10 Premalignancy

Question 1

Leukoplakia (premalignant lesion)

Answer 1

A white patch or plaque that won’t rub off and which can’t be diagnosed as any specific condition. It is a clinically descriptive term.

Question 2

Does physical injury cause leukoplakia?

Answer 2

No

Question 3

Frictional keratosis

Answer 3

• reversible hyperkeratosis secondary to physical irritant

- not premalignant

Question 4

What is considered the main etiology of leukoplakia?

Answer 4

Tobacco (smoked & topical)

Question 5

What is stomatitis nicotina?

Answer 5

white palate, small red macules (inflamed ducts), not premalignant.

Question 6

What three epithelial changes account for about 80% of the histological features of leukoplakia?

Answer 6

hyperparakeratosis, hyperorthokeratosis, and acanthosis

Question 7

Hyperparakeratosis

Answer 7

increased amount of parakeratin on surface of epithelium

Question 8

Hyperorthokeratosis

Answer 8

increased amount of orthokeratin on surface of epithelium

Question 9

Acanthosis

Answer 9

increase in thickness of epithelium

Question 10

What is epithelial dysplasia or carcinoma-in-situ?

Answer 10

Process the epithelium goes through prior to becoming malignant as determined by cytologic alterations of the cells.

Question 11

What are some characteristics of epithelial dysplasia or carcinoma-in-situ?

Answer 11

1. Increased and/or abnormal mitoses
2. Abnormal keratinization
3. Increased nuclear/cytoplasmic ratios
4. Cellular disorientation
5. Hyperchromatism (increased nuclear staining)
6. Pleomorphism (many different shapes)

Question 12

What are some key anatomic sites involved (“at risk”, “high-risk” sites) with leukoplakia?

Answer 12

a. Floor of the mouth and ventral tongue (approaches 50% dysplastic/invasive)
b. Lateral border of tongue (25% dysplastic/invasive)
c. Lower lip (actinic keratosis) (35% dysplastic/invasive)
vermilion becomes atrophic and blends with skin, variably white ± erosion ± crusting

Question 13

Discuss the limitations of a single incisional biopsy of a dysplasic site.

Answer 13

A single incisional biopsy will underdiagnose 30% of the time when compared to the surgical excision which will also display carcinoma 12% of the time. With multiple biopsies, underdiagnosis will be reduced to 12% and carcinoma to 2.4%.

Question 14

What are some clinical variations of leukoplakia?

Answer 14

homogeneous leukoplakia and non-homogeneous leukoplakia: erythroleukoplakia (erosive), nodular leukoplakia (speckled leukoplakia), and verrucous leukoplakia

Question 15

What is proliferative verrucous leukoplakia (PVL)?

Answer 15

Rare form of progressive leukoplakia that is characterized by progression, multifocality, verrucous morphology, recurrence after excision, progression to SCC and death.

Question 16

What is the relative malignant transformation of leukoplakia (overall, if dysplastic, and if not dysplastic, respectively)?

Answer 16

4-6% overall
15% if dysplastic
1-3.5% if not dysplastic

Question 17

What is erythroplakia?

Answer 17

A red patch which can’t be diagnosed as a specific condition.
A clinically descriptive term considerably less common than leukoplakia

Question 18

What are some clinical features of erythroplakia?

Answer 18

• tendency for high risk sites

- may produce symptoms

Question 19

What are some histological features of erythroplakia?

Answer 19

Dysplasia, carcinoma in situ or carcinoma (approaches 100% (Most early asymptomatic oral carcinomas are red or red and white lesions

Question 20

What treatment is recommended for dysplastic pre-malignant lesions?

Answer 20

• mild - moderate: Modify risk factors ± excise

* Severe, CIS: Modify risk factors + excise

Question 21

What treatment is recommended for non-dysplastic pre-malignant lesions?

Answer 21

Modify risk factors and follow

Question 22

Approximately what percentage of cases of leukoplakia/erythroplakia resolve with tobacco cessation?

Answer 22

50% smoked

95% spit/topical