09/02 - Malignant Epithelial Lesions

Question 1

What is the most common skin cancer?

Answer 1

basal cell carcinoma

*nearly 3 million cases diagnosed annually in the USA

Question 2

Who is most at risk for basal cell carcinoma?

Answer 2

patients over 40 years old, who have a fair complexion, and a history of chronic sun exposure

Question 3

Where do the majority of basal cell carcinoma develop?

Answer 3

• 80% arise on the head and neck

- most develop in the middle 1/3 of the face (from eyebrows to above the lips)

Question 4

What are the 3 types of basal cell carcinoma?

Answer 4

• nodulo-ulcerative basal cell carcinoma
• pigmented basal cell carcinoma
• sclerosing (morpheaform) basal cell carcinoma

Question 5

What is the most common clinical presentation of basal cell carcinoma?

Answer 5

nodulo-ulcerative basal cell carcinoma

Question 6

Describe a nodulo-ulcerative basal cell carcinoma.

Answer 6

• small nodule with a raised border
• frequently has a history of bleeding
• umbilicated pearly papule that may show central ulceration
• lack of adnexal skin structures (hair)
• may have fine blood vessels

Question 7

Describe the histopathology of nodulo-ulcerative basal cell carcinoma.

Answer 7

• basaloid cells that appear to “drop off” of the basal cell layer of the epidermis
• large lobules of tumor cells are characteristic (think “nodulo”)

Question 8

What do pigmented basal cell carcinoma resemble?

Answer 8

melanocytic nevi due to the presence of benign melanocytic colonization

Question 9

Describe a pigmented basal cell carcinoma.

Answer 9

• relatively short history (weeks/months) duration
• lack of hair
• pigmented

Question 10

Describe the histopathology of pigmented basal cell carcinoma.

Answer 10

• most have nodulo-ulcerative pattern with large lobules of tumor cells invading superficial connective tissue
• lesion is pigmented because of activation of benign melanocytes

Question 11

What is the least common basal cell carcinoma? What is the most aggressive basal cell carcinoma?

Answer 11

sclerosing (morpheaform) is the least common, but most aggressive form

Question 12

Describe a sclerosing (morpheaform) basal cell carcinoma.

Answer 12

• clinically resembles a scar due to induction of collagen formation by tumor cells
• may be a firmness to lesion because fibrotic change

Question 13

Describe the histopathology of sclerosing basal cell carcinoma.

Answer 13

• tiny infiltrative nests of tumor cells in a collagenous background
• very difficult to assess borders clinically because of this infiltrative growth pattern

Question 14

What is the treatment for basal cell carcinoma?

Answer 14

• scalpel excision
• electrocautery and curettage
• cryotherapy
• topical agents (5-FU, imiquimod)
• Mohs micrographic surgery

Question 15

Describe the steps of Mohs micrographic surgery.

Answer 15

• lesion is outlined on a patient’s face
• curettage is performed
• incisions are made along the outline and reference points are cut to align it
• sliced tissue is removed
• diagram is drawn on paper using the reference points
• additional tissue is taken as needed and area is cauterized and sutured

Question 16

What is the general prognosis for basal cell carcinoma?

Answer 16

• generally excellent with over 95% of patients cured after first treatment
• patients at increased risk for 2nd lesions
• rare metastatic spread has been reported

Question 17

What features warrant Mohs surgery?

Answer 17

basal cell carcinoma that has:

• larger lesions
• recurrent lesions
• tumor in areas of embryonic fusion

Question 18

What is the most common oral malignancy and the second most common cutaneous malignancy?

Answer 18

squamous cell carcinoma

Question 19

What areas are most affected by squamous cell carcinoma?

Answer 19

skin and lower vermilion zone of the lip

Question 20

What does cutaneous squamous cell carcinoma often arise from? Where?

Answer 20

• arises from pre-existing actinic keratosis, due to chronic sun exposure (UV light)
• face, helix of ear, dorsum of hand, arms

Question 21

What is the treatment for cutaneous squamous cell carcinoma? Prognosis?

Answer 21

• TX: surgical excision
• PROGNOSIS: usually actinically-induced squamous cell carcinomas are well-differentiated and slow-growing so generally good prognosis if diagnosed early

Question 22

What are the risk factors for oral squamous cell carcinoma?

Answer 22

• 75-80% are associated with cigarette smoking (further increased with combined cigarette and alcohol)
• 20-25% have no identifiable risk factor

Question 23

If there is no identifiable risk factor, where is oral squamous cell carcinoma likely to develop?

Answer 23

• lateral tongue of younger people

- gingiva of older women

Question 24

In what age group and gender is oral squamous cell carcinoma most often found?

Answer 24

• most in adults over age 45
• men outnumber women 2.5:1
• accounts for 3-4% of all cancers in USA

Question 25

Describe an oral squamous cell carcinoma lesion.

Answer 25

- irregular shape, mixture of red and white clinically - often ulcerated - exophytic or endophytic growth pattern - often much firmer than surrounding tissues - early lesions are asymptomatic; pain is later feature - ragged radiolucency is characteristic of lesions that involve the underlying bone

Question 26

When does squamous cell carcinoma of the lip often develop? What type of growth? Prognosis?

Answer 26

- commonly involved site secondary to chronic sun exposure (actinic cheilitis) - slow-growing well-differentiated lesions - relatively good prognosis, but if they are not producing a lot of keratin, they are of a higher grade and more progressive lesion

Question 27

Where does squamous cell carcinoma of the tongue often develop? What are the highest risk factors?

Answer 27

- lateral tongue - majority of patients have history of cigarette and alcohol abuse, but when it is seen in younger people, it almost always develops at this site

Question 28

What are the 2 most common sites for oral squamous cell carcinoma?

Answer 28

- lateral tongue | - floor of the mouth

Question 29

Who is most commonly afflicted with squamous cell carcinoma of the gingiva and alveolar mucosa?

Answer 29

- more common in women (2:1) - more common in patients with no identifiable risk factors - unusual site epidemiologically for oral squamous cell carcinoma *there is no link between use of smokeless tobacco and oral cancer

Question 30

True or false: The buccal mucosa is a common site for oral squamous cell carcinoma.

Answer 30

FALSE

Question 31

Where do most squamous cell carcinomas of the palate arise? Where could it have originated?

Answer 31

- mostly on lateral soft palate - relatively uncommon presentation - may be difficult to determin whether lesion originated in oral cavity or developed in maxillary antrum and perforated sinus floor

Question 32

What are some of the clinical differential diagnoses of sqamous cell carcinoma?

Answer 32

- non-specific ulcer - specific infection (tuberculosis, syphilis, deep fungal) - immune-mediated conditions (Wegener's granulomatosis, Crohn's disease)

Question 33

Describe squamous cell carcinoma radiographically.

Answer 33

- due to direct invasion of the bone (usually a late phenomenon) - ragged "moth-eaten" radiolucency - ill-defined borders - pathologic fracture possible

Question 34

Describe the histopathology of squamous cell carcinoma.

Answer 34

- microscopically, invasive cords and nests of malignant squamous epithelial cells arise from dysplastic surface epithelium - tumor cells show increased nuclear/cytoplasmic ratio, cellular and nuclear pleomorphism, and mitotic activity - varying degrees of keratin production may be seen (well vs. poorly differentiated)

Question 35

What is the treatment for squamous cell carcinoma?

Answer 35

- wide surgical excision and/or radiation therapy - combined radiochemotherapy used with extensive loco-regional involvement or in cases where surgery is contraindicated - surgery is the basis *periodic follow-up examination after treatment is complete is absolutely necessary

Question 36

What is the prognosis for squamous cell carcinoma?

Answer 36

- generally poor because most patients present in Stage III or IV - metastasis to regional lymph nodes - at 60% 5-year survival, one of the worst prognoses of any major cancer - (after treatment is complete?) 10-20% of these patients will develop new upper aerodigestive tract malignancies, particularly if carcinogenic habits are continued

Question 37

What is verrucous carcinoma?

Answer 37

less aggressive, relatively uncommon, form of squamous cell carcinoma

Question 38

Who is most often affected by verrucous carcinoma?

Answer 38

- usually develops in elderly males - smokeless tobacco is often mentioned as contributing factor (most of our cases have not shown association with smokeless tobacco)

Question 39

What is the clinical presentation of verrucous carcinoma? Most frequent sites?

Answer 39

- diffuse white or mixed red/white plaque; tends to grow laterally - alveolar mucosa, hard palate, and buccal mucosa are most frequent sites

Question 40

Describe the histopathology of verrucous carcinoma.

Answer 40

- microscopically appears very bland - often misdiagnosed - broad pushing border, not infiltrating at the base

Question 41

How is verrucous carcinoma diagnosed?

Answer 41

based on the overall architecture of the tumor, rather than the appearance of individual cells

Question 42

What is the treatment for verrucous carcinoma?

Answer 42

- surgical excision is generally recommended - radiation therapy have been generally discouraged due to sporadic reports of transformation into more aggressive squamous cell carcinoma! - approximately 20-25% of verrucous carcinoma, upon completion of excision, show foci of tranformation to routine squamous cell carcinoma