Oral Path Exam 2 - Premalignant White and Red Lesions Part 1

Question 1

A lesion which has an increased risk of transformation to cancer

Answer 1

Premalignant/precancerous lesion

Question 2

A disease or habit associated with an increased risk to develop a premalignant lesion or cancer in tissues affected

Answer 2

Premalignant/precancerous condition

Question 3

To be histologically premalignant, a lesion must show _____________ ___________

Answer 3

epithelial dysplasia

Question 4

Alteration of epithelial maturation (dysmaturation)

Answer 4

Epithelial dysplasia

Question 5

T/F: A premalignant/precancerous lesion will turn into cancer

Answer 5

FALSE, it can turn into cancer, but it doesn’t mean it will

Question 6

The oral mucosa is mostly parakeratinized stratified squamous epithelium, except for the __________ __________ and ___________, which is orthokeratinized

Answer 6

hard palate; gingiva

Question 7

List the layers of epithelium from top to bottom

Answer 7

Corneum
Granulosum
Spinosum
Basale

Question 8

What is the histologic criteria for dysplasia? (5)

Answer 8

Bulbous, tear-drop shaped rete ridges
Loss of polarity (cells are crowded/jumbled)
Keratin or epithelial pearls
Loss of epithelial cell cohesiveness
Intact BM (lack of invasion)

Question 9

Describe the cytologic changes of dysplasia (6)

Answer 9

Enlarged cells, nuclei, and nuceloli
Increased nuclear/cytoplasm ratio
Hyperchromatism
Pleomorphism (cellular and nuclear)
Increased, altered, and displaced mitoses
Dyskeratosis

Question 10

Premature keratinization of individual cells

Answer 10

Dyskeratosis

Question 11

The thickness of the altered epithelium affected determines the __________

Answer 11

grade

Question 12

Lower 1/3 of epithelium is affected

Answer 12

Mild dysplasia

Question 13

Lower 1/2 of epithelium is affected

Answer 13

Moderate dysplasia

Question 14

Lower 2/3 of epithelium is affected

Answer 14

Severe dysplasia

Question 15

Full thickness of epithelium is affected with dysplasia w/o maturation (no keratin, cells at bottom look like the cells at top)

Answer 15

Carcinoma in situ (CIS)

Question 16

T/F: Dysplasia and carcinoma in situ are NOT cancer, as there is no invasion with access to blood and lymphatics

Answer 16

True

Question 17

Some clinical white lesions don’t show dysplasia, so they aren’t precancerous, but are still microscopically abnormal. This is called a “histologic gray area.” What may these lesions be diagnosed as? (3)

Answer 17

Hyperkeratosis
Hyperkeratosis + atypia
Epithelial hyperplasia/acanthosis

Question 18

Thickened keratin layer

Answer 18

Hyperkeratosis

Question 19

Thickened keratin, and the basal and parabasal cell layers are altered

Answer 19

Hyperkeratosis + atypia

Question 20

Spinous layer is thickened

Answer 20

Epithelial hyperplasia/acanthosis

Question 21

T/F: Based on the clinical presentation of hyperkeratosis, hyperkeratosis + atypia, and epithelial hyperplasia/acanthosis, some may have premalignant potential and require follow-up

Answer 21

True

Question 22

What type of lesion?

Gray/white, translucent plaque with rippled appearance and blending borders

Answer 22

Smokeless tobacco keratosis

Question 23

What type of lesion?

Probably not a true leukoplakia- small increased risk for oral cancer for moist snuff, chewing tobacco

Answer 23

Smokeless tobacco keratosis

Question 24

What type of lesion?

Resolution expected within 6 weeks (usually 2-3 weeks) of changing placement site of product

Answer 24

Smokeless tobacco keratosis

Question 25

What type of lesion? Biopsy leathery or nodular areas

Answer 25

Smokeless tobacco keratosis

Question 26

What type of lesion? Chronic progressive scarring disease

Answer 26

Oral submucous fibrosis

Question 27

What type of lesion? High-risk precancerous condition associated with betel nut chewing; seen in India and Southeast Asia

Answer 27

Oral submucous fibrosis

Question 28

What type of smokeless tobacco? Little evidence for significant increased risk between smokeless tobacco use and oral cancer

Answer 28

Moist snuff and dip (US and Europe)

Question 29

What type of smokeless tobacco? Increased risk for leukoplakia and oral cancer

Answer 29

Betel quid (India and Southeast Asia)

Question 30

What type of smokeless tobacco? Nut of the Areca palm is wrapped in the leaf of a Piper betel vine, together with slaked lime (calcium hydroxide), tobacco and spices

Answer 30

Betel quid

Question 31

What type of smokeless tobacco? The slaked lime enhances alkaloids released from the areca nut

Answer 31

Betel quid

Question 32

What does the areca nut release?

Answer 32

Alkaloids Flavenoids

Question 33

Which product of the areca nut? Stimulates collagen synthesis and causes euphoria

Answer 33

Alkaloid

Question 34

Which product of the areca nut? Inhibits collagenase

Answer 34

Flavenoids

Question 35

What type of smokeless tobacco? Activated inflammatory cells release cytokines/growth factors, which promotes fibrosis

Answer 35

Betel quid

Question 36

T/F: Tobacco is carcinogenic, leading to epithelial dysplasia

Answer 36

True

Question 37

Why is smoking worse than smokeless tobacco?

Answer 37

Burning of tobacco releases carcinogens

Question 38

What type of lesion? Signs/symptoms occur within 2-3 years with 2-5 betel quids per day, with daily frequency being more important than duration

Answer 38

Oral submucous fibrosis

Question 39

What type of lesion has the following symptoms? Vesicles Petechiae Xerostomia Oral burning sensation Intolerance to spicy foods

Answer 39

Oral submucous fibrosis

Question 40

What type of lesion? Gradual collagen deposition causes fibrous bands w/ oral pallor and stiffness leading to increasing trismus

Answer 40

Oral submucous fibrosis

Question 41

What type of lesion? Can't open the mouth as much

Answer 41

Oral submucous fibrosis

Question 42

What type of lesion? Some develop leukoplakia that can become dysplastic or turn into oral cancer

Answer 42

Oral submucous fibrosis

Question 43

What does stomatopyrosis mean?

Answer 43

Oral burning sensation

Question 44

What type of lesion? Patients should stop the betel nut habit, but cessation does not stop the lesion

Answer 44

Oral submucous fibrosis

Question 45

What type of lesion? All pts should be biopsied to confirm the diagnosis and assess for dysplasia

Answer 45

Oral submucous fibrosis

Question 46

What type of lesion? If there is trismus: Intralesional corticosteroids may improve mild cases Severe cases may require surgical splitting of fibrous bands, w/ skin grafts and mouth props, physiotherapy

Answer 46

Oral submucous fibrosis

Question 47

What does leukoplakia mean?

Answer 47

White patch (leuko = white; plakia = patch)

Question 48

A white patch or plaque that cannot be characterized clinically or pathologically as any other disease

Answer 48

Leukoplakia

Question 49

A clinical term only. Should be used after exclusion of known entities that produce white patches/plaques

Answer 49

Leukoplakia

Question 50

When defined this way (i.e. other clinical entities are excluded), it can be considered a premalignant lesion

Answer 50

Leukoplakia

Question 51

Which diagnoses must be excluded? (not leukoplakia) (9)

Answer 51

Leukoedema Cheek chewing Frictional keratosis Nicotine stomatitis Tobacco pouch keratosis Chemical burn Candidiasis Lichen planus Contact rxn (like cinnamon)

Question 52

What type of lesion? Most common oral premalignant lesion

Answer 52

Leukoplakia

Question 53

What type of lesion? 1.5-4.3% prevalence worldwide

Answer 53

Leukoplakia

Question 54

What type of lesion? Male predilection, usually > 40 years (increases with age, average is 60 years)

Answer 54

Leukoplakia

Question 55

What type of lesion? Sharply demarcated white patch or plaque

Answer 55

Leukoplakia

Question 56

What type of lesion? Variable surface texture: Thin or thick Smooth or rough Granular/nodular or verrucous Homogenous or non-homogenous

Answer 56

Leukoplakia

Question 57

What is leukoplakia called if a red component is present?

Answer 57

Speckled leukoplakia Erythroleukoplakia

Question 58

What type of lesion? Some degree of hyperkeratosis (wet keratin looks white) and thickening of the spinous cell layer (acanthosis)

Answer 58

Leukoplakia

Question 59

What type of lesion? Demonstration of epithelial dysplasia histologically proves lesion is premalignant

Answer 59

Leukoplakia

Question 60

What type of lesion? If dysplasia is not seen, it does not mean that it doesn't have premalignant potential. Clinical correlation is needed

Answer 60

Leukoplakia

Question 61

What type of lesion? Tx for moderate dysplasia or worse: remove by the most convenient means available (excision, laser, electrocautery, cryosurgery)

Answer 61

Leukoplakia

Question 62

What type of lesion? Tx for mild dysplasia or hyperkeratosis w/ atypia varies: D/c carcinogenic habits (smoking) may lead to resolution Mild dysplasia may remove or observe closely based on size and location

Answer 62

Leukoplakia

Question 63

What is the malignant transformation risk for: Thin leukoplakia Thick, homogeneous leukoplakia Granular/verruciform leukoplakia Non-homogeneous leukoplakia Erythroleukoplakia

Answer 63

Thin: Sseldom transforms w/o clinical alteration Thick, homogeneous: 1-7% Granular/verruciform: 4-15% Non-homogeneous: > 4-15% Erythroleukoplakia: 28%

Question 64

Rank the leukoplakia phases from lowest to highest malignant transformation risk

Answer 64

Thin Thick, homogenous Granular or verruciform Non-homogeneous Erythroleukoplakia

Question 65

T/F: White (leukoplakia) or red (erythroplakia) patches/plaques show variable risk to show dysplasia or squamous cell carcinoma based on the location where they occur

Answer 65

True

Question 66

What are the high risk sites for dysplasia or squamous cell carcinoma?

Answer 66

Lateroventral tongue Floor of mouth Soft palate/tonsillar pillar Lip vermillion

Question 67

What are the intermediate risk sites for dysplasia or squamous cell carcinoma?

Answer 67

Gingiva

Question 68

What are the low risk sites for dysplasia or squamous cell carcinoma?

Answer 68

Buccal mucosa (if pt doesn't use betel quid) Hard palate Dorsal tongue

Question 69

What is the malignant transformation risk for: Non-dysplastic leukoplakia Mild dysplastic leukoplakia Moderate dysplastic leukoplakia Severe dysplastic leukoplakia

Answer 69

Non-dysplastic: 0.85-2% Mild: 4% Moderate: 4-11% Severe: 20-43%

Question 70

What is the malignant transformation risk for all dysplastic leukoplakia combined?

Answer 70

<2% per year 12% over time

Question 71

What are other risk factors to determine malignant transformation of leukoplakia? (6)

Answer 71

Female Age Non-smoking status Lesion persistence Large size Ventrolateral tongue/FOM

Question 72

What are the features that increase the risk that leukoplakia will progress to cancer? (4)

Answer 72

Site Appearance Presence of dysplasia Increasing dysplasia grade

Question 73

Which 3 features involving the appearance of leukoplakia are predictors of higher risk for malignant transformation?

Answer 73

Non-homogeneous Red/speckled Ulcerated

Question 74

How many leukoplakias recur after excision?

Answer 74

1/3

Question 75

Transformation of leukoplakia usually occurs within ___________, but can be variable, so you need to follow closely

Answer 75

2-4 years

Question 76

How often should you follow-up on a patient that has had an excised leukoplakia with dysplasia?

Answer 76

Every 3 months

Question 77

How often should you follow-up on a patient that has had an excised leukoplakia without dysplasia?

Answer 77

Every 6 months (but if other risk factors are present, then every 3 months)

Question 78

What does erythroplakia mean?

Answer 78

Erythro = red Plakia = patch/plaque

Question 79

A red patch/plaque that cannot be clinically or pathologically be diagnosed as any other condition

Answer 79

Erythroplakia

Question 80

What is the prevalence of erythroplakia?

Answer 80

< 1%

Question 81

What type of lesion? Velvety red, well-demarcated patch, usually affecting the lateral tongue, floor of the mouth or soft palate

Answer 81

Erythroplakia

Question 82

What type of lesion? Red appearance is due to the lack of surface keratin production and epithelial atrophy

Answer 82

Erythroplakia

Question 83

What type of lesion? Same risk factors are leukoplakia, but usually more advanced when detected

Answer 83

Erythroplakia

Question 84

What type of lesion? 90% of these lesions are severe epithelial dysplasia or worse at time of biopsy

Answer 84

Erythroplakia

Question 85

What type of lesion? Tx and prognosis are similar for that of leukoplakia having a similar degree of epithelial dysplasia

Answer 85

Erythroplakia

Question 86

What type of lesion? Surgical excision often preferred to rule out cancer

Answer 86

Erythroplakia