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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 5  |  Issue : 2  |  Page : 245-247

Oral lichen sclerosus in a breast cancer patient on anastrozole therapy: A case report with brief review of literature


Department of Medical Oncology, Rajiv Gandhi Cancer Institute and Research centre, New Delhi, India

Date of Web Publication15-Dec-2017

Correspondence Address:
Chaturbhuj Agrawal
Department of Medical Oncology, Rajiv Gandhi Cancer Institute and Research Centre, Rohini, New Delhi - 110 085
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_17_17

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  Abstract 

Aromatase inhibitors are approved hormonal agents for the treatment of breast cancer since the past few decades. These agents are usually well tolerated except some common side effects seen in day-to-day practice such as arthralgia and mood changes. Some of the side effects of these agents are still very uncommon and must be considered in differential diagnosis while evaluating these patients on follow-up as this therapy is usually taken for prolonged time period and careful risk–benefit assessment must be done before considering discontinuation of therapy. In this conversation, we report the occurrence of lichen sclerosis of oral cavity in an elderly female suffering from breast cancer who developed it while being on anastrozole therapy.

Keywords: Anastrozole, aromatase inhibitors, lichen sclerosus


How to cite this article:
Agrawal C, Pradeep Babu K V, Dash PK, Saini R. Oral lichen sclerosus in a breast cancer patient on anastrozole therapy: A case report with brief review of literature. Arch Med Health Sci 2017;5:245-7

How to cite this URL:
Agrawal C, Pradeep Babu K V, Dash PK, Saini R. Oral lichen sclerosus in a breast cancer patient on anastrozole therapy: A case report with brief review of literature. Arch Med Health Sci [serial online] 2017 [cited 2018 Sep 22];5:245-7. Available from: http://www.amhsjournal.org/text.asp?2017/5/2/245/220821




  Introduction Top


Aromatase inhibitors (AI) are well-approved agents for the treatment of breast cancer in both adjuvant and metastatic setting either alone (in postmenopausal women) or in combination with ovarian function suppression (in premenopausal women). The three main approved agents in this class include exemestane, anastrozole, and letrozole. As a group, they are relatively safe and well-tolerated drug; however, some of the side effects of this therapy can be disabling. These includes certain nonspecific side effects such as arthralgia, asthenia, headache, nausea, peripheral edema, fatigue, and vomiting, while some endocrinological side effects that can be seen include hot flushes and vaginal dryness. In advanced breast cancer, these side effects result in treatment withdrawal in <4% of cases.[1] The most significant among these side effects is arthralgia occurring in many patients. In multicenter Arimidex, Tamoxifen, Alone or in Combination trial, arthralgia was seen in up to 35% of patients on anastrozole.[2] There are well-defined criteria for diagnosis of AI-induced arthralgia, and well-defined algorithms are available for the management of the same.[3] However, some of the uncommon side effects are very little extrapolated in literature due to the paucity of data and lack of well-defined algorithms and guidelines for their management. However, the treating physician/oncologist must be aware about these uncommon side effects as patients usually take these drugs for prolonged periods of times (5–10 years in adjuvant setting and till disease progression in metastatic setting). Herein, we describe an elderly female who developed lichen sclerosis of oral cavity while being on anastrozole therapy.


  Case Report Top


A 56-year-old female is diagnosed as a case of Stage II carcinoma breast 4 years back. She underwent modified radical mastectomy for the same, and final histopathology revealed a 3.2 cm × 3 cm infiltrating ductal carcinoma of right breast. The tumor was estrogen receptor positive, and none of the sentinel nodes were positive out of total ten nodes examined. She received adjuvant anthracycline- and taxane-based chemotherapy for a total of six cycles followed by adjuvant hormonal therapy. In view of postmenopausal status, she was started on anastrozole therapy as adjuvant hormonal therapy (tablet Arimidex 1 mg OD). She experienced mild side effects in the form of bilateral knee arthralgia and infrequent insomnia post 6 months of therapy which subsided with symptomatic treatment. Three years later, while on anastrozole, she reported dryness of mouth with whitish nonscrapable patches over the tongue which were gradual in onset and slowly increasing [Figure 1]. There was no history of associated pain or bleeding or similar lesions elsewhere in the body. Medical history otherwise was insignificant. A formal dermatological consult was taken, and she was diagnosed as a case of oral lichen sclerosus on clinical grounds. A causality assessment using Naranjo nomogram [13] was done for evaluating the causal role of anastrozole for these dermatological sequelae which revealed a probable adverse drug reaction [Table 1].
Figure 1: Clinical picture of patient showing oral whitish nonscrapable lesions over tongue suggestive of lichen sclerosus

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Table 1: Causality assessment using Naranjo Nomogram

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Her symptoms improved with temporary withdrawal of anastrozole therapy and application of topical steroids.


  Discussion Top


Lichen sclerosus is a chronic inflammatory disease of unknown origin, which affects not only mostly women in the fifth and sixth decades of life but can also occur in men and children. The disease usually runs a chronic, progressive, protracted course with exacerbations and remissions but spontaneous remissions are uncommon. The lesions are most commonly found on the skin and anogenital region (affected in 80% of cases) and are characterized by white atrophic macula.[4] The involvement of the oral mucosa alone or together with other forms of presentation is extremely rare, requiring a differential diagnosis with other diseases of the oral cavity, particularly lichen planus and oral lichenoid reaction. Oral lichen planus is also a chronic mucocutaneous disorder characterized by recurrent, itchy lesions more frequent on buccal mucosa near molars. The clinical criteria to diagnose lichen planus and histologically similar oral lichenoid reaction are characteristic symmetrical, almost always bilateral lesions, presence of Wickham's striae (fine white lines arising radially from the papules).[5],[6] However, there were no such features in our case. The second important differential diagnosis is oral lichenoid reactions which is clinically and histologically similar to oral lichen planus, with the only difference that in the former, the cause is clearly identifiable. Among the known causes of oral lichenoid reactions important one mentioned in literature are antihypertensives, antimalarials, and nonsteroid anti-inflammatory drugs.[7] Anastrozole has not been reported till date to have any relation with either of these conditions. Moreover, the clinical features do not fit into either lichen planus or lichenoid reaction as discussed earlier. There are <30 cases of lichen sclerosus in the oral mucosa described in the literature, and there are no reports on malignant transformation so far.[8] Diagnosis is mainly clinical; however, a punch biopsy may be done if diagnosis is in doubt. The association of lichen sclerosus with anastrozole has been previously described in literature, but the data are very sparse regarding the same with only a few case reports published.[9] Moreover, oral lichen sclerosus in association with this therapy is further rare. Treatment of oral lichen sclerosus is usually unnecessary because of its asymptomatic nature, benign behavior, few cosmetic concerns, and no evidence of recurrence.[10] Topical application of corticosteroids has been reported, the outcome being variable.[11] Literature shows successful treatment of refractory generalized extragenital lichen sclerosus with pulsed high-dose corticosteroids combined with methotrexate.[12] In our case, the patient has shown symptomatic improvement with temporary withdrawal of anastrozole from treatment schedule and application of topical steroids. Diagnosis of these rare dermatological sequelae of anastrozole requires a high degree of suspicion by the treating physician/oncologist.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Goss PE. Risks versus benefits in the clinical application of aromatase inhibitors. Endocr Relat Cancer 1999;6:325-32.  Back to cited text no. 1
[PUBMED]    
2.
Howell A, Cuzick J, Baum M, Buzdar A, Dowsett M, Forbes JF, et al. Results of the ATAC (Arimidex, Tamoxifen, Alone or in Combination) trial after completion of 5 years' adjuvant treatment for breast cancer. Lancet 2005;365:60-2.  Back to cited text no. 2
[PUBMED]    
3.
Niravath P. Aromatase inhibitor-induced arthralgia: A review. Ann Oncol 2013;24:1443-9.  Back to cited text no. 3
[PUBMED]    
4.
Jiménez Y, Gavaldá C, Carbonell E, Margaix M, Sarrión G. Lichen sclerosus of the oral mucosa: A case report. Med Oral Patol Oral Cir Bucal 2008;13:E403-6.  Back to cited text no. 4
    
5.
Abbate G, Foscolo AM, Gallotti M, Lancella A, Mingo F. Neoplastic transformation of oral lichen: Case report and review of the literature. Acta Otorhinolaryngol Ital 2006;26:47-52.  Back to cited text no. 5
[PUBMED]    
6.
Eisen D. The clinical features, malignant potential, and systemic associations of oral lichen planus: A study of 723 patients. J Am Acad Dermatol 2002;46:207-14.  Back to cited text no. 6
[PUBMED]    
7.
Scully C, Carrozzo M. Oral mucosal disease: Lichen planus. Br J Oral Maxillofac Surg 2008;46:15-21.  Back to cited text no. 7
[PUBMED]    
8.
Louvain D, Jacques CM, Ferreira AF, Carneiro LH, Quintella L, Cuzzi T, et al. Lichen sclerosus in the oral mucosa: A rare form of presentation. nation 2012;4:6-10.  Back to cited text no. 8
    
9.
Potter JE, Moore KA. Lichen sclerosus in a breast cancer survivor on an aromatase inhibitor: A case report. J Gen Intern Med 2013;28:592-5.  Back to cited text no. 9
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10.
Jensen T, Worsaae N, Melgaard B. Oral lichen sclerosus et atrophicus: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:702-6.  Back to cited text no. 10
[PUBMED]    
11.
Buajeeb W, Kraivaphan P, Punyasingh J, Laohapand P. Oral lichen sclerosus et atrophicus. A case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:702-6.  Back to cited text no. 11
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12.
Kreuter A, Tigges C, Gaifullina R, Kirschke J, Altmeyer P, Gambichler T. Pulsed high-dose corticosteroids combined with low-dose methotrexate treatment in patients with refractory generalized extragenital lichen sclerosus. Arch Dermatol 2009;145:1303-8.  Back to cited text no. 12
[PUBMED]    
13.
Busto U, Naranjo CA, Sellers EM. Comparison of two recently published algorithms for assessing the probability of adverse drug reactions. Br J Clin Pharmacol 1982;13:223-7.  Back to cited text no. 13
[PUBMED]    


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