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Thursday, July 24, 2008

Esophageal Oral Lichen Planus

Annular lichen planus involving the esophagus: a rare diagnosis.

Cameo

International Journal of Dermatology. 43(5):373-374, May 2004.
Belloul, Lamia MD; Akhdari, Nadia MD; Hassar, Imane MD; Lakhdar, Hakima MD

Abstract:
A 49-year-old woman presented with a 2-year history of a sore mouth, annular, atrophic patches, and chronic ulcerative vulvovaginitis. For 6 years, she had suffered from dysphagia to solids which was increasing in severity. There was no past history of heartburn or other symptoms of esophageal reflux.

Mucocutaneous examination showed white erosive patches on the buccal mucosa, cicatricial alopecia, dystrophic nails, and annular atrophic pigmented plaques localized on the trunk ( Fig. 1). Genital examination showed atrophic and sclerotic vulvovaginal lesions with synechia. Cutaneous biopsy showed an atrophic epidermis, a dense lymphocytic infiltrate in the upper dermis with degeneration of the basal epithelium, and Civatte bodies. Serologic tests for hepatitis B and C were negative. A diagnosis of cutaneous annular lichen planus with nail, scalp, oral, and genital involvement was made.

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The evaluation of cutaneous, genital, scalp, nail, esophageal, and ocular involvement in patients with oral lichen planus.

Oral Medicine

Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, & Endodontics. 88(4):431-436, October 1999.
Eisen, Drore MD, DDS a

Abstract:
Objective. Lichen planus, in its classical presentation, involves the oral cavity and skin. This study evaluated patients with oral lichen planus for extraoral manifestations of the disease.

Study design. A total of 584 patients with oral lichen planus were evaluated for cutaneous, genital, scalp, nail, esophageal, and ocular lichen planus.

Results. Extraoral manifestations included cutaneous lichen planus in 93 patients, genital lichen planus in 19% of 399 examined women and 4.6% of 174 examined men, nail involvement in 11 patients, lichen planopilaris in 6 patients, esophageal lichen planus in 6 patients, and conjunctival lichen planus in 1 patient. Thirty-three patients developed lichen planus in 3 or more sites.

Conclusions. Because a relatively high percentage of patients with oral lichen planus develop extraoral manifestations, a thorough evaluation should routinely be performed. A complete history and physical examination by a multidisciplinary group of health care providers uncovers common and uncommon extraoral features of the disease.

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Esophageal Lichen Planus: Case Report and Review of the Literature.

Case Report

American Journal of Surgical Pathology. 24(12):1678-1682, December 2000.
Abraham, Susan C. M.D.; Ravich, William J. M.D.; Anhalt, Grant J. M.D.; Yardley, John H. M.D.; Wu, Tsung-Teh M.D., Ph.D.

Abstract:
Involvement of the esophagus by lichen planus is a rarely reported condition. The histologic features of esophageal lichen planus, which may differ from those of cutaneous disease, have only rarely been illustrated. We describe a 58-year-old woman with skin and oral lichen planus who presented with dysphagia and an esophageal stricture that were ultimately diagnosed as esophageal lichen planus. Multiple esophageal biopsies demonstrated a lichenoid, T cell-rich lymphocytic infiltrate, along with degeneration of the basal epithelium and Civatte bodies. Correct diagnosis of esophageal lichen planus is critical because of its prognostic and therapeutic distinction from other more common causes of esophagitis and stricture formation.

See full report

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Esophageal lichen planus: the Mayo Clinic experience.

Dis Esophagus. 1999;12(4):309-11.
Harewood GC, Murray JA, Cameron AJ.
Dept of Gastroenterology, Mayo Clinic Rochester, MN 55905, USA.

Lichen planus (LP) is an inflammatory papulosquamous disease which may affect the squamous epithelium of the esophagus. We reviewed six patients with esophageal lichen planus (ELP) seen at Mayo Clinic Rochester between 1984 and 1998. The presenting symptoms were dysphagia (in all six patients) and odynophagia (two patients). Cervical esophageal strictures were seen in four patients; average number of esophageal dilatations required was 15 (range, 10-18). Esophageal biopsies demonstrated the classical histologic findings of ELP in two patients, and a lymphocytic infiltrate in the other four. Concomitant lichen planus (LP) was seen at other sites in five patients: all five had oral LP preceded by ELP symptoms in all five; three had genital LP preceded by ELP symptoms in all three; two had dermal LP, preceded by ELP symptoms in one. Proton pump inhibitors were tried unsuccessfully in all patients. Four patients were started on systemic steroid medication; three had resolution of symptoms within 1 month.

PMID: 10770369 [PubMed - indexed for MEDLINE]

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Esophageal Lichen Planus

Archives of Pathology and Laboratory Medicine: Vol. 132, No. 6, pp. 1026–1029.
Vishal S. Chandan, MD; Joseph A. Murray, MD; Susan C. Abraham, MD


Esophageal lichen planus is an under recognized condition, with fewer than 50 cases reported to date. Unlike cutaneous lichen planus, esophageal lichen planus occurs almost exclusively in middle-aged or older women who also have oral involvement. It commonly involves the proximal esophagus and manifests as progressive dysphagia and odynophagia. Endoscopic findings can include lacy white papules, pinpoint erosions, desquamation, pseudomembranes, and stenosis. Histologic features of esophageal lichen planus have only rarely been illustrated. They differ from those of cutaneous disease in several respects, including the presence of parakeratosis, epithelial atrophy, and lack of hypergranulosis. Correct diagnosis of esophageal lichen planus is difficult but bears important therapeutic implications. It is typically a chronic and relapsing condition that can require systemic or local immunosuppressive therapy and repeated endoscopic dilatations for esophageal strictures. Esophageal lichen planus may have malignant potential, as evidenced by 3 patients who developed squamous carcinoma of the esophagus after longstanding disease.

From the Division of Anatomic Pathology (Drs Chandan and Abraham) and the Division of Gastroenterology and Hepatology (Dr Murray), Mayo Clinic, Rochester, Minn. Dr Abraham is currently with the Department of Pathology, The University of Texas M. D. Anderson Cancer Center, Houston

Accepted November 28, 2007

See Full Text

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Two siblings with lichen planus and squamous cell carcinoma of the oesophagus.

Case Reports

European Journal of Gastroenterology & Hepatology. 18(10):1111-1115, October 2006.
Schwartz, Matthijs P. a; Sigurdsson, Vigfus b; Vreuls, Willem c; Lubbert, Pieter H.W. d; Smout, Andre J.P.M. a

Abstract:
Lichen planus is a mucocutaneous disease which can also affect the oesophagus. Unlike in oral lichen planus an increased risk for the development of squamous cell carcinoma in the oesophagus has not been established. We describe two sisters with a history of long-standing cutaneous lichen planus who developed oesophageal squamous cell carcinoma, diagnosed at the ages of 68 and 70 years, respectively. In one of the cases, dysplastic areas were identified by high-magnification chromoendoscopy. In both cases, oesophageal resection was carried out with a curative intent. For the first time these sibling case reports suggest an increased precancerous potential of oesophageal lichen planus.

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Dis Esophagus. 2003;16(1):47-53.

Lichen planus esophagitis: report of three patients treated with oral tacrolimus or intraesophageal corticosteroid injections or both.

Keate RF, Williams JW, Connolly SM.

Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ 85259, USA. keate.ray@mayo.edu

Clinically significant involvement of the esophagus is uncommon in patients who have lichen planus, a common disorder of squamous epithelium. In three patients who had oral, cutaneous, and esophageal lichen planus, endoscopic intralesional esophageal injection of corticosteroids (in all three patients) and oral tacrolimus (FH506) (in two patients) resulted in improvement in dysphagia, a less frequent need for dilation, and improvement in esophageal inflammation.

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Lichen planus in the oesophagus: are we missing something?

Shenfine J, Preston SR
Northen Oesophago-Gastric Unit, Royal Victoria Infirmary,
Newcastle upon Tyne, UK.

Lichen planus of the oesophagus is rare with a predilection for middle-aged to elderly women. There is a potential risk of malignant transformation to squamous cell carcinoma. Squamous cell carcinoma of the oesophagus still accounts for 30-40% of oesophageal cancer cases in the west and is almost exclusively the disease still encountered in the rest of the world. An increased awareness of oesophageal lichen planus is suggested in patients with cutaneous, oral or vulval disease. Endoscopic investigation of patients with lichen planus, possibly initially limited to those with oesophageal symptoms, and consideration of surveillance in patients with proven oesophageal lichen planus, will aid understanding of natural history of lesions and may help detect early stage tumours. Squamous cell carcinoma still accounts for 30-40% of oesophageal cancer cases in the west and is almost exclusively the disease still encountered elsewhere. Lichen planus of the oesophagus is potentially a premalignant condition for squamous cell carcinoma that could be surveilled in order to detect early-stage tumours with a consequent greater chance of cure. Oesophageal lichen planus is, however, rare, frequently asymptomatic and although the majority of cases occur in conjunction with lichen planus in other sites, the oesophageal features may be subtle and easily missed by endoscopic assessment. Furthermore, the histological changes are difficult to interpret and there may be significant underreporting. As a consequence, the true prevalence of these lesions is hard to determine. The difficulties in detection may mean that we are underestimating the frequency of oesophageal lichen planus. Endoscopic detection may be aided by the use of magnification indigo carmine chromoendoscopy and this warrants further evaluation. The risk of malignant transformation is currently unknown but may parallel that of oral lesions at approximately 1-3%. An increased awareness of the condition can only help to identify more cases and increase our understanding of this interesting condition.

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