pre-malignant lesions + PE

what are the layers of the epithelium from most superficial to deep

stratum corneum → stratum lucidum →stratum granulosum → stratum spinosum → stratum basale

dysplasia refers to what layer

epithelium

definition of premalignant lesion

morphologically atypical tissues which appear abnormal under microscopic examination, and in which cancer is more likely to occur

definition of dysplasia

the presence of cells of an abnormal type within a tissue, which may signify a stage preceding the development of cancer - premalignant stages

what are the 6 criteria of dysplasia

• inc and/or abnormal mitosis

• abnormal keratinization

• inc nuclear/cytoplasmic ratios

• cellular disorientation

• hyperchromatic (inc in nuclear staining)

• pleomorphism (many different shapes)

what are the stages of dysplasia

mild → moderate → severe → carcinoma in situ

mild dysplasia is limited to…

atypical morphology in the bottom 1/3 of the epithelium

moderate dysplasia is limited to…

atypical morphology up to 2/3 of the epithelium

severe dysplasia is limited to…

atypical morphology above the mid 2/3 to entire thickness of the epithelium

carcinoma in situ is limited to…

atypical morphology of the entire epithelium

management of mild dysplasia

close follow up

moderate dysplasia management

close follow up or surgical removal/laser ablation and close follow up

severe dysplasia management

surgical removal and close follow up

carcinoma in situ management

surgical removal and close follow up

what are the high risk sites of dysplasia and oral cancer

1. floor of the mouth

2. lateral/ventral border of the tongue

3. soft palate

4. lower lip

out of these, in which direction is it most concerning for malignant transformation potential to oral cancer

which is the management for mild dysplasia:

surgical removal

incisional biopsy

follow-up

laser removal

follow-up

atypical morphology involving the entire thickness of the epithelium:

mild dysplasia

severe dysplasia

squamous cell carcinoma

moderate dysplasia

severe dysplasia

leukoplakia represents what percent of precancerous lesions

85%

common age affected by leukoplakia

adults, inc w age

common location of leukoplakia

anywhere in oral mucosa; 70% are found on lip, B mucosa, gingiva

tx for leukoplakia

incisional biopsy, follow up, surgical excision, laser

dx

leukoplakia

which is leukoplakia, which is chewing trauma

• left leukoplakia

• right chewing trauma

what is proliferative verrucous leukoplakia

very high risk form of leukoplakia; multiple slowly spreading keratotic plaques w rough surface, persistent growth that will eventually develop into dysplasia and cancer

cancer risk of proliferative verrucous leukoplakia

50-80%

what is leukoplakia

white plaque which will not rub off and which cannot be dx as a specific disease; exclusion of other entities

gender association w proliferative verrucous leukoplakia

strong female predilection (4:1)

common age affected by proliferative verrucous leukoplakia

adults

common location for proliferative verrucous leukoplakia

anywhere but gingiva is highly involved

tx of proliferative verrucous leukoplakia

incisional biopsy, follow up, surgical removal, laser

dx

proliferative verrucous leukoplakia

what is erythroleukoplakia “speckled”

one of the highest risks for cancer

color of erythroleukoplakia

red/pink/white patches

how does erythroleukoplakia show on a biopsy

advanced dysplasia

tx for erythroleukoplakia

incisional biopsy, surgical excision, follow up

dx

erythroplakia “speckled”

what is erythroplakia

a red patch of plaque that cannot be dx clinically as any other condition

cancer risk of erythroplakia

90% show dysplasia, majority are carcinoma in situ

high risk sites of erythroplakia

lateral/ventral tongue, FOM, soft palate

tx for erythroplakia

incisional biopsy, surgical excision, follow up

dx

erythroplakia

what is oral submucous fibrosis

chronic, progressive scarring due to betal quid use (tobacco, lime, areca, but, betal leaf)

where is oral mucous fibrosis most commoon

southeast asia and india

onset of oral submucous fibrosis

takes years to develop

cancer risk of oral submucous fibrosis

19x more likely

clinical manifestations of oral submucous fibrosis

trismus, fibrous bands (buccal, soft palate), stomatopyrosis (general oral burning from spicy food)

tx for oral submucous fibrosis

intralesional steroid injection mild lesion, surgical splitting of fibrous bands, physical therapy lifelong, close clinical follow up

what is actinic cheilosis

premalignant alteration of the lower lip

causes of actinic cheilosis

UV light exposure

common gender affected by actinic cheilosis

M>F 10:1

common age affected by actinic cheilosis

>45 yrs

prevalence of actinic cheilosis

more common is rural areas

cancer risk of actinic cheilosis

2-6% develop into cancer if not removed

pleomorphism:

abnormal # of cells

abnormal architecture

abnormal shape and size of cell

abnormal miotic figures

abnormal shape and size of cell

tx for actinic cheilosis

incisional biopsy, surgical excision

clinical manifestations of actinic cheilosis

blended vermillion borders, atrophy, fissuring, leukoplakia, ulcerated, rough and scaly area

what is actinic keratosis

a premalignant skin lesion

what can cause actinic keratosis

long-term sun exposure

clinical manifestations of actinic keratosis

rough, scaly patches on face, ears, neck, scalp, and other areas

cancer risk for actinic keratosis

5-10% can become cancer

tx for actinic keratosis

biopsy and surgical excision

what is smokeless tobacco keratosis

6% in US are due to chewing tobacco

common location for smokeless tobacco keratosis

mandibular vestibule

what is the controversy w smokeless tobacco keratosis

precancerous white macule

clinical manifestations smokeless tobacco keratosis

leathery white fissured plaque or fissures, gingival recession

what can inc caries risk for a pt w smokeless tobacco keratosis

if sweeter is added

tx for smokeless tobacco keratosis

stop habit → keratosis will be gone in 2-4 mo

when would you do an excisional biopsy

complete surgical removal; small lesions <2 cm; appears benign on clinical

what lesions would you do an excisional biopsy

• fibroma

• mucocele

• lipoma

• papilloma

when would do an incisional biopsy

lesions are larger than 2 cm

what type of lesions would you do an incisional biopsy on

• leukoplakia/erythroplakia

• ulcer

• SCC

• tumor (benign or malignant)

• lichen planus or other autoimmune conditions

what are adjunct tools and what do they tell us

• brush

• velscope

• unreliable

• false results

• does not provide a dx

which of the following is indicated for an excisional biopsy:

fibroma

squamous cell carcinoma

leukoplakia

actinic cheilosis

fibroma

which of the following is a clinical term used to describe a white premalignant lesion:

leukoplakia

actinic cheilosis

erythroplakia

dysplasia

leukoplakia

which is a common site for proliferative verrucous leukoplakia:

dorsum tongue

soft palate

buccal mucosa

gingiva

gingiva

all of the following are premalignant lesions EXCEPT:

erythroplakia

tocacco pouch keratosis

actinic lentigo

submucous fibrosis

actinic lentigo

which of the following is NOT true regarding actinic keratosis:

due to sun exposure

occurs on the skin

can become cancerous

a smooth white lesion

a smooth white lesion

which is FALSE regarding erythroplakia:

most often are high dsyplasia or cancer

a red patch that cannot be dx clinically as any other condition

high-risk site is floor of the mouth

Excisional biopsy is indicated

excisional biopsy is indicated

all of the following are high risk sites for premalignant cancer EXCEPT:

FOM

soft palate

dorsum of tongue

lower lip

dorsum of tongue