6. Pathology of Mouth & Esophagus Flashcards
Oral pathology: what problems did we cover?
- infectious diseases
- benign and malig lesions
- salivary gland neoplasms
Esophageal pathology: what did we cover?
- congenital and acquired conditions
- Reflux esophagitis
- Barrett esophagus
- malignant tumors
what are the most common infections of the oral cavity?
- Herpes (HSV1 and 2)
- CMV
- Fungal (candida, aspergillus, mucor)
Fungal infections of the oral cavity: which are superficial, which are deeper?
Candida is superficial
Aspergillus and Mucor are deep (they are angioinvasive)
what does a herpetic vesicle look like on histo?
edema, cells within the edematous space, disorganized
what does a herpetic ulcer look like on histo?
(ulcer = erupted herpetic vesicle)
granulation tissue (L side of pic) abutting squamous cell epithelial hyperplasia (R side of pic).
what are the 3 M’s of HSV infection on histo?
Multinucleation, Margination, nuclear Molding
what cells are infected by HSV?
epithelial cells
what do the 3 M’s actually mean (histo of HSV)?
- Multinucleation: self-explanatory
- Margination: the nuclear chromatin is pushed to the margin/edge of the nucleus
- nuclear Molding: the nuclei are fitted together, squished together
HSV: the viral inclusions are where?
intra-nuclear
CMV: viral inclusions are where?
both intra-nuclear and cytoplasmic
CMV: what do the infected cells look like?
owl-eye cells, big in size (at least 2x RBCs), particles in cytoplasm
CMV: infects what types of cells?
epithelial and mesenchymal/stromal
Candida: what is unique about its presence in the mouth?
it can be scraped off, unlike leukoplakia
Candida: appearance on biopsy?
fungal pseudohyphae are perpendicular to squamous cell layer. image she gave looks like red confetti.
Candida infection ulceration: appearance of tongue scraping on histo?
lots of pink, can see budding yeast forms (linear) and also pseudohyphae
Oral candida is most likely to occur in what patients?
immunosuppressed (post-transplant, diabetes, HIV+)
Aspergillus: characteristics of the fungus? deep or superficial infection?
hyphal forms only
septate hyphae, 45 deg angle branching
deeper infection due to angioinvasion
Mucormycosis: characteristics of the fungus? deep or superficial infection?
hyphal forms only
broad, bulbous, non-septate hyphae, right angle branching
deeper infection due to angioinvasion
Pyogenic granuloma: wtf is it? what pts does it typically occur in?
lesion of the oral cavity. benign, may regress, may progress to fibroma. occurs in young, sometimes associated with pregnancy
pyogenic granuloma: how is it described pathologically? can it be resected?
description: lobular capillary hemangioma w surface ulceration.
looks edematous, can see surface breakage on histo
can be surg resected, won’t recur
what is an aphthous ulcer? what does it look like?
oral cavity lesion: donut/annular shaped, edematous ring with sunken center.
Aphthous ulcer: prognosis? sx? associated with what?
will resolve on its own, painful, occurs on lip/tongue most commonly. associated with stress
hairy leukoplakia: occurs in what patients?
immunocompromised: post-transplant, chemo, HIV+
hairy leukoplakia: occurs in what part of mouth? associated with what virus?
sides of tongue (cannot scrape off)
associated with EBV in HIV+
associated with immunocompromised state
hairy leukoplakia: appearance on histo?
hyperparakeratosis (thickened epit layer), acanthosis, “balloon” cells
hyperplasia but no dysplasia
leukoplakia: what is this? is it the same as hairy leukoplakia? tests needed?
-general term for plaque that cannot be scraped away.
5-25% are pre-malignant.
Pathoma says this often represents squamous cell dysplasia.
- hairy leukoplakia is a benign subtype.
- get a biopsy to rule out carcinoma
erythroplakia: how is this different from hairy leukoplakia? why?
red lesion of oral cavity. not necessarily on tongue, can be gumline.
more ominous because it is vascularized, inflamed. more concerning for cancer
squamous cell carcinoma of the oral cavity: accounts for what % of oral cancer? what are risk factors? what is mortality rate?
95% of oral cancer
associated with cigs, EtOH, HPV
50% mortality rate
squamous cell carcinoma of the oral cavity: what are some of the mutations?
- p16
- p53
- CyclinD (cell becomes immortal -> lesion -> invasive SCC)
where can I find a good chart detailing the progression of SCC in the mouth?
Slide 21 of this lecture (or Robbins text) shows normal mucosa -> hyperplasia -> dysplasia -> SCC (both histo and gross)
neoplasms of the parotid, submandibular, sublingual glands: which have the highest % malignancy?
sublingual (80% are malignant)
(the smaller the gland, the greater the chance of malignancy)
which strains of HPV are highest risk for SCC?
Types 16, 18 SCC that is associated with HPV (rather than cigs, EtOH) have better prognosis
two types of benign salivary gland tumors?
- Pleomorphic adenoma (50% of these tumors)
- Warthin tumor (5-10%)
three types of malignant salivary gland tumors?
- Mucoepidermoid carcinoma (15%)
- Acinic cell carcinoma (5%)
- Adenoid cystic carcinoma (5%)
Salivary gland tissue made up of what kinds of glands? parotid has more of which? sublingual has more of which?
serous and mucinous parotid: more serous
sublingual: more mucinous.
(think that mucus is heavier -> stays on bottom/lower glands. also, 80% of sublingual neoplasms are malignant –> Malig/Mucinous)
two types of benign salivary gland tumors?
Pleomorphic adenoma (50% of these tumors)
Warthin tumor (5-10%)
three types of malignant salivary gland tumors?
- Mucoepidermoid carcinoma (15%)
- Acinic cell carcinoma (5%)
- Adenoid cystic carcinoma (5%)
Pleomorphic Adenoma: benign or malig? type of cells involved? most common in what glands? tx?
benign, with risk of transformation -> malig
biphasic: both ductal and myoepithelial cells
more common in parotid than subman/subling glands
Tx: excise completely given risk of malignancy
Warthin tumor: benign or malig? type of cells involved? most common in what glands?
- Benign
- two components: epithelial (dense, eosin, granular) and lymphoid
- almost always in parotid
Warthin tumor: benign or malig? type of cells involved? most common in what glands? Most common in what pts?
- Benign.
- Epithelial & lymphoid cells
- almost always in parotid
- Males, usually due to smoking
Pleomorphic Adenoma: appearance on histo?
duct structures should be visible, with scattered spindle-like cells and myoepithelial cells.
define oncocytic
tumor composed of oncocytes (large, eosinophilic cells with round small nuclei and plentiful mitos) in the context of a Warthin Tumor, know that it is oncocytic and therefore eosinophilic.
what gives a Warthin tumor its eosinoiphilic appearance?
oncocytes: abundant mitochondria in cytoplasm
Warthin tumor: gross appearance?
cystic tumor. cystic fluid is motor-oil looking. black stuff within cysts is proteinaceous debris
Mucoepidermoid Carcinoma: arises in which salivary gland? what might it invade?
Pathoma: mainly occurs in parotid. May invade the facial nerve.
Mucoepidermoid Carcinoma: how do the 2 cell types stain differently?
-squamous cells stain as you would expect on H/E -mucinous cells stain orange with special stain
Mucoepidermoid Carcinoma: can the 2 cell types help with prognosis?
Low grade: mucous cells predominate. 90% 5 yr survival High grade: squamous cells predominate. 50% 5 yr survival
Mucoepidermoid Carcinoma: arises in which salivary gland? what might it invade?
Pathoma: mainly occurs in parotid. May invade the facial nerve.
Adenoid Cystic Carcinoma: progression of the tumor? prognosis?
-slow growing, but high rate of recurrence and long term survival is low (30% surv at 10y)
Adenoid Cystic Carcinoma: what is distinct about this tumor?
perineural invasion. there is a pic on slide 38.
survival rate for which type of malignant salivary gland tumor is best at 20 yrs?
Mucoepidermoid carcinoma
Congenital abnormalities of the esophagus: what are the two types?
- Atresia: absence or malformation of esop
- Fistula: connection between esop and trachea
Congenital abnormalities of the esophagus: what is the most common variant?
proximal esophageal atresia, with distal esophagus arising from the trachea. incompatible with life.
what is achalasia?
Pathoma: disorder of esop motility -> inability to relax lower esop sphincter
- dysphagia (both solids and liqs)
- bad breath
- bird-beak sign on barium study
what are a few acquired lesions of the esop?
-Achalasia -Esop webs -Esop rings -Mallory-Weiss tear -Boerhaave Syndrome -Esophageal Varices -Reflux Esophagitis
what are esop webs? patients who typically present with this?
-thin protrusion of esop mucosa, usually in upper portion -women 40+ -may cause partial obstruction of esop -> dysphagia
What is plummer-vinson syndrome?
-esop web -severe iron deficiency anemia -glossitis (beefy-red tongue) -cheilosis -risk for carcinoma of upper esop
what are esop rings? how do they present?
-overgrowths of mucosa -“A” ring occurs in lower esop, above the gastroesophageal jct (GEJ) -“B” ring (Schatzki’s) occurs at the GEJ -present with episodic dysphagia
what is a Mallory-Weiss tear? what causes it?
-longitudinal laceration at the GEJ -caused by forceful vomiting (alcoholism, bulimia) -painful hematemesis
what is Boerhaave Syndrome? what causes it?
-rupture of esop leading to air in the mediastinum. catastrophic! -due to forceful vomiting (this is the extreme end of the Mallory-Weiss spectrum)
what are esop varices? causes?
-dilated submucosal veins in lower esop -consequence of portal HTN secondary to cirrhosis -major cause of bleeding if rupture? Pathoma: these are asymptomatic but risk for rupture -> death
what is reflux esophagitis?
acid reflux damages esop mucosa, leads to metaplasia and hyperplasia. characterized by eosinophil infiltration (can see on histo)
esophageal carcinoma: squamous cell and adenocarcinoma: which is most prev worldwide? in US?
90% of esop cancer worldwide = SCC
Most prev in US is adenocarcinoma
causes of squamous cell carcinoma of esop?
EtOH, cigs, fungus-derived carcinogens, nitrosamines
causes of adenocarcinoma?
Barrett esophagus
SCC: appearance on gross?
may appear as ulceration of esop, circumferential constriction, or longitudinal growth
SCC: appearance on histo?
cord-like infiltrative cells
criteria for dx of Barrett Esop?
-endoscopic evidence of columnar epithelium in the distal esophagus AND intestinal metaplasia (goblet cells) on a mucosal biopsy from here
why does Barrett Esop occur?
reaction of lower esophageal cells to acidic stress
what does Barrett Esop look like with endoscopy?
squamous cells are pale pink, columnar mucosa is darker red. normally the Z line is well-defined between these cell types. With BE, border is irregular, with darker columnar mucosa extending up into esop.
what does Barrett Esop look like on histo?
presence of goblet cells/columnar mucosa in the esop
once you have diagnosed BE, what should your followup be?
keep an eye out for dysplasia - need to biopsy regularly
what does low grade dysplasia look like in BE?
immature cells rising to external layer. dark, stratified (still organized)
what does high-grade dysplasia look like in BE?
N:C ratio increased, cells are disorganized all the way to the top of the layer. glands also disorganized - back to back, look inflated
once BE progresses to cancer, what is prognosis?
high mortality
regular endoscopy v chromoendoscopy?
chromoendoscopy = newer biopsy technique, can recognize dysplasia more easily. allows more targeted biopsying
Treatment for esop adenocarcinoma?
esophagectomy is standard. take it out. newer tx: resection of part of the mucosa. more limited, can be used early in the course of the cancer.
squamous cell carcinoma: more common in what portion of the esop?
mid-esop Pathoma says upper or middle third.
adenocarcinoma: more common in what portion of the esop?
lower third.
