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A presidential viewpoint: “Nobody knew that benign vascular lesions of the lip could be so complicated”

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By Warren R. Heymann, MD
April 14, 2017

Well, maybe not as befuddling as replacing Obamacare, but there may be occasional difficulties in diagnosing benign vascular lesions of the lip, with implications for appropriate therapy.

Tobouti et al, in a study from an oral pathology service, found that of 131 lip lesions, the frequencies were: pyogenic granuloma (48%), followed by venous lake (17.5%), thrombus (14.5%), papillary endothelial hyperplasia (9.1%), infantile hemangioma (6.1%), caliber-persistent artery (3%) and vascular malformation (1.5%). (Remember, that pathology specimens received — I presume far more PGs will be biopsied compared to benign venous lakes, which are certainly more prevalent clinically.) Glucose transporter protein of the erythrocyte type was positive only in infantile hemangioma. The other markers (CD34 and smooth muscle action) were positive in all lesions, except for podoplanin, which was negative. The authors provide an appropriate framework for assessing these lesions, beginning with the history: Were the lesions congenital? What age did they appear? Did the lesions change with time? This is especially important in differentiating vascular malformations (do not involute), from congenital hemangiomas (rapidly involuting — RICH, non-involuting — NICH, or partially involuting) or infantile hemangiomas. If such lesions are biopsied (which is usually not necessary), only infantile hemangiomas stain with anti-GLUT1 antibodies (1).

I cannot recall when (if ever) I have given much thought about venous lakes of the lip (VLL), other than to reassure patients of their benignity or if they wanted them removed for cosmetic reasons. Although hemorrhagic complications may occur, I do not recall having dealt that complaint. Patients simply don’t like them. VLL are soft, compressible, dark blue to violaceous papules that usually appear on elderly lips. Histologically, a single layer of flattened endothelial surrounded by a thick wall of fibrous tissue. Menni et al found a prevalence of VLL of 3.7%, with a mean age of 76.7 years. The reiterate that despite the unknown cause of VLL, both sun exposure and smoking may play a role (2). While many patients are content to learn that VLL are benign, others desire cosmetic removal. Surgical excision, cryosurgery, infrared coagulation, intense pulsed light, argon laser, pulsed dye laser, Nd:YAG laser, diode laser, carbon dioxide laser, sclerosing agents, and electrosurgery can accomplish this. Weiss et al describe the successful use of a 30-gauge hypodermic needle to deliver a low-powered, high frequency electrical current from a hyfrecator. This inexpensive, simple approach was used in 8 patients (3).

So where is the complexity, you ask? Don’t misdiagnose the caliber persistent labial artery (CPLA)! CPLA usually presents as an asymptomatic papule on the lower lip easily mistaken for a mucocele, hemangioma, venous lake, varix, or fibroma. Although lesions may be pulsatile, they may not be (4).   CPLA carries the risk of profuse bleeding if the artery undergoes transection during biopsy. Awni and Conn, in a study of 5 patients with CPLA aged between 28 and 88 years, presented with discrete lesions of the lower lip, initially diagnosed clinically as either mucocele or squamous cell carcinoma. Lesions were treated by excisional biopsies. The specimens demonstrated a prominent muscular vessel in the stroma that was associated with ulceration in 2 cases. Hemostasis was achieved by either application of surgical diathermy or ligation with deep sutures at the wound area. Persistence of the lesion after excision was seen in only 1 case, another single case the patient complained of persistent paresthesia at the surgical site at 7 months review after biopsy. The authors assert that CPLA should be considered in the differential diagnosis of any raised soft tissue lesion affecting the lip. Careful inspection with palpation for pulse during clinical examination should permit an accurate clinical diagnosis and may prevent unnecessary surgical treatment or prepare the operator for the possibility of hemorrhage during surgery (5).

In conclusion, these mucosal lesions need your attention, not just lip service.

1. Tobouti PL, et al. Benign vascular lesions of the lips: Diagnostic approach. J Cutan Pathol 2017 Jan 23 [Epub ahead of print]
2. Menni S, et al. Venous lakes of the lips: Prevalence and associated factors. Act Derm Venereol 2014; 94: 74-5.
3. Weiss J, et al. A simplified minimally invasive technique for the treatment of venous lakes. Dermatol Online J 2014; 20 (1): 21257.
4. Santagata M, et al. Calibre persistent labial artery: Clinical features and immunohistochemistry diagnosis. J Maxillofac Oral Surg 2015; 14: 845-7.
5. Awni S, Conn B. Caliber-persistent labial artery: A rarely recognized cause of a lower lip swelling – report of 5 cases and review of the literature. J Oral Maxillofac Surg 2016; 74: 1391-5.

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