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  Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 10  |  Issue : 6  |  Page : 695-697  

Squamous cell carcinoma and lymph node metastasis with hypertrophic lichen planus in a 12 year old boy


1 Department of Dermatology, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Radiotherapy, Christian Medical College, Vellore, Tamil Nadu, India
3 Department of General Pathology, Christian Medical College, Vellore, Tamil Nadu, India

Date of Web Publication1-Nov-2019

Correspondence Address:
Renu George
Department of Dermatology, Christian Medical College, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/idoj.IDOJ_27_19

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   Abstract 


Hypertrophic lichen planus (HLP) is a chronic variant of lichen planus with an estimated risk of 0.4% developing squamous cell carcinoma (SCC) in later years. We report the case of a 12-year- old boy with history of hypertrophic lichen planus since 4 years of age, with malignant transformation into squamous cell carcinoma along with lymph node metastasis.

Keywords: Hypertrophic lichen planus, metastasis, squamous cell carcinoma


How to cite this article:
George A, George R, Varghese SS, Telugu RB. Squamous cell carcinoma and lymph node metastasis with hypertrophic lichen planus in a 12 year old boy. Indian Dermatol Online J 2019;10:695-7

How to cite this URL:
George A, George R, Varghese SS, Telugu RB. Squamous cell carcinoma and lymph node metastasis with hypertrophic lichen planus in a 12 year old boy. Indian Dermatol Online J [serial online] 2019 [cited 2019 Nov 12];10:695-7. Available from: http://www.idoj.in/text.asp?2019/10/6/695/270207




   Introduction Top


Hypertrophic lichen planus (HLP) is a chronic variant of lichen planus (LP) affecting the skin with an increased risk of developing squamous cell carcinoma (SCC). It presents as thick hyperkeratotic scaly plaques affecting mostly the lower extremities which can mimic SCC. The lesions can as well undergo malignant transformation.[1],[2] We report the case of a 12-year-old boy with history of HLP since 4 years of age who presented with a rapidly progressive ulcer on the right shin since 2 months. It is very uncommon in this age group, most cases being reported in adults.


   Case Report Top


A 12-year-old boy presented to us with pruritic hyperpigmented lesions on the legs since 4 years of age. There was a gradual progress in the size of lesion on the right shin with watery discharge since 4 months and ulceration since 2 months. He was treated symptomatically elsewhere with no significant improvement. Cutaneous examination showed multiple hypertrophic plaques ranging in size from 2-4 cms over both shins with central depigmentation and a peripheral margin of hyperpigmentation [Figure 1]. A large cauliflower like ulcer 7 × 9 cms in size, non-tender with everted margins and surrounding induration was present over the right shin, over a plaque of LP [Figure 2]. The vertical group of inguinal lymph nodes were enlarged, 3 × 3 cms in size, non-tender, mobile, and firm to palpation. Mucosal examination was within normal limits. A wedge biopsy was done from the ulcer along with an inguinal lymph node biopsy. Histopathology revealed a tumor arising from the overlying stratified squamous epithelium arranged in nests and trabeculae and sheets of polygonal cells with pleomorphic vesicular nuclei, dispersed chromatin and visible nucleoli. Keratin pearls were present with tumor infiltration to subcutaneous tissue along with lymphovascular, and focal perineural invasion [Figure 3]. Metastatic deposits were seen in 4 deep inguinal lymph nodes with maximum size of tumor deposit being 1 cm. The findings were consistent with moderately differentiated SCC (Grade 2) with inguinal lymph node metastasis. Histopathology of the adjacent hypertrophic skin lesion was consistent with LP. The chest X-ray was normal and CT imaging of abdomen and pelvis did not show deep nodal involvement. He was staged as T3N2M0 (Stage 4). A wide local excision of the ulcer was done with 1-1.5 cms margins on all sides according to the NCCN guidelines 2018 which recommends a margin of more than 1 cm for high risk patients.[3] A split thickness skin grafting and right ilioinguinal block dissection was also done. The wound site healed rapidly and patient was initiated on local and regional radiotherapy in view of high risk features. He received 60 Gy in 30 fractions over 6 weeks for right inguinal node metastasis. A total of 48 Gy in 16 fractions with surface mold brachytherapy was offered to the right lower leg as well. He was also started on acitretin 10 mg daily for HLP. The ulcer was healing on follow up at 3 months and there were no new LP lesions [Figure 4].
Figure 1: Hypertrophic plaques on the left shin with central depigmentation and a peripheral rim of hyperpigmentation

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Figure 2: Cauliflower like ulcer with everted margins and surrounding induration on the right shin over a plaque of lichen planus

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Figure 3: Well-differentiated tumor mass show prominent keratinization forming pearl like structures with a moderate lymphoplasmacytic infiltrate H and E 40×

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Figure 4: Re-epithelialisation of the ulcer on right shin after grafting and post radiotherapy, at 3 months follow up

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   Discussion Top


HLP is a T cell mediated chronic variant of lichen planus and the malignant predisposition is controversial. The estimated risk of malignant transformation is 0.4% with less than 50 cases reported in literature till date,[1],[2],[3],[4],[5] youngest being 17 years.[6] The lag time for developing SCC on cutaneous lesions ranges from 3 months to 40 years. Our patient developed SCC over HLP lesions after a period of 8 years. Besides SCC, keratoacanthomas and verrucous carcinomas have also been reported supporting an association between HLP and keratinocyte malignancies.[1] A population based study of 2,071 Swedish patients established oral lesions as a precursor of SCC than cutaneous LP.[7]

The proposed risk factors for malignant transformation include immune alterations, arsenic exposure, chronic tar application and ionizing or ultraviolet radiation treatment.[1],[8] Our patient did not have any risk factors. The long standing non-healing ulcers over LP lesions and long duration of HLP with chronic pruritus further predispose to SCC.[8] In oral LP, the co-expression of podoplanin and ATP-binding cassette transporter G2 (ABCG2), a transcription factor is a prognostic marker which may indicate the carcinogenic potential of LP.[9]

Metastatic SCC is extremely rare with only 2 reports till date.[8],[10] Our patient had not taken any treatment for HLP and consulted us nearly 4 months after changes were observed on the cutaneous lesions. This necessitates the importance of treating HLP at an early stage and counseling patients regarding the potential risk of malignancy.


   Conclusion Top


To our knowledge this is the youngest reported patient to develop metastatic SCC on longstanding HLP. We would like to emphasize the importance of regular follow up in HLP and periodic biopsies are highly recommended in the presence of danger signs such as sudden increase in size of lesions or ulceration as in our case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Knackstedt TJ, Collins LK, Li Z, Yan S, Samie FH. Squamous cell carcinoma arising in hypertrophic lichen planus: A review and analysis of 38 cases. Dermatol Surg 2015;4:1411-8.  Back to cited text no. 1
    
2.
Levandoski KA, Nazarian RM, Asgari MM. Hypertrophic lichen planus mimicking squamous cell carcinoma: The importance of clinicopathologic correlation. J Am Acad Dermatol 2017;3:151-4.  Back to cited text no. 2
    
3.
National Comprehensive Cancer Network. Squamous Cell Skin Cancer (Version 2.2018). Available from: https://oncolife.com.ua/doc/nccn/Squamous_Cell_Skin_Cancer.pdf. [Last accessed on 2019 Feb 24].  Back to cited text no. 3
    
4.
Gawkrodger DJ, Stephenson TJ, Thomas SE. Squamous cell carcinoma complicating lichen planus: A clinico-pathological study of three cases. Dermatology 1994;188:36-9.  Back to cited text no. 4
    
5.
Singh SK, Saikia UN, Ajith C, Kumar B. Squamous cell carcinoma arising from hypertrophic lichen planus. J Eur Acad Dermatol Venereol 2006;20:745-6.  Back to cited text no. 5
    
6.
Bhole AB, Sudhanan VM, Mishra DK. Malignant transformation of lichen planus hypertrophicus into squamous cell carcinoma. Indian J Paediatr Dermatol 2016;17:18-20.  Back to cited text no. 6
  [Full text]  
7.
Sigurgeirsson B, Lindelöf B. Lichen planus and malignancy. An epidemiologic study of 2071 patients and a review of the literature. Arch Dermatol 1991;127:1684-8.  Back to cited text no. 7
    
8.
Tong LX, Weinstock MJ, Drews R, Sheikine Y, Kim CC. Widely metastatic squamous cell carcinoma originating from malignant transformation of hypertrophic lichen planus in a 24-year-old woman: Case report and review of the literature. Pediatr Dermatol 2015;32:e98-101.  Back to cited text no. 8
    
9.
Shi P, Liu W, Zhou Z, He Q, Jiang W. Podoplanin and ABCG2: Malignant transformation risk markers for oral lichen planus. Cancer Epidemiol Biomarkers Prev 2010;19:844-9.  Back to cited text no. 9
    
10.
Ardabili M, Gambichler T, Rotterdam S, Altmeyer P, Hoffmann K, Stücker M. Metastatic cutaneous squamous cell carcinoma arising from a previous area of chronic hypertrophic lichen planus. Dermatol Online J 2003;9:10.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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