FPC4: Pathology Week 2

Leukoplakia

A white patch or plaque that CANNOT be characterized clinically or pathologically as any other disease

Leukoplakia requires a _______ diagnosis

clinical

What is the most common precancer feature?

Leukoplakia

The cause of leukoplakia is ________

multifactorial

_____% of oral cancers have leukoplakia nearby

33

What are the contributing factors for leukoplakia?

Tobacco

Alcohol

UV radiation

Trauma*

Sanguinaria*

Microorganisms*

T/F: Leukoplakia has been found 5 years earlier in those who developed squamous cell carcinoma

True

Thin leukoplakia appearance (homogenous)

Flat, slightly elevated, white, or gray plaque

Thick leukoplakia appearance (non-homogenous)

thickened, leathery, distinctly white plaques

Granular/Nodular Leukoplakia

Increased surface irregularities

Verrucous/Verruciform Leukoplakia

Blunt, sharp, wart like projections

What is the best identification method for leukoplakia?

Thorough head and neck exam

Biopsy

What features of histology slides under a microscope would indicate dysplasia has occured?

Bulbous rete ridges

loss of maturation

Dyskeratosis

Hyperchromasia

Pleomorphism

Mild grade dysplasia

lower 1/3 of epithelium

Moderate grade dysplasia

Lower 1/2 of the epithelium

Severe grade of dysplasia

above the midpoint

Carcinoma in situ (CIS)

Full thickness dysplasia, NO invasion

You should biopsy the _____ areas of leukoplakia

worst

If you biopsied leukoplakia and the histology results showed no dysplasia, what is the next step?

Follow up every 6 months

If you biopsied leukoplakia and the histology results showed mild dysplasia,, what is the next step?

Excise or conservative measures

If you biopsied leukoplakia and the histology results showed moderate to severe dysplasia, what is the next step?

Complete removal, LONG TERM follow up is essential!

What is the ratio of F:M for Proliferative Verrucous Leukoplakia?

4:1

F>>M

What are the characteristics of Proliferative Verrucous Leukoplakia?

MULTIPLE, slowly spreading, keratotic plaques

*This will eventually transform into SCC

No association with tobacco use is one of the findings for which premalignant epithelial pathology?

Proliferative Verrucous Leukoplakia

What is the clinical presentation of Proliferative Verrucous Leukoplakia?

Diffuse

Rough

Corrugated

thickened

Leukoplakia lesions of hard palate, lingual gingiva, alveolar ridge, BM

Erythroplakia

Red plaque or patch that cannot be clinically identified or pathologically diagnosed as any other condition

Which premalignant epithelial pathology shows severe epithelial dysplasia, CIS, or invasive SCCa at the time of biopsy?

Erythroplakia

Where are the most common sites for erythroplakia?

Floor of mouth

tongue

Soft palate

What are the features of Erythroplakia?

Well-delineated

Velvety red

Flat lesion

T/F: Biopsy is not required for erythroplakia

False

What is the treatment for erythroplakia?

BIOPSY!

Recurrence is common

If the erythroplakia histology results come back with moderate dysplasia a or worse, what is the next step?

Remove all lesions!

Long term follow up is recommended

Erythroleukoplakia

Erythroplakia + Leukoplakia

Speckled/intermixed red and white lesions

What is erythroleukoplakia frequently diagnosed as in a biopsy?

Dysplasia

What is Nicotine Stomatitis?

White change of hard palate

Associated with smoking

Response to heat (chronic drinkers of hot drinks)

What is the clinical presentation of Nicotine Stomatitis?

"Dried Mud Appearance"

Diffuse gray/white mucosa

Elevates papules with punctate red centers

inflamed minor salivary glands

What is the treatment for nicotine stomatitis?

Encourage pt to stop smoking

Should return normal after 1-2 weeks

What is the prognosis for nicotine stomatitis?

Reversible

Which condition in itself is NOT considered premalignant?

Nicotine Stomatitis

What populations are more likely to develop Smokeless Tobacco Keratosis?

Tobacco chewers (15%)

Snuff users (60%)

Very Common in Young individuals**

What is the clinical presentation of Smokeless tobacco keratosis?

Velvety, wrinkled gray white appearance

Stretching reveals a pouch ~Rippled sand

thin distinct borders

If a smokeless tobacco keratosis lesion becomes thickened, leathery ulcerated, or nodular, what should you do?

Biopsy

Smokeless Tobacco keratosis

These histology characteristics are indicative of what oral pathology?

Intracellular Edema & glycogen rich cells

CHEVRONS

Amorphous Eosinophilic material

What is the prognosis for smokeless tobacco keratosis?

Low malignant transformation risk

Biopsy atypical appearances

Patients with Smokeless tobacco keratosis can develop squamous cell carcinoma after a few ________

decades

What premalignant epithelial lesion is considered to be a "high risk lesion"?

Oral Submucous fibriosis

What causes Oral submucous fibrosis?

Chronic progressive connective tissue scarring.

This leads to mucosal rigidity

What is the etiology of oral submucous fibrosis?

Betel Quid (paan)

What is the main symptom of oral submucous fibrosis?

Trismus (difficulty opening mouth all the way)

What is the clinical presentation of oral submucous fibrosis?

Petechiae

Vesicles

Xerostomia

Melanosis

Blotchy, Marble-like appearance

might be able to feel fibrous bands

Which premalignant epithelial pathology does not regress?

Oral Submucous fibrosis

Which premalignant epithelial pathology puts you at the highest risk of developing squamous cell carcinoma?

Oral Submucous Fibrosis

What is actinic keratosis?

A premalignant cutaneous lesion caused by UV damage

Which premalignant epithelial lesion is a common medical complaint to physicians?

Actinic Keratosis

What is the clinical presentation of actinic keratosis?

Irregular, scaly plaques

Erythematous background area

"Sandpaper texture"

can have a central horn

Actinic Keratosis

These histology characteristics are indicative of what epithelial pathology?

Hyperkeratosis

Dysplasia

Solar Elastosis

Chronic inflammation

What is the treatment for actinic keratosis?

Premalignant!

Should be excised

Long term follow up

Protective measures (30 SPF)

What is actinic cheilitis?

Actinic Keratosis of the lip & vermillion border

Due to chronic UV exposure

What premalignant epithelial pathology has a strong male predilection?

Actinic cheilitis

What is the clinical presentation of actinic cheilitis?

Diffuse, irregular border of lower lip

Blotchy, smooth pale areas

What are the early signs of actinic cheilitis?

Atrophy of lips, dryness/fissures

blurring of the margins with the skin

What are progression signs of actinic cheilitis?

Roughened, scaly areas on the drier portions

For actinic cheilitis, _____ ulcerations SHOULD BE BIOPSIED

chronic

Actinic cheilitis

These histology characteristics are indicative of what premalignant epithelial pathology?

*Solar Elastosis*

Inflammation

Dysplasia

Hyperkeratosis

What is the treatment for actinic cheilitis?

Its irreversible

biopsy this

Protect yourself from sun

What epithelial pathology doubles the risk for developing SCCa of the lip?

Actinic cheilitis

What are the characteristics of Keratocanthoma?

NOT seen intra-orally

95% are solitary lesions

Enlarges rapidly

Can mimic SCCa

cause: UNKNOWN

What is the clinical presentation of keratocanthoma?

ASYMPTOMATIC

CENTAL KERATIN PLUG

Verruciform, irregular surface

Can be black, brown, yellow, red

Firm, well demarcated

Sessile, dome shaped

What occurs in the "growth" stage of a Keratocanthoma?

Lesion grows 1-2 cm within 6 weeks

What occurs in the "stationary" phase of keratocanthoma?

The lesion stabilizes in size

What ocurs in the "involution" stage of Keratocanthoma?

Spontaneous regression of lesion

6-12 mo

Usually scars

What are the histology characteristics of Keratocanthoma?

Dyskeratosis

Keratin pearls

Central crater buttress

Pronounced chronic inflammation

What is the treatment for keratocanthoma?

Excision without waiting for regression

*this is difficult to distinguish from SCCa clinically

4-8% recur

Carcinoma refers to _________ cancer

Epithelial

Squamous cell carcinoma refers to cancer on the _____ and _______

Skin, Mucosa

Adenocarcinoma refers to cancer on the _______ and _________

glands, glandular epithelium

Sarcoma is _________ _______ cancer

connective tissue

Why/how is tobacco a risk factor for epithelial cancers?

DOSE DEPENDENT + CUMULATIVE

80% of those with oral cancer were smokers

Contains >70 carcinogens

Smokeless tobacco risk factors

Chronic use increases risk

50% of all cancers in occurs occur at the placement site

Betel Quid (paan) risk factors

Combination of betel lieaf, slaked lime, areca palm nuts, and tobacco leaf

Associated with pre-cancerous lesions

Alcohol risk factors

DOSE DEPENDENT + TIME DEPENDENT

2-14x increase risk in heavy drinkers only

Alcohol in combination with tobacco increases the risk of developing cancer by ______x

15

What is the "risk profile" for HPV?

Caucasian males

Associated with sexual behavior

NOT associated with tobacco/alcohol use

What are the high risk types of HPV?

HPV-16 and HPV-18

What are the characteristics of HPV?

Persistent infection

70% of oropharyngeal cancers in N. America

High risk EPV E6 and E7 oncogene expression

What does HPV E6 ad E7 oncogene expression do?

E6--Degrades p53 (tumor suppressor gene)

E7-- Inactives Rb (tumor suppressor gene)

What are the characteristics of Squamous Cell carcinoma?

Multifactorial

>90% of oral cavity cancers*

Tobacco and alcohol are most common causes **

Risk increases with age

increased HPV associated oropharyngeal tumors

Pt's with squamous cell carcinoma are usually aware of changes ____-____ months before seeking help

4-8

What are the HIGH RISK locations for squamous cell carcinoma?

1. Tongue (50%) 2/3 are painless

--Posterolateral

--Ventral

2. Floor of mouth

What are the radiographic features of squamous cell carcinoma?

Bone destruction

Irregular borders

Moth Eaten

What are the Characteristics of Squamous Cell Carcinoma Of the Vermillion Border?

Chronic UV radiation

70% have outdoor jobs

**Usually associated with Actinic Cheilosis

90% on the lower lip

What is the clinical presentation of Squamous Cell Carcinoma Of the Vermillion Border?

Asymptomatic

Crusted

Oozing

Indurated

Slow growing "problem" for 12-16 months

Pts with _______ ______ ______ commonly present with lesions like leukoplakia or erythroplakia first

squamous cell carcinoma

Intra-oral SCC locations: Tongue Characteristics

50% of intra-oral cancers

2/3 are asymptomatic, indurated masses or ulcers

Intra-oral SCC locations: Floor of mouth characteristics

The lesion is usually in the midline

Intra-oral SCC locations: Gingiva Characteristics

Asymptomatic

Usually posterior mandible

OFTEN MIMIC BENIGN LESIONS (4 P'S, etc)

Intra-oral SCC locations: Buccal Mucosa characteristics

Common site with betel quid users

Intra-oral SCC locations: Retromolar trigone characteristics

This is WORRISOME*

It can spread to many other areas if it starts in the RM trigone

Which types of high risk HPV are associated with Oropharyngeal Carcinomas?

HPV-16

HPV-18

HPV-33

What are the characteristics of Oropharyngeal Carcinoma?

Location: tonsillar region, base of tongue, soft palate, posterior pharyngeal wall (hard to see)

Often unrecognized for long periods of time

80% are late stage diagnoses