Comments on “Malignant transformation of oral squamous cell papilloma: a case report”

To the Editor,

Oral squamous cell papilloma was originally described as a benign neoplasia of the prickle cell layer of the epithelium, which is notable even taking into account the nomenclature of the lesion [1]. Its etiopathogenesis is clearly linked with HPV types 6 and 11 [2,3]. It can also present as a reactive lesion when the virus is not detected [4], although this could be related to a failure in the methodology used for its detection [5].

We read with interest the article entitled “Malignant transformation of oral squamous cell papilloma: a case report” by Saad et al. for the International Journal of Surgery Case Report [6]. Through clinical and histopathological analyses, this study presents the case of an oral squamous cell papilloma in a 61-year-old immunocompromised female patient. In the first clinical presentation, according to Fig. 1 [6], the lesion isn't compatible with the characteristics of an oral squamous cell papilloma, but with the clinical diagnostic hypothesis of at least a verrucous leukoplakia, but most likely a verrucous carcinoma, given we see a white heterogeneous-appearing lesion, with verruciform proliferations, fissures and erosions/ulcerations on its surface [7]. Likewise, the extension of the lesion presented in Fig. 1 [6] reassures that the clinical characteristics are not those found in an oral squamous cell papilloma [8].

Histological analysis (Fig. 2 [6]), shown by the indicated structures pointed out by the blue arrows, are consistent with digitiform projections, although they are not pathognomonic for an oral squamous cell papilloma. Moreover, the extension of the lesion is not compatible with those found in an oral squamous cell papilloma, as well as the clinical characteristics encountered, which should be smaller, most of the times pedunculated and have a larger number of projections. Taking into account the immunosuppressed condition of the patient, multiple papillomatous HPV-related lesions of smaller dimensions would be expected [9] if it would be the case of an HPV-induced lesion.

Also, in Fig. 2 [6], black arrows revealed the presence of hypothetic koilocytes, characterized by pyknotic nuclei, which are also consistent with premalignant lesions, not being exclusive of an oral squamous cell papilloma [10]. Thus, it would be pertinent to present the immunohistochemical test showing positive nuclei for HPV, revealing the cytopathic effect on the cell. In addition, the white arrows point to epithelial cells presenting pyknotic nuclei, since we do not observe individual keratinization of these cells. Furthermore, although the authors discussed the relationship between oral squamous cell papilloma and HPV, and indicated the presence of a papilloma in histological analyses, the viral infection was not confirmed neither by in situ hybridization test, nor by immunohistochemistry. Over and above that, HPV PCR would be advisable if possible [2,11].

The authors reported that after six months the initial lesion clinically extended to the floor of the mouth and to the extraoral skin of the right cheek (Figs. 3 and 4 [6]). Even though the postoperative pathological diagnosis came back as squamous cell carcinoma, they failed to acknowledge that first of all the lesion clinically evolved from an leukoerythroplakia and, most probably, verrucous carcinoma, which should have been a clinical diagnostic hypothesis since the patient's first evaluation [12]. It should be noted that the new WHO classification designates that architectural alterations, such as corrugated, hyperkeratotic, papillary and/or verrucous lesions, even in the absence of cellular atypia, must be considered a mild epithelial dysplasia and should not be neglected [13]. Additionally, the authors describe the subsequent histopathological analysis as a moderately differentiated tumor. However, the images seen in Figs. 5 and 6 [6] do not resemble the description, where a poorly differentiated tumor is clearly seen. In the same images, keratin pearls, prominent nucleolus and mitosis figure are theoretically shown, however, they are pyknotic nucleus (which may also be seen in necrotic cells) and nuclear pleomorphism, respectively, which are most likely features of an epithelium with cellular atypia [14].

The authors set out that this report was based in SCARE Guidelines, however, according to the guideline itself, an “incomplete description of methodologies and clinical details can lead to incomplete understanding and erroneous conclusions” [15,16]. In this matter, the initial diagnostic hypothesis most likely had a direct influence on the outcome of the patient [15,16], which reinforces the need for oral medicine practitioners to always beware of potentially malignant disorders in their differential diagnosis [7].

Ethical approval

Since it is a Letter to the Editor, does not require ethical approval.

Funding

None.

CRediT authorship contribution statement

Study concept or design: Daniel Cohen Goldemberg.

Data collection: Daniela Amorim Marco Peres, Beatriz Nascimento Monteiro da Silva, Tamires Ferreira Alves, Andreia Cristina de Melo, Daniel Cohen Goldemberg.

Data analysis or interpretation: Daniela Amorim Marco Peres, Beatriz Nascimento Monteiro da Silva, Andreia Cristina de Melo, Daniel Cohen Goldemberg.

Writing the paper: Daniela Amorim Marco Peres, Beatriz Nascimento Monteiro da Silva, Tamires Ferreira Alves, Andreia Cristina de Melo, Daniel Cohen Goldemberg.

Guarantor

Daniel Cohen Goldemberg.

Declaration of competing interest

None.