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
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
3
Q
Because 90% of oral cancers arise from the surface epithelium, the term “oral cancer” generally denotes _______________
A
squamous cell carcinoma
4
Q
What are 4 other primary oral cancers? (besides squamous cell carcinoma)
A
Salivary gland carcinoma
Lymphoma
Melanoma
Sarcoma
5
Q
A metastasis to the oral cavity from a distant site (e.g. carcinoma, sarcoma, lymphoma, leukemia, etc)
A
Secondary cancer
6
Q
T/F: Unless specified, oral cancer data includes all oral cancers
A
True
7
Q
Oral cancer makes up what % of all cancers in the US?
A
2%
8
Q
Oral cancer is the most common cancer in men in which country?
A
India
9
Q
T/F: Oral cancer affects women more than men
A
FALSE, oral cancer affects men more than women (2:1)
10
Q
When is the highest risk of oral cancer for white men?
A
> 65 years
11
Q
When is the highest risk of oral cancer for black men?
A
Middle age
12
Q
What % of all oral cancers are squamous cell carcinoma?
A
> 90%
13
Q
Oral cancer has increasing incidence overall if the ___________ is included
A
oropharynx
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
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
16
Q
T/F: The risk factors for oral cancer are similar to premalignant oral lesions
A
True
17
Q
80% of oral cancers are associated with cigarettes, with or without ___________
A
alcohol
18
Q
20-25% of oral cancers have no identifiable risk factor. __________ ___________ for young women; _____________ for older women
A
Lateral tongue; gingiva
19
Q
Does heredity play a major causative role in oral cancer?
A
NO
20
Q
What shape is oral cancer?
A
Irregular
21
Q
What color is oral cancer?
A
Mix of red and white
22
Q
What is the growth pattern of oral cancer?
A
Exophytic (growing out) or endophytic (growing in)
23
Q
What is the texture of oral cancer?
A
Firm (indurated)
24
Q
Are early oral cancer lesions asymptomatic or painful?
A
Asymptomatic
(pain is usually a late feature)
25
What does oral cancer look like once there is bone involvement?
Ragged radiolucency
26
Which site for squamous cell carcinoma?
One of the more common sites of involvement, not really intraoral
Lip
27
Which site for squamous cell carcinoma?
Secondary to UV light exposure
Lip
28
Which site for squamous cell carcinoma?
Arises in setting of actinic cheilitis
Lip
29
Which site for squamous cell carcinoma?
90% found on the lower lip
Lip
30
Which site for squamous cell carcinoma?
Crusted, non-tender, indurated ulceration, typically < 1 cm when discovered
Lip
31
Which site for squamous cell carcinoma?
Slow growing, well-differentiated lesion
Lip
32
Which site for squamous cell carcinoma?
Relatively good prognosis
Lip
33
What is the most common intraoral site of squamous cell carcinoma? (> 50%)
Lateroventral tongue
34
Which site for squamous cell carcinoma?
Majority of pts have history of cig smoking and alcohol abuse
Lateroventral tongue
Floor of mouth
35
Which site for squamous cell carcinoma?
When seen in pts under 40, it almost always develops at this site
Lateroventral tongue
36
Which site for squamous cell carcinoma?
Uncommon
Dorsal tongue
37
What is the 2nd most common intraoral site of squamous cell carcinoma?
Floor of mouth
38
Which site for squamous cell carcinoma?
Most likely location to develop from pre-existing white/red lesion
Floor of mouth
39
Which site for squamous cell carcinoma?
Associated with 2nd primary malignancy
Floor of mouth
40
What is the 3rd most common intraoral site of squamous cell carcinoma?
Gingiva/alveolar mucosa
41
Which site for squamous cell carcinoma?
Intermediate risk site
Gingiva/alveolar mucosa
42
Which site for squamous cell carcinoma?
Most common in women at this site (2:1) and those without identifiable risk factors
Gingiva/alveolar mucosa
43
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
Gingiva/alveolar mucosa
44
Which site for squamous cell carcinoma?
May develop in the maxillary sinus and invade through the sinus floor
Palate
45
Which site for squamous cell carcinoma?
Most arise on lateral soft palate; likely show a visible premalignant lesion
Palate
46
Which site is rare for squamous cell carcinoma, unless the pt does reverse smoking?
Hard palate
47
Which cancer usually arises from the tonsillar region without a visible precursor lesion?
Oropharyngeal carcinoma
48
Which oral cancer has the following symptoms?
Dysphagia
Persistent sore throat
Dull/sharp pain may be referred to ear
Odynophagia (pain on swallowing)
Oropharyngeal carcinoma
49
Which site for squamous cell carcinoma?
Low risk (uncommon) site for western world
Buccal mucosa
50
Which site for squamous cell carcinoma?
Very common site in those who use betel quid
Buccal mucosa
51
What is included in the clinical differential diagnosis for oral squamous cell carcinoma?
Non-specific ulcer (i.e. traumatic)
Specific infections (TB, deep fungal, syphilis)
Immune-mediated conditions (granulomatosis w/ polyangiitis, Crohn's disease)
52
How do you determine periodontal disease vs squamous cell carcinoma?
Perio look smooth/shiny
SCC looks pebbly/granular
53
What does direct tumor invasion of bone look like for squamous cell carcinoma?
Ragged/ill-defined radiolucency ("moth-eaten")
54
Which oral cancer?
Pathologic fracture is possible
Squamous cell carcinoma
55
Why do malignant white and red lesions feel firm?
Desmoplasia (tumor-induced fibrosis)
56
Histologically, malignant white and red lesions have ___________ cords and nests of malignant ____________ epithelial cells arising from, but not connected to, dysplastic surface epithelium
invasive; squamous
57
Histologically, malignant white and red lesions have tumor cells that show an ____________ nuclear/cytoplasmic ratio, cellular and nuclear ____________, and ___________ activity
increased; pleomorphism; mitotic
58
Histologically, malignant white and red lesions have varying degrees of ____________ production and dyskeratosis
keratin
59
What is an example of keratin production?
Keratin pearls
60
Tumor-induced fibrosis
Desmoplasia
61
Very early lesions are sometimes described as superficially invasive or ______________
microinvasive
62
Which grade?
Well-differentiated
Grade I; low grade
63
Which grade?
Moderately differentiated
Grade II; intermediate grade
64
Which grade?
Poorly differentiated
Grade III, IV; high grade
65
T/F: Differentiation influences staging
FALSE, differentiation influences grading only
66
Which microscopic features affect staging and prognosis?
Depth of invasion
Extranodal extension
67
Depth of invasion (> 5mm) correlates with an increased risk for what?
Nodal metastasis
68
Extracapsular spread outside a lymph node, called "extranodal extension" is associated with what?
Worse prognosis
69
What test do all oropharyngeal squamous cell carcinomas require?
High-risk HPV testing
(bc it affects staging)
70
T/F: You should do high-risk HPV testing on oral cancers
FALSE, only on oropharyngeal cancers
71
The presence of which HPV types indicates transcriptionally active (clinically relevant) HPV infection?
E6 and E7
72
Which high-risk HPV test is the routine test that is used because it is inexpensive?
p16 immunohistochemistry
73
Which high-risk HPV test is the gold standard, but is more expensive?
Test directly for E6 and E7
74
After a biopsy proves oral squamous cell carcinoma (or other H/N cancer), what's next?
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
If the H/N cancer has spread to > N1 nodes, what is done by the oncologist to check for distant metastases?
PET/CT
76
Early, moderate, or advanced disease?
Tx: wide surgical excision (1 cm margin) or radiation if pt can't have surgery
Early (T1, T2)
77
Early, moderate, or advanced disease?
Tx: surgery and adjuvant radiation (try to avoid mandible) or combined chemo
Moderate
78
Early, moderate, or advanced disease?
Tx: radiation and/or chemo
Advanced
(recurrent, metastasis, or inoperable)
79
What type of dissection?
Removal of lymphatics of lateral triangle of neck and associated structures (IJV, SMG, SCM, SAN)
Radical neck dissection
80
What type of dissection?
Just removal of lymph nodes; preserves associated structures
Modified radical neck dissection
81
What type of dissection?
Just removal of select groups of lymph nodes
Selective neck dissection
82
What type of radiation?
Targets the tumor site and minimizes damage to surrounding tissue
Intensity-modulated radiation therapy (IMRT)
83
What type of radiation?
Placement of tiny, radioactive seeds; used for small intraoral tumors or with IMRT to increase dosage
Brachytherapy
84
Which chemotherapy is not really beneficial for oral cancer?
Induction (neoadjuvant) chemotherapy
85
Chemo done before surgery
Induction (neoadjuvant) chemotherapy
86
Chemo done after surgery
Post-operative chemotherapy
87
Which chemotherapy gives the best locoregional control and disease-free survival?
Post-op concurrent chemoradiation therapy
88
Which chemotherapy is used for distant metastasis?
Single/multi-agent chemotx
89
What drug is used with the conventional fractioned radiation for post-op concurrent chemoradiation therapy?
Cisplatin
(Other drugs: carboplatin, 5-fluorouracil, taxanes)
90
What is the fractioned radiation dose for post-op concurrent chemoradiation therapy?
70 gray
(2 gray -> 5 days per week over 7 weeks)
91
What is the dose for Cisplatin when used with post-op concurrent chemoradiation therapy?
Every 3 weeks (up to 3 doses)
92
What are the 2 targeted therapies for squamous cell carcinoma?
EGFR monoclonal antibody (Cetuximab)
Immunotherapy
93
Which targeted therapy for squamous cell carcinoma?
Also called Cetuximab
EGFR monoclonal antibody
94
Which drug targets the epidermal growth factor receptor (EGFR) in treatment of oral squamous cell carcinoma?
Cetuximab
95
Which targeted therapy for squamous cell carcinoma?
Antibodies used to block checkpoints (PD-1, CTLA-4) and thereby allow immune response to occur
Immunotherapy
96
Which targeted therapy for squamous cell carcinoma?
Good response in melanoma and lung cancer
Immunotherapy
97
Which targeted therapy for squamous cell carcinoma?
Used for recurrent or metastatic H/N SCC who have progressed on or following platinum-based chemotherapy
Immunotherapy
98
Which targeted therapy for squamous cell carcinoma?
Approved drugs: Nivolumab and Pembrolizumab
Immunotherapy
99
When do most recurrences (locally, to lymph nodes, or distant metastasis) occur?
Within first 2 years
100
What is necessary for the life of the patient after having oral squamous cell carcinoma?
Periodic follow-up exam of entire mouth
(may need biopsy of multiple areas)
101
T/F: All mucosa exposed to carcinogen has the potential for cancer development ("condemned mucosa")
True
102
What is the term used to describe the theory that all mucosa exposed to carcinogen has the potential for cancer development ("condemned mucosa")?
Field effect/cancerization
103
Give 3 examples of the field effect/cancerization of oral SCC
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
What is the overall 5 year survival for oral and oropharyngeal SCC?
67%
105
What is the most important prognostic indicator for oral SCC?
Stage
(size of tumor and extent of spread)
106
What is the most important prognostic indicator for oropharyngeal SCC?
HPV status
107
T/F: Oropharyngeal SCC is usually poorly differentiated and non-keratinizing
True
108
Which oropharyngeal SCC tumors respond better to chemo and/or radiation, HPV+ or HPV-?
HPV+
109
Why do HPV+ tumors in oropharyngeal SCC respond better to chemo and/or radiation?
They lack TP53 mutations and field effect/cancerization
110
Even though most oropharyngeal SCCs are diagnosed at an advanced stage, why is early-stage survival similar?
Prognosis based on HPV status
111
T/F: Prognosis of oral SCC is generally poor because 2/3 of patients present with Stage III or IV disease
True
112
Once there is lymph node spread, what is the stage?
At least Stage III
113
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
True
114
Less aggressive form of SCC; large lesions can develop regular SCC in them
Verrucous carcinoma
115
Proliferative verrucous leukoplakia may give rise to what 2 cancers?
Verrucous carcinoma
Classic SCC
116
What are the most frequent sites for verrucous carcinoma?
Alveolar mucosa
Buccal mucosa
Hard palate
117
What do verrucous carcinomas look like?
White or red/white
Papillary/verrucous
Plaque or mass
(look like warts)
118
Verrucous carcinomas tend to grow __________. Invades with a ________ ________, but does not infilatrate
laterally; pushing margin
119
T/F: Verrucous carcinomas are microscopically bland; they can easily be misdiagnosed as hyperplasia
True
120
What is the tx for verrucous carcinoma?
Surgical excision
(radiation can be used as adjunctive tx, but is less effective than surgery)
121
When should you do a H/N exam?
New pt
Yearly on established pts
Whenever signs/symptoms suggest a need
122
What are the known molecular changes that occur in the development of oral squamous cell carcinoma?
p53 mutation
p16 hypermethylation (silencing)
Cyclin D1 overexpression
123
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
Alcohol
Smoking
Radiation therapy to oral cavity
HIV/AIDS
124
What are the 4 ways that verrucous carcinoma is significantly different than oral squamous cell carcinoma?
Location of oral lesions
Pattern of growth
Histologic appearance
Biologic aggressiveness
