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Actinic cheilosis graduation? What for?


Robledo F. Rocha

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Some months ago, our admirable colleague Dra. Marcia Lanzoni de Alvarenga Lira warned me that clinicians were starting to request dysplasia grading in cases of actinic cheilosis with the aim of predict malignant transformation and guide a more suitable therapeutic decision for an individual patient. At that time, I still hadn't received such a request. However, things changed somewhat in the last few weeks. Nowadays in my routine practice, clinicians not only started to request dysplasia grading in the new cases of actinic cheilosis, but also in the cases that had been signed out recently.

Nonetheless, and paraphrasing ungraciously a verse written by a great Brazilian poet, actinic cheilosis graduation is a rhyme to malignant transformation, but it is not a solution for predicting the behavior of the disease.

First of all, I believe actinic cheilosis is not precursor of squamous cell carcinoma. In my opinion, actinic cheilosis do not undergo malignant transformation just because it already is squamous cell carcinoma of the lip in early stage, as I explained elsewhere. That's precisely why I prefer the word 'cheilosis' since the Greek suffix -itis means inflammation, so 'chelitis' is etymologically equivalent to 'inflammation of the lip'.

Apart from conceptual and nomenclature problems, actinic cheilosis graduation is worthless. The most widely used dysplasia classification system was outlined on pages 177-179 of the WHO Head and Neck Tumors blue book. As far it carries a low reproducibility and fails in accomplish significant clinicopathologic correlation, a binary system was proposed and successfully improved inter- and intra-examiner agreement, but nothing more than this.

In a master's thesis in Oral Pathology, unfortunately published only in Portuguese, the author concluded that actinic cheilosis lesions adjacent to labial squamous cell carcinoma have shown important genetic alterations similar to the main tumor, although most of them were disproportionately classified as mild/moderate dysplasia according to the WHO system and as low risk according to the binary system. "The results suggest that the application of epithelial dysplasia morphological classification for estimation and decision-making of the treatment in cases of actinic cheilitis may not be appropriate", wrote the author.

In sum, if it weren't worthless, dysplasia grading would be another mandatory item of the checklist in cases of actinic cheilosis and would be recommended by the most prestigious textbooks of Dermatopathology, Head and Neck Pathology, and Oral Pathology.

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