Oral proliferative verrucous leukoplakia: A case report with an update

Proliferative verrucous leukoplakia, an enigma to the pathologists: Report of two cases

The oral cavity presents with an array of white lesions ranging from physiological alteration to extensive malignant entities. Among them, proliferative verrucous leukoplakia is a rare highly aggressive multifocal form of leukoplakia that poses a high risk for malignant transformation. Etiopathogenesis and its diagnostic criteria have remained speculative since its inception. The diagnosis of this form of leukoplakia is challenging and it requires updated knowledge and expertise to identify this condition. All the cases of proliferative verrucous leukoplakia are resistant to treatment and have high chances of recurrence. In the present case report, we aim to report and document two cases of proliferative verrucous leukoplakia, which were diagnosed in a dental college. The present case report can serve as a guide to young dental surgeons to spot cases of proliferative verrucous leukoplakia and to refer them to tertiary care hospitals for treatment.

Proliferative verrucous/multifocal leukoplakia: Updates and literature review "case report"

RATIONALE

Proliferative verrucous leukoplakia (PVL) is a multifocal, slowly evolving lesion that resists all types of treatment and has a high propensity for malignant transformation into oral squamous cell carcinoma. Lack of awareness and acquaintance with white lesions of the oral cavity makes it difficult to diagnose. Besides being rare, PVL significantly aggressive, so clinicians need to be aware of it carefully. Therefore, it is recommended to have the earliest possible diagnosis and total excision of this lesion. We report this case to present typical clinical and histologic features of PVL so a For the purpose of sensitizing clinician.

PATIENT CONCERN

A 61-year-old female came to the clinic concerning of recurring painless, white patch on the tongue 2 months ago, associated with oropharyngeal dryness.

DIAGNOSES

This case satisfies these major and minor criteria to diagnosed PVL.

INTERVENTION

An excisional biopsy of the lesion was done to check for the presence of dysplasia, as lesions were persisting. Hemostasis was achieved with single interrupted sutures.

OUTCOME

no recurrence has been observed since excisional 1 year follow-up.

LESSON

The key feature is early detection, precisely in cases of PVL it is critical for better treatment outcomes, lifesaving, quality-of-life enhancement. To detect and treat any potential pathologies, clinicians should meticulously examine the oral cavity and patients have to be aware and informed of the importance of regular screenings. This lesion is resistant to the presently available treatment modalities; therefore, total excision with free surgical margins is critical combined with a lifelong follow-up.

Oral Potentially Malignant Disorders: Etiology, Pathogenesis, and Transformation Into Oral Cancer

Among oral diseases, oral cancer is a critical health issue due to its life-threatening potential. Globocan, in its 2020 report, estimated ∼0.37 million new cases of oral cancer, with the majority of them coming from the Asian continent. The WHO has anticipated a rise in the incidences of oral cancer in the coming decades. Various factors, such as genetic, epigenetic, microbial, habitual, and lifestyle factors, are closely associated with oral cancer occurrence and progression. Oral lesions, inherited genetic mutations (dyskeratosis congenital syndrome), and viral infections (HPV) are early signs of oral cancer. Lesions with dysplastic features have been categorized under oral potentially malignant disorders (OPMDs), such as oral leukoplakia, erythroplakia, oral submucous fibrosis (OSMF), and proliferative verrucous leukoplakia, are assumed to have a high risk of malignancy. The incidence and prevalence of OPMDs are recorded as being high in South-Asian countries. Early detection, prevention, and treatment of OPMDs are needed to prevent its malignant transformation into oral cancer. Many advanced diagnostic techniques are used to predict their progression and to assess the risk of malignant transformation. This communication provides insight into the importance of early detection and prevention of OPMDs.

Proliferative Verrucous Leukoplakia Revisited: A Retrospective Clinicopathological Study

(1) Objective: To review the criteria proposed by Cerero-Lapiedra et al. and to retrospectively identify the under-diagnosed disease in patients diagnosed with proliferative verrucous leukoplakia. (2) Materials and methods: In this study, we included patients who were diagnosed with leukoplakia (histological label consistent with the clinical diagnosis, n = 95), and cases with a final diagnosis within the spectrum of proliferative verrucous leukoplakia (n = 110) as defined by Batsakis et al. We applied the criteria proposed by Cerero-Lepiedra et al. to screen for the possible cases of proliferative verrucous leukoplakia. (3) Results: Although many of our patients satisfied specific isolated criteria, only 11 cases satisfied specific combinations of the guidelines to satisfy a diagnosis of proliferative verrucous leukoplakia. However, due to the lack of follow-up data, the disease is not confirmed in these 11 cases. (4) Conclusion: A limited number of cases of proliferative verrucous leukoplakia were diagnosed using the criteria given by Cerero-Lapiedra et al. The true natural history of the disease could not be studied due to the lack of follow-up data. (5) Clinical relevance: Proliferative verrucous leukoplakia presenting as hyperkeratosis or mild epithelial dysplasia are often not followed up, and they subsequently transform into carcinoma. Thus, clinicians must be vigilant whenever they encounter leukoplakia, especially with multifocal presentations. In such cases, the follow-up data are the key to understanding the true nature of the disease entity.

Clinicopathologic analysis of verrucous hyperplasia, verrucous carcinoma and squamous cell carcinoma as part of the clinicopathologic spectrum of oral proliferative verrucous leukoplakia: A literature review and analysis

OBJECTIVE

Proliferative verrucous leukoplakia is classified as a potentially malignant disorder because of its high rate of malignant transformation. PVL progresses in a series of clinical stages where the early stage represents multiple, multifocal leukoplakias with a high recurrence rate. The intermediate and late stages are clinically exophytic lesion, diagnosed microscopically as verrucous hyperplasia that often progresses into verrucous carcinoma and/or squamous cell carcinoma. There is no single histologic definition and the diagnosis is retrospective following observed progression of the disorder. The goal of the current study was to conduct a literature review and analysis of PVL in the later stages to gain further knowledge on their clinicopathologic features.

DATA SOURCES

Medline's PubMed and Google Scholar were searched for adequately documented cases from 1985 to 2018. References of published articles were searched for additional cases.

REVIEW METHODS

Overall, 57 manuscripts were analyzed. 35/57 manuscripts provided adequate data on the clinicopathologic features in the premalignant and malignant stages.

RESULTS

Malignant transformation rate was 50% (average of 57 months). Gingiva, palate and buccal mucosa were the most common locations. Clinicopathologic features included; well differentiated carcinoma (78%), perineural invasion (3%), lymph node metastasis (4%); distant metastasis (0%), average duration of illness (65 months), DOD-dead of disease (44%). Moderate dysplasia, severe dysplasia and carcinoma in situ were exceptionally uncommon in the premalignant stages (0.8%).

CONCLUSION

Prognostic factors such as perineural invasion, lymph node metastasis and distant metastasis were uncommon occurrences which may have practical implications on treatment. Further studies are needed to substantiate our findings.

Breeding parameters on a mink farm infected with Aleutian mink disease virus following the use of methisoprinol

Aleutian mink disease virus is one of the greatest threats to modern mink farming. The disease reduces fecundity and causes high mortality among kits. The aim of this study was to evaluate the effectiveness of methisoprinol in counteracting the effects of Aleutian disease, both by inhibiting replication of the virus and by mitigating the harmful effects of the disease on the fecundity and weight of infected animals. The study included 300 individuals with confirmed infection, divided according to antibody titres into three experimental groups, which received a 20% methisoprinol solution, and three control groups, which did not receive the immunostimulant. In the mink from the experimental groups, the number of copies of the genetic material of the virus in the spleens and lymph nodes was one order of magnitude lower than in the case of the control groups. Mink receiving the supplement also showed higher fecundity (on average 5.83 in the experimental groups and 4.83 in the control groups), and the weight of their offspring before slaughter was over 200 g higher. Given the lack of effective methods for immunoprophylaxis and treatment, methisoprinol supplementation can be an effective means of counteracting the effects of AMDV on persistently infected farms.

Potentially malignant disorders revisited-The lichenoid lesion/proliferative verrucous leukoplakia conundrum

BACKGROUND

Clinically identifiable potentially malignant disorders (PMD) precede oral squamous cell carcinoma development. Oral lichenoid lesions (OLL) and proliferative verrucous leukoplakia (PVL) are specific precursor lesions believed to exhibit both treatment resistance and a high risk of malignant transformation (MT).

METHODS

A retrospective review of 590 PMD patients treated in Northern England by CO₂ laser surgery between 1996 and 2014 was carried out. Lesions exhibiting lichenoid or proliferative verrucous features were identified from the patient database and their clinicopathological features and outcome post-treatment determined at the study census date of 31 December 2014.

RESULTS

One hundred and 98 patients were identified as follows: 118 OLL and 80 PVL, most frequently leukoplakia at ventrolateral tongue and floor of mouth sites, equally distributed between males and females. Most exhibited dysplasia on incision biopsy (72% OLL; 85% PVL) and were treated by laser excision rather than ablation (88.1% OLL; 86.25% PVL). OLL were more common in younger patients (OLL 57.1 year; PVL 62.25 years; P = .008) and more likely than PVL to present as erythroleukoplakia (OLL 15.3%; PVL 2.5%; P = .003). Whilst no significant difference was seen between OLL and PVL achieving disease-free status (69.5% and 65%, respectively; P = .55), this was less than the overall PMD cohort (74.2%). MT was identified in 2 OLL (1.7%) and 2 PVL (2.5%) during follow-up.

CONCLUSION

One-third of PMD cases showed features of OLL or PVL, probably representing a disease presentation continuum. Post-treatment disease-free status was less common in OLL and PVL, although MT was infrequent.

Gingival fibroma versus verrucous leukoplakia - A clinical dilemma!!!

Gingival overgrowths found in the oral cavity are mostly due to reactive hyperplasia and rarely depict neoplastic nature. It is a challenge for the clinician to give final diagnoses of gingival overgrowth. Gingiva is a common site for various benign and malignant lesions. Oral cavity is an ideal niche for the manifestation of various precancerous and cancerous lesions. Fibrous growths present in the oral cavity include a varying group of reactive, precancerous, and cancerous conditions. This report describes a case of a 55-year-old male who clinically presented with a localized fibromatous gingival overgrowth in relation to lower left mandibular canine-premolar region that was diagnosed as a gingival fibroma associated with leukoplakia. On histopathological examination, it was diagnosed as a case of proliferative verrucous leukoplakia. Many a times, clinicians face dilemma while diagnosing an overgrowth as it is difficult to differentiate clinically. Hence, a thorough clinical knowledge and a pathologist's opinion become mandatory to give final diagnosis to such gingival overgrowths.

Diode laser: In treatment of recurrent verrucous leukoplakia

Laser first came into light in 1960 and had been used extensively in various fields of medicine. Laser has been experimented in the various dental field, and its utility is being recognized and established well in the dentistry. Lasers are widely used for a number of procedures such as cavity preparation, scaling, and root planning, surgical procedures like excision of soft tissue growths, etc., Improved healing, hemostasis, and sutureless excisions are some of the many advantages of laser over conventional treatment modalities. It is because of these advantages that laser is becoming more and more popular as a treatment option in various aspects of dentistry. We hereby present a case report, where we have used diode laser for surgical management of a proliferative verrucous leukoplakia (PVL), because of its many advantages over conventional methods. It presents very specific characteristics, mainly a more aggressive biological behavior than other forms of leukoplakia expressed by: A tendency toward multifocality (field cancerization); a high prospect of recurrence; and a high rate of malignant transformation, which can range between 40% and 100% in a follow-up period of 4.4–11.6 years. In this case, we evaluated the advantages of diode laser for the treatment of verrucous leukoplakia, where the results that we obtained were excellent. The patient had come for evaluation till the time of complete healing.

[Proliferative verrucous leukoplakia: Three cases and literature review]

BACKGROUND

The aim of this study was to collect epidemiological, aetiopathogenic, clinical, histological and therapeutic data concerning proliferative verrucous leucoplakia (PVL) and to report three new cases.

PATIENTS AND METHODS

A literature review performed using the Medline database enabled us to collate 39 studies involving 607 cases. Three new cases were added.

RESULTS

PVL is a rare disease characterized by extensive and multifocal oral leucoplakic lesions. Its histological pattern depends on the stage of the disease: hyperkeratosis, verrucous hyperplasia, verrucous carcinoma and squamous cell carcinoma. The aetiopathogenesis of PVL is poorly understood and there is no clear consensus concerning therapy. Malignant transformation occurs in over 50 % of cases.

DISCUSSION

Diagnosis of PVL is difficult because of the presenting signs, which can be mistaken for those of other diseases. Management may be complicated and long-term follow-up is essential.

Oral precursor lesions and malignant transformation--who, where, what, and when?

Oral potentially malignant disorders (PMD) are recognisable mucosal conditions that have an unpredictable risk of transformation to squamous cell carcinoma (SCC), a lethal and deforming disease of rising incidence. Contemporary management is based on clinical recognition of suspicious lesions and incisional biopsy to enable histopathological assessment and grading of dysplasia, together with excision of high-risk lesions and long-term surveillance. However, it is impossible to predict clinical outcome or risk of malignant transformation. Our aim was to evaluate the relevance of previously identified oral precursor lesions for the development of SCC and staging of disease. We therefore retrospectively reviewed 1248 cases of SCC diagnosed in oral and maxillofacial surgery units at Newcastle upon Tyne and Sunderland hospitals between 1996 and 2009. Of them, 58 identifiable precursor lesions became malignant but only 25 had been dysplastic on initial biopsy; 19 of 33 non-dysplastic lesions exhibited lichenoid inflammation only. SCC arose most often on the ventrolateral tongue and floor of the mouth, with a mean transformation time of 29.2 months. Transformation time was significantly shorter in men (p=0.018) and those over 70 years of age (p=0.010). Patients who consumed more than 21 units of alcohol/week and those who had had interventional laser surgery to treat precursor lesions, had higher-staged tumours (p=0.048). Although retrospective, this study shows that the results of incisional biopsy and grading of dysplasia have limited use as predictive tools, and supports the view that cancer may arise in the absence of recognisable epithelial dysplasia. Our findings confirm the importance of clinical vigilance and active surveillance in the management of all patients with clinically suspicious oral lesions, irrespective of the histological findings.

Proposed Clinico-Pathological Classification for Oral Exophytic Lesions

Oral exophytic lesions often have proven to be diagnostically challenging due to the varied clinical presentation. The exophytic growth of the oral lesions is due to the type of pathology and histological changes. Careful clinical interpretation with a better histological understanding of exophytic lesions may ease the diagnosis from the differential diagnosis panel. The purpose of proposing classification system is to categorize the exophytic lesions of interest under specific clinical and/or histological explanation; and this will eventually lead to better understanding of the pathological condition that is described. To the best of our knowledge, there is no such classification system available for oral exophytic lesions and hence proposal of classification system is attempted in this study. Further, proposing a new classification system is not just to influence the academic contribution, but also to assist at greatest extent for diagnosis during clinical practice.

Optimal Management of Proliferative Verrucous Leukoplakia

Objective

Proliferative verrucous leukoplakia (PVL) is a rare and recalcitrant form of leukoplakia. The purpose of this review is to further characterize the risk factors, clinical course, and optimal treatment for this highly aggressive, premalignant lesion.

Data Sources

Twenty-six articles on PVL with a total of 329 PVL cases.

Review Methods

A systematic review of the literature using Ovid, PubMed, Cochrane Database, and gray literature was conducted of all PVL cases reported between 1985 and 2014. Inclusion criteria required reporting of patient follow-up and recurrence rates. Data were analyzed using descriptive statistics. Student t test and Fisher exact test were used to identify factors associated with malignant transformation.

Results

The mean patient age was 63.9 years. Most patients were female (66.9%) and nontobacco users (65.22%). Mean follow-up was 7.4 years, with an average of 9.0 biopsies per patient during this period. Proliferative verrucous leukoplakia exhibited histopathologic features along a progressive spectrum, evolving from leukoplakia to verrucous hyperplasia and ultimately invasive carcinoma. Surgery was the most common treatment implemented, but recurrence rates among 222 patients reached 71.2%. Subgroup analysis of 277 patients identified a 63.9% malignant transformation rate, and 39.6% of patients died of their disease. Age, sex, and tobacco use were not identified as risk factors associated with progression to cancer.

Conclusions

Proliferative verrucous leukoplakia is a rare form of leukoplakia with a high rate of malignant transformation. It necessitates high clinical suspicion, to include a lifetime of close follow-up and repeat biopsies by a health care provider well versed in oral carcinoma.