Author(s) : Zekayi Kutlubay, Emek Kocaturk, Cüyan Demirkesen, Mukaddes Kavala, Sükran Sarigul, Ilkin Zindanci , Dermatology Dept, Türkiye Hospital, Bozova Sk. Bayirbasi Apt. No: 4/10, Mecidiyeköy, 34034 Istanbul, Turkey, Göztepe Training and Research Hospital, Istanbul, Turkey, Istanbul University Cerrahpasa Medical School, Istanbul, Turkey, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey. |
ARTICLE
Auteur(s) : Zekayi Kutlubay1, Emek Kocaturk2, Cüyan
Demirkesen3, Mukaddes Kavala2, Sükran
Sarigul4, Ilkin Zindanci2
1Dermatology Dept, Türkiye Hospital, Bozova Sk.
Bayirbasi Apt. No: 4/10, Mecidiyeköy, 34034 Istanbul, Turkey
2Göztepe Training and Research Hospital, Istanbul,
Turkey
3Istanbul University Cerrahpasa Medical School,
Istanbul, Turkey
4Fatih Sultan Mehmet Training and Research
Hospital, Istanbul, Turkey
Malignant transformation of cutaneous lichen planus (LP) has
rarely been described. In the majority of the 74 cases reported,
squamous cell carcinoma (SCC) arose from hypertrophic LP on the
lower limbs. The average time between the diagnosis of LP and
development of the carcinoma was reported to be 12 years [1, 2]. We
report a 70-year-old man who developed SCC in hypertrophic LP on
the lower leg diagnosed 6 years earlier.
A 70-year-old man presented to our clinic with a non-healing
ulcer over the left pretibial region which had existed for 6 years.
The lesion was first a small, very itchy, violaceus plaque.
A biopsy from this lesion revealed a band-like lichenoid
infiltration in the upper dermis, mainly composed of lymphocytes
and histiocytes (figure
1A). Although the stratum corneum was removed during the
biopsy process, hypergranulosis, hydropic degeneration and
apoptotic cells in the basal cell layer of the epidermis were
consistent with the diagnosis of lichen planus. Since then he was
given topical steroids and emollients with no improvement. After
years the lesion grew slowly and the patient kept on scratching it.
Dermatological examination revealed a verrucous, 7 × 8 cm
sized tumor; the surrounding skin was thickened and lichenified
with hypopigmented macular lesions (figure 1B).
Histopathological examination of the tumor showed a moderately
differentiated squamous cell carcinoma (Grade 2, tumor thickness,
9 mm) (figure
1C). The tumor was surgically removed. After 4 months,
surgical excision of left inguinal lymph nodes and radiotherapy to
pelvic and inguinal lymph nodes (6000 cGy) was performed. He had no
recurrence after 7 months.
Discussion
Most SCC are induced by ultraviolet light, while carcinogenic
chemicals and human papilloma viruses are also implicated [3]. SCC
complicating cutaneous LP has an incidence of 0.4% and most of the
reported cases are hypertrophic type [1]. While an increased risk
of the development of SCC in oral LP is generally accepted, it is
still unclear if there exists a true association between LP and
SCC. In a recent long-term retrospective analysis of malignancy in
patients with LP, a statistically significant association was found
between oral LP and SCC with a relative risk of 5.9%, especially in
men, where smoking, alcohol or poor dentition were proposed to
explain these findings. In comparison, no significant association
was found between cutaneous LP and subsequent SCC development. Of
the small number of these SCCs, nearly all were hypertrophic lichen
planus of the lower leg. The conclusion in this study was that
cutaneous LP is not a risk factor for the development of SCC. Here
the limitation is that both chronic and acute LP were included in
the study; a separate analysis of chronic LP may lead to different
results [4]. It is hypothesized that prolonged chronic skin
inflammation and anemia could be confounders, just as an increased
turnover of basal cells in LP may increase the risk of genetic
errors [5].
Our patient had no history of arsenic exposure, radiation or
chronic tar application, but had been scratching the lesion for 6
years. Speculatively, chronic cutaneous inflammatory processes with
oncogenic-like “overdrive” of growth factors constantly stimulating
epithelial cells may lead to malignant transformation. There have
been two case reports concerning squamous cell carcinoma arising
from ulcerative prurigo nodularis, emphasizing that chronic
scratching and inflammation may play a role in carcinogenesis [6].
In our patient, the interval between cutaneous LP and occurrence of
SCC was relatively short; 6 years; intensive scratching might have
accelerated the neoplastic process.
As a conclusion, although very rare, the possibility of
malignancy arising on cutaneous LP must be kept in mind and when
treatment fails, skin biopsies on a regular basis must be done for
early diagnosis of an arising SCC.
Acknowledgements
Financial support: none. Conflict of interest: none.
References
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