Proliferative Verrucous Leukoplakia: An Update

Review Article

Austin J Dermatolog. 2023; 10(2): 1109.

Proliferative Verrucous Leukoplakia: An Update

Gante J1,2*; Dubuc A1,2,4; Laurencin-Dalicieux S1,3,4; Cousty S1,2,5

1Division of General Dentistry, Health Campus, Paul Sabatie

2Oral surgery Oral Medicine Department, CHU Toulouse, France

3Periodontology Department, CHU Toulouse, France

4CERPOP UMR 1295 INSERM, Paul Sabatier University, Toulouse, France

5LAPLACE UMR CNRS 5213, Paul Sabatier University, Toulouse, France

*Corresponding author: Gante J Oral Surgery Intern, Oral Medicine Department, CHU Toulouse Rangueil, 3 chemin des Maraîchers, 31 400 Toulouse, France. Tel: + 33 6 86 35 84 09 Email: gantejulie@yahoo.fr

Received: September 25, 2023 Accepted: October 19, 2023 Published: October 26, 2023

Abstract

Objectives: Proliferative verrucous leukoplakia was first described by Hansen et al. in 1985. It is a rare form of oral leukoplakia with a high risk of malignant transformation.

A review of the scientific literature indicates that there is no consensus on the management and follow-up of proliferative verrucous leukoplakia.

This article aims to provide an update on the epidemiological, clinical, histological and immunohistochemical, diagnostic, treatment and follow-up data on the disease.

Materials and Methods: We performed a narrative review by searching the Pubmed and Google Scholar databases using keywords.

Results: 93 out of 446 selected articles were selected for analysis.

The majority of affected patients are women. The lesions are multifocal and usually occur on the gingiva and alveolar mucosa. The aetiology is idiopathic. The diagnosis is retrospective and based on the history of the disease. Apart from mapping the lesions using repeated biopsies to detect a malignant area progression, there is no recommended treatment to cure the disease.

Conclusion: The current understanding of this entity is based on the analysis of retrospective studies with weak scientific evidence. Expert recommendations regarding follow-up and management would facilitate better control of recurrence and malignant transformation rates.

Keywords: Multifocal verrucous leukoplakia ; Oral leukoplakia; Proliferative verrucous leukoplakia; Verrucous carcinoma

Introduction

Oral mucosal leukoplakia is a type of potentially malignant oral cavity lesion [1].

Among oral leukoplakias, there is a distinct pathological entity first described by Hansen et al. in 1985: proliferative verrucous leukoplakia (PVL), previously referred to as Oral Florid Papillomatosis (OFP) [2].

The lesions are slow growing, persistent and irreversible with a tendency to be multifocal and almost inevitably proliferate.

In addition to the lack of specific histopathological diagnostic criteria, the wide variety of morphological terminology used to describe the microscopic findings is subject to different interpretations, thus making its diagnosis difficult.

Diagnosis is usually retrospective and depends on the clinician’s ability to recognise its progressive clinical-pathological stages, envisaged as a continuum of diseases from simple oral leukoplakia to squamous cell carcinoma after several years.

The malignant transformation rate is the highest of all potentially malignant lesions in the oral cavity [3].

A review of the scientific medical literature indicates that there is no consensus on the management and follow-up of this condition. The literature describes several treatments: from simple monitoring to invasive surgical treatment, laser excision or non-surgical treatments (medication, chemotherapy, phototherapy, radiotherapy) but there is no gold standard in terms of their efficacy.

In 2007, the World Health Organization (WHO) expert group proposed recommendations on precancerous lesions (1) and in 2020, the WHO updated this classification of potentially malignant lesions, still focused almost exclusively on their clinical features [4]. Despite the imperfection of the term PVL, the workgroup recommended that it continued to be used.

In 2021, a new group of experts, from the American Academy of Oral and Maxillofacial Pathology (AAOMP) and the North American Society of Head and Neck Pathologists (NASHNP), recommended the use of standardised histopathological criteria and appropriate descriptive terminology [5]. However, these criteria have not yet been widely evaluated, particularly in a clinical context.

The rationale for this work is the lack of national or international guidelines on the management of proliferative verrucous leukoplakia from the learned societies of dermatology, oral surgery or maxillofacial surgery.

The purpose of this article is to propose a narrative synthesis on PVL focusing on five themes: (1) epidemiology, (2) clinical, histology and immunohistochemistry, (3) diagnostics, (4) treatment and (5) follow-up.

Materials and Methods

Research Strategy

We performed the literature search by searching the MEDLINE database (Pubmed) and the Google Scholar search engine. The last search was conducted on February 13th 2023. The keywords entered were: proliferative, verrucous, multifocal, leukoplakia and leucoplakia.

The common limits of the queries were as follows:

- Only complete articles written in English and French were selected;

- The publication year of the articles ranged from September 1985 to January 2023;

- Only clinical trials, meta-analysis, systematic reviews, retrospective studies, cohort studies, case-control studies, descriptive epidemiological studies, and case series and case reports dealing exclusively with the treatment used were analysed;

- Case reports and series not dealing exclusively with the treatment used, articles dealing with potentially malignant lesions without mentioning separate data on PVL, letters to the editor, theses, updates or “mini-reviews” of the literature and citations were excluded.

The articles were selected based on the title and abstract and then on the availability of the full text. We also performed additional manual searches using the references of the selected articles.

Results

Screening of Studies

The research strategy yielded 446 publications and article abstracts. 329 were left after removing duplicates. At the end of this procedure, 93 articles were selected for analysis. The flow chart in Figure 1, created according to the PRISMA recommendations, summarises the selection process [6].