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Squamous Cell Carcinoma Complicating Plaque of Lupus Erythematosus-A Case Series

Lupus Erythematosus is a multisystem disorder with a wide spectrum of clinical presentations ranging from cutaneous involvement to widespread systemic involvement. Squamous cell carcinoma formation in cutaneous lesions of LE is rare but had greater chances of metastases. Here, we report two cases, one of Discoid Lupus Erythematosus and other of Systemic Lupus Erythematosus complicated by development of squamous cell carcinoma over cutaneous lesions.


PRESENTATION OF CASE
A 35-year-old female, a known case of systemic lupus erythematosus since 8 years, who is on irregular treatment, came with complaints of exophytic growth over the lower lip since last three months. It later progressed in size gradually to size of 2 X 3 cm approximately. Since one week, burning sensation over the lesions was present. There was development of ulcers over preexisting lesions over her back and legs. There was history of scaling and crusting over the lesions. Patient had photosensitivity and arthalgia of small joints of her hands, wrists and shoulders. She is also a known case of seizure disorder and is on regular treatment for the same on the advice of neurologist. On inspection, multiple hypopigmented discoid scaly lesions over face, scalp, posterior neck and extremities were seen. [Figs. 1A and 1B ] Few of the lesions were erythematous and ulcerated with crust formation. Scarring alopecia of the scalp was seen. Patient had an exophytic mass of size 2x2 cm over her lower lip with crust formation. It was non-tender and firm on palpation. A biopsy was taken from the lesion which showed proliferative epidermal mass, keratin pearls and features of atypicality yielding a diagnosis of squamous cell carcinoma. [Figs. 2A, 2B] Patient was then referred to general surgery and wide local surgical excision was performed. Hydroxychloroquine and systemic prednisolone with other supportive medications were given as a treatment of SLE.
Another case of 50yr old female came with chief complaints of hyperpigmented elevated lesions with central depigmentation over right shoulder and lips since 1.5 years followed by development of a verrucous plaque over right shoulder since 2 months for which she was on treatment. History of photosensitivity was present. On examination, verrucous growth was seen over the depigmented scaly plaque over the right shoulder. [Fig. 3] Similar depigmented lesion seen over the lip. There is no tenderness, no ulceration. A biopsy was performed from the verrucous lesion which showed features of atypicality and keratin pearls. [Fig. 4A, 4B] Hence, a diagnosis of Squamous cell carcinoma was made. Wide local surgical excision was done by the general surgeon. Patient was started on hydroxychloroquine as a treatment for lupus erythematosus.

DISCUSSION
Lupus erythematosus is a multisystem autoimmune disorder which prominently affects the skin.It mainly occurs due to production of autoantibodies against own body tissue components which later leads to formation of antigen-antibody complexes which cause inflammation and injury to the tissue. Nucleic acid and their associated protein constituent of cell nuclei are targetted by autoantibodies,called as anti-nuclear antibodies (ANA).Other autoantibodies like anti-dsDNA, anti-Sm, anti-la ,anti-ro can also be detected. There are few factors which prompts the onset and progression of the disease which include ultraviolet radiation, medications, Epstein-barr virus infection, emotional stress, estrogen levels [3]. In Indian population, development of SCC over DLE in the is found to be 0.98% to 3.4% with a male-tofemale ratio of 1.6:1 [4]. In SCC development, preference for lips might be due to reasons like, it being a common site of DLE, constant sun exposure, tobacco use, and irritation from food [5]. These factors may accelerate carcinogenic process in turn leading to shorter time for development of carcinoma after DLE diagnosis [6]. Fitzpatrick skin type I,II and 3 are more prone for Squamous cell carcinoma [7]. Prognosis of the actual LE disease is considered to be poor when development of carcinoma is seen [8]. Long term follow up for such patients is warranted as there are high chances of recurrences [9]. The interval between development of DLE and SCC has varied from 4 to 20 years [10].

CONCLUSION
Development of malignancy over discoid lesions of LE is rare. However, close follow up of lesion with supervision for any atypical changes is important. These SCC as well as the disease LE as such both are more severe when associated with each other in comparison to conventional ones. Thus, here dermatologists play important role in suspecting SCC in early stage. In turn, early treatment can limit the spread in early stages itself.

ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s).

CONSENT
As per international standard or university standard, patients' written consent has been collected and preserved by the author(s).