7 - Pathology - Mucosal Diseases

Question 1

Oral potentially malignant disorders - Prevention

Answer 1

• Primary Prevention – Prevention of cancer by avoidance of carcinogens
  
  • Cessation advice
    
    • Cessation of smoking 1-4 yrs decreases risk by 30%
    • Cessation of smoking >20yrs decreases risk to baseline
  • HPV vaccine
• Secondary Prevention
  
  • Screening and early detection of cancer
  • Prevention of malignant transformation
    
    • Chemoprevention
    • Surgery
• Tertiary Prevention
  
  • Early detection of second primary tumours and recurrences

Question 2

Orofacial Granulomatosis Aetiology and Differentials

Answer 2

• Wiesenfeld 1985
  
  • Coined the termed “Orofacial granulomatosis”
  • Granulomas occuring in the orofacial region in the absence of any recognised systemic condition
    ​
• Aetiology
  No definitive cause, 5 processes implicated
  
  • Genetic
    
    • Familial association
  • Food Allergy
  • Dental Materials Allergy
  • Infective
  • Autoimmune
    
    • Biopsy of lesion shows a diversity in cell surface markers indicating an influx of lymphocytes from the blood
      ​
• Differentials
  
  • Crohns Disease
    
    • GI manifestations
  • Sarcoidosis
    
    • Pulmonary, cutaneous, lachrymal, neurological and skeletal features
  • Allergic angioedema
    
    • Pt commonly have history of atopy
    • Usually a precipitant
  • Mieschke’s cheilitis granulomatosis
    
    • Can appear similar to OFP
  • Melkersson-Rosenthal Syndrome
    
    • Triad of Lip or facial swelling, Recurrent facial paralysis and Fissured tongue
  • Tuberculosis
    
    • Caseating granulomas
    • Rarely affects lip
    • Localised swellings and ulcers

Question 3

Orofacial Granulomatosis Management

Answer 3

• Grave 2008
  DOI: 10.1111/j.1601-0825.2008.01500.x
  
  • Corticosteroids
    
    • Intralesional - difficult in children
    • Systemic
  • Clofazimine
    
    • Lipophilic dye that scavenges for hypochloric acid - reducing the chlorination of proteins by neutrophils
    • Exact protocol not clear
  • TNF-alpha antibodies
    
    • Clinical efficacy not translatable to all patients based on small studies

Question 4

WHO Dysplasia Classification

Answer 4

• WHO Definition - Oral epithelial dysplasia
  
  • Oral epithelial dysplasia is a spectrum of architectural and cytological epithelial changes caused by accumulation of genetic changes associated with an increased risk of progression to squamous cell carcinoma
• Architectural changes
  
  • Irregular epithelial stratification
  • Loss of polarity of basal cells
  • Drop shaped rete ridges
  • Increased number of mitotic figures
  • Abnormal superifical mitosis
  • Dyskeratosis - Premature keratinization in single cells
  • Keratin pearls within Rete ridges
  • Loss of epithelial cell cohesion
    ​
• Cellular changes
  
  • Anisonucleosis - Abnormal variation in nuclear size
  • Nuclear pleomorphism - Abnormal variation in nuclear shape
  • Anisocytosis - Abnormal variation in cell size
  • Cellular pleomorphism - Abnormal variation in cell shape
  • Increase nuclear to cytoplasmic ratio
  • Atypical mitotic figures
  • Increased number and size of nucleoli
  • Hyperchromasia

Question 5

Dysplasia Transformation Rate

Answer 5

• Mehanna 2009
  12% overall
  Usually occurs within 4 years
  
  • Mild - 5%
  • Mod - 10%
  • Severe - 25%
  • Surgery
    
    • Cutting out reduces risk to 5%
      35% recurrence risk

Question 6

Oral potentially malignant disorders

Answer 6

• Pre-malignant lesions (WHO 2017)
  
  • Leukoplakia
  • Proliferative verrucous leukoplakia
  • Erythroleukoplakia
  • Erythroplakia
  • Smokeless tobacco keratosis
  • Palatal lesions associated with reverse smoking
  • Submucous fibrosis
  • Chronic hyperplastic candidiasis
  • Syphilitic glossitis
  • Actinic cheilitis
  • Oral lichen planus/Oral lichenoid lesions
    ​
• Pre-malignant conditions
  
  • Discoid lupus erythematosus (WHO 2017)
  • Dyskeratosis congenita (WHO 2017)
  • Fanconi anaemia (AAOMS Position Paper)
  • Li-Fraumeni syndrome (AAOMS Position Paper)
  • Bloom syndrome (AAOMS Position Paper)
  • Plummer Vinson syndrome (AAOMS Position Paper)
  • Acquired Immunodeficiency (AAOMS Position Paper)
    
    • Graft vs Host
  • Xeroderma pigmentosum
  • Epidemolysis bullosa

Question 7

Dysplasia Malignant Transformation

Answer 7

Speight 2018

• Clinical Features
  
  • Size of lesion > 2cm -Strong
  • Non homogenous -Strong
  • Colour - Red / Speckled -Strong
  • Site - Tongue & FOM -Strong
  • Gender - Female -Medium
  • Age > 50yrs -Medium
  • Habits - Non smoker -Weak
    ​
• Histological
  
  • Dysplasia - Severe or High -Strong
  • HPV 16+ve -Medium
  • DNA aneuploidy -Medium
    
    • Presence or absence of one or more chromosomes
  • Loss of heterozygosity -Medium
    
    • Describes an event where there is not a specific tumour suppressor gene present
    • Heterozygous state refers to a state where an individual only has one functional TSG. This may be the result of a congenital genetic abnormality or prior mutations
    • The remaining functional TSG can be inactivated due to mutations of other mechanisms
    • Loss of heterozygocity does not refer or imply a homozygous state

Question 8

Leukoplakia vs Proliferative Leukoplakia

Answer 8