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DEN 7208 Oral Cancer > Exam 2 Oral Premalignant Cancers > Flashcards

Exam 2 Oral Premalignant Cancers Flashcards

1
Q

Oral cancer is a nonspecific term that denotes:

A

All malignancies in the oral cavity

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2
Q

What types of malignancies can be found in the oral cavity?

A
  • Epithelial malignancies
  • Mesenchymal malignancies
  • Hematopoetic malignancies
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3
Q

Examples of epithelial malignancies

A
  • Squamous cell carcinoma
  • Basal cell carcinoma
  • Salivary gland malignancies
  • Odontogenic carcinomas
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4
Q

Examples of mesenchymal malignancies

A
  • Soft tissue sarcomas
  • Osteosarcoma
  • Chondrosarcoma
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5
Q

Examples of hematopoetic malignancies

A
  • Lymphoma
  • Leukemia
  • Multiple myeloma
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6
Q

90% of all oral cancers are _____

A

Squamous cell carcinomas

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7
Q

What is a leukoplakia?

A

A white, plaque-like lesion which cannot be wiped off and cannot be characterized clinically or pathologically as any other disease

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8
Q

Does leukoplakia imply a specific histologic diagnosis?

A

No - clinical term only

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9
Q

Leukoplakia is a diagnosis of ____

A

Exclusion (must rule out other clinically distinct entities such as lichen planus, smokeless tobacco keratosis, frictional hyper keratosis, leukoedema, etc)

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10
Q

5-25% of leukoplakias are diagnosed as ____ after microscopic exam

A

Epithelial dysplasia (premalignant)

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11
Q

4% of leukoplakias are diagnosed as ____ after microscopic exam

A

Squamous cell carcinoma

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12
Q

True leukoplakias are considered to be?

A

Potentially premalignant lesions

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13
Q

What is the incidence of leukoplakias?

A

1.5-4.3% worldwide

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14
Q

____ is the most common oral premalignant lesion

A

Leukoplakia

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15
Q

Leukoplakias affects what gender?

A

Males > females

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16
Q

What ages are affected by leukoplakias?

A

> 40 years (60 years average)

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17
Q

Risk factors for leukoplakias

A
  • Tobacco
  • Alcohol
  • Sanguinaria use
  • UV radiation
  • Microorganisms (HPV, fungal candidiasis)
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18
Q

____ may be a risk factor for leukoplakias

A

Chronic inflammation

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19
Q

Alcohol has ____ effects with tobacco

A

Synergistic

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20
Q

70% of leukoplakias are found on:

A
  • Lip vermillion
  • Buccal mucosa
  • Gingiva
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21
Q

What locations account for 90% of leukoplakias that show dysplasia? (high risk sites for dysplasia and SCC)

A
  • Lateral-ventral tongue
  • Floor of mouth
  • Soft palate
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22
Q

____ and ____ are high risk leukoplakia sites for betel quid users

A

Buccal mucosa and commissures

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23
Q

What is the clinical appearance of leukoplakia?

A
  • White in color
  • Flat to slightly raised plaques
  • Often with well defined borders
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24
Q

What are the surface variations for leukoplakias?

A
  • Thin vs thick
  • Smooth vs rough
  • Homogenous vs heterogenous
  • Granular, verruciform
  • Well vs ill-defined
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25
Q

What are two special clinical variants of leukoplakias?

A
  • Erythroleukoplakia, speckled leukoplakia
  • Proliferative Verrucous Leukoplakia (PVL)
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26
Q

What is erythroleukoplakia?

A

Leukoplakia admixed with erythroplakia (mixed red-white lesions)

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27
Q

Erythroleukoplakias usually show:

A

High grade dysplastic changes, SCC

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28
Q

What is Proliferative Verrucous Leukoplakia (PVL)?

A
  • Rare high-risk form of leukoplakia
  • Multifocal leukoplakia with all grades of dysplastic changes
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29
Q

What location is Proliferative Verrucous Leukoplakia (PVL) found?

A

Any mucosal site, especially gingiva

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30
Q

Proliferative Verrucous Leukoplakia (PVL) has a ____ predilection and has no association with ____

A

Female; smoking

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31
Q

Proliferative Verrucous Leukoplakia (PVL) typically develops ____

A

Dysplastic changes, SCC

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32
Q

True or false: Proliferative Verrucous Leukoplakia (PVL) rarely regresses and recurs with removal

A

True (poor prognosis)

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33
Q

What is the clinical and microscopic progression of leukoplakias?

A

Normal mucosa –> thin, smooth leukoplakia –> thick, fissured leukoplakia –> granular, verruciform leukoplakia –> Erythroleukoplakia (speckled leukoplakia)

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34
Q

True or false: not all leukoplakia lesions will progress

A

True

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35
Q

UV Radiation-Associated Leukoplakia

A

Actinic Cheilitis (leukoplakia blends into vermillion border)

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36
Q

Leukoplakia histopathology includes:

A
  • Hyperkeratosis
  • Epithelial dysplasia
  • Carcinoma in situ (CIS)
  • Early squamous cell carcinoma
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37
Q

Hyperkeratosis makes up about ____ of leukoplakia cases

A

80%

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38
Q

Types of hyperkeratosis

A
  • Hyperparakeratosis
  • Hyperorthokeratosis
  • Epithelial hyperplasia/hyperkeratosis
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39
Q

What is hyperparakeratosis?

A

Nuclei retained in keratin layer

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40
Q

What is hyperorthokeratosis?

A
  • No nuclei in keratin layer
  • Prominent granular cell layer
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41
Q

Epithelial dysplasia is ____

A

Premalignant

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42
Q

Carcinoma in situ and early squamous cell carcinoma are ____

A

Malignant

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43
Q

What are the cellular features of dysplasia?

A
  • Enlarged nuclei and cells; increased nuclear-to-cytoplasmic ratio
  • Hyperchromatic (dark-staining) nuclei
  • Prominent nucleoli
  • Cellular and nuclear pleomorphism
  • Dyskeratosis (premature keratinization)
  • Increased mitotic activity; abnormal mitotic figures
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44
Q

What are the tissue architectural features of dysplasia?

A
  • Bulbous, tear-drop shaped rete ridges
  • Loss of polarity (disorganized maturation)
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45
Q

Grading the dysplasia of leukoplakias is based on:

A

Thirds of epithelial thickness involved

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46
Q

What are the grades of leukoplakia dysplasia?

A
  • Mild dysplasia
  • Moderate dysplasia
  • Severe dysplasia
  • Carcinoma in situ
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47
Q

What is a mild dysplasia?

A

Dysplasia involving lower 1/3 of epithelium (primarily basal and parabasal layers)

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48
Q

What is a moderate dysplasia?

A

Dysplasia involving lower 2/3 of epithelium (basal cell layer to mid portion)

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49
Q

What is a severe dysplasia?

A

Dysplasia extending to upper 1/3 of epithelium (basal cell layer to above mid-portion)

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50
Q

What is carcinoma in situ (CIS)?

A

Dysplasia involving entire thickness of epithelium with no evidence of penetration of basement membrane

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51
Q

What is needed for leukoplakia diagnosis?

A
  • Clinical presentation AND
  • Tissue biopsy
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52
Q

What other techniques/adjuncts can be used for leukoplakia diagnosis?

A
  • Vital dyes
  • Chemiluminescence (Vizilite)
  • Autofluorescence (VELscope)
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53
Q

____ and ____ remain gold standard for assessment of oral leukoplakia

A

Careful examination and conventional biopsy

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54
Q

To treat leukoplakia, patient should discontinue”

A

Contributing factors

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55
Q

Leukoplakia treatment is guided by:

A

Histologic diagnosis, anatomic location, risk factors

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56
Q

How is hyperkeratosis or mild dysplasia treated (leukoplakia)?

A
  • Clinical follow-up every 6 months (re-biopsy as necessary) OR
  • Complete removal (surgical, laser, etc.)
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57
Q

How is moderate dysplasia or worse treated (leukoplakia)?

A

Complete removal (surgical, laser, etc)

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58
Q

Leukoplakia treatment requires careful _____

A

Long-term follow up

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59
Q

Recurrence rate of leukoplakia

A

10-35%

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60
Q

Recurrence rate is ____ for granular, verruciform leukoplakia

A

83%

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61
Q

True or false: there is possible development of additional leukoplakias

A

True

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62
Q

Risk for dysplasia:
- Thin leukoplakia ____
- Thick leukoplakia ____
- Granular, verruciform leukoplakia ____
- Erythroleukoplakia ____

A

Seldom (80% hyperkeratosis); 1-7%; 4-15%; 18-47%

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63
Q

Rates of malignant transformation to SCC:
Moderate dysplasia ____
Severe dysplasia ____
Overall malignant transformation rate ____

A

4-11%; 20-43%; 2%

64
Q

Malignant transformation usually ____ after onset of leukoplakia

A

2-4 years

65
Q

Risk of malignant transformation is increased if:

A
  • Persistent lesions
  • FOM
  • Ventral tongue location
66
Q

What is an erythroplakia?

A

A red patch/plaque that cannot be clinically or pathologically diagnosed as any other condition

67
Q

Most erythroplakias (90%) are diagnosed as ____ on microscopic exam

A

High-grade epithelial dysplasia, carcinoma in situ, or SCC

68
Q

True erythroplakias are considered to be:

A

Very premalignant lesions

69
Q

Incidence of erythroplakia

A

1:2500 adults (much less frequent than leukoplakia)

70
Q

What gender is affected in erythroplakia?

A

Males&raquo_space;» females

71
Q

What age is affected in erythroplakia?

A

Middle-aged and older adults

72
Q

Risk factors of erythroplakia

A

Same as SCC

73
Q

Location of erythroplakia

A

Mostly FOM, tongue, soft palate (overlap with high risk sites for leukoplakia)

74
Q

Erythroplakia is often well ____

A

Demarcated

75
Q

What does erythroplakia look like?

A

Red plaque/patch

76
Q

Erythroplakia feels:

A

Soft, velvety

77
Q

Erythroplakia may have an adjacent:

A

Leukoplakia (erythroleukoplakia)

78
Q

Erythroplakia histopathology

A
  • Lack of keratinization
  • Often epithelial atrophy
  • Chronic inflammation in connective tissue
79
Q

Majority of erythroplakia (> 90%) will show:

A
  • Dysplasia (usually severe)
  • Carcinoma in situ
  • Squamous cell carcinoma
80
Q

What is needed for Erythroplakia diagnosis?

A

Clinical presentation AND tissue biopsy

81
Q

____ should be performed to establish histologic diagnosis for Erythroplakia

A

Biopsy

82
Q

If irritation/trauma suspected, _______. Biopsy if lesion does not resolve in ____

A

Remove the source of trauma and follow up; 2 weeks

83
Q

Erythroplakia treatment is guided by:

A

Histologic diagnosis, anatomic location

84
Q

In general, Erythroplakia has more ____ treatment than with leukoplakia

A

Aggressive

85
Q

Recurrence and multifocality is common in ____

A

Erythroplakia

86
Q

What is a squamous cell carcinoma?

A

Malignant neoplasm of squamous epithelium (skin, mucosal sites)

87
Q

Squamous cell carcinoma makes up ____ of all oral cancers

A

> 90%

88
Q

SCC is the ____ most common cancer in US men and ____ in US women

A

11th; 16th

89
Q

SCC has much higher prevalence in:

A

SE Asia (India)

90
Q

One pt dies from oral cancer each ____ in US

A

Hour

91
Q

Oral cavity SCC arise in:

A

Intra-oral anatomic sites

92
Q

Oral cavity SCC is most related to ____ risk factors

A

Conventional (smoking, etc)

93
Q

Where to oropharyngeal SCC arise?

A

Base of tongue, tonsillar region, oropharynx

94
Q

Majority of oropharyngeal SCC are ____

A

HPV +

95
Q

Racial predilection of SCC

A

Caucasians > African americans

96
Q

SCC mortality is higher among ____

A

African American males

97
Q

____ at higher risk for HPV+ oropharyngeal SCC

A

Caucasian men

98
Q

SCC risk increases with ____

A

Age

99
Q

SCC usually affects what age?

A

Older adults, especially > 65 years

100
Q

What gender is affected more in SCC?

A

Males&raquo_space;> females (2.5:1)
(may be equal in younger adults/peds, may be altered by popularity of harmful habits)

101
Q

SCC risk factors

A
  • Tobacco
  • Large amounts of alcohol
  • Environmental/occupational pollution
  • Radiation
  • Mineral/vitamin deficiency (iron)
  • Microorganisms
  • Immunosuppression
  • Hereditary factors
  • Oropharyngeal HPV 16, 18
102
Q

Intra-oral SCC locations

A
  • Posterior lateral/ventral tongue (50% of all cases)
  • FOM
  • Gingiva and buccal mucosa incidence increasing
  • Intraosseous
103
Q

Most common site of metastasis for SCC

A

FOM

104
Q

Lip vermillion SCC locations

A

Lower lip (> 90% of lip SCCs)

105
Q

Lip vermillion SCC is preceded by:

A

Actinic cheilitis

106
Q

Risk factors for lip vermillion SCC

A
  • Fair complexion
  • Chronic UV light exposure
  • Outdoor occupations
107
Q

Oropharyngeal SCC locations

A

Tonsillar region (70-80%); soft palate, base of tongue, posterior pharyngeal wall

108
Q

Delayed diagnosis of oropharyngeal SCC results in:

A
  • Large tumor size
  • Cervical nodes involvement
  • Distant metastasis often at presentation
109
Q

SCC is most preceded by:

A

Leukoplakia and erythroplakia

110
Q

Clinical features of SCC - color

A

White, red, mixed

111
Q

Clinical features of SCC - surface architecture

A

Plaque, nodule, mass

112
Q

Clinical features of SCC - consistency

A

Firm, indurated, rarely soft

113
Q

Clinical features of SCC - growth patterns

A

Exophytic, endophytic

114
Q

Clinical features of SCC - specific characteristics

A

Ulceration

115
Q

Clinical features of SCC - surface texture

A

Papillary, verrucous, fungating, granular, +/- pain

116
Q

SCC radiographic features

A
  • Destruction of underlying bone
  • Ill defined borders (moth-eaten)
  • Radiolucent
  • Can mimic periodontal disease
117
Q

Metastasis is a ____ event in oral SCC and ____ in oropharyngeal SCC

A

Late; early

118
Q

____ have cervical LN metastasis in oropharyngeal SCC

A

> 50%

119
Q

Route of metastasis of SCC

A

Mainly lymphatics (ipsilateral cervical LN)

120
Q

SCC of lower lip would metastasize through:

A

Submental LNs

121
Q

SCC of posterior oral cavity would metastasize through:

A

subMD, superior jugular, digastric LNs

122
Q

What does metastasis look like initially?

A

Enlarged, non-tender, firm node

123
Q

What does metastasis look like later?

A

Fixed (non-movable) with extracapsular penetration

124
Q

Distant metastasis can be seen in what other areas of the body?

A

Lungs, liver, bones

125
Q

SCC Histopathology

A
  • Invasive islands, cords of malignant squamous epithelial cells
  • Cellular, nuclear pleomorphism
  • Altered nuclear: cytoplasmic ratio
  • Increased mitotic activity
  • Keratin pearls, individually keratinized cells
126
Q

SCC may have ____ or ____ invasion

A

Perineural or vascular

127
Q

What is histologic grading?

A

Degree of differentiation

128
Q

Histologic grading is dependent on what factor?

A

Resemblance of tumor to its tissue of origin

129
Q

Low grade (I)

A

Well differentiated

130
Q

Intermediate grade (II)

A

Moderately differentiated

131
Q

High grade (III/IV)

A

Poorly differentiated

132
Q

Histologic grade may correlate with:

A

Clinical behavior

133
Q

HPV+ Oropharyngeal SCC Histopathology

A
  • Poorly differentiated
  • Detection of HPV via P16 immunohistochemistry and HPV-16 RNA in-situ hybridization (ISH)
134
Q

What are the best predictors of prognosis for oral SCC?

A

Tumor size and extent of metastatic spread

135
Q

What is TNM staging?

A

T- primary tumor size
N - regional lymph node involvement
M - distant metastasis

136
Q

TNM staging is staged from:

A

I-IV

137
Q

____ is a better predictor of prognosis than histologic grade

A

Clinical stage

138
Q

Any lymph node involvement is stage ____

A

III

139
Q

M1 distant metastasis is stage ____

A

IV

140
Q

The higher the stage, the ____ the prognosis. What is an exception?

A

Worse; Oropharyngeal SCC have same 5 year survival rates for stage 1-3

141
Q

____ seems to be the best predictor of prognosis for oropharyngeal SCC

A

HPV status

142
Q

SCC treatment depends on:

A

Clinical stage

143
Q

SCC treatment options

A
  • Surgical resection
  • +/- adjuvant chemotherapy and or radiation
  • +/- radical neck dissection
  • Immunotherapy?
144
Q

5 year survival for combined oral and oropharyngeal SCC

A

65%

145
Q

Intraoral/lip SCC ____ is the best predictor of prognosis

A

Clinical stage

146
Q

Patients with one carcinoma of the oral cavity or throat are at increased risk for:

A

Second primary SCC

147
Q

Second SCC can occur ____ or ____

A

Synchronous or metachronous (concurrent or later)

148
Q

What is the cause of a second SCC occurring?

A

Field cancerization or clonal divergence

149
Q

Risk of a second SCC

A

Males who continue smoking and using alcohol

150
Q

What is a diagnostic adjunct?

A

A technique applied to an identified lesion which aides in the characterization of the lesion to better identify high-risk lesions and/or select appropriate regions for further evaluation

151
Q

What are some light-based adjuncts?

A
  • VELscope
  • Vizilite
  • Identifi3000
152
Q

A true positive appears ____ with VELscope

A

Darker (black)

153
Q

Vital stains

A
  • T-blue
  • Lugon’s solution
154
Q

____ us a cytopathologic adjunct

A

Oral CDx brush biopsy

155
Q

Brush biopsy: OralCDx possible results (4)

A
  • Negative: no cellular abnormalities
  • Positive: definitive cellular evidence of epithelial dysplasia or carcinoma
  • Atypical: abnormal epithelial changes warranting further investigation
  • Sample insufficient for diagnosis

DEN 7208 Oral Cancer (10 decks)

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