Dermatology Online Journal

Metastatic cutaneous squamous cell carcinoma arising from a previous area of chronic hypertrophic lichen planus
Michael Ardabili MD, Thilo Gambichler MD, Sebastian Rotterdam, Peter Altmeyer MD, Klaus Hoffmann MD, and Markus Stücker MD
Dermatology Online Journal 9 (1): 10

Department of Dermatology, Ruhr-University Bochum, Bochum, Germany

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Abstract

Malignant transformation of cutaneous lichen planus is a rare event. We report a 34 year old Caucasian male who presented with an exophytic tumor on the right foreleg. The tumor gradually developed within previous areas of histologically proven hypertrophic lichen planus that had existed for about 10 years. However, the current histological examination of the excised tumor revealed highly differentiated squamous cell carcinoma with a depth of tumor invasion of 10 mm. At that time, neither sentinel lymph node biopsy nor further imaging diagnostics revealed evidence for metastatic spreading. Nevertheless, five months after surgery inguinal lymph node metastases were detected. Initial chemotherapy and inguinal lymph node dissection were unable to stop the spread of the tumor. One year later, parailiacal lymph node metastases were detected by computed tomography. Further cycles of chemotherapy resulted in significant reduction of the parailiacal tumor masses. This report indicates that the long-standing hypertrophic form of lichen planus seems to have a considerable propensity for malignant transformation, even in young patients.

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Introduction

In European countries, the annual rate of incidence of cutaneous squamous cell carcinoma (SCC) is about 25 cases per 100,000 people, with the occurrence being highest among those aged 60 to 70 years. SCC has a multitude of clinical, histological, and etiological subtypes. The aggressiveness of the tumor varies greatly, depending upon histology, location and host immune factors. Epidemiologically, ultraviolet light exposure is the primary cause. Other extrinsic factors include ionizing radiation, chemical exposure (arsenic, tar) and infectious agents. Intrinsic factors in the development of SCC include skin type, age and immune status. Unusual types of SCC may occur in association with scars, lymphedema, chronic ulcers and chronic inlammatory skin diseases.[1, 2] We report a young male with aggressive squamous cell carcinoma that developed in preexisting lichen planus hypertrophicus.

Case Report

Figure 1	Figure 2
Figure 1. Ulcerated exophytic tumor 5 cm in diameter. Note the multiple white-greyish horn pearls.
Figure 2. Lichen planus hypertrophicus. Parakeratosis, acanthosis, dyskeratotic cells, and vacuolar alteration of the basal layer. A lichenoid infiltrate of lymphocytes in the papillary dermis.

In 1999, a 34 year old Caucasian male presented with an ulcerated exophytic tumor (5 cm in diameter) on the right foreleg (Figure 1). The tumor had developed in an area of chronic lichen planus hypertrophicus which had been present for about 10 years and was biopsy proven in 1995 (Figure 2). Treatment had consisted of the intermittent use of topical corticosteroids. There was no history of other medical problems.

Figure 3	Figure 4
Figure 3. Ulcerated highly differentiated squamous cell carcinoma, tumor thickness 10 mm. Within the dermis epithelial tumor islands of varying size. Several horn pearls and dyskeratotic cells with hyperchromatic nuclei are present within the islands.
Figure 4. Lymph node metastasis (groin) of the SCC. Due to the aggressive growth pattern the lymph node capsule and the architecture of the lymphatic tissue was destroyed.

At the initial visit we completely excised the suspect tumor. Histopathologically (Figure 3), a highly differentiated SCC with a tumor thickness of 10 mm was found. Neither sentinel lymph node biopsy nor imaging studies (ultrasound, chest X-ray, computed tomography) revealed evidence for metastatic disease (pT2N0M0 , stage II). However, five months after the tumor had been excised the patient presented with an subcutaneous nodule of the right groin. Ultrasound examination revealed a suspicious lymph node that was excised subsequently. Histological examination of the nodule was consistent with the diagnosis of metastatic SCC (Figure 4). Despite inguinal lymph node dissection and chemotherapy with four cycles of cisplatin (30 mg/m²) and paclitaxel (30 mg/m²) progression of the disease could not be halted. One year later, parailiacal lymph node metastases were detected by computed tomography. Four cycles of chemotherapy with cisplatin (75 mg/m²) and paclitaxel (175 mg/m²) resulted temporarily in significant reduction of parailiacal tumor masses. Currently, the patient is undergoing further palliative chemotherapy in the oncological department.

Discussion

The degree of differentiation of SCC as well as size and depth of tumor invasion are extremely important prognostic variables. A tumor size larger than 2 cm doubles the recurrence rate and triples the metastatic rate as compared with lesions less than 2 cm. In a previous study, the cumulative metastasis/recurrence-free survival at three years was 98% tumors for tumors less than or equal to 3.5 mm and 84% for tumors thicker than 3.5 mm. [1, 2] Although our patient had a highly differentiated SCC, which is known to have a relatively low risk for metastatic disease, the ulceration and tumor thickness of 10 mm indicated a poor prognosis. However, the etiology of SCC must also be considered. While SCCs developing from precursor lesions such as actinic keratoses are considered less likely to metastasize, SCCs developing at certain sites or within scars, chronic ulcers or inflammatory processes have a significant propensity for metastasis. [3, 4, 5, 6]

Neoplastic transformation of lichen planus is a rare event. Reports of cancer development in lichen planus mostly concern the oral erosive form. SCC may develop in 0.3% to 3% of patients with the oral form of lichen planus. Approximately 40 cases of SCC arising in cutaneous lichen planus have been reported. In three of these cases, cutaneous verrucous carcinoma, a low-grade variant of SCC, was associated with lichen planus. [7] Interestingly, of the cases where SCC has been associated with lichen planus, it has frequently been reported in association with the long-standing hypertrophic form of lichen planus on the lower extremities. [5] The underlying mechanisms of this association are not known. Speculatively, chronic cutaneous inflammatory processes with oncogenic-like "overdrive" of growth factors constantly stimulating epithelial cells may lead to malignant transformation. Additionally, disorders of cutaneous circulation probably play a role in malignant transformation. In a previous follow-up study of 1100 patients with venous leg ulcers, the risk of developing SCC in the ulcer was significantly increased. [3]

This report has described the unusual development of a metastasizing SCC in lesions of long-standing lichen planus hypertrophicus of the lower leg in a young man. Despite the patient's young age and apparent good health, the tumor followed an aggressive, metastatic course. Chronic, localized inflammatory conditions, such as lichen planus, should be followed carefully to allow the early detection of a developing SCC.

References

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