Leukoplakia and erythroplakia: A clinicians perspective and

Journal of Advanced Clinical & Research Insights (2016), 3, 143–146
ORIGINAL ARTICLE
Leukoplakia and erythroplakia: A clinicians perspective
and histopathologist verdict - A retrospective study
S. V. Sreelatha1, Supreetha Chuppa1, Dhivya Bharati1, Chitta Ranjan Chowdhury2, Pushparaj Shetty1
Department of Oral Pathology and Microbiology, A.B. Shetty Memorial Institute of Dental Sciences, Mangalore, Karnataka, India, 2Department of Oral Biology,
A.B. Shetty Memorial Institute of Dental Sciences, Mangalore, Karnataka, India
1
Keywords
Epithelial dysplasia, erythroplakia, leukoplakia
Correspondence
Dr. S.V. Sreelatha, Department of Oral
Pathology and Microbiology, A.B. Shetty
Memorial Institute of Dental Sciences,
Mangalore - 575 018, Karnataka, India.
Phone: +91-9845043804.
E-mail: [email protected]
Received 12 May 2016;
Revised 30 June 2016
doi: 10.15713/ins.jcri.124
Abstract
Background: Precancerous lesions and conditions which are replaced by the term
potentially malignant disorders (PMDs) may precede oral cancer. The PMDs present as
visible clinical changes may belie the true nature of the lesion. Histopathologic diagnosis
is the gold standard in evaluating these lesions for dysplasia and malignant potential. The
aim of the present study is to evaluate the clinicopathological findings of oral leukoplakia
and erythroplakia.
Materials and Methods: Pathological report of cases, which were clinically diagnosed as
leukoplakia and erythroplakia, were studied retrospectively from 2013 to 2015.
Results: Of the 20 cases reviewed, 12 were homogenous leukoplakia, 3 speckled
leukoplakia, and 5 erythroplakia cases. Age ranged from 27 to 77 years. Males 14 and
females 6. The buccal mucosa was the common site. Histopathology study revealed out
of 12 cases of homogenous leukoplakia, 9 showed hyperkeratosis and mild epithelial
dysplasia was seen in 3 cases. In 3 cases of speckled leukoplakia, mild epithelial dysplasia
was seen in 2 cases (2/3) and severe epithelial dysplasia was seen in 1 case (1/3). In
5 cases of erythroplakia, 2 showed mild dysplasia, 1 showed severe dysplasia, and 1
squamous cell carcinoma (SCC).
Conclusion: Oral leukoplakia and erythroplakia can demonstrate a wide spectrum of
histopathological features ranging from hyperkeratosis, dysplasia to SCC.
Introduction
Leukoplakia and erythroplakia are the two prevalent oral
potentially malignant disorders (OPMDs). OPMDs include
both premalignant lesions and conditions, which shows higher
risk of transformation to malignancy, especially in the form of
oral squamous cell carcinoma (OSCC).[1,2]
OPMDs may indicate an increased risk for malignancy not
only at the site of the lesion but also in normal appearing oral
mucosa. The World Health Organization (WHO) working
group on oral cancer have included the following lesions
under OPMDs, which includes leukoplakia, erythroplakia, oral
submucous fibrosis, palatal changes associated with reverse
smoking, oral lichen planus, and discoid lupus erythematosus.[3]
The histopathologic evidence in the form of presence and
the degree of epithelial dysplasia are the important and best
predictors for indicating the risk of malignancy. The clinical
presentation of OPMDs may present with varying microscopic
evidence ranging from hyperkeratosis to epithelial dysplasia,
to SCC. Epithelial dysplasia has susceptibility for malignant
transformation in the range of 5-18%.[4] The histopathological
study is the best predictor in the evaluation of malignancy
in OPMDs. The objective of our study was to evaluate the
relevance of histopathological findings in lesions presenting as
oral leukoplakia and erythroplakia.
Materials and Methods
A retrospective study was conducted in the Department of Oral
Pathology from January 2013 to December 2015, in which the
cases were selected based on inclusion and exclusion criteria.
The cases, which were clinically diagnosed as leukoplakia
and erythroplakia and associated with tobacco habit, were
included for the study. The cases which did not have the clinical
records were excluded from the study. Pathologic report of
20 cases of the patients was retrieved and reviewed in detail
which fulfilled the preset criteria. Clinical features, which were
Journal of Advanced Clinical & Research Insights ● Vol. 3:4 ● Jul-Aug 2016143
Sreelatha, et al.
recorded, include age, gender, site, clinical diagnosis, and their
histopathological findings. The presence of epithelial dysplasia
was graded using the WHO 2005 grading. They were graded as:
Mild epithelial dysplasia, moderate epithelial dysplasia, severe
epithelial dysplasia, and carcinoma in situ. Architectural changes,
which involved the lower one-third of the epithelium along
with the cytological atypia, were considered as mild epithelial
dysplasia. Architectural changes, which involved the middle
third of the epithelium, were graded as moderate epithelial
dysplasia. Architectural changes extending more than 2/3rd of
the epithelium and the increased number of the cytological
atypia were graded as severe epithelial dysplasia. Full thickness of
the epithelium exhibiting architectural disturbances, abnormal
superficial mitosis, and atypical figures was included under
carcinoma in situ.[5] Results were then correlated with the clinical
diagnosis.
Results
A total of 20 cases were selected for the study which met the
inclusion criteria. The age ranged from 27 to 77 years, with a
mean age of occurrence was seen involving 54 years. The age
group commonly affected was 40-60 years. Male predilection
was seen in the ratio of male to female of 7:3. Table 1 summarizes
the patient’s age distribution in the study group.
Clinical presentation was seen to involve a single site,
commonly affected was buccal mucosa and next the tongue.
In 3 patients, it was observed that there was multiple site
involvement. The site of involvement is shown in Table 2.
In the clinical presentation, out of the 20 cases, 12 presented
with homogenous leukoplakia [Figure 1], 5 being erythroplakia,
and 3 were speckled leukoplakia.
Histopathology report of 12 cases of homogenous leukoplakia
showed hyperkeratosis in 9/12 [Figure 2], and mild epithelial
dysplasia was seen in 3/12 [Figure 3]. Histopathology report of
5 cases of erythroplakia was diagnosed as mild dysplasia in 3/5,
severe dysplasia in 1/5, and 1 case of SCC were reported (1/5)
[Figure 4]. The histopathology report of 3 cases of speckled
leukoplakia was diagnosed as mild epithelial dysplasia in 2/3 and
severe dysplasia in 1/3 as depicted in the Table 3.
A clinicopathologic retrospective study of oral leukoplakia and erythroplakia
Figure 1: Clinical picture: It shows homogenous leukoplakia on the
right buccal mucosa
Figure 2: Hyperkeratosis with no dysplasia (H and E, ×100)
Discussion
Leukoplakia is defined as ‘‘A white plaque of questionable risk
having excluded (other) known diseases or disorders that carry
no increased risk for cancer.” Leukoplakia can present in any
location in the oral cavity. Leukoplakia can be divided clinically
as a homogeneous type (flat, thin, uniform white) and a nonhomogeneous type. The non-homogeneous type has been defined
as erythroleukoplakia/speckled (a white and red lesion) that may be
either irregularly flat or nodular.”[6] Leukoplakia has the prevalence
rate of approximately 2%. The rate of malignant transformation in
oral leukoplakia varies among studies, ranging from <1% to 20%.
144
Figure 3: Mild epithelial dysplasia: Dysplastic feature seen in
basal and suprabasal cell layer of stratified squamous epithelium
(H and E, ×400)
Journal of Advanced Clinical & Research Insights ● Vol. 3:4 ● Jul-Aug 2016
Sreelatha, et al.
A clinicopathologic retrospective study of oral leukoplakia and erythroplakia
reported a prevalence rate of erythroplakia to vary in the range of
0.02% and 0.83%.[7]
Erythroplakia cases on histopathologic study most often
show epithelial dysplasia of varying grade and may even show
carcinoma in situ or SCC.[8] The cases presenting clinically as
erythroplakia are rare, and hence, there are very few documented
data that would reliably predict its malignancy potential.[6]
The concept of oral cancer development being a two-step
process that is the initial presence of a precursor lesion which
subsequently develops into cancer has been accepted. Oral
leukoplakia and erythroplakia are well-known precursor lesions
hence our aim was to find a clinicopathologic correlation of these
common precursor lesions.
Our study showed leukoplakia and erythroplakia cases
presented mainly in the fifth decade of life. However, in a study
done by Scott and Cheah (1989),[9] the result showed that the
sixth and seventh decades as the common age of occurrence.
Liu et al., in 2010,[10] conducted a study on potentially malignant
lesions which showed a higher incidence in fifth decade; this
finding was similar in our study, which is a decade earlier than
the previous studies. There was one case seen in a 27 year
old this could be attributed to the easier access to gutka/pan
masala, smoking, peer pressure, and advertisement in media,
e.g., television and the internet may be the cause for a change in
the trend that we have seen.
In our study, there was an increase presentation seen in males
compared to females in a ratio of male to female that is 7:3.
Studies conducted by Liu et al.,[10] Dietrich et al.,[11] and Misra
et al.[12] also showed increase incidence in males. The reason for
greater incidence in males is due to increase use of tobacco in
males.
We found that most of the cases presented with lesions
involving a single site which was seen on the buccal mucosa most
commonly and then on the lateral border of the tongue. Similar
result was seen in studies conducted by Misra et al.[12] and Lee
et al.[13] but not in accordance with results of Liu et al.,[10] in which
the common site of involvement was the tongue.
In our study, the most common case was of homogenous
leukoplakia (12) followed by erythroplakia (5) and speckled
leukoplakia (3). Histopathological finding of homogenous
leukoplakia was mainly hyperkeratosis followed by mild
epithelial dysplasia. In cases diagnosed as speckled leukoplakia,
histopathological study showed mild and severe dysplasia, and
in erythroplakia cases, its histopathologic diagnosis was mild
epithelial dysplasia, severe epithelial dysplasia, and one case
of SCC. A study conducted, in 2006, by Holmstrup et al.[14]
showed, out of 236 patients, there were 39 cases of homogenous
Erythroplakia is defined as ‘‘A fiery red patch that cannot be
characterized clinically or pathologically as any other definable
disease.” The clinical presentation may be flat or depressed with
a smooth or granular surface. Non-homogeneous leukoplakia
(‘‘erythroleukoplakia”) presents as a mixed red and white lesion.
The important etiologic factors are considered to be tobacco and
alcohol use. Studies conducted in South- and Southeast-Asia has
Figure 4: Squamous cell carcinoma: It shows dysplastic epithelium
invading the connective tissue (H and E, ×100)
Table 1: The age distribution of patients in the study group
Age group (years)
21‑30
Number of patients
2
31‑40
2
41‑50
2
51‑60
8
61‑70
5
71‑80
1
Table 2: The site of involvement
Site of the lesion
Buccal mucosa
Number of patients
10
Tongue
3
Gingival
2
Vestibule
1
Retromolar trigone
1
Multiple sites
3
Table 3: Correlation of histopathology with clinically diagnosed cases of leukoplakia and Erythroplakia
Cases
Homogenous
Number of cases
12
Hyperkeratosis
9
Mild epithelial dysplasia
3
Severe epithelial dysplasia
0
Squamous cell carcinoma
0
Speckled
3
0
2
1
0
Erythroplakia
5
0
3
1
1
Journal of Advanced Clinical & Research Insights ● Vol. 3:4 ● Jul-Aug 2016145
Sreelatha, et al.
leukoplakia, 46 cases were non-homogenous leukoplakia, and
9 cases were erythroplakia. Epithelial dysplasia was seen in
71% of the cases. 20% of non-homogenous leukoplakia showed
malignant development and only 3% of the homogenous
leukoplakia developed malignancy. The present study showed
that most of the cases presented as homogenous leukoplakia while
erythroplakia was uncommon which was similar to the previous
studies. Lee et al.[13] conducted a study, in which 1046 patients
were selected who were diagnosed as oral leukoplakia, 408 cases
showed only epithelial hyperplasia, and/or hyperkeratosis,
477 cases presented with epithelial dysplasia. Out of 477 cases,
200 cases showed mild dysplasia, 234 showed moderate, 43
showed severe, and 135 cases showed invasive SCC. The
incidence of malignancy in our study was seen in only one case
that is in case of erythroplakia.
Above finding necessitates the need for taking biopsies and
histopathologic diagnosis of cases which are clinically diagnosed
as speckled leukoplakia and erythroplakia. In our study, tobacco
was the only habit recorded since it was a retrospective study
some of the files did not have detailed information of the duration
and frequency of the habits. Tobacco was the most prevalent of
the habits recorded.
Future prospects for the study would be to consider all the
OPMD which are clinically diagnosed and histopathologically
studied using a larger sample and with better evidence.
Conclusion
Our study result showed that the incidence of leukoplakia and
erythroplakia was higher in males in the ratio of 7:3. Age of
presentation was commonly seen in the fifth decade. Clinical
presentation commonly showed homogenous leukoplakia.
Histopathological evidence showed a wide range of presentation
ranging from hyperkeratosis to epithelial dysplasia of varying
grade to frank SCC. Hence, we would emphasize that followup of the patients and counseling regarding cessation of the risk
factors are measures to be taken and biopsy is the gold standard
for diagnosis or to rule out malignancy, especially in cases of
erythroplakia and speckled leukoplakia.
References
1. Farah CS, Woo SB, Zain RB, Sklavounou A, McCullough MJ,
Lingen M. Oral cancer and oral potentially malignant disorders.
Int J Dent 2014;2014:853479.
146
A clinicopathologic retrospective study of oral leukoplakia and erythroplakia
2.Sarode SC, Sarode GS, Tupkari JV. Oral potentially
malignant disorders: A proposal for terminology and
definition with review of literature. J Oral Maxillofac Pathol
2014;18 Suppl 1:S77-80.
3. Hosagadde S, Dabholkar J, Virmani N. A clinicopathological
study of oral potentially malignant disorders. J Head Neck
Physicians Surg 2016;4:29-34.
4. Lumerman H, Freedman P, Kerpel S. Oral epithelial dysplasia
and the development of invasive squamous cell carcinoma. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:321-9.
5. Sadiq H, Gupta P, Singh N, Thakar SS, Prabhakar I, Thakral J.
Various grading systems of the oral epithelial dysplasia:
A review. Int J Adv Health Sci 2015;1:20-6.
6. van der Waal I. Potentially malignant disorders of the oral and
oropharyngeal mucosa; terminology, classification and present
concepts of management. Oral Oncol 2009;45:317-23.
7. Gupta PC, Mehta FS, Daftary DK, Pindborg JJ, Bhonsle RB,
Jalnawalla PN, et al. Incidence rates of oral cancer and natural
history of oral precancerous lesions in a 10-year follow-up
study of Indian villagers. Community Dent Oral Epidemiol
1980;8:283-333.
8.Reichart PA, Philipsen HP. Oral erythroplakia – A review. Oral
Oncol 2005;41:551-61.
9. Scott J, Cheah SB. The prevalence of oral mucosal lesions in the
elderly in a surgical biopsy population: A retrospective analysis
of 4042 cases. Gerodontology 1989;8:73-8.
10.Liu W, Wang YF, Zhou HW, Shi P, Zhou ZT, Tang GY. Malignant
transformation of oral leukoplakia: A retrospective cohort study
of 218 Chinese patients. Cancer 2010;10:685.
11.Dietrich T, Reichart PA, Scheifele C. Clinical risk factors of oral
leukoplakia in a representative sample of the US population.
Oral Oncol 2004;40:158-63.
12.Misra V, Singh PA, Lal N, Agarwal P, Singh M. Changing pattern
of oral cavity lesions and personal habits over a decade: Hospital
based record analysis from Allahabad. Indian J Community
Med 2009;34:321-5.
13.Lee JJ, Hung HC, Cheng SJ, Chen YJ, Chiang CP, Liu BY,
et al. Carcinoma and dysplasia in oral leukoplakias in Taiwan:
Prevalence and risk factors. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2006;101:472-80.
14.Holmstrup P, Vedtofte P, Reibel J, Stoltze K. Long-term
treatment outcome of oral premalignant lesions. Oral Oncol
2006;42:461-74.
How to cite this article: Sreelatha SV, Chuppa S, Bharati D,
Chowdhury CR, Shetty P. Leukoplakia and erythroplakia:
A clinicians perspective and histopathologist verdict - A
retrospective study. J Adv Clin Res Insights 2016;4:143-146.
Journal of Advanced Clinical & Research Insights ● Vol. 3:4 ● Jul-Aug 2016