Proliferative verrucous leukoplakia and its progression to oral carcinoma: report of three cases

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 Squamous Papilloma Mimicking Oral Verrucous Leukoplakia

The human papillomavirus (HPV) is a non-enveloped DNA virus that causes a variety of skin and mucosal lesions. This report reviews a likely HPV-related lesion of oral squamous cell papilloma clinically mimicking oral verrucous leukoplakia. A 71-year-old white male presented with a raised white lesion on the palatal mucosa. It felt hard on palpation and had a sessile fixed base, and a rough verrucous surface. The lesion was fully excised. Histopathology showed short, thin, fingerlike projections lined by stratified squamous epithelium with thin central connective tissue cores. The epithelial superficial layers demonstrated focal koilocytotic changes suggestive of an HPV infection. High-risk HPV-related lesions have the potential to turn malignant. Early diagnosis and management are critical to preventing serious complications.

Characterization of initial/early histologic features of proliferative leukoplakia and correlation with malignant transformation: a multicenter study

The aim of this multicenter retrospective study is to characterize the histopathologic features of initial/early biopsies of proliferative leukoplakia (PL; also known as proliferative verrucous leukoplakia), and to analyze the correlation between histopathologic features and malignant transformation (MT). Patients with a clinical diagnosis of PL who have at least one biopsy and one follow-up visit were included in this study. Initial/early biopsy specimens were reviewed. The biopsies were evaluated for the presence of squamous cell carcinoma (SCCa), oral epithelial dysplasia (OED), and atypical verrucous hyperplasia (AVH). Cases that lacked unequivocal features of dysplasia were termed "hyperkeratosis/parakeratosis not reactive (HkNR)". Pearson chi-square test and Wilcoxon test were used for statistical analysis. There were 86 early/initial biopsies from 59 patients; 74.6% were females. Most of the cases had a smooth/homogenous (34.8%) or fissured appearance (32.6%), and only 13.0% had a verrucous appearance. The most common biopsy site was the gingiva/alveolar mucosa (40.8%) and buccal mucosa (25.0%). The most common histologic diagnosis was OED (53.5%) followed by HkNR (31.4%). Of note, two-thirds of HkNR cases showed only hyperkeratosis and epithelial atrophy. A lymphocytic band was seen in 34.8% of OED cases and 29.6% of HkNR cases, mostly associated with epithelial atrophy. Twenty-eight patients (47.5%) developed carcinoma and 28.9% of early/initial biopsy sites underwent MT. The mortality rate was 11.9%. Our findings show that one-third of cases of PL do not show OED with most exhibiting hyperkeratosis and epithelial atrophy, but MT nevertheless occurred at such sites in 3.7% of cases.

Prognostic outcomes of OSCC derived from proliferative verrucous leukoplakia: a systematic review

OBJECTIVE

This study aimed to evaluate prognostic outcomes of PVL-derived oral squamous cell carcinomas (P-OSCC) based on recurrence, new primary tumour, metastasis and survival information.

STUDY DESIGN

Five databases and grey literature were searched electronically with the following main keywords (proliferative verrucous leukoplakia, squamous cell carcinoma and malignant transformation) to answer the following review question: 'Are survival outcomes for P-OSCC worse?' based on the PECOS principle. The Joanna Briggs Institute Critical Appraisal tool was used to identify possible biases and assess the quality of each of the primary studies.

RESULTS

A total of 21 articles met the inclusion criteria, and the results of this systematic review suggest that P-OSCC can recur and generate new primary tumours; however, metastases are rare. Thus, most patients remain alive for an average period of 5 years.

CONCLUSION

Apparently, P-OSCC has better clinical prognostic characteristics than conventional OSCC. There is a lack of information on the main prognostic outcomes of P-OSCC; therefore, specific studies must be performed to achieve a better comparison between P-OSCC and conventional OSCC progression.

Malignant development of proliferative verrucous/multifocal leukoplakia: A critical systematic review, meta-analysis and proposal of diagnostic criteria

BACKGROUND

Proliferative verrucous/multifocal leukoplakia (PVML) is an oral potentially malignant disorder (OPMD) that exhibits high rates of malignant development (MD). This study aimed to analyse the risk of MD of PVML, as well as to investigate the possible risk factors associated with its malignization.

METHODS

A bibliographical search of the PubMed, Embase, Web of Science, and Scopus databases was conducted. PVML MD rates were calculated as a pooled proportion, and the risk factors were calculated as risk ratios, using fixed and random models based on the presence of heterogeneity.

RESULTS

From a total of 417 records, 16 articles were retrieved for inclusion. The subgroup analysis revealed a higher MD rate in the studies that were conducted in America, and, likewise, said studies involved a longer follow-up time (>6 years). There was a non-significant lower risk of malignization among males. A negative correlation was observed between MD and the year in which the studies were published.

CONCLUSIONS

The pooled MD of PVML was 65.8% (95% CI: 55.3-76.2, p < 0.001). Prospective studies of PVML must be designed using simple and universal clinical diagnostic criteria to be able to make an early diagnosis of this important OPMD and acknowledge the frequency of MD.

Prognosis Parameters of Oral Carcinomas Developed in Proliferative Verrucous Leukoplakia: A Systematic Review and Meta-Analysis

Simple Summary

Proliferative verrucous leukoplakia is considered by the WHO as an oral potentially malignant disorder that presents the highest tendency to recurrence and malignant transformation rate. However, to date limited evidence-based prognostic data for oral carcinomas developed in patients with proliferative verrucous leukoplakia (PVL-OC) have been published, and these carcinomas probably perform better than conventional oral carcinomas. In this study we present a systematic review and meta-analysis to evaluate the current evidence in relation to the prognosis of oral carcinomas developed in patients PVL-OC.

Abstract

Proliferative verrucous leukoplakia (PVL) is contemplated by the World Health Organization (WHO) as an oral potentially malignant disorder (OPMD) with a high the highest malignant transformation ratio among all OPMD (approximately 50%). Our aim was to evaluate the current evidence in relation to the prognosis of oral carcinoma developed in patients with proliferative verrucous leukoplakia (PVL-OC). We searched PubMed, Embase, Web of Science and Scopus for published studies (upper date limit = June 2021). We evaluated the quality of studies (QUIPS tool). We carried out meta-analyses, examined inter-study heterogeneity through subgroup and meta-regression analyses, and performed sensitivity and small-study effects analyses to test the stability and reliability of results. 23 studies met inclusion criteria (505 patients with PVL, of which 288 developed a total of 504 carcinomas). The meta-analyzed overall mortality rate was 21.29% (pooled proportions [PP] = 95% confidence intervals [CI] = 8.77–36.36) for PVL-OC, clearly lower than the 34.7–50% mortality rate for conventional oral cancer reported in previous studies. In comparison with a single study reporting on conventional oral cancers, mortality was significantly lower for PVL-OC (hazard ratio = 0.29 [95%CI = 0.10–0.89], p = 0.03). Univariable meta-regression verified that case series that presented higher proportions of verrucous carcinomas showed a better survival of PVL-OC (p = 0.05), but not with higher proportion of oral squamous cell carcinomas (p = 0.74). Significant differences were not found for other relevant variables such as follow up period (p = 0.44) or multiple tumor development (p = 0.74). In conclusion, PVL-OC show favorable prognostic parameters, especially with regard to the mortality rate.

A Scoping Review on Gaps in the Diagnostic Criteria for Proliferative Verrucous Leukoplakia: A Conceptual Proposal and Diagnostic Evidence-Based Criteria

Proliferative verrucous leukoplakia (PVL) is considered as an oral potentially malignant disorder (OPMD) that presents with a high tendency to recurrence after treatment and has the highest malignant transformation ratio among all OPMD (50%). Evidence-based publications have indicated that the malignant evolution reported is significantly related to the inconsistent diagnostic criteria used in primary-level studies; so, it has been hypothesized that the risk of oral cancer for this disease could even be underestimated. This is important because PVL requires specific management protocols, evidence-based, aimed at the early diagnosis of cancer developing in these lesions. We present a scoping review-a novel approach to mapping the available literature on a given topic to provide an overview of the available research evidence and to highlight possible gaps in the evidence-especially related in our study to the diagnostic aspects of PVL, and to issue a conceptual proposal and diagnostic criteria for PVL. We conclude that PVL is a white, multifocal and progressive lesion with a high malignant transformation rate which is diagnosed mainly around the age of 60 years without any specific histological characterization. We also advise a personal reflection on the level of certainty with which the clinician makes the diagnosis of a particular case of PVL.

Oral squamous cell carcinoma around dental implants: a systematic review

OBJECTIVE

This systematic review aimed to evaluate the epidemiologic profile, screen for possible risk factors, and evaluate the spectrum of clinical characteristics of oral squamous cell carcinoma (OSCC) around dental implants (DIs).

METHODS

The systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta- Analyses statement.

RESULTS

Thirty-three articles met the eligibility criteria. In total, the sample consisted of 63 patients, and women comprised the majority (55.5%). The mean age of patients was 66.7 years. Oral potentially malignant disorders were reported in 46% of patients, of which 65.5% occurred in women. The most common lesion found in women was oral lichen planus (52.6%). In 88.8% of patients OSCC around DIs occurred in the mandible, and the most common clinical appearance of the lesions was an exophytic mass (46%). Most of these lesions were initially treated as peri-implantitis.

CONCLUSIONS

Most patients with OSCC around DIs were women without known risk factors. It is important to emphasize that these lesions may present clinical and radiographic features that could resemble peri-implantitis, which can lead to delay in the diagnosis and subsequent treatment.

Potentially malignant disorders of the oral cavity and oral dysplasia: A systematic review and meta-analysis of malignant transformation rate by subtype

IMPORTANCE

Potentially malignant disorders of the oral cavity (OPMD) are a heterogeneous group of lesions associated with a variable risk of malignant transformation (MT) to invasive cancer. Leukoplakia (LE), lichen planus (LP), oral lichenoid lesions (OLL), oral erythroplakia (OE), oral submucous fibrosis (OSF), and proliferative verrucous leukoplakia (PVL) are among the most common of these lesions. Oral dysplasia is a mucosal area characterized by cellular and architectural derangement, which may be associated with OPMDs or not.

OBJECTIVE

To define the MT rate of OPMDs and the risk of development into cancer of mild vs moderate/severe oral dysplasia. This in order to implement adequate follow-up strategies and treatment decisions.

STUDY DESIGN

We performed a systematic review and meta-analysis on studies reporting the MT rates of OPMDs and oral dysplasia. Ninety-two studies were included for the analysis. Cumulative rates were reported for OPMDs overall and as a subgroup, a comparison was made of mild vs moderate/severe dysplasia. Meta-regression on OPMD and year of publication was also performed.

MAIN OUTCOME AND MEASURES

Overall MT rates of OPMDs and odds ratio of MT of mild vs moderate/severe dysplasia.

RESULTS

Overall MT rate across all OPMD groups was 7.9% (99% confidence interval [CI] 4.9%-11.5%). MT rates of the specific OPMD subgroups were as follows: LP 1.4% (99% CI 0.9%-1.9%), LE 9.5 (5.9%-14.00%), OLL 3.8% (99% CI 1.6%-7.00%), OSF 5.2% (99% CI 2.9%-8.00%), OE 33.1% (99% CI 13.6%-56.1%), and PVL 49.5% (99% CI 26.7%-72.4%). Regarding the dysplasia grades comparison, the meta-analysis showed that moderate/severe dysplasia is meaningfully associated to a much greater risk of MT compared to mild dysplasia with an odds ratio of 2.4 (95% CI 1.5-3.8) [Correction added on 27 December 2019, after first online publication: CI updated from 99% to 95%.]. Heterogeneity was not significant. Annual MT rates were approximated based on the average follow-up as reported in the various subgroups. Lichen planus had an annual MT of 0.28%, OLL of 0.57%, leukoplakia of 1.56%, PVL of 9.3%, and OSF of 0.98%. Mild dysplasia had an annual MT of 1.7%, while severe dysplasia of 3.57%. Meta-regression showed a significant negative correlation of PVL MT rate and year of the study (P value <.001).

CONCLUSIONS AND RELEVANCE

OPMDs and oral dysplasia are relatively common conditions that general practitioners, head and neck, and oral medicine specialists, face in their everyday practice. Our analysis confirms the significant risk of MT of these lesions, although variable among the subgroups. Moderate/severe dysplasia bears a much higher risk of cancer evolution than mild dysplasia. It is important to raise public health awareness on the MT rates of these conditions, at the same time efficacious communication with the patient is of utmost importance. This, coupled with strict follow-up measures and optimal treatment strategies, would help in reducing the transformation of these oral conditions into invasive cancer.

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.

Proliferative verrucous leukoplakia: diagnosis, management and current advances

Introduction

Proliferative verrucous leukoplakia is a multifocal and progressive lesion of the oral mucosa, with unknown etiology, and commonly resistant to all therapy attempts with frequent recurrences. It is characterized by a high rate of oral squamous cell carcinoma and verrucou carcinoma transformations.

Objective

To analyze the studies about Proliferative verrucous leukoplakia and develop a concise update.

Methods

A Pubmed search identifying studies (laboratory research, case series and reviews of literature) that examined patients with Proliferative verrucous leukoplakia was realized.

Results

There are not enough studies about Proliferative verrucous leukoplakia in the literature. The few found studies not present a consensus about its etiology and diagnosis criteria. Although several treatment strategies have been proposed, most of them still show a high recurrence rate.

Conclusion

More research about Proliferative verrucous leukoplakia is necessary to understand and treat this disease.

Low expression of angiotensinogen and dipeptidyl peptidase 1 in saliva of patients with proliferative verrucous leukoplakia

AIM

To elucidate the profile of the salivary proteome.

METHODS

Unstimulated whole mouth saliva was collected from 30 volunteers [15 proliferative verrucous leukoplakia (PVL) patients and 15 controls] and proteins were submitted for mass spectrometry-based proteomics using the discovery approach, followed by analyses of variance and logistic regression tests.

RESULTS

A total of two hundred and eighty-three proteins were confidently identified in saliva. By combining two low abundance proteins from the PVL group, angiotensinogen (AGT) and dipeptidyl peptidase 1 (DPP1), a model for group differentiation was built with a concordance index of 94.2%, identifying both proteins as potential etiologic biomarkers for PVL.

CONCLUSION

This study suggests that both AGT and DPP1 may be involved in developmental mechanisms of PVL.

The development of proliferative verrucous leukoplakia in oral lichen planus. A preliminary study

Background

Was to describe 14 cases of a proliferative verrucous leukoplakia as a clinical evolution of oral lichen planus.

Material and Methods

The clinical and histopathological characteristics of 14 cases of OLP that progress towards a plaque-like and verrucous form were indicated, with monitoring over a period of six to 24.3 years.

Results

The female/male ratio was 11/3, (78.6 and 21.4%). The mean age when the first biopsy was undertaken was 56.4 years old. None of the patients smoked during the study. As bilateral reticular was clinically diagnostic criterion, the second most frequent clinical form was the plaque form (n=10; 71.4%), followed by the atrophic (n=6; 42.8%), and erosive forms (n=4; 28.5%). Clinically it spread towards attached gingival mucosa and the hard palate. In the histopathologic study, there were a predominance of hyperkeratosis and verrucous epithelial hyperplasia. Three of the cases progressed to a squamous cell carcinoma, and one patient developed two verrucous carcinoma.

Conclusions

Further research is needed to demonstrate if proliferative multifocal oral lichen planus and proliferative multifocal oral leukoplakia are the same disorder but have different behaviour of malignancy for reasons of origin.

Key words:Oral lichen planus, proliferative verrucous oral leukoplakia, malignant oral lichen planus, multifocal verrucous oral lichen planus, proliferative verrucous oral lichen planus.

[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.

Proliferative verrucous leukoplakia may initially mimic lichenoid reactions

Proliferative verrucous leukoplakia is an intriguing disease, which occurs particularly in women aged greater than 60 years, is not associated with tobacco and alcohol, and has a high risk of recurrence and malignant transformation. Although it is well known that the typical presentation is characterized by multifocal and verrucous white lesions, there is no description that its initial clinical presentation may simulate a lichenoid reaction.

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.

Oral squamous cell carcinoma associated with proliferative verrucous leukoplakia compared with conventional squamous cell carcinoma--a clinical, histologic and immunohistochemical study

OBJECTIVE

Proliferative verrucous leukoplakia (PVL), a potentially malignant disorder, often undergoes malignant transformation to oral squamous cell carcinoma. The aim of our study was to document and compare the histologic, immunohistochemical, and clinical features and the survival rates of carcinoma arising in patients with PVL (p-scca) with conventional squamous cell carcinoma (c-scca) in order to determine if p-scca should be categorized as a separate clinical entity.

MATERIALS AND METHODS

A retrospective review of 11 patients with PVL, 38 with p-scca tumors and 49 with c-scca tumors: buccal mucosa (n = 28) and gingiva or palate (n = 21). Immunohistochemistry was performed by using antibodies directed against p16, p53, and ki67.

RESULTS

P-scca had lower clinical stage (P = .0001), smaller tumor size (P = .0033), no lymph node metastasis (P = .0002) or distant metastasis (P = .05), and better short term (P = .03), but not long term (P = .12) survival. Microscopically, p-scca tumor thickness was significantly less (P = .0001). P-53 overexpression was more common in p-scca (P = .0043) but not ki67 or p16 overexpression.

CONCLUSIONS

P-scca, compared with c-scca, presented with significantly better prognostic factors and short-term survival rates and longer duration of disease. Our results suggest that p-scca may represent a distinct entity, which may have practical implications when deciding on treatment. Further studies on a larger cohort of patients are recommended.

Between-lesion discrepancies in terms of dysplasia, cell turnover and diagnosis in patients with multiple potentially malignant oral lesions

Objective:

The present study assessed patients with multiple oral lesions to evaluate the mis-estimation rate in terms of diagnosis and risk of malignant transformation when only one biopsy is performed.

Study Design:

Thirty-five patients presenting at least two white and/or red lesions in different oral mucosa sites with a final diagnosis of leuko/erythroplakias or lichenoid lesions were included, for a total of 70 biopsies.

Results:

Nineteen patients (54%) had at least one between-lesion discrepancy considering the presence/absence of dysplasia (10 patients), normal/high cell turnover (13 patients) or diagnosis (5 patients). Discrepancies were not related to clinical aspect or within-patient similarity of lesions.

Conclusions:

Multiple oral lesions in the same patient can significantly differ in terms of dysplasia, high cell turnover and, even diagnosis. Multiple biopsies are imperative and diagnosis as well as risk of malignant transformation should be formulated for each single lesion rather than for each individual patient.

Urban legends series: oral leukoplakia

To date, the term oral leukoplakia (OL) should be used to recognize 'predominantly white plaques of questionable risk, having excluded (other) known diseases or disorders that carry no increased risk of cancer'. In this review, we addressed four controversial topics regarding oral leukoplakias (OLs): (i) Do tobacco and alcohol cause OLs?, (ii) What percentage of OLs transform into oral squamous cell carcinoma (OSCC)?, (iii) Can we distinguish between premalignant and innocent OLs?, and (iv) Is proliferative verrucous leukoplakia (PVL) a specific entity or just a form of multifocal leukoplakia? Results of extensive literature search suggest that (i) no definitive evidence for direct causal relationship between smoked tobacco and alcohol as causative factors of OLs, (ii and iii) the vast majority of OLs follow a benign course and do not progress into a cancer, and no widely accepted and/or validated clinical and/or biological factors can predict malignant transformation, and (iv) the distinction between multifocal/multiple leukoplakias and PVL in their early presentation is impossible; the temporal clinical progression and the high rate of recurrences and development of cancer of PVL are the most reliable features for diagnosis.

High incidence of DNA ploidy abnormalities and increased Mcm2 expression may predict malignant change in oral proliferative verrucous leukoplakia

AIMS

To assess the DNA content of cases of oral proliferative verrucous leukoplakia (PVL) and correlate the DNA ploidy findings with the expression of Mcm2, geminin, and Ki67, and with clinicopathological data.

METHODS AND RESULTS

DNA quantification was performed by image cytometry using the ACIS III Automated Cellular Imaging System. Expression of Ki67, Mcm2 and geminin was determined by immunohistochemistry. There were 21 cases of PVL, the female/male ratio was 6:1, and the average age was 65.5 years. Seventeen patients (81.0%) did not report tobacco and alcohol consumption. Nine patients (42.9%) developed verrucous or squamous cell carcinoma. Levels of Mcm2 expression showed a positive correlation with increasingly severe epithelial changes (P = 0.03). Twenty patients had their DNA examined by ACIS III, and 19 (95%) showed aneuploidy. The frequency and severity of aneuploidy (P < 0.0001), the mean values of the DNA heterogeneity index (P < 0.0001) and the 5n-exceeding fractions (P = 0.0007) increased according to epithelial alterations. Abnormal DNA content was observed even in the more indolent lesions.

CONCLUSIONS

Mcm2 expression and DNA ploidy analysis could be used to predict areas of malignant transformation. The clinicopathological findings associated with the immunohistochemical and DNA ploidy results support the distinct and aggressive profile of this entity.

[Current concepts in diagnosis and treatment of oral malignant tumors]

This article offers a short review of risk factors, oral precancerous conditions, and oral precancerous lesions which may cause oral squamous carcinoma. Current diagnostic methods and multidisciplinary strategies for the early detection and appropriate therapy of oral squamous carcinomas are discussed. Close cooperation of oral and maxillofacial surgeons, head and neck surgeons, radiotherapists, and oncologists is essential for the effective therapy of oral squamous carcinomas.

A brief review of common oral premalignant lesions with emphasis on their management and cancer prevention

Long-term outcomes associated with oral cancer and its management over the past several decades has caused concern and the value of mass oral cancer screenings has come under scrutiny. Though not all oral carcinomas are preceded by premalignant lesions as clinically visible morphological alterations occur secondary to the cellular or molecular changes, certain high risk lesions have been identified. Their management remains controversially polarized between surgical excision to prevent malignant change and conservative medical or surveillance techniques. Though oral cancer is one of the "major killers" of modern times, there seem to be no widely accepted criteria for decision making in clinical practice, the evidence base is scanty and uncertainty persists throughout investigation, diagnosis, and treatment. In this article, we have briefly discussed the common premalignant lesions, with an emphasis on their evidence based management and prevention.

ELECTRONIC SUPPLEMENTARY MATERIAL

The online version of this article (doi:10.1007/s12262-011-0286-6) contains supplementary material, which is available to authorized users.

Contemporary concepts in the diagnosis of oral cancer and precancer

This article addresses several issues in the approach to diagnosis of oral cancer. The term oral cancer is clarified. Key aspects of the biologic basis of development of oral cancer and the known risk factors associated with the disease are summarized. The clinical presentation of oral cancers and precancerous lesions and their histopathologic correlates is discussed. The importance of conventional tissue biopsy as the prevailing gold standard for diagnosis is emphasized. Other current technologies available for detecting and diagnosing oral cancer and premalignant lesions are acknowledged, and their respective strengths and weaknesses are discussed.

A case of oral multiple primary cancer including Spindle Cell Carcinoma

Spindle Cell Carcinoma (SPCC) is a relatively rare tumour that is classified as a subtype of squamous cell carcinoma (SCC). Histologically, SPCC is composed of a SCC region and epithelium-derived spindle cells with mesenchymal differentiation. We encountered an interesting case of multiple cancer including SPCC. A histopathologically atypical papillary lesion was found 13 years before our initial examination. Multiple verrucous leukoplakia later developed in the oral mucosa, for which an oral vitamin A derivative (a retinoid) was intermittently administered. Multiple cancer including SPCC subsequently developed in the lower gingiva. We investigated the case histologically and immunohistologically based on the concept of field cancerization.

Clinicopathological features and immunohistochemical expression of p53, Ki-67, Mcm-2 and Mcm-5 in proliferative verrucous leukoplakia

BACKGROUND

Proliferative verrucous leukoplakia (PVL) is a distinct and aggressive type of oral leukoplakia which affects elderly women without risk behavior and presents high rates of malignant transformation. The objective of the present study was to evaluate the clinicopathological characteristics and the distribution of cell proliferation markers, aiming to elucidate the distinct biological behavior of the PVL.

METHODS

Clinical and microscopical features of 12 patients with PVL were reviewed. Immunohistochemical analysis for p53, Ki-67, Mcm-2 and Mcm-5 were performed and the data were correlated.

RESULTS

All patients were women, above 50 years of age, 91.7% were non-smoker and 100% were non-habitual drinker. Alveolar ridge (66.6%), tongue (50%) and buccal mucosa (41.6%) were the most affected sites. Four patients developed squamous cell carcinoma (SCC). The immunohistochemical findings showed higher positivity for p53, Ki-67, Mcm-2 and Mcm-5 in SCCs. However, some patients with mild or moderate dysplasia, specially the patients who developed SCC, presented high expression of Mcm-2 and Mcm-5.

CONCLUSIONS

High immunoexpression of Mcm-2 and Mcm-5 in mild and moderate dysplasia could be helpful to predict the malignant transformation of PVL.

Failure to diagnose and delayed diagnosis of cancer: medicolegal issues

BACKGROUND

Failure to diagnose and delayed diagnosis of cancer can have a significant effect on patients' morbidity and mortality. Oral health care professionals should be alert for oral premalignant and malignant disease and head and neck involvement by malignant disease. These issues have patient care and medicolegal implications.

CASE DESCRIPTION

To provide guidance to practitioners, the authors present a series of cases of oral and head and neck cancer that resulted in legal action. They chose the medicolegal cases to highlight dental professionals' potential legal liability and provide guidance in patient care.

CLINICAL IMPLICATIONS

Clinicians need to obtain complete comprehensive histories, perform thorough head and neck and oral examinations and appreciate the importance of being vigilant for abnormalities that may lead to early detection of potentially malignant disease.

Proliferative verrucous leukoplakia and its progression to oral carcinoma: a review of the literature

BACKGROUND

Proliferative verrucous leukoplakia (PVL) is a distinct clinical form of oral leukoplakia defined by its progressive clinical course, changing clinical and histopathological features, and potential to develop into cancer. PVL behaves in a more aggressive and relentless manner than the more innocuous white oral lesions that it can resemble clinically.

METHODS

A PubMed search was conducted which identified studies that examined patients with PVL and reported data meeting inclusion criteria.

RESULTS

PVL is seen much more frequently in females and most often diagnosed after the sixth decade of life. Tobacco use is not strongly linked to the presence of PVL (63% of patients did not use tobacco products). Most (74%) of the patients with PVL progressed to oral carcinoma.

CONCLUSION

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 favorable outcome.