10: Epithelial Pathology Flashcards
5 papillomas?
Squamous papilloma, Verruca vulgaris, Condyloma accuminatum, Verruciform Xanthoma, and Focal Epithelial hyperplasia
Benign proliferation of stratified squamous epithelium thought to be virally induced (HPV), but not as infective?
Squamous papilloma
Squamous papilloma character?
Soft painless usually pedunculated exophytic nodule with numerous fingerlike surface projections giving a cauliflower or wartlike look
Squamous papilloma treatment?
Surgery. May remain same if untreated
This is a benign, virus induced (HPV), focal hyperplasia of stratified squamous epithelium
Verruca Vulgaris (common wart)
Is verruca vulgaris contagious?
Yes, can spread by autoinoculation
Age Verruca vulgaris common in, and where is it rarely found
Children, mouth
Verruca Vulgaris treatment (4)? Which is used for oral warts?
Liquid nitrogen, Cryotherapy/Surgical laser (especially if oral), Salicylic or lactic acid (topical keratinolytic agents)
If untreated, how long will it take for Verruca Vulgaris to resolve?
2 years
Extreme accumulation of compact keratin resulting in hard surface projection several millimeters in height found in Verruca Vulgaris?
Cutaneous horn/Keratin horn
Virus induced (HPV) proliferation of stratified squamous epithelium of genitalia, perianal region, mouth, larynx?
Condyloma accuminatum (Venereal wart)
Condyloma acuminatum is considered what type of disease? When?
STD; several papillomas seen
Condyloma acuminatum age normally diagnosed?
Teenagers/young adults
Condyloma acuminatum occur orally where?
labial mucosa, soft palate, lingual frenum
Histologic indication of Condyloma acuminatum
Koilocytes: acanthotic stratified squamous epithelium w/ cover having pynknotic nuclei surrounded by clear zone
Which 2 HPV are associated with Cancer?
HPV 16, HPV 18. Present in urogenital condyloma acuminatum
Hyperplastic condition of epithelium of mouth, skin, and genitalia with a characteristic accumulation of lipid-laden histiocytes beneath the epithelium?
Verruciform Xanthoma
Is Verruciform Xanthoma an HPV papilloma?
No
Gender, Age, race for Verruciform Xanthoma?
White, females, 40-70 yo
What is the histology looking for when differentiating for a Verruciform Xanthoma?
Lipid laden histiocytes under the epithelium
What are two ways to differentiate verruciform xanthoma from other papillomas?
Faovr gingiva and alveolar mucosa (50%)
How do we tx Verruciform xanthoma?
Conservative surgical tx
HPV 13 and HPV 32 induced localized proliferation of oral squamous epithelium?
Focal Epithelial Hyperplasia
Age Focal Epithelial Hyperplasia found
Childhood
Clinical appearance of Focal Epithelial Hyperplasia?
multiple flat or rounded papules which are clustered with normal color (not white)
What is the hallmark histo for Focal Epithelial Hyperplasia?
acanthosis
What is acanthosis (Wiki def)?
thickening upper layer of epithelium: diffuse epidermal hyperplasia, increases thickness of stratum spinosum
Treatment for Focal Epithelial Hyperplasia? Prognosis?
Conservative surgical for diagnosis or esthetics, but will regress spontaneously; spontaneous regression reported months to years later
Common skin condition of elderly representing axquired benign proliferation of epidermal basal cells, associated with chronic sun exposure?
Seborrheic Keratosis
Clinical appearance of Seborrheic Keratosis?
Brown plaque that grows up and appears to be stuck on skin (popcorn kernel)
What is sebhorrheic keratosis identical to when it is a small macule (early stages)?
Actinic lentigenes
Form of Sebhorrheic keratosis in African Americans?
Dermatosis papulosa nigra
Where is sebhorrheic keratosis normally found on body (3) and when first seen?
Face, trunk, and extremities during 4th decade and become more prevalent with each passing decade
Sudden appearance of numerous seborrheic keratoses with pruritis that is associated with internal malignancy?
Laser-Trelat sign
Histo feature of Seborrheic Keratosis?
Deep keratin filled invaginations that look cystic = horn cyst/pseudo-horn cysts
Common small hyperpigmented macule of skin that represents a region of increased melanin production? Prediliction?
Ephelis (Freckle); blond and red-heads
How do you prevent new ephelises and darkening of old ones?
Sunscreen
Benign brown macule that results from chronic UV light damage to skin. Not seen in mouth, but common on face.
Actinic lentigo
Layman’s term for Actinic Lentigo?
Age spots/liver spots
Demographics for Actinic Lentigo? What age group is rare to see it in?
Older whites >70 (90%); before age of 40
Does Actinic Lentigo undergo malignant transformation?
No
Actinic lentigo tx?
Topical retinoic acid can reduce intensity and completely destroyed with Q-switched ruby laser
Diffuse hyperpigmentation of the facial skin in pregnant women?
Melasma
Flat brown mucosal discoloration produced by focal increase in melanin deposition and possibly concomitant increase in number of melanocytes?
Oral Melanotic Macule
Prevention of melanoma?
Minimize sun exposure or don’t get pregnant
Is the oral melanotic macule related to sun exposure?
No
Demographics for Melanotic macule
2:1 Females, can be on vermillion border
6 causes/syndromes/demographics associated w/ melanin pigmentation?
Racial, Peutz-Jehgers, Addison’s disease, Neurofibromatosis (cafe au late), Chronic trauma, Smoker’s Melanosis
What 4 drugs can cause melanin pigmentation?
Chloroquine/quinine derivatives, Phenolphthalein, Estrogen, and AIDS meds
Benign acquired pigmentation characterized by dendritic macrophages dispersed throughout epithelium?
Oral Melanoacanthoma
Oral Melanoacanthoma is found exclusively in what race, common site, and age? Tx?
Blacks w/ female predilection, Buccal mucosa, and 3rd-4th decade; biopsy to rule out melanoma and may resolve after biopsy
Freckle like lesions of the hands, perioral skin, oral mucosa, in conjunction with intestinal polyps?
Peutz-Jeghers syndrome
Benign, localized proliferation of cells from the neural crest called nevus cells. Represent the most commonly recognized nevus?
Acquired melanocytic nevus
Other name for Acquired Melanocytic Nevus?
Mole
Most common places to have an acquired
melanocytic nevus intraorally?
Palatal or gingivally
Melanoma transformation risk for Acquired melanocytic nevus?
1 in 1 million
At what age do acquired melanocytic nevi normally present? Demographic?
Whites before 35
What are the three types of moles? What is it generally based on?
Junctional, compound and intramucosal; location of growth compared to CT
White lesion that does not rub off and cannot be characterized as any other disease?
Leukoplakia
What are the four pathologies you must rule out first before diagnosing leukoplakia?
Leukoedema, lichen planus, candidiasis, linea alba
What type of lesion is Leukoplakia considered?
Premalignant
3 areas of high risk for Leukoplakia?
Floor of mouth, ventral tongue, soft palate
1/3 of oral cancers have what in close proximity?
Leukoplakia
Most common oral precancer?
Leukoplakia (85% of lesions)
Most common etiology for Leukoplakia?
Tobacco
What race and sex does leukoplakia affect more often?
Whites and males (70% of cases)
If patient had UV radiation induced Leukoplakia, where would it appear orally?
Lower lip
With Leukoplakia, which is worse: thick or thin? Homogenous or heterogenous?
Thick; homogenous
High risk form of leukoplakia characterized by multiple keratotic plaques with roughened surface projections?
Proliferative Verrucous Leukoplakia (PVL)
How many years after PVL diagnosis will pt likely receive squamous cell carcinoma?
8 years
Leukoplakia that is red, representing sites in which epithelial cells are so immature or atrophic they no longer produce keratin?
Erythroplakia
If have a mixed Leukoplakia/erythroplakia lesion, where do you biopsy?
Biopsy in the red
4 grades of dysplasia?
Mild, moderate, severe, carcinoma in-situ
What is carcinoma-in-situ?
Entire thickness of epithelium involved. At basement membrane but not through
7 precancerous changes in erythroplakia or leukoplakia?
Enlarged hyperchromatic nuceli, increased nuclear-to-cytoplasm, plemorphic nuclei, increased mitotic activity, dyskeratosis/keratin pearls, loss of epithelial cohesiveness, bulbous rete ridges
What must be breached to diagnose cancer?
Basement membrane
What is the histology of leukoplakia?
Hyperkeratosis (thickened keratin layer of surface epithelium), which can be hyperparakeratinized or hyperorthokeratinized. May or may not have thickened spinous layer (acanthosis)
What is orthokeratin versus parakeratin?
Parakeratin has nuclei in top layer
What is the malignant/premalignant risk for
Erythroplakia?
80-90%
Soft fissured gray white lesion of lower labial mucosa located in the area of chronic snuff placement?
Tobacco pouch keratosis
What is first oral lesion you get with dip? first thing you get with chew?
Dip get recession; Chew get root caries
What is the Indian form of dip or chew? How much greater risk over tobacco?
Betal quid; 10x
How long will tobacco pouch keratosis remain if dipping ceases?
Disappear in 2-6 weeks, >6 weeks biopsy
Is there pain involved precancerous epithelial changes with smokeless tobacco or dip?
No
What is the appearance of the tobacco pouch lesion? Does it extend past where the tobacco touches?
Confined to areas in direct contact with tobacco; thin gray or gray-white plaque with a border that blends gradually into the surrounding mucosa
Chronic, progressive, scarring high-risk precancerous oral condition seen primarily in India due to betel quid/paan?
Oral Submucous Fibrosis
Oral Submucous Fibrosis clinical appearance?
Feel the fibrous bands with blotchy, marble-like pallor and progressive stiffness of subepithelial tissues. Can be brownish red
Does oral submucous fibrosis have a high malignant transformation rate?
Yes
What is quid?
Areca nut and slaked lime, usually with sweeteners and condiments wrapped in a betal leaf (chew 16+ hours)
What are the symptoms of oral sub mucous fibrosis?
Mucosal rigidity, trismus and mucosal pain when eating spicy foods; Tongue immobile if involved
Common premalignant alteration of the lower lip vermillion that results from long-term or excessive exposure to UV component of sunlight?
Actinic Cheilosis (Actinic Cheilitis)
Gender predilection for Actinic Cheilosis
Males 10:1
Approximately 94% of all oral malignancies are…
Squamous cell carcinoma
When are white men at greatest risk for squamous cell carcinoma?
> 65 yo
In middle age, what race is at greatest risk for squamous cell carcinoma?
Blacks
What may patients with actinic cheiolosis say they have?
Scaly material that can be peeled off with some difficulty, only to reform in a few days
Smoking increases lung cancer, but what increases oral cancer? What aspect of the wood industry increases SCC?
Smoking + alcohol; phenols (may also cause nasal/nasopharyngeal cancers)
Most common site for intraoral carcinoma?
tongue, posterior lateral and ventral surfaces most common
How does squamous cell carcinoma etiology differ between sexes?
Older males due to smoking; non-smokers are young females (mutation in p53 chromosome)
What human papilloma virus is associated with intraoral cancers?
HPV 16
Is there a link between Herpes Type I and oral cancer?
No
What is the most common site for Squamous Cell
Carcinoma on the floor of the mouth?
Midline near frenum. Most often ass’d with development of a secondary primary malignancy
What are six other potential causes of SCC?
Radiation, iron defiency, Vitamin A deficiency, syphilis, candidal infection, immunosupression
What iron-defiency syndrome may also be ass’d with SCC?
Plummer-Vinson
How long does it typically take before an older man will seek professional help for oral alterations?
4-8 months (8-24 months for lower SEC)
Location of 3/4 Oropharyngeal carcinomas
Tonsillar area or soft palate
What accounts for 50% of intraoral lesions?
Carcinoma of the tongue
Where are the most common locations on tongue?
2/3 posterior lateral border and ventral tongue
If lesions is <2cm, what is the likelihood of metastases based on location of tongue?
Anterior: 20% metastasized
Posterior: 80% metastasized
What SCC most likely comes from pre-existing leuko- or erythroplakia?
Carcinoma of the floor of the mouth
What is the 5-year survival rate of carcinoma of lip?
95%
How do we stage cancer?
T = size of primary tumor, M = distant metastasis, N= nodal involvement
If you see a lesion on the the lateral border of the tongue, then feel it and it is not indurated (hard), but soft, what is it likely?
Normal Folliate papillae
Have cancer survival rates increased for whites? Blacks? Why?
Whites yes, blacks, no; lack of education in lower incomes
Carcinoma lesion, frequently associated with snuff, appearing as a well demarcated, painless, thick plaque with papillary or verruciform surface projections?
Verrucous Carcinoma
Is verrucous carcinoma more or less aggressive than squamous cell carcinoma?
Less aggressive
Maxillary sinus carcinomas are classified as?
Squamous cell carcinoma
What are four clinical symptoms?
Unilateral stuffiness, mass of hard palate/alveolar bone, teeth in area are loosened/moth-eaten radiographically, superior displacement may cause protrusion of the eyeball
What is the most common skin cancer and most common of all cancers?
Basal cell carcinoma
Locally invasive, slowly spreading, primary epithelial malignancy that arises from the basal cell layer of the skin?
Basal cell carcinoma
Basal cell carcinoma is a disease of whom?
White adults with fair complexion
Does Basal Cell Carcinoma metastasize?
No
What syndrome has many basal cell carcinomas that develop over a relatively short period of time?
Nevoid basal cell carcinoma syndrome
Malignant neoplasm of melanocytic origin that arises from a benign melanocytic lesion?
Melanoma
4 risks for melanoma?
Red hair, fair skin, blue eyes, sun
Most common from of oral melanoma?
Actinic lentiginous melanoma
In what two cancers is sun damage most important?
Basal cell carcinoma and squamous cell carcinoma (not melanoma)
For melanoma, which is more important: acute or chronic sun exposure?
Acute (e.g. really bad sunburn)
What are four types of melanoma and which is most common?
Superficial spreading melanoma (most common), nodular melanoma, lentigo malignant melanoma, acral elntiginous melanoma
Where on the body is superficial spreading melanoma most commonly found?
Interscapular region in males and back of legs in females
Majority of oral melanomas are found where?
Hard palate or maxillary aveolus
3 most common skin cancers in order?
basal cell, SCC, melanoma
Melanoma that begins almost immediately in vertical growth phase (poor prognosis) and are typically amelanotic?
Nodular melanoma
Develops from precursor lesion called Lentigo maligna/Hutchinson’s freckle arising in the midface region of older adults and is a melanoma in situ in purely radial growth phase for first 15 years?
Lentigo malignant melanoma
Melanoma found on palms of hands, soles of feet, subungual areas and mucous membranes?
Acral lentiginous melanoma
What are the four criteria for classification of melanoma?
ABCDE:
Asymmetry, border irregularity, color variegation, diameter (>6mm)
Prognosis for oral melanoma?
Poor- 20-45% 5-year survival rate
Worse prognosis locations for melanoma?
BANS: Back, posterior upper Arm, posterior and lateral Neck, and Scalp
What are the variations of color you need to be wary of when diagnosing melanoma?
Black, brown, red, white and blue (or no color)
