6. epithelial pathology pt 2 ✅

SQUAMOUS CELL CARCINOMA

most common malignancy in the oral cavity

Oral cancer, <3% of all US cancers

• 90% are squamous cell carcinomas

Approximately 54,540 new cases of oral or oropharyngeal cancer cases diagnosed annually

11,580 deaths from oral/oropharyngeal cancer each year

Risk increases with age

Male-to-female gender ratio 3:1

lateral boarder = most common

causes of SCC

Multifactorial

Extrinsic factors - Tobacco *most important, alcohol (only in combination w tobacco), syphilis

Sunlight (vermilion cancers only) precursor = actinic cheilitis

Intrinsic factors - systemic states, malnutrition or iron-deficiency anemia

Heredity does not play a major etiologic role

SCC- Clinical Presentation

Leukoplakic, erythroplakic

Erythroleukoplakic

Leuko / erythroplakic early cases - No mass / ulceration

Exophytic (protruding out) - Irregular / papillary, normal color to red to white

Endophytic - Depressed, irregular, ulcerated, "rolled” border (deep seated ulcer)

• if ulcer doesnt heal can be SCC as d/d

very deceptive

shallow type of ulcer

aphthous ulcer

Differential diagnosis for endophytic SCC

Deep fungal infections (e.g. histo or blasto) (no trauma + doesnt smoke

Tuberculosis

Syphilis

Traumatic granuloma (behaves like scc, deep seated + can last a while, if they dont smoke + had trauma)

ALL OF THESE DEPEND ON HISTORY

3 DD for deep nonhealing ulcer are SCC, trauma or pathogen

Lip Vermilion Carcinoma

Chronic ultraviolet radiation

Almost 90% on lower lip

Vermilion carcinoma crusted, non tender, indurated ulceration

Slow growing, late to metastasize

INTRA-ORAL SCC

90% - Floor of mouth, soft palate, anterior tonsillar pillar complex, ventral / lateral tongue

Most common - Posterior lateral & ventral surfaces of tongue followed by floor of mouth

Only 4% on dorsum (rare)

SQUAMOUS CELL CARCINOMA on floor of the mouth

Carcinoma of oral floor 35% of intraoral cancers.

Most common site is midline near the frenum

SQUAMOUS CELL CARCINOMA: gingival/ alveolar carcinoma

Mimics benign inflammatory / reactive lesions

Clinically evident after tooth extraction

SQUAMOUS CELL CARCINOMA: STAGING

Tumor size and extent of metastatic spread

Staging protocol is tumor-node-metastasis (TNM) system

T - Tumor size (cm)

N - Spread to local lymph nodes

M- Presence or absence of distant metastasis

Higher stage worse prognosis

Histopathologic Features: “Grading“

Degree of tumor resemblance to parent tissue (squamous epithelium) & production of normal product (keratin)

Lesions graded as I to IV

Low-grade (I)

well-differentiated tumors closely resemble tissue of origin, grow slower, metastasize later

High-grade (III/IV)

poorly differentiated, or anaplastic tumor - very pleomorphic cells, little or no keratin, difficult to identify, enlarge rapidly, metastasizes early

what dictates the prognosis? stage or grade?

stage, size and spread!!

higher stage = worse ;(

Metastasis

Spread through lymphatics to ipsilateral cervical lymph nodes

Perforates nodal capsule, node becomes "fixed"

2% have distant metastases at diagnosis

Most common sites : Lungs, liver, bone

Ca of lower lip / floor to submental nodes

Posterior tumors to superior jugular / digastric nodes

Delay in diagnosis, approx. 21% cervical metastases

Treatment and Prognosis

Treatment guided by stage of disease

Wide excision, radiation therapy or both

Single treatment modality for smaller carcinomas

Larger lesions or lesions with palpable lymph nodes - Combined therapy including either a modified or radical neck dissection

VERRUCOUS CARCINOMA (Snuff Dipper's Cancer)

Low-grade variant of SCC, predominantly in men 55+

More frequent in users of spit tobacco / snuff

Mandibular vestibule, buccal mucosa, hard palate

Extensive, often present for 2-3 years prior to diagnosis

Diffuse, well demarcated, painless thick white / pink, papillary

Leukoplakia or tobacco pouch keratosis on adjacent mucosal surfaces

good prognosis

if not from smoking or drinking it is from HPV 16

verrucous carcinoma histopathology

Deceptively benign microscopically (no dysplasia + doesnt cross basement membrane)

can turn in to SCC if not removed

Wide / elongated rete ridges push into underlying tissue

“Parakeratin plugging" between surface projections

KNOW THIS HISTOPATHOLOGY

verrucous carcinoma Treatment and Prognosis

Metastasis extremely rare

• locally invasive

Surgical excision w/o radical neck dissection

90% are disease-free after 5 years

Radiotherapy effective, less popular

Have transformed after radiation into poorly differentiated carcinoma

BASAL CELL CARCINOMA (Rodent Ulcer)

most common skin malignancy on the SKIN, not in oral cavity

Locally invasive, slowly spreading malignancy

Arises from basal cell layer of skin

500,000 new cases diagnosed annually, 80% of all skin cancers

Chronic exposure to ultraviolet radiation

Does not occur intraorally

Epithelial islands demonstrate palisading of peripheral cells

*histopath will be asked

Nevoid Basal Cell Carcinoma Syndrome:

Sun-exposed and protected areas of skin

multiple basal cell carcinoma lesions, Hundreds of lesions

seen in areas of no sun exposure + in younger populations

BASAL CELL CARCINOMA characteristics

Adult whites

Firm, painless papule

Central depression with rolled border, ulceration in central depressed area

Telangiectatic vessels over rolled border

Destruction of underlying bone / cartilage possible

Metastasis extremely rare, invades deep locally

BASAL CELL CARCINOMA treatment

Depends on size and site of lesion

Radical surgery and radiation for large or aggressive lesions

Small lesions (<1 cm), routine surgical excision or curettage

Cure rate 95-98%

MELANOMA (Malignant Melanoma)

Malignant neoplasm of melanocytic origin

Arises from benign melanocytic lesion or de novo or congenital nevi

UV - Major causative factor

• Acute sun damage of greater etiologic importance than chronic

Risk of melanoma 2-8x greater with familial history

Fair complexion and light hair

History of painful or blistering sunburns in childhood

History of dysplastic nevus

growth of melanoma( Radial growth phase and vertical growth phase) : radial growth phase

Malignant melanocytes spread horizontally through basal layer

growth of melanoma (Radial growth phase and vertical growth phase): vertical growth phase

Malignant cells invade underlying connective tissue

Five Clinicopathologic Types of melanoma

1. Superficial spreading melanoma

2. Nodular melanoma

3. Lentigo maligna melanoma

4. Acral melanoma

5. Mucosal melanoma

MELANOMA – A, B, C, D, E Rule

Asymmetry (because of its uncontrolled growth pattern)

Border irregularity (often with notching)

Color variegation (shades of brown to black, white, red, and blue)

Diameter greater than 6 mm (diameter of a pencil eraser)

Evolving (changes in size, shape, color, symptoms over tim

Areas with worse prognosis "BANS" (interscapular area of Back, posterior upper Arm, posterior and lateral Neck, and Scalp)

ACRAL LENTIGINOUS MELANOMA

Most common form of melanoma in African-American population

Most common form of oral melanoma

Palms, soles, subungual area, mucous membranes

ORAL MELANOMA

Mostly on hard palate, max gingiva / alveolar mucosa

Begins as brown to black macule with irregular borders

Thickened areas develop as vertical growth is initiated

Prognosis extremely poor

Radical surgical removal

normally metastatic

Treatment & Prognosis

Depth of invasion correlates with prognosis for cutaneous melanoma

Clark system & Breslow classification- Cutaneous melanoma

1-cm margin for small tumors

Larger, invasive tumors - wide surgical excision

Removal of regional lymph nodes with depth of invasion >1.24 mm

Oral – Prognosis dependent on TNM classification

Radical surgery, adjunctive radiation therapy

DD for oral melanoma

melanotic macule

blue nevi

melanoacanthoma