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D2 Spring > Oral Path Exam 2 - Malignant White and Red Lesions (Surface Epithelial Origin) > Flashcards

Oral Path Exam 2 - Malignant White and Red Lesions (Surface Epithelial Origin) Flashcards

1
Q

What are the 2 white and red oral malignancies?

A

Squamous cell carcinoma
Verrucous carcinoma

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2
Q

T/F: Historically, “Oral Cancer” data has varied
depending on how cancers from the lip, oral cavity, and the oropharynx are compiled. Today, these 3 anatomic sites should be studied and reported separately as they have different risk factors and prognoses

A

True

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3
Q

Because 90% of oral cancers arise from the surface epithelium, the term “oral cancer” generally denotes _______________

A

squamous cell carcinoma

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4
Q

What are 4 other primary oral cancers? (besides squamous cell carcinoma)

A

Salivary gland carcinoma
Lymphoma
Melanoma
Sarcoma

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5
Q

A metastasis to the oral cavity from a distant site (e.g. carcinoma, sarcoma, lymphoma, leukemia, etc)

A

Secondary cancer

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6
Q

T/F: Unless specified, oral cancer data includes all oral cancers

A

True

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7
Q

Oral cancer makes up what % of all cancers in the US?

A

2%

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8
Q

Oral cancer is the most common cancer in men in which country?

A

India

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9
Q

T/F: Oral cancer affects women more than men

A

FALSE, oral cancer affects men more than women (2:1)

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10
Q

When is the highest risk of oral cancer for white men?

A

> 65 years

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11
Q

When is the highest risk of oral cancer for black men?

A

Middle age

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12
Q

What % of all oral cancers are squamous cell carcinoma?

A

> 90%

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13
Q

Oral cancer has increasing incidence overall if the ___________ is included

A

oropharynx

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14
Q

T/F: No significant improvement of oral cancer has been made in the early diagnosis (more at lower stage) of oral/pharyngeal cancer in last 30 years

A

True

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15
Q

Which oral cancer?

Incidence rates have increased to ~ 1% per year since mid-2000s, mostly due to oropharyngeal cases

A

Squamous cell carcinoma

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16
Q

T/F: The risk factors for oral cancer are similar to premalignant oral lesions

A

True

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17
Q

80% of oral cancers are associated with cigarettes, with or without ___________

A

alcohol

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18
Q

20-25% of oral cancers have no identifiable risk factor. __________ ___________ for young women; _____________ for older women

A

Lateral tongue; gingiva

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19
Q

Does heredity play a major causative role in oral cancer?

A

NO

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20
Q

What shape is oral cancer?

A

Irregular

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21
Q

What color is oral cancer?

A

Mix of red and white

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22
Q

What is the growth pattern of oral cancer?

A

Exophytic (growing out) or endophytic (growing in)

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23
Q

What is the texture of oral cancer?

A

Firm (indurated)

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24
Q

Are early oral cancer lesions asymptomatic or painful?

A

Asymptomatic

(pain is usually a late feature)

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25
Q

What does oral cancer look like once there is bone involvement?

A

Ragged radiolucency

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26
Q

Which site for squamous cell carcinoma?

One of the more common sites of involvement, not really intraoral

A

Lip

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27
Q

Which site for squamous cell carcinoma?

Secondary to UV light exposure

A

Lip

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28
Q

Which site for squamous cell carcinoma?

Arises in setting of actinic cheilitis

A

Lip

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29
Q

Which site for squamous cell carcinoma?

90% found on the lower lip

A

Lip

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30
Q

Which site for squamous cell carcinoma?

Crusted, non-tender, indurated ulceration, typically < 1 cm when discovered

A

Lip

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31
Q

Which site for squamous cell carcinoma?

Slow growing, well-differentiated lesion

A

Lip

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32
Q

Which site for squamous cell carcinoma?

Relatively good prognosis

A

Lip

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33
Q

What is the most common intraoral site of squamous cell carcinoma? (> 50%)

A

Lateroventral tongue

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34
Q

Which site for squamous cell carcinoma?

Majority of pts have history of cig smoking and alcohol abuse

A

Lateroventral tongue
Floor of mouth

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35
Q

Which site for squamous cell carcinoma?

When seen in pts under 40, it almost always develops at this site

A

Lateroventral tongue

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36
Q

Which site for squamous cell carcinoma?

Uncommon

A

Dorsal tongue

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37
Q

What is the 2nd most common intraoral site of squamous cell carcinoma?

A

Floor of mouth

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38
Q

Which site for squamous cell carcinoma?

Most likely location to develop from pre-existing white/red lesion

A

Floor of mouth

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39
Q

Which site for squamous cell carcinoma?

Associated with 2nd primary malignancy

A

Floor of mouth

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40
Q

What is the 3rd most common intraoral site of squamous cell carcinoma?

A

Gingiva/alveolar mucosa

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41
Q

Which site for squamous cell carcinoma?

Intermediate risk site

A

Gingiva/alveolar mucosa

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42
Q

Which site for squamous cell carcinoma?

Most common in women at this site (2:1) and those without identifiable risk factors

A

Gingiva/alveolar mucosa

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43
Q

Which site for squamous cell carcinoma?

Most likely site for misdiagnosis as it may mimic benign/reactive gingival lesions (ex: pyogenic granuloma) or perio disease

A

Gingiva/alveolar mucosa

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44
Q

Which site for squamous cell carcinoma?

May develop in the maxillary sinus and invade through the sinus floor

A

Palate

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45
Q

Which site for squamous cell carcinoma?

Most arise on lateral soft palate; likely show a visible premalignant lesion

A

Palate

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46
Q

Which site is rare for squamous cell carcinoma, unless the pt does reverse smoking?

A

Hard palate

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47
Q

Which cancer usually arises from the tonsillar region without a visible precursor lesion?

A

Oropharyngeal carcinoma

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48
Q

Which oral cancer has the following symptoms?

Dysphagia
Persistent sore throat
Dull/sharp pain may be referred to ear
Odynophagia (pain on swallowing)

A

Oropharyngeal carcinoma

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49
Q

Which site for squamous cell carcinoma?

Low risk (uncommon) site for western world

A

Buccal mucosa

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50
Q

Which site for squamous cell carcinoma?

Very common site in those who use betel quid

A

Buccal mucosa

51
Q

What is included in the clinical differential diagnosis for oral squamous cell carcinoma?

A

Non-specific ulcer (i.e. traumatic)
Specific infections (TB, deep fungal, syphilis)
Immune-mediated conditions (granulomatosis w/ polyangiitis, Crohn’s disease)

52
Q

How do you determine periodontal disease vs squamous cell carcinoma?

A

Perio look smooth/shiny
SCC looks pebbly/granular

53
Q

What does direct tumor invasion of bone look like for squamous cell carcinoma?

A

Ragged/ill-defined radiolucency (“moth-eaten”)

54
Q

Which oral cancer?

Pathologic fracture is possible

A

Squamous cell carcinoma

55
Q

Why do malignant white and red lesions feel firm?

A

Desmoplasia (tumor-induced fibrosis)

56
Q

Histologically, malignant white and red lesions have ___________ cords and nests of malignant ____________ epithelial cells arising from, but not connected to, dysplastic surface epithelium

A

invasive; squamous

57
Q

Histologically, malignant white and red lesions have tumor cells that show an ____________ nuclear/cytoplasmic ratio, cellular and nuclear ____________, and ___________ activity

A

increased; pleomorphism; mitotic

58
Q

Histologically, malignant white and red lesions have varying degrees of ____________ production and ____________

A

keratin; dyskeratosis

59
Q

What is an example of keratin production?

A

Keratin pearls

60
Q

Tumor-induced fibrosis

A

Desmoplasia

61
Q

Very early lesions are sometimes described as ______________ invasive or ______________

A

superficially; microinvasive

62
Q

Which grade?

Well-differentiated

A

Grade I; low grade

63
Q

Which grade?

Moderately differentiated

A

Grade II; intermediate grade

64
Q

Which grade?

Poorly differentiated

A

Grade III, IV; high grade

65
Q

T/F: Differentiation influences staging

A

FALSE, differentiation influences grading only

66
Q

Which microscopic features affect staging and prognosis?

A

Depth of invasion
Extranodal extension

67
Q

Depth of invasion (> 5mm) correlates with an increased risk for what?

A

Nodal metastasis

68
Q

Extracapsular spread outside a lymph node, called “extranodal extension” is associated with what?

A

Worse prognosis

69
Q

What do all oropharyngeal squamous cell carcinomas require?

A

High-risk HPV testing

(bc it affects staging)

70
Q

T/F: You should do high-risk HPV testing on oral cancers

A

FALSE, only on oropharyngeal cancers

71
Q

The presence of which HPV types indicates transcriptionally active (clinically relevant) HPV infection?

72
Q

Which high-risk HPV test is the routine test that is used because it is inexpensive?

A

p16 immunohistochemistry

73
Q

Which high-risk HPV test is the gold standard, but is more expensive?

A

Test directly for E6 and E7

74
Q

After a biopsy proves oral squamous cell carcinoma (or other H/N cancer), what’s next?

A
  1. Complete H/N exam by oncologist
  2. Dental exam (PANX or CBCT) and tx any disease
  3. Imaging (MRI or CT) to look at primary tumor & nodal disease
  4. Multidisciplinary consultations as needed
75
Q

If the H/N cancer has spread to > N1 nodes, what is done by the oncologist to check for distant metastases?

76
Q

Early, moderate, or advanced disease?

Tx: wide surgical excision (1 cm margin) or radiation if pt can’t have surgery

A

Early (T1, T2)

77
Q

Early, moderate, or advanced disease?

Tx: surgery and adjuvant radiation (try to avoid mandible) or combined chemo

78
Q

Early, moderate, or advanced disease?

Tx: radiation and/or chemo

A

Advanced

(recurrent, metastasis, or inoperable)

79
Q

What type of dissection?

Removal of lymphatics of lateral triangle of neck and associated structures (IJV, SMG, SCM, SAN)

A

Radical neck dissection

80
Q

What type of dissection?

Just removal of lymph nodes; preserves associated structures

A

Modified radical neck dissection

81
Q

What type of dissection?

Just removal of select groups of lymph nodes

A

Selective neck dissection

82
Q

What type of radiation?

Targets the tumor site and minimizes damage to surrounding tissue

A

Intensity-modulated radiation therapy (IMRT)

83
Q

What type of radiation?

Placement of tiny, radioactive seeds; used for small intraoral tumors or with IMRT to increase dosage

A

Brachytherapy

84
Q

Which chemotherapy is not really beneficial for oral cancer?

A

Induction (neoadjuvant) chemotherapy

85
Q

Chemo done before surgery

A

Induction (neoadjuvant) chemotherapy

86
Q

Chemo done after surgery

A

Post-operative chemotherapy

87
Q

Which chemotherapy gives the best locoregional control and disease-free survival?

A

Post-op concurrent chemoradiation therapy

88
Q

Which chemotherapy is used for distant metastasis?

A

Single/multi-agent chemotx

89
Q

What drug is used with the conventional fractioned radiation for post-op concurrent chemoradiation therapy?

What are some of the other drugs used?

A

Cisplatin

Other drugs: carboplatin, 5-fluorouracil, taxanes

90
Q

What is the fractioned radiation dose for post-op concurrent chemoradiation therapy?

A

70 gray

(2 gray -> 5 days per week over 7 weeks)

91
Q

What is the dose for Cisplatin when used with post-op concurrent chemoradiation therapy?

A

Every 3 weeks (up to 3 doses)

92
Q

What are the 2 targeted therapies for squamous cell carcinoma?

A

EGFR monoclonal antibody (Cetuximab)
Immunotherapy

93
Q

Which targeted therapy for squamous cell carcinoma?

Also called Cetuximab

A

EGFR monoclonal antibody

94
Q

Which drug targets the epidermal growth factor receptor (EGFR) in treatment of oral squamous cell carcinoma?

95
Q

Which targeted therapy for squamous cell carcinoma?

Antibodies used to block checkpoints (PD-1, CTLA-4) and thereby allow immune response to occur

A

Immunotherapy

96
Q

Which targeted therapy for squamous cell carcinoma?

Good response in melanoma and lung cancer

A

Immunotherapy

97
Q

Which targeted therapy for squamous cell carcinoma?

Used for recurrent or metastatic H/N SCC who have progressed on or following platinum-based chemotherapy

A

Immunotherapy

98
Q

Which targeted therapy for squamous cell carcinoma?

Approved drugs: Nivolumab and Pembrolizumab

A

Immunotherapy

99
Q

When do most recurrences (locally, to lymph nodes, or distant metastasis) occur?

A

Within first 2 years

100
Q

What is necessary for the life of the patient after having oral squamous cell carcinoma?

A

Periodic follow-up exam of entire mouth

(may need biopsy of multiple areas)

101
Q

T/F: All mucosa exposed to carcinogen has the potential for cancer development (“condemned mucosa”)

102
Q

What is the term used to describe the theory that all mucosa exposed to carcinogen has the potential for cancer development (“condemned mucosa”)?

A

Field effect/cancerization

103
Q

Give 3 examples of the field effect/cancerization of oral SCC

A

Multiple primary tumors at same time (synchronous)
Second primary tumors later on (metachronous)
New upper aerodigestive tract malignancies (especially if habits like smoking continue)

104
Q

What is the overall 5 year survival for oral and oropharyngeal SCC?

105
Q

What is the most important prognostic indicator for oral SCC?

A

Stage

(size of tumor and extent of spread)

106
Q

What is the most important prognostic indicator for oropharyngeal SCC?

A

HPV status

107
Q

T/F: Oropharyngeal SCC is usually poorly differentiated and non-keratinizing

108
Q

Which oropharyngeal SCC tumors respond better to chemo and/or radiation, HPV+ or HPV-?

109
Q

Why do HPV+ tumors in oropharyngeal SCC respond better to chemo and/or radiation?

A

They lack TP53 mutations and field effect/cancerization

110
Q

Even though most oropharyngeal SCCs are diagnosed at an advanced stage, why is early-stage survival similar?

A

Prognosis based on HPV status

111
Q

T/F: Prognosis of oral SCC is generally poor because 2/3 of patients present with Stage III or IV disease

112
Q

Once there is lymph node spread, what is the stage?

A

At least Stage III

113
Q

T/F: While prognosis has improved a little, oral SCC is still one of the worst prognoses of any major cancer. Even with tx there is significant disfigurement, disability, and pain

114
Q

Less aggressive form of SCC; large lesions can develop regular SCC in them

A

Verrucous carcinoma

115
Q

Proliferative verrucous leukoplakia may give rise to what 2 cancers?

A

Verrucous carcinoma
Classic SCC

116
Q

What are the most frequent sites for verrucous carcinoma?

A

Alveolar mucosa
Buccal mucosa
Hard palate

117
Q

What do verrucous carcinomas look like?

A

White or red/white
Papillary/verrucous
Plaque or mass

(look like warts)

118
Q

Verrucous carcinomas tend to grow __________. Invades with a ________ ________, but does not infilatrate

A

laterally; pushing margin

119
Q

T/F: Verrucous carcinomas are microscopically bland; they can easily be misdiagnosed as hyperplasia

120
Q

What is the tx for verrucous carcinoma?

A

Surgical excision

(radiation can be used as adjunctive tx, but is less effective than surgery)

121
Q

When should you do a H/N exam?

A

New pt
Yearly on established pts
Whenever signs/symptoms suggest a need

122
Q

What are the known molecular changes that occur in the development of oral squamous cell carcinoma?

A

p53 mutation
p16 hypermethylation (silencing)
Cyclin D1 overexpression

123
Q

Which are known to increase risk for the development of oral squamous cell carcinoma?

Alcohol
Smoking
Oral bacteria
Candida
Chronic trauma (broken teeth, ill-fitting denture)
Radiation therapy to oral cavity
Alcohol-containing mouthwash
HPV
Sanguinaria
HIV/AIDS

A

Alcohol
Smoking
Radiation therapy to oral cavity
HIV/AIDS

124
Q

What are the 4 ways that verrucous carcinoma is significantly different than oral squamous cell carcinoma?

A

Location of oral lesions
Pattern of growth
Histologic appearance
Biologic aggressiveness

D2 Spring (38 decks)

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