Malignancies of Surface Epithelial Origin Flashcards
what are the 4 malignancies of surface epithelial origin
- basal cell ca
- cutaneous SSC
- oral SSC
- verrucous Ca
where does basal cell Ca come from?
basal cells of the epidermis
what is significant about basal cell Ca
most common skin cancer (over 1 million cases dx annually in the US
who is most affected by basal cell Ca?
-pts over 40 who have a fair complexion and a hx of chronic sun exposure
where is basal cell Ca most often found?
- middle third of the face
- be aware that any cutaneous area of the head and neck may be affected though
what is the most common clinical presentation of basal cell Ca?
nodulo-ulcerative type
umbilicated papule that may show central ulceration
(lack of adnexal skin structures like hair)
what is the histology of basal cell Ca?
- basaloid cells that appear to “drop off” of the basal cell layer of the epidermis
- pigmented basal cells are NOT rare
what is the histology of nodulo-ulcerative basal cell Ca?
large lobules of tumor cells are characteristics
what does basal cell Ca resemble?
melanotic nevi due to the presence of benign melanocytic colonization
what should help to distinguish basal cell Ca from a nevus?
- hx of short duration
- lack of hair
why are basal cell lesions often pigmented?
colonization by benign melanocytes
what is unique about sclerosing (morpheaform) basal cell Ca?
it is the least common, but the most aggressive
what is the clinical appearance of sclerosing (morpheaform) basal cell Ca?
resembles a scar due to the induction of collagen formation by the tumor cells
- characterized by tiny infiltrative nests of tumor cells in a collagenous background
- very difficult to assess borders clinically bc of this infiltrative growth pattern
what are the tx options of basal cell Ca?
- scapel excision
- electrodesiccation and curretage
- mohs microscopically controlled surgery, uses pathology and surgery
- cryotherapy
- radiation therapy
what is the px for basal cell Ca?
- generally excellent, with over 95% of pts cured after tx
- rare metastisis is supported
what types of lesions of basal cell Ca require Mohs surgery?
- larger lesions
- recurrent lesions
- tumors in areas of embryonic fusion
*bc they are all more agressive
what is significant about SSC?
-most common oral malignancy and second most common cutaneous malignancy
where does SSC come from?
surface epi cells
where is SSC most often found?
skin and lower vermillion zone of the lip cancers are due to UV light eposure
where does cutaneous SSC come from?
- arises from pre-existing actinic keratosis
- due mainly to chronic sun exposure, can also be from medical ionizing radiation to specific site
where is cutaneous SSC most often found?
- face
- helix of ear
- dorsum of hands
- arms
what is the tx of cutaneous SSC
surgical excision
what type of SSCs are generally well-differentiated and grow slowly?
actinically-induced SSC
75-80% of oral SSCs are often associated with what?
tobacco (cigs) with or without alcohol
of the 20% of oral SSCs that are NOT associated with tobacco use, where and whom do they affect?
- lateral tongue of young ppl
- gingiva of older women
where is oncogenic HPV subtypes of oral SSC found?
base of tongue and tonsils
which type of HPV is implicated in oropharyngeal SSC?
type 16
which has a better px: HPV+/- oropharyngeal SSC?
HPV +
oral SSC accounts for about how much of all cancers in the US?
3-4%
who does oral SSC most often occur in?
- older males
- males 2:1
what are the risk factors for oral SSC
- same as leukoplakia and erythroplakia
- tobacco (maybe alcohol)
*there is NO link with mouthwashes
what are the clinical features of oral SSC?
- irregular shape, mixture of red and white clinically
- often ulcerated
- exophytic (growing out)
- endophytic (growing in)
- much firmer than surrounding tissues
what in unique about pain in reference to oral SSC?
a late feature, so often ppl do not come in for tx until it is far into its course
*ragged radioleucency is characteristic of bone involvement
what could possibly cause SSC on the lip?
actinic cheilitis (along with ultraviolet light)(secondarily) -slow growing, well-differentiated lesions usually
which location of SSC has a better px: upper or lower lip?
lower lip
- upper has high risk for lymph node metastasis, however, SCC on upper lip is rare
- pt neglect can result in considerable destruction
what three things does oral SCC arise from?
- leukoplakia
- erythroplakia
- proliferative verrucous leukoplakia
what is proliferative verrucous leukoplakia?
- leukoplakia that grows laterally and involves multiple sites
- females more with only 1/3 having traditional risk factors
- 65yo for females and 49yo for males
from most common to least common, what are the sites for oral squamous cell Ca?
- tongue (post/lat/vent)(post is highest risk)
- FOM, near frenum
- gingiva
- labial and buccal mucosa
- hard palate (very rare)
what is the MOST COMMON site of oral SCC?
lateral tongue
most pts with oral SCC have a hx with what?
smoking and alcohol abuse
when oral SCC is seen in YOUNGER pts, it almost ALWAYS develops at what site?
lateral tongue
is alcohol alone a risk factor for oral SCC?
no, must have smoking too
oral SCC at the gingiva is more common for men/women?
women
*more common in pts with no identifiable risk factors for oral SCC (often a non-smoker)
most oral SCC that arise on the palate arise where on the palate?
lateral soft palate
why is it difficult to dx an oral SCC on the palate
difficult to determine whether lesion developed in max sinus and invaded through the floor
what are the differential dxs for oral SCC?
- non-specific ulcers - gone in a few weeks
- specific infections - TB, syphillis, fungal infections
- immune mediated conditions - wegner’s granulomatosis and crohn’s disease
what does oral SCC appear as radiographically?
- due to direct invasion of bone, radioleucency is often a late phenomenon
- ragged “moth eaten”
- ill-defined borders
- pathologic fracture is possible
what are the histological features of SSC?
- invasive CORDS and NESTS of malignant squamous epi cells arise from DYSPLASTIC surface epi
- tumor cells show and inc nuclear/cytoplasmic ratio, cellular and nuclear pleomorphism, and mitotic activity
- varying degrees of keratin production may be seen (well vs poorly defined)
***she said “big nucleus, irregular shape, abnormal mitosis”
what is the tx for oral SCC?
- wide surgical excision and/or radiation therapy
- chemo has NOT shown much impact
- neoadjuvant therapy to shrink the tumor initially
- molecular based targeted therapies are anticipated for the future
what is the px for oral SCC?
gernerally poor bc pts present in stage III or IV (bc dont get pain until then)
- metastasis to regional lymph nodes
- at 60% 5-year survival, it is one of the worst pxs of any mojor cancer
what is needed after tx is completed for oral SCC?
periodic follow-up exam after tx
-10-25% of these pts will develop new upper aerodigestive tract malignancies, particularly if carcinogenic habits are continued
less aggressive, realatively uncommon form of SCC
verrucous ca
who does verrucous ca usually develop in?
elderly males
what is often a contributing factor for verrucous ca?
SMOKELESS TOBACCO particullary in southern states
-women who use dry snuff
what is the clinical presentation of verrucous ca?
diffuse white or mixed red and white plaque that tends to grow LATERALLY
where in the mouth is verrucous ca usually found?
- alveolar mucosa
- hard palate
- buccal mucosa
- grows laterally
what is the dx of verrucous ca based on?
overall architecture of the tumor, rather than the appearance of individual cells in a histological sense
what is the treatment for verrucous ca?
- surgical excision is generally recommended
- radiation therapy has been DISCOURAGED due to sporadic reports of transformation to more aggressive SCC
how likely is verrucous ca to transform to routine SCC?
20-25% of verrucous ca’s show foci of transformation to routine SCC
