Chapter 10: Epithelial Pathology PART 2 Flashcards
___ is an oral counterpart to ephelis
oral melanotic macule
___ is a brown asymptomatic macule produced by a focal increase in melanin deposition
oral melanotic macule
are oral melanotic macules dependent on sun exposure?
no
what is the most common site of oral melanotic macules?
vermillion zone of the lower lip (labial melanotic macule)
___% of oral melanotic macules are solitary
80%
there is no malignant transformation potential of oral melanotic macule, but it is clinically indistinguishable from what?
early melanoma
a biopsy is mandatory
___ is an acquired pigmentation of the oral mucosa that appears to be a reactive process due to trauma
oral melanoacanthoma
oral melanoacanthoma is characterized by ___ throughout the epithelium
dendritic melanocytes
oral melanotic macule
labial melanotic macule
is oral melanoacanthoma related to melancanthoma of the skin?
no
oral melanoacanthoma is seen almost exclusively in what population, and is it more common in males or females?
african americans
F>M
oral melanoacanthoma is most common in what age?
20-30s
what is the most common site of oral melanoacanthoma occurrence?
buccal mucosa
oral melanoacanthoma is typically asymptomatic, but can cause ___ and ___
pain and burning
how does oral melanoacanthoma clinically appear?
smooth, dark brown macule
lesions increase rapidly in size
incisional biopsy is indicated in cases of oral melanoacanthoma to rule out ___
melanoma
what is the treatment for oral melanoacanthoma? is there a risk of malignant transformation
- biopsy to rule out melanoma
- no further treatment - lesions regress after incisional biopsy
- is there a risk of malignant transformation?
bottom photo is after biopsy
oral melanoacanthoma
___ is the most commonly recognized nevus
acquired melanocytic nevus
aka mole
___ is a benign, localized proliferation of cells from the neural crest, and is the most common of all adult tumors
acquired melanocytic nevus
white adults can have how many acquired melanocytic nevus lesions? where are most lesions present?
- 10-40
- above the waist
what are the 3 clinical stages of acquired melanocytic nevus?
- junctional
- compound
- intradermal
which stage of acquired melanocytic nevus is the earliest presentation and appears as a dark macule less than 6mm?
junctional
which stage of acquired melanocytic nevus occurs as the nevus cells proliferate and the lesion becomes a slightly elevated, soft papule with a smooth surface; the degree of pigmentation decreases
compound
which stage of acquired melanocytic nevus is characterized by the lesion surface becoming somewhat papillomatous; hairs grown from the center; loses most or all of its pigmentation? what is the name give to it if it is in the oral cavity?
- intradermal
- intramucosal if it is in the oral cavity
are intraoral melanocytic nevi common? what is the fraction that are found in females?
- uncommon
- 2/3 are found in females
most intraoral melanocytic nevi have an evolution and appearance similar to ___, and have a predilection for the ___
- skin nevi
- palate
what is the treatment for acquired melanocytic nevi? what is the risk of transformation?
- no treatment necessary unless there is clinical change or found in the oral cavity
- most will regress
- risk of transformation of an acquired melanocytic nevus is one in a million
acquired melanocytic nevus
acquired melanocytic nevus
acquired intraoral melanocytic nevus
acquired intraoral melanocytic nevus
congenital melanocytic nevi affect ___% of newborns
1%
congenital melanocytic nevi are divided into what two categories?
small (less than 20cm) and large (greater than 20cm)
small type congenital melanocytic nevi are similar in appearance to ___, except they are usually larger
acquired melanocytic nevi
describe large type congenital melanocytic nevi
- plaques with a rough or nodular surface and often change with time
- common feature is hypertrichosis (excess)
a very large congenital nevus can be called a ___ or ___
bathing trunk or garment nevus
up to ___% of large congenital nevi may undergo malignant transformation into melanoma. what should you do with these lesions?
- 15%
- these lesions should be removed entirely if feasible; otherwise, close follow-up is required
a ___ is a melanocytic nevus with a surrounding pale hypopigmented border
halo nevus
halo nevi are thought to result from what?
nevus cell destruction by the immune system
congenital melanocytic nevus
large type (characteristic hypertrichosis)
halo nevus
___ is an uncommon, benign proliferation of dermal (or intramucosal) melanocytes that comes in two forms: common and cellular
blue nevus
what is the blue color of blue nevi due to?
- tyndall effect - melanin particles are deep to the surface, so the light reflected back must pass through overlying tissues
- colors with long wavelenths (red/yellow) are more easily absorbed by the tissues
- blue has a shorter wavelength and is reflected
how are blue nevi treated? what is the risk of malignant transformation?
- conservative surgical excision with minimal chance of recurrence
- oral lesions must be biopsied to rule out melanoma
- malignant transformation has been reported but is very rare
intraoral blue nevus
blue nevus
___ is an intraoral white plaque that does not rub off and cannot be identified as any well known entity
leukoplakia
- if it can be rubbed off, it is not leukoplakia
- if it is easily recognizable as a well known entity, it is not leukoplakia
why are leukoplakia lesions white?
because there is something (keratin, microbial colony, scar tissue, necrosis, etc.) that is blocking the “redness” of the underlying vascular tissue
what are some examples of white lesions that can be scraped off?
- materia alba
- white coated tongue
- burn (thermal, chemical, cotton roll, etc)
- pseudomembranous candidiasis
- sloughing from toothpaste
leukoplakia is considered a ___ lesion
premalignant
leukoplakia comprises ___% of oral precancer
85%
___ or ___ is seen in 20% of biopsy samples of clinical leukoplakia
dysplastic epithelium or squamous cell carcinoma
80% of leukoplakia biopsies are ___
benign hyperkeratosis
what is the malignant transformation potential of leukoplakia?
5-50%, depending on the clinical subtype
leukoplakia has a strong ___ predilection
male
what are the 6 etiologies of leukoplakia?
- tobacco
- smoking
- sanguinaria
- UV radiation
- microorganisms
- trauma
describe leukoplakia with a tobacco etiology
- 80% of patients with leukoplakia smoke
- smokeless tobacco = tobacco pouch keratosis
leukoplakia with an alcohol etiology has a synergistic effect with ___
tobacco
describe leukoplakia with a sanguinaria etiology
- an herbal extract found in toothpaste or mouth rinses
- leukoplakia occurs in the maxillary vestibule or alveolar mucosa of the maxilla
- 80% of patients with leukoplakic lesions here have a history of using sanguinaria products
leukoplakia with a UV radiation etiology causes leukoplakia in what location?
lower lip vermillion
describe leukoplakia with a microorganism etiology
- treponema pallidum (glossitis in 3rd stage syphilis)
- candida albicans can colonize the superficial oral mucosa to produce a thick plaque (candidal hyperplasia)
- HPV 16 and 18 has been identified in some leukoplakias
describe leukoplakia with a trauma etiology
- not precancerous
- not true leukoplakia
- exmamples: nicotine stomatitis and frictional keratosis
the prevalence of leukoplakia increases rapidly with ___
age
70% of leukoplakia lesions are found where?
lip vermillion, buccal mucosa, gingiva
90% of leukoplakias with dysplasia or carcinoma are found where?
lip vermillion, lateral/ventral tongue, floor of mouth
lesions that demonstrate scattered red patches are termed ___
erythroplakia
erythroplakia found in areas of leukoplakia represents site in which ___ cells are so immature they can no longer produce ___
- epithelial
- keratin
red (erythroplakia) and white (leukoplakia) intermixed lesions are termed ___ or ___
erythropeukoplakia or speckled leukoplakia
erythroplakia and erythroleukoplakia frequently reveal advanced ___ on biopsy
dysplasia
___ is a special high-risk form of leukoplakia characterized by multiple keratotic plaques with roughened surface projections
proliferative verrucous leukoplakia (PVL)
proliferative verrucous leukoplakia lesions spread slowly throughout the ___, and as the lesion progresses, ___ can develop
- mouth
- carcinoma
is PVL difficult to treat? do lesions recur?
it is difficult to treat, and lesions will recur
why is PVL unusual?
there is a 4:1 F:M predilection and no association with tobacco use
the histoplathology of leukoplakia includes what 4 things?
- hyperkeratosis - thickened keratin layer
- hyperparakeratosis - no granular cell layer; nuclei are retained
- hyperorthokeratosis - granular cell layer; nuclei are lost
- acanthosis - thickened spinous layer
when there is concern about malignancy with leukoplakia, ___ techniques such as cytologic testing (including brush biopsy) and lesion staining with supravital dyes should not be considered as substitutes for ___
- noninvasive screening
- biopsy
the first step in treating leukoplakia is arriving at a ___. therefore, ___ is mandatory
- definitive diagnosis
- biopsy
- taken from most severe looking areas of involvement
describe the alterations found in leukoplakia biopsies that are consistent with mild dysplasia, moderate dysplasia, severe dysplasia, and carcinoma in situ
- mild dysplasia - alterations are limited to the lower 1/3
- moderate dysplasia - alterations are limited to the lower 1/2
- severe dysplasia - alterations are present above the lower 1/2
- carcinoma in situ - alterations are present throughout epithelium
management of leukoplakia with mild dysplasia is guided by what?
the size of the lesion and the response to more conservative measures (aka smoking cessation)
management of leukoplakia with moderate epithelial dysplasia or worse warrants what?
complete removal or tissue
why is long-term follow up after leukoplakia treatment important?
- recurrences are frequent (85% in verruciform)
- additional leukoplakias may develop
- overall, 5% of leukoplakias become squamous cell carcinoma, usually within 2-4 years
what are 4 factors that increase the risk for cancer in leukoplakias?
- persistence over several years
- female patient
- nonsmoker
- oral floor or ventral tongue lesions
___ is defined as a red patch that cannot be diagnosed as any other condition
erythroplakia
T or F:
true erythroplakias are benign
false
true erythroplakias are never completely benign
90% of erythroplakias show ___ on biopsy
moderate dysplasia or worse
what are the causes of erythroplakia?
unknown, but they are assumed to be the same as invasive squamous cell carcinoma
erythroplakia predominantly occurs in what age patient, and with what gender predilection?
- middle-aged to older adults (average = 70yo)
- no gender predilection
what are the most common locations of erythroplakia?
- floor of mouth
- ventral tongue
- soft palate
what does the altered mucosa look like in erythroplakia?
well-demarcated macule or plaque with a soft, velvety texture
is erythroplakia typically symptomatic or asymptomatic?
asymptomatic
erythroplakias are red in color due to what?
- lack of keratin and epithelial thinness
- allows underlying vasculature to show
___ is mandatory for erythroplakia, and treatment is guided by ___
- biopsy
- definitive diagnosis
describe recurrence and multifocal oral involvement of erythroplakia
both are common, therefore long-term follow up is required
proliferative verrucous leukoplakia
proliferative verrucous leukoplakia
erythroleukoplakia
does not rub off
leukoplakia
erythroplakia
erythroplakia
what are the 3 types of smokeless tobacco, and what population most commonly uses each?
- chewing tobacco - men during outdoor activities
- moist snuff - most popular
- dry snuff - southern women
what is the most common local change seen in patients using smokeless tobacco?
- characteristic, painless loss of gingival tissues in area of tobacco contact
- gingival recession may be accompanied by destruction of facial surface of alveolar bone; correlates with quantity of daily use and duration of habit
a ___ stain on the teeth is common in patients using smokeless tobacco
brown-black extrinsic tobacco stain
halitosis is a frequent finding of patients using ___
smokeless tobacco
what is smokeless tobacco keratosis?
a characteristic white plaque that is produced on the mucosa in direct contact with smokeless tobacco
do smokeless tobacco keratosis lesions develop shortly after tobacco use or after a long history of use?
shortly after heavy tobacco use begins; new lesions seldom arise in people with a long history of tobacco use
what do smokeless tobacco keratosis lesions look like clinically?
thin, gray or white plaque with a border that blends into the surrounding mucosa; appears fissured or rippled
do smokeless tobacco keratosis lesions exhibit induration, ulceration, pain, or epithelial dysplasia?
- NO induration, ulceration, or pain
- epithelial dysplasia is uncommon, but if it is present, it is mild
when is a biopsy warranted in smokeless tobacco keratosis lesions?
only for more severe lesions or for a lesion remaining 6 weeks after habit is stopped
what is the treatment for smokeless tobacco keratosis?
- altnerate the site of tobacco placement
- habit cessation leads to normal mucosal appearance in 98% of users, usually in 2 weeks
gingival recession due to smokeless tobacco
smokeless tobacco keratosis
smokeless tobacco keratosis
smokeless tobacco keratosis
