Marginal linear gingival leukoplakia progressing to "ring around the collar"-An ominous sign of proliferative verrucous leukoplakia

Proliferative Verrucous Leukoplakia Presenting as a Ring Around the Collar and Cancer: A Case Report

Proliferative verrucous leukoplakia (PVL) is an oral mucosa lesion with a high rate of malignant transformation. The diagnosis is often difficult, especially when the initial lesion is a simple homogeneous white leukoplakia, and when located only on the gingiva or palate. Moreover, the anatomopathological analysis is non-specific in the initial stages. The gingival PVL localisation (gPVL) is described as the most aggressive form with the highest rate of malignant transformation. Cases with a unique gingival localisation are rare, described with a "ring around the collar" clinical form. Considering the difficulty of early diagnosis of gPVL, we report the case of a 72-year-old woman, who presented "white lesions on her gingiva" with a slight discomfort in February 2019. The lesion was initially limited to the buccal part of the mandibular right gingiva, but rapidly extended to all the lingual and buccal mandibular gingiva during follow-up, leading to a diagnosis of gPVL. Two biopsies were performed, which concluded a verrucous hyperplasia and papilloma with a lichenoid part. The diagnosis of gPVL was made after a six-month follow-up based on clinical and anatomopathological factors. The gPVL transformed into a squamous cell carcinoma (SCC) after 18 months of follow-up. A surgical right mandibular bone excision with an autologous left fibula graft associated with radiotherapy was performed. Three years after the surgery, the patient remains under monitoring, with several gPVL and SCC recurrences treated. This case highlights that gPVL is a rare and aggressive form of PVL, with a high risk of fast malignant transformation. Knowledge about its aetiology, anatomic pathology, and biological markers is highly needed to speed up the diagnosis and develop specific follow-up and treatment.

Reactive and Nonreactive White Lesions of the Oral Mucosa

White lesions in the oral cavity may be diverse in etiology and may present with significant clinical and sometimes histologic overlap between categories, making accurate diagnosis difficult at times. Although white lesions of immune and infectious etiology are covered in another article, this article discusses the differential diagnosis between developmental, reactive, idiopathic, premalignant, and malignant white lesions focusing on clinical features of each category.

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.

Proliferative Verrucous Leukoplakia: An Expert Consensus Guideline for Standardized Assessment and Reporting

The many diverse terms used to describe the wide spectrum of changes seen in proliferative verrucous leukoplakia (PVL) have resulted in disparate clinical management. The objective of this study was to produce an expert consensus guideline for standardized assessment and reporting by pathologists diagnosing PVL related lesions. 299 biopsies from 84 PVL patients from six institutions were selected from patients who had multifocal oral leukoplakic lesions identified over several years (a minimum follow-up period of 36 months). The lesions demonstrated the spectrum of histologic features described in PVL, and in some cases, patients developed oral cavity squamous cell carcinoma (SCC). An expert working group of oral and maxillofacial and head and neck pathologists reviewed microscopic features in a rigorous fashion, in combination with review of clinical photographs when available. The working group then selected 43 single slide biopsy cases for whole slide digital imaging (WSI) review by members of the consensus conference. The digital images were then reviewed in two surveys separated by a washout period of at least 90 days. Five non-PVL histologic mimics were included as controls. Cases were re-evaluated during a consensus conference with 19 members reporting on the cases. The best inter-observer diagnostic agreement relative to PVL lesions were classified as "corrugated ortho(para)hyperkeratotic lesion, not reactive" and "SCC" (chi-square p = 0.015). There was less than moderate agreement (kappa < 0.60) for lesions in the "Bulky hyperkeratotic epithelial proliferation, not reactive" category. There was ≥ moderate agreement (> 0.41 kappa) for 35 of 48 cases. This expert consensus guideline has been developed with support and endorsement from the leadership of the American Academy of Oral and Maxillofacial Pathology and the North American Society of Head and Neck Pathologists to recommend the use of standardized histopathologic criteria and descriptive terminology to indicate three categories of lesions within PVL: (1) "corrugated ortho(para)hyperkeratotic lesion, not reactive;" (2) "bulky hyperkeratotic epithelial proliferation, not reactive;" and (3) "suspicious for," or "squamous cell carcinoma." Classification of PVL lesions based on a combination of clinical findings and these histologic descriptive categories is encouraged in order to standardize reporting, aid in future research and potentially guide clinical management.