7 Benign/Premalignant Epithelial Lesions Flashcards
HPV
- # of subtypes?
- # of type identified in lesions affected the head and neck?
- # of genuses of the family
- 2 major groups:
- basic structure?
- 200 subtypes
- ~24 that affect head/neck
- 5 genuses of the Papillomaviridae family
- 2 groups: cutaneous and mucosal
- circular dsDNA
most common sexually transmitted infection in the US, but not all are sexually transmitted
HPV
How does HPV infects cells?
Virus is epitheliotropic –> enters through wounds/abrasion and infects basal cells (only actively dividing cells in the epithelium)
low risk HPV
- viral genome remains separate in the host nucleus
- replication of the viral genome occurs in parallel with host genome replication
- stable viral copy number distributed among daughter epithelial cells
low risk HPV types
6, 11 (squamous papilloma, condyloma aacuminatum)
benign papillary proliferation of squamous epithelium, all ages, any location
squamous papilloma
Clinical findings: -
- “wart-like”
- exophytic
- soft
- pedunculated or sessile
- finger-like projections
- pink or white
squamous papilloma and verruca vulgaris
tx of squamous papilloma
surgical removal
aka common wart
verruca vulgaris
benign papillary proliferation of squamous epithelium, any location but skin is most common
verruca vulgaris (common wart)
single papillary lesion (2)
squamous papilloma
verruca vulgaris
clinical findings: exophytic, soft, pedunculated or sessile, rough papillary surface, can see multiple lesions, pink or white
verruca vulgaris
tx for verruca vulgaris
surgical removal (oral), cryotherapy (skin)
any age but most commonly adolescents and young adults, multiple lesions
condyloma acuminatum
incubation period of condyloma acuminatum
1-3 months from time of sexual contact
caused by HPV 6, 11
squamous papilloma
condyloma acuminatum
causes 90% of genital warts
condyloma acuminatum
Clinical findings: more likely sessile, pink, well-demarcated, nontender exophytic mass, short, blunted surface projections (cauliflower like
condyloma acuminatum
tx of condyloma acuminatim
surgical excision
tx for all intraoral warts
- recommend surgical removal
- laser ablation has been used (airborne secretions of HPV possible)
- some lesions may resolve on their own
- recommend removal given risk of spread (discuss risk of spread with patients)
- not routinely evaluated by the pathologist for the presence of high-risk HPV genotypes
caused by HPV 13, 32
multifocal epithelial hyperplasia (Heck’s disease)
initially reported in Native Americans and Innuits
multifocal epithelial hyperplasia (Heck’s disease)
age group affected by multifocal epithelial hyperplasia (Heck’s disease)
children most common
most common sites affected by multifocal epithelial hyperplasia
labial, buccal, and lingual mucosa
Clinical findings:
- 3-10 mm lesions
- multiple, usually clustered
- coalescing (merge together)
- soft
- nontender
- flattened or rounded papules
- color of normal mucosa
- spontaneous regression after months or years
- rarely seen in adults
multifocal epithelial hyperplasia (Heck’s disease)
tx for Heck’s disease
biopsy for dx, monitor, remove lesions subject to recurrent trauma, remove for aesthetic purposes
HPV vaccine
Gardasil 9-9vHPV
Gardasil
- Age given recommended?
- Age range given?
- Expanded age range?
11-12 yo
9-26 yo
27-45
CDC guideline for the decision on whether or not to give the gardasil vaccine to pts 27-45
shared clinical decision making
benign OR premalignant
smokeless tobacco keratosis
formation of a white plaque where the mucosa directly contacts the tobacco product
smokeless tobacco keratosis
appearance is wrinkled, fissured, or rippled (“sand on a beach at ebbing tide”)
smokeless tobacco keratosis
state that uses the most smokeless tobacco
West Virgina
Wyoming
Mississippi
Smokeless tobacco contains ____ carcinogens.
28
forms of smokeless tobacco
Chewing tobacco
Snuff- dry or moist, fire cured
Snus- steam pasteurized
consequences of smokeless tobacco use
- caries due to high sugar levels
- gingival recession/bone loss
- staining of teeth
- halitosis
- cardiovascular disease
- oral cancer increases with long term use
ADA reports ___x greater risk for oral cancer for those who use smokeless tobacco than never users
4x
Which is better? wet or dry snuff
wet snuff
histo: hyperkeraotic, acanthotic (thickened, hyperplastic) epithelium, fibrosis of CT, dysplasia may be seen
smokeless tobacco keratosis
tx for smokeless tobacco keratosis
- counsel pt to quit
- if unwilling, have them move product to different site
- lesion should resolve in 2-6 weeks following cessation
- biopsy if lesion persists after 6 weeks without tobacco use
What does a severe biopsy look like?
intensely white, sharply defined borders, verrucous surface, ulceration, erythematous appearance, induration (palpable mass under the surface) or mass
High risk sites for premalignant/malignant lesions:
What percentage of all oral cancers occur in these location?
lateral/ventral tongue, roof of mouth, soft palate/oropharynx (lower lip also but develops from UV exposure so very different behavior)
90% of oral cancers occur in these locations!!
- white plaque that cannot be diagnosed clinically as another entity
- cannot be wiped off
- has a risk to develop into cancer
- more commonly has sharply defined borders
- a clinical term only, have to biopsy to know what it is (may be benign, premalignant, or malignant)
leukoplakia
cannot be wiped off
leukoplakia
average age of leukoplakia
60
Patients at increased risk for cancer development within a leukoplakia include:
- female patients
- nonsmokers
- persistent lesion over several years
- lesion on the floor of mouth or ventral tongue
After biopsy, leukoplakia may be:
- hyperkeratosis
- atypia (atrophy, acanthosis, hyperplasia)
- mild, moderate, or severe dysplasia
- carcinoma in-situ
- SCC
What does normal squamous look like?
- cells above the basal layer show progressive flattening of the cell body
- nuclear condensation as the cell differentiates/matures
- mitoses are almost never seen above the basal layer
histo appearance of dysplasia
- enlarged nuclei and cells
- large and prominent nucleoli
- increased nuclear-to-cytoplasmic ratio
- hyperchromatic nuclei (darkly staining)
- pleomorphic nuclei and cells
- dyskeratosis- premature keratinization
- increased mitotic activity
- abnormal mitotic figures
- mitotic figures above the basal layer
- bulbous (teardrop) shaped rete ridges
- lack of maturation toward surface
mild vs moderate vs severe vs full thickness dysplasia
Mild = extends to basilar 1/3 of the epithelium
Moderate = extends to basilar 1/2 of the epithelial thickness
Severe = extends beyond 1/2 of the epithelial thickness but not full thickness
Full thickness = carcinoma in-situ, almost cancer or “intra-epithelial neoplasm”
*The closer the cellular changes are to the surface, the worse the dysplasia
intra-epithelial neoplasm
carcinoma in-situ (or almost cancer)
histo: tissue with dysplastic epithelial cells that extend from the basal layer to the epithelial surface, “top-to-bottom” change, no invasion has occurred yet, basement membrane is intact
carcinoma in-situ
entire epithelial thickness exhibits dysplastic changes, basement membrane is intact
carcinoma in-situ
- persistent red patch that cannot be classified as anything else
- sharply demarcated borders
- frequently asymptomatic
- less common than leukoplakia
- biopsy for definitive diagnosis
- final tx dictated by microscopic diagnosis
erythroplakia (erythroleukoplakias)
~90% are severe dysplasia, carcinoma in-situ, or SCC
erythroplakia
- an aggressive form of oral leukoplakia
- persistent
- often multifocal, slowly spreading plaques
- rough surface projections
- high risk of recurrence
- high risk of malignant transformation
proliferative verrucous leukoplakia
etiology unknown, not associated with tobacco, alcohol, HPV, or other virus
PVL/PL
management of pts with PVL/PL
- photographs at every visit and submitted with biopsy specimens
- reassess every 3-6 months
- if biopsy shows hyperkeratosis, atrophy, or acanthosis –> followed
- if biopsy shows mild/moderate dysplasia –> excised
- severe dysplasia or CIS –> complete excision
management protocol for pts with diagnosed oral premalignancy
- removal of precancer
- discontinue tobacco and/or heavy alcohol
- upper aerodigestive tract evaluation
- clinical re-evaluation every 3-6 months
- repeat biopsy if clinically indicated
leukoplakia vs PVL/PL
Leukoplakia
- single site
- men > women
- 5th decade and beyond
- higher correlation with tobacco and alcohol
- ~40% have dysplasia at first biopsy
- moderate rate of malignant transformation (3-15%)
PVL/PL
- multifocal
- women > men
- 6th-8th decades
- lower correlation with tobacco and alcohol
- < 10% have dysplasia on first biopsy
- high rate of malignant transformation (70-100%)
malignant transformation potential from high to low
PVL erythroplakia erythroleukoplakia granular leukoplakia actinic chelitis smooth thick leukoplakia smokeless tobacco smooth thin leukoplakia
