Exam 2 Oral Premalignant Cancers Flashcards
1
Q
Oral cancer is a nonspecific term that denotes:
A
All malignancies in the oral cavity
2
Q
What types of malignancies can be found in the oral cavity?
A
- Epithelial malignancies
- Mesenchymal malignancies
- Hematopoetic malignancies
3
Q
Examples of epithelial malignancies
A
- Squamous cell carcinoma
- Basal cell carcinoma
- Salivary gland malignancies
- Odontogenic carcinomas
4
Q
Examples of mesenchymal malignancies
A
- Soft tissue sarcomas
- Osteosarcoma
- Chondrosarcoma
5
Q
Examples of hematopoetic malignancies
A
- Lymphoma
- Leukemia
- Multiple myeloma
6
Q
90% of all oral cancers are _____
A
Squamous cell carcinomas
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
8
Q
Does leukoplakia imply a specific histologic diagnosis?
A
No - clinical term only
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)
10
Q
5-25% of leukoplakias are diagnosed as ____ after microscopic exam
A
Epithelial dysplasia (premalignant)
11
Q
4% of leukoplakias are diagnosed as ____ after microscopic exam
A
Squamous cell carcinoma
12
Q
True leukoplakias are considered to be?
A
Potentially premalignant lesions
13
Q
What is the incidence of leukoplakias?
A
1.5-4.3% worldwide
14
Q
____ is the most common oral premalignant lesion
A
Leukoplakia
15
Q
Leukoplakias affects what gender?
A
Males > females
16
Q
What ages are affected by leukoplakias?
A
> 40 years (60 years average)
17
Q
Risk factors for leukoplakias
A
- Tobacco
- Alcohol
- Sanguinaria use
- UV radiation
- Microorganisms (HPV, fungal candidiasis)
18
Q
____ may be a risk factor for leukoplakias
A
Chronic inflammation
19
Q
Alcohol has ____ effects with tobacco
A
Synergistic
20
Q
70% of leukoplakias are found on:
A
- Lip vermillion
- Buccal mucosa
- Gingiva
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
22
Q
____ and ____ are high risk leukoplakia sites for betel quid users
A
Buccal mucosa and commissures
23
Q
What is the clinical appearance of leukoplakia?
A
- White in color
- Flat to slightly raised plaques
- Often with well defined borders
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
25
What are two special clinical variants of leukoplakias?
- Erythroleukoplakia, speckled leukoplakia
- Proliferative Verrucous Leukoplakia (PVL)
26
What is erythroleukoplakia?
Leukoplakia admixed with erythroplakia (mixed red-white lesions)
27
Erythroleukoplakias usually show:
High grade dysplastic changes, SCC
28
What is Proliferative Verrucous Leukoplakia (PVL)?
- Rare high-risk form of leukoplakia
- Multifocal leukoplakia with all grades of dysplastic changes
29
What location is Proliferative Verrucous Leukoplakia (PVL) found?
Any mucosal site, especially gingiva
30
Proliferative Verrucous Leukoplakia (PVL) has a ____ predilection and has no association with ____
Female; smoking
31
Proliferative Verrucous Leukoplakia (PVL) typically develops ____
Dysplastic changes, SCC
32
True or false: Proliferative Verrucous Leukoplakia (PVL) rarely regresses and recurs with removal
True (poor prognosis)
33
What is the clinical and microscopic progression of leukoplakias?
Normal mucosa --> thin, smooth leukoplakia --> thick, fissured leukoplakia --> granular, verruciform leukoplakia --> Erythroleukoplakia (speckled leukoplakia)
34
True or false: not all leukoplakia lesions will progress
True
35
UV Radiation-Associated Leukoplakia
Actinic Cheilitis (leukoplakia blends into vermillion border)
36
Leukoplakia histopathology includes:
- Hyperkeratosis
- Epithelial dysplasia
- Carcinoma in situ (CIS)
- Early squamous cell carcinoma
37
Hyperkeratosis makes up about ____ of leukoplakia cases
80%
38
Types of hyperkeratosis
- Hyperparakeratosis
- Hyperorthokeratosis
- Epithelial hyperplasia/hyperkeratosis
39
What is hyperparakeratosis?
Nuclei retained in keratin layer
40
What is hyperorthokeratosis?
- No nuclei in keratin layer
- Prominent granular cell layer
41
Epithelial dysplasia is ____
Premalignant
42
Carcinoma in situ and early squamous cell carcinoma are ____
Malignant
43
What are the cellular features of dysplasia?
- 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
44
What are the tissue architectural features of dysplasia?
- Bulbous, tear-drop shaped rete ridges
- Loss of polarity (disorganized maturation)
45
Grading the dysplasia of leukoplakias is based on:
Thirds of epithelial thickness involved
46
What are the grades of leukoplakia dysplasia?
- Mild dysplasia
- Moderate dysplasia
- Severe dysplasia
- Carcinoma in situ
47
What is a mild dysplasia?
Dysplasia involving lower 1/3 of epithelium (primarily basal and parabasal layers)
48
What is a moderate dysplasia?
Dysplasia involving lower 2/3 of epithelium (basal cell layer to mid portion)
49
What is a severe dysplasia?
Dysplasia extending to upper 1/3 of epithelium (basal cell layer to above mid-portion)
50
What is carcinoma in situ (CIS)?
Dysplasia involving entire thickness of epithelium with no evidence of penetration of basement membrane
51
What is needed for leukoplakia diagnosis?
- Clinical presentation AND
- Tissue biopsy
52
What other techniques/adjuncts can be used for leukoplakia diagnosis?
- Vital dyes
- Chemiluminescence (Vizilite)
- Autofluorescence (VELscope)
53
____ and ____ remain gold standard for assessment of oral leukoplakia
Careful examination and conventional biopsy
54
To treat leukoplakia, patient should discontinue"
Contributing factors
55
Leukoplakia treatment is guided by:
Histologic diagnosis, anatomic location, risk factors
56
How is hyperkeratosis or mild dysplasia treated (leukoplakia)?
- Clinical follow-up every 6 months (re-biopsy as necessary) OR
- Complete removal (surgical, laser, etc.)
57
How is moderate dysplasia or worse treated (leukoplakia)?
Complete removal (surgical, laser, etc)
58
Leukoplakia treatment requires careful _____
Long-term follow up
59
Recurrence rate of leukoplakia
10-35%
60
Recurrence rate is ____ for granular, verruciform leukoplakia
83%
61
True or false: there is possible development of additional leukoplakias
True
62
Risk for dysplasia:
- Thin leukoplakia ____
- Thick leukoplakia ____
- Granular, verruciform leukoplakia ____
- Erythroleukoplakia ____
Seldom (80% hyperkeratosis); 1-7%; 4-15%; 18-47%
63
Rates of malignant transformation to SCC:
Moderate dysplasia ____
Severe dysplasia ____
Overall malignant transformation rate ____
4-11%; 20-43%; 2%
64
Malignant transformation usually ____ after onset of leukoplakia
2-4 years
65
Risk of malignant transformation is increased if:
- Persistent lesions
- FOM
- Ventral tongue location
66
What is an erythroplakia?
A red patch/plaque that cannot be clinically or pathologically diagnosed as any other condition
67
Most erythroplakias (90%) are diagnosed as ____ on microscopic exam
High-grade epithelial dysplasia, carcinoma in situ, or SCC
68
True erythroplakias are considered to be:
Very premalignant lesions
69
Incidence of erythroplakia
1:2500 adults (much less frequent than leukoplakia)
70
What gender is affected in erythroplakia?
Males >>>> females
71
What age is affected in erythroplakia?
Middle-aged and older adults
72
Risk factors of erythroplakia
Same as SCC
73
Location of erythroplakia
Mostly FOM, tongue, soft palate (overlap with high risk sites for leukoplakia)
74
Erythroplakia is often well ____
Demarcated
75
What does erythroplakia look like?
Red plaque/patch
76
Erythroplakia feels:
Soft, velvety
77
Erythroplakia may have an adjacent:
Leukoplakia (erythroleukoplakia)
78
Erythroplakia histopathology
- Lack of keratinization
- Often epithelial atrophy
- Chronic inflammation in connective tissue
79
Majority of erythroplakia (> 90%) will show:
- Dysplasia (usually severe)
- Carcinoma in situ
- Squamous cell carcinoma
80
What is needed for Erythroplakia diagnosis?
Clinical presentation AND tissue biopsy
81
____ should be performed to establish histologic diagnosis for Erythroplakia
Biopsy
82
If irritation/trauma suspected, _______. Biopsy if lesion does not resolve in ____
Remove the source of trauma and follow up; 2 weeks
83
Erythroplakia treatment is guided by:
Histologic diagnosis, anatomic location
84
In general, Erythroplakia has more ____ treatment than with leukoplakia
Aggressive
85
Recurrence and multifocality is common in ____
Erythroplakia
86
What is a squamous cell carcinoma?
Malignant neoplasm of squamous epithelium (skin, mucosal sites)
87
Squamous cell carcinoma makes up ____ of all oral cancers
> 90%
88
SCC is the ____ most common cancer in US men and ____ in US women
11th; 16th
89
SCC has much higher prevalence in:
SE Asia (India)
90
One pt dies from oral cancer each ____ in US
Hour
91
Oral cavity SCC arise in:
Intra-oral anatomic sites
92
Oral cavity SCC is most related to ____ risk factors
Conventional (smoking, etc)
93
Where to oropharyngeal SCC arise?
Base of tongue, tonsillar region, oropharynx
94
Majority of oropharyngeal SCC are ____
HPV +
95
Racial predilection of SCC
Caucasians > African americans
96
SCC mortality is higher among ____
African American males
97
____ at higher risk for HPV+ oropharyngeal SCC
Caucasian men
98
SCC risk increases with ____
Age
99
SCC usually affects what age?
Older adults, especially > 65 years
100
What gender is affected more in SCC?
Males >>> females (2.5:1)
(may be equal in younger adults/peds, may be altered by popularity of harmful habits)
101
SCC risk factors
- Tobacco
- Large amounts of alcohol
- Environmental/occupational pollution
- Radiation
- Mineral/vitamin deficiency (iron)
- Microorganisms
- Immunosuppression
- Hereditary factors
- Oropharyngeal HPV 16, 18
102
Intra-oral SCC locations
- Posterior lateral/ventral tongue (50% of all cases)
- FOM
- Gingiva and buccal mucosa incidence increasing
- Intraosseous
103
Most common site of metastasis for SCC
FOM
104
Lip vermillion SCC locations
Lower lip (> 90% of lip SCCs)
105
Lip vermillion SCC is preceded by:
Actinic cheilitis
106
Risk factors for lip vermillion SCC
- Fair complexion
- Chronic UV light exposure
- Outdoor occupations
107
Oropharyngeal SCC locations
Tonsillar region (70-80%); soft palate, base of tongue, posterior pharyngeal wall
108
Delayed diagnosis of oropharyngeal SCC results in:
- Large tumor size
- Cervical nodes involvement
- Distant metastasis often at presentation
109
SCC is most preceded by:
Leukoplakia and erythroplakia
110
Clinical features of SCC - color
White, red, mixed
111
Clinical features of SCC - surface architecture
Plaque, nodule, mass
112
Clinical features of SCC - consistency
Firm, indurated, rarely soft
113
Clinical features of SCC - growth patterns
Exophytic, endophytic
114
Clinical features of SCC - specific characteristics
Ulceration
115
Clinical features of SCC - surface texture
Papillary, verrucous, fungating, granular, +/- pain
116
SCC radiographic features
- Destruction of underlying bone
- Ill defined borders (moth-eaten)
- Radiolucent
- Can mimic periodontal disease
117
Metastasis is a ____ event in oral SCC and ____ in oropharyngeal SCC
Late; early
118
____ have cervical LN metastasis in oropharyngeal SCC
> 50%
119
Route of metastasis of SCC
Mainly lymphatics (ipsilateral cervical LN)
120
SCC of lower lip would metastasize through:
Submental LNs
121
SCC of posterior oral cavity would metastasize through:
subMD, superior jugular, digastric LNs
122
What does metastasis look like initially?
Enlarged, non-tender, firm node
123
What does metastasis look like later?
Fixed (non-movable) with extracapsular penetration
124
Distant metastasis can be seen in what other areas of the body?
Lungs, liver, bones
125
SCC Histopathology
- Invasive islands, cords of malignant squamous epithelial cells
- Cellular, nuclear pleomorphism
- Altered nuclear: cytoplasmic ratio
- Increased mitotic activity
- Keratin pearls, individually keratinized cells
126
SCC may have ____ or ____ invasion
Perineural or vascular
127
What is histologic grading?
Degree of differentiation
128
Histologic grading is dependent on what factor?
Resemblance of tumor to its tissue of origin
129
Low grade (I)
Well differentiated
130
Intermediate grade (II)
Moderately differentiated
131
High grade (III/IV)
Poorly differentiated
132
Histologic grade may correlate with:
Clinical behavior
133
HPV+ Oropharyngeal SCC Histopathology
- Poorly differentiated
- Detection of HPV via P16 immunohistochemistry and HPV-16 RNA in-situ hybridization (ISH)
134
What are the best predictors of prognosis for oral SCC?
Tumor size and extent of metastatic spread
135
What is TNM staging?
T- primary tumor size
N - regional lymph node involvement
M - distant metastasis
136
TNM staging is staged from:
I-IV
137
____ is a better predictor of prognosis than histologic grade
Clinical stage
138
Any lymph node involvement is stage ____
III
139
M1 distant metastasis is stage ____
IV
140
The higher the stage, the ____ the prognosis. What is an exception?
Worse; Oropharyngeal SCC have same 5 year survival rates for stage 1-3
141
____ seems to be the best predictor of prognosis for oropharyngeal SCC
HPV status
142
SCC treatment depends on:
Clinical stage
143
SCC treatment options
- Surgical resection
- +/- adjuvant chemotherapy and or radiation
- +/- radical neck dissection
- Immunotherapy?
144
5 year survival for combined oral and oropharyngeal SCC
65%
145
Intraoral/lip SCC ____ is the best predictor of prognosis
Clinical stage
146
Patients with one carcinoma of the oral cavity or throat are at increased risk for:
Second primary SCC
147
Second SCC can occur ____ or ____
Synchronous or metachronous (concurrent or later)
148
What is the cause of a second SCC occurring?
Field cancerization or clonal divergence
149
Risk of a second SCC
Males who continue smoking and using alcohol
150
What is a diagnostic adjunct?
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
What are some light-based adjuncts?
- VELscope
- Vizilite
- Identifi3000
152
A true positive appears ____ with VELscope
Darker (black)
153
Vital stains
- T-blue
- Lugon's solution
154
____ us a cytopathologic adjunct
Oral CDx brush biopsy
155
Brush biopsy: OralCDx possible results (4)
- Negative: no cellular abnormalities
- Positive: definitive cellular evidence of epithelial dysplasia or carcinoma
- Atypical: abnormal epithelial changes warranting further investigation
- Sample insufficient for diagnosis
