High prevalence of esophageal involvement in lichen planus: a study using magnification chromoendoscopy

Background and study aims: The first cases of squamous cell carcinoma in esophageal lichen planus were recently described. We performed a study to establish the prevalence of endoscopic and histopathologic abnormalities consistent with lichen planus and (pre-) malignancy in a cohort of patients with lichen planus.

Patients and methods: A total of 24 patients with lichen planus were prospectively studied using high-magnification chromoendoscopy. Focal esophageal abnormalities were mapped, classified, and biopsied. Biopsies were also taken from normal-appearing esophageal mucosa at three levels (proximal, middle, and distal). The presence of a lymphohistiocytic interface inflammatory infiltrate and Civatte bodies (i. e. apoptotic basal keratinocytes) at histopathologic examination was considered diagnostic for esophageal lichen planus. Symptoms were assessed using validated questionnaires.

Results: A total of 38 focal abnormalities were biopsied. These consisted of: layers of mucosa peeling off, hyperemic lesions, papular lesions, submucosal plaques/papules, a flat polypoid lesion, and segments of cylindrical epithelium. No endoscopic signs of dysplasia were present. Esophagitis consistent with gastroesophageal reflux disease was noted in 12 / 24 patients. Histopathology showed chronic inflammation of the esophageal mucosa in the majority (18 / 24) of patients. In 50 % (12 / 24), the diagnosis of esophageal lichen planus was made. Dysplasia was not present. There were no differences in symptoms between patients with and without esophageal lichen planus.

Conclusions: At screening endoscopy a high prevalence (50 %) of esophageal lichen planus was found in patients with orocutaneous lichen planus. No dysplasia was found.

References

• 1 Eisen D. The evaluation of cutaneous, genital, scalp, nail, esophageal, and ocular involvement in patients with oral lichen planus.  Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999;  88 431-436
• 2 Eisen D. The clinical manifestations and treatment of oral lichen planus.  Dermatol Clin. 2003;  21 79-89
• 3 Lodi G, Scully C, Carrozzo M. et al . Current controversies in oral lichen planus: report of an international consensus meeting. Part 2. Clinical management and malignant transformation.  Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;  100 164-178
• 4 van der Meij E H, Schepman K P, van der Waal I. The possible premalignant character of oral lichen planus and oral lichenoid lesions: a prospective study.  Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;  96 164-171
• 5 Al-Shihabi B M, Jackson J M. Dysphagia due to pharyngeal and oesophageal lichen planus.  J Laryngol Otol. 1982;  96 567-571
• 6 Sheehan-Dare R A, Cotterill J A, Simmons A V. Oesophageal lichen planus.  Br J Dermatol. 1986;  115 729-730
• 7 van MP , Gunther M, Groth W. et al . Lichen ruber mucosae with esophageal involvement.  Endoscopy. 1988;  20 158-160
• 8 Celinski K, Krasowska D, Pokora J, Lecewicz-Torun B. Esophageal lichen planus.  Endoscopy. 1994;  26 755-756
• 9 Ali A, Runzi M, Rosien U. et al . Lichen planus esophagitis with secondary candidiasis: successful combination treatment with ketoconazole and a corticosteroid.  Endoscopy. 1996;  28 460
• 10 Bobadilla J, van der Hulst R W, ten Kate F J, Tytgat G N. Esophageal lichen planus.  Gastrointest Endosc. 1999;  50 268-271
• 11 Harewood G C, Murray J A, Cameron A J. Esophageal lichen planus: the Mayo Clinic experience.  Dis Esophagus. 1999;  12 309-311
• 12 Abraham S C, Ravich W J, Anhalt G J. et al . Esophageal lichen planus: case report and review of the literature.  Am J Surg Pathol. 2000;  24 1678-1682
• 13 Ukleja A, DeVault K R, Stark M E, Achem S R. Lichen planus involving the esophagus.  Dig Dis Sci. 2001;  46 2292-2297
• 14 Westbrook R, Riley S. Esophageal lichen planus: case report and literature review.  Dysphagia. 2008;  23 331-334
• 15 Chandan V S, Murray J A, Abraham S C. Esophageal Lichen Planus.  Arch Pathol Lab Med. 2008;  132 1026-1029
• 16 Chryssostalis A, Gaudric M, Terris B. et al . Esophageal lichen planus: a series of eight cases including a patient with esophageal verrucous carcinoma. A case series.  Endoscopy. 2008;  40 764-768
• 17 Dickens C M, Heseltine D, Walton S, Bennett J R. The oesophagus in lichen planus: an endoscopic study.  BMJ. 1990;  300 84
• 18 Calabrese C, Fabbri A, Benni M. et al . Squamous cell carcinoma arising in esophageal lichen planus.  Gastrointest Endosc. 2003;  57 596-599
• 19 Schwartz M P, Sigurdsson V, Vreuls W. et al . Two siblings with lichen planus and squamous cell carcinoma of the oesophagus.  Eur J Gastroenterol Hepatol. 2006;  18 1111-1115
• 20 Talley N J, Verlinden M, Jones M. Validity of a new quality of life scale for functional dyspepsia: a United States multicenter trial of the Nepean Dyspepsia Index.  Am J Gastroenterol. 1999;  94 2390-2397
• 21 Lundell L R, Dent J, Bennett J R. et al . Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification.  Gut. 1999;  45 172-180
• 22 Endoscopic C lassification. Update on the paris classification of superficial neoplastic lesions in the digestive tract.  Endoscopy. 2005;  37 570-578
• 23 Kumagai Y, Inoue H, Nagai K. et al . Magnifying endoscopy, stereoscopic microscopy, and the microvascular architecture of superficial esophageal carcinoma.  Endoscopy. 2002;  34 369-375
• 24 Ohashi A, Niwa Y, Ohmiya N. et al . Quantitative analysis of the microvascular architecture observed on magnification endoscopy in cancerous and benign gastric lesions.  Endoscopy. 2005;  37 1215-1219
• 25 Sanli H, Cetinkaya H, Tursen U. et al . Upper gastrointestinal findings in oral lichen planus.  Turk J Gastroenterol. 2002;  13 31-34
• 26 Nandurkar S, Talley N J, Martin C J. et al . Esophageal histology does not provide additional useful information over clinical assessment in identifying reflux patients presenting for esophagogastroduodenoscopy.  Dig Dis Sci. 2000;  45 217-224
• 27 Takubo K, Honma N, Aryal G. et al . Is there a set of histologic changes that are invariably reflux associated?.  Arch Pathol Lab Med. 2005;  129 159-163
• 28 Vieth M, Peitz U, Labenz J. et al . What parameters are relevant for the histological diagnosis of gastroesophageal reflux disease without Barrett"s mucosa?.  Dig Dis. 2004;  22 196-201
• 29 Zentilin P, Savarino V, Mastracci L. et al . Reassessment of the diagnostic value of histology in patients with GERD, using multiple biopsy sites and an appropriate control group.  Am J Gastroenterol. 2005;  100 2299-2306
• 30 Ronkainen J, Aro P, Storskrubb T. et al . High prevalence of gastroesophageal reflux symptoms and esophagitis with or without symptoms in the general adult Swedish population: a Kalixanda study report.  Scand J Gastroenterol. 2005;  40 275-285
• 31 Labenz J, Jaspersen D, Kulig M. et al . Risk factors for erosive esophagitis: a multivariate analysis based on the ProGERD study initiative.  Am J Gastroenterol. 2004;  99 1652-1656
• 32 Calabrese C, Fabbri A, Bortolotti M. et al . Dilated intercellular spaces as a marker of oesophageal damage: comparative results in gastro-oesophageal reflux disease with or without bile reflux.  Aliment Pharmacol Ther. 2003;  18 525-532
• 33 Tobey N A, Carson J L, Alkiek R A, Orlando R C. Dilated intercellular spaces: a morphological feature of acid reflux-damaged human esophageal epithelium.  Gastroenterology. 1996;  111 1200-1205
• 34 Tobey N A, Hosseini S S, Argote C M. et al . Dilated intercellular spaces and shunt permeability in nonerosive acid-damaged esophageal epithelium.  Am J Gastroenterol. 2004;  99 13-22
• 35 Vieth M, Fiocca R, Haringsma J. et al . Radial distribution of dilated intercellular spaces of the esophageal squamous epithelium in patients with reflux disease exhibiting discrete endoscopic lesions.  Dig Dis. 2004;  22 208-212