Oral and oesophageal pathology

Question 1

Lining of normal oesophagus?

Answer 1

Stratified squamous epithelium

Question 2

Categories of inflammatory disorders affecting the oesophagus?

Answer 2

Acute oesophagitis - rare and is corrosive following chemical ingestion; infectons of the oesophagus are rare unless immunocompromised, e.g: candidiases, herpes, CMV

Chronic oesophagitis - common and is a reflux disease (reflux oesophagitis); rare causes include Crohn’s disease and radiation

Question 3

Definition of reflux oesophagitis?

Answer 3

Inflammation of oesophagus due to refluxed low pH gastric contents

Question 4

Causes of reflux oesophagitis?

Answer 4

Defective sphincter mechanism can occur due to a hiatus hernia (loss of LOS mechanism)

Abnormal oesophageal motility

Increased intra-abdominal pressure, e.g: pregnancy or obesity

Question 5

Microscopic appearance of reflux oesophagitis?

Answer 5

Reflux damages superficial squamous epithelium; there is a compensatory basal call hyperplasia and elongation of the connective tissue papillael also, there is inflammatory cell exudation, e.g: intra-epithelial neutrophils, lymphocytes and eosinophils

Question 6

Complications of reflux oesophagitis?

Answer 6

Ulceration (bleeding)

Stricture and difficulty swallowing

Barrett’s oesophagus

Question 7

What is Barrett’s oesophagus?

Answer 7

Metaplastic change of stratified squamous epithelium to columnar epithelium (gastric epithelium affords more protection against acid), due to chronic reflux of acid or bile

This protective response allows faster regeneration

Question 8

Two methods of development of Barrett’s oesophagus?

Answer 8

Expansion of columnar epithelium from gastric glands or from submucosal glands

Differentiation from oesophageal stem cells

Question 9

Clinical management of Barrett’s oesophagus?

Answer 9

Increased risk of developing dysplasia and adenocarcinoma of the oesopahgus; must be monitored

Question 10

What is allergic oesophagitis?

Answer 10

AKA eosinophilic oesophagitis

Question 11

Clinical diagnosis of allergic oesophagitis?

Answer 11

Personal/family history of atopic issues, often in children and young adults (part. males) and these people do not improve when treated for reflux

Eosinophils infiltrate the squamous epithelium and there will be increased eosinophils in blood and a large number of intra-epithelial eosinophils

Oesophageal pH studies are negative for reflux and inflammation favours the proximal oesophagus

Question 12

Appearance of allergic oesophagitis?

Answer 12

Corrugated (ridged)/spotty oesophagus

Question 13

Treatment of allergic oesophagitis?

Answer 13

Steroids (not in children)

Chromoglycate

Montelukast

Question 14

Types of oesophageal tumours?

Answer 14

Benign (rare):
Epithelial
Stromal
Lymphoid

Malignant:
Squamous cell carcinoma (more common in males)
Adenocarcinoma (gland-forming)

Question 15

Most common benign oesophageal tumour?

Answer 15

Epithelial tumours, like squamous cell papilloma; it is asymptomatic and sometimes it is HPV-related

Question 16

Other types of benign oesophageal tumours?

Answer 16

Leiomyomas
Lipomas
Fibrovascular polyps
Granular cell tumours

Question 17

Risk factors associated with squamous cell carcinoma of oesophagus?

Answer 17

Smoking
Alcohol
HPV
Oesophagitis
Genetic
Tannic acid/strong tea
Vitamin A and zinc deficiency

Question 18

Pathogenesis of squamous cell carcinoma?

Answer 18

1. Normal
2. GORD
3. Severe dysplasia

Question 19

Which type of cancer is associated with Barret’s oesophagus?

Answer 19

Adenocarcinoma (more common than SCC due to increase in Barret’s oesophagus)

Question 20

Pathogenesis of oesophageal adenocarcinoma?

Answer 20

1. Genetic factors, reflux disease and other factors lead to chronic reflux oesophagitis
2. Barrett’s oesophagus (intestinal metaplasia) develops
3. Low grade and then high grade dysplasia (precancerous changes)
4. Adenocarcinoma produces dysphagia (urgent endoscopy)

Question 21

Mechanisms of metastases?

Answer 21

Direct/local invasion - many produce fistulas

Lymphatic permeation - regional lymph nodes at mediastinum and also left gastric nodes

Vascular invasion - may spread to sieve-like organs, e.g: the liver

Question 22

Symptoms of oesophageal carcinoma?

Answer 22

Dysphagia due to tumour obstruction

General symptoms of malignancy:
Anaemia
Weight loss
Loss of energy

Question 23

Most common type of oral cancer?

Answer 23

Oral squamous cell carcinoma (SCC)

Question 24

Presentation of oral SCC?

Answer 24

White, red, speckled, ulcer lump

High risk sites inc. the floor of mouth, ventral and lateral aspects of the tongue and the retromolar trigone (behind mandibular 3rd molar tooth); rarely, they can be of the hard palate or dorsum of the tongue

Question 25

Risk factors of oral SCC?

Answer 25

Tobacco and alcohol

? Viral causes, e.g: HPV
? Chronic infections

Nutritional deficiencies

? Genetics

Post Transplant

Patients with a history of primary oral SCC have increased risk of developing new second primary

Question 26

How is oral SCC graded?

Answer 26

By differentiation:
Well-differentiated tumour cells very obviously squamous with ‘prickles’ and keratinization

Moderately differentiated

Poorly differentiated, may be difficult to identify tumour cells as epithelial

Question 27

Histopathological features assoc. with a poorer prognosis of oral SCC?

Answer 27

Poorer differentiation of tumour cells

Increased tumour diameter and depth of invasion

Presence of neural or lymphovascular invasion

Metastatic disease

Extracapsular spread of lymph node metastases

Generally, the prognosis worsens with the most posterior tumours

Question 28

Staging of Oral SCC?

Answer 28

TNM staging