of ulceration of the lower lip, associated with a 'calibre-persistent artery', is presented. The lesion was diagnosed clinically as squamous cell carcinoma and excised accordingly. 'Calibre-persistent artery' is not a widely known entity, has not been described previously in the dermatological literature and should be sought in any lip ulcer of obscure aetiology.