Oral Path Exam 2 - Premalignant White and Red Lesions Part 1 Flashcards
A lesion which has an increased risk of transformation to cancer
Premalignant/precancerous lesion
A disease or habit associated with an increased risk to develop a premalignant lesion or cancer in tissues affected
Premalignant/precancerous condition
To be histologically premalignant, a lesion must show _____________ ___________
epithelial dysplasia
Alteration of epithelial maturation (dysmaturation)
Epithelial dysplasia
T/F: A premalignant/precancerous lesion will turn into cancer
FALSE, it can turn into cancer, but it doesn’t mean it will
The oral mucosa is mostly parakeratinized stratified squamous epithelium, except for the __________ __________ and ___________, which is orthokeratinized
hard palate; gingiva
List the layers of epithelium from top to bottom
Corneum
Granulosum
Spinosum
Basale
What is the histologic criteria for dysplasia? (5)
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)
Describe the cytologic changes of dysplasia (6)
Enlarged cells, nuclei, and nuceloli
Increased nuclear/cytoplasm ratio
Hyperchromatism
Pleomorphism (cellular and nuclear)
Increased, altered, and displaced mitoses
Dyskeratosis
Premature keratinization of individual cells
Dyskeratosis
The thickness of the altered epithelium affected determines the __________
grade
Lower 1/3 of epithelium is affected
Mild dysplasia
Lower 1/2 of epithelium is affected
Moderate dysplasia
Lower 2/3 of epithelium is affected
Severe dysplasia
Full thickness of epithelium is affected with dysplasia w/o maturation (no keratin, cells at bottom look like the cells at top)
Carcinoma in situ (CIS)
T/F: Dysplasia and carcinoma in situ are NOT cancer, as there is no invasion with access to blood and lymphatics
True
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)
Hyperkeratosis
Hyperkeratosis + atypia
Epithelial hyperplasia/acanthosis
Thickened keratin layer
Hyperkeratosis
Thickened keratin, and the basal and parabasal cell layers are altered
Hyperkeratosis + atypia
Spinous layer is thickened
Epithelial hyperplasia/acanthosis
T/F: Based on the clinical presentation of hyperkeratosis, hyperkeratosis + atypia, and epithelial hyperplasia/acanthosis, some may have premalignant potential and require follow-up
True
What type of lesion?
Gray/white, translucent plaque with rippled appearance and blending borders
Smokeless tobacco keratosis
What type of lesion?
Probably not a true leukoplakia- small increased risk for oral cancer for moist snuff, chewing tobacco
Smokeless tobacco keratosis
What type of lesion?
Resolution expected within 6 weeks (usually 2-3 weeks) of changing placement site of product
Smokeless tobacco keratosis
What type of lesion?
Biopsy leathery or nodular areas
Smokeless tobacco keratosis
What type of lesion?
Chronic progressive scarring disease
Oral submucous fibrosis
What type of lesion?
High-risk precancerous condition associated with betel nut chewing; seen in India and Southeast Asia
Oral submucous fibrosis
What type of smokeless tobacco?
Little evidence for significant increased risk between smokeless tobacco use and oral cancer
Moist snuff and dip (US and Europe)
What type of smokeless tobacco?
Increased risk for leukoplakia and oral cancer
Betel quid (India and Southeast Asia)
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
Betel quid
What type of smokeless tobacco?
The slaked lime enhances alkaloids released from the areca nut
Betel quid
What does the areca nut release?
Alkaloids
Flavenoids
Which product of the areca nut?
Stimulates collagen synthesis and causes euphoria
Alkaloid
Which product of the areca nut?
Inhibits collagenase
Flavenoids
What type of smokeless tobacco?
Activated inflammatory cells release cytokines/growth factors, which promotes fibrosis
Betel quid
T/F: Tobacco is carcinogenic, leading to epithelial dysplasia
True
Why is smoking worse than smokeless tobacco?
Burning of tobacco releases carcinogens
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
Oral submucous fibrosis
What type of lesion has the following symptoms?
Vesicles
Petechiae
Xerostomia
Oral burning sensation
Intolerance to spicy foods
Oral submucous fibrosis
What type of lesion?
Gradual collagen deposition causes fibrous bands w/ oral pallor and stiffness leading to increasing trismus
Oral submucous fibrosis
What type of lesion?
Can’t open the mouth as much
Oral submucous fibrosis
What type of lesion?
Some develop leukoplakia that can become dysplastic or turn into oral cancer
Oral submucous fibrosis
What does stomatopyrosis mean?
Oral burning sensation
What type of lesion?
Patients should stop the betel nut habit, but cessation does not stop the lesion
Oral submucous fibrosis
What type of lesion?
All pts should be biopsied to confirm the diagnosis and assess for dysplasia
Oral submucous fibrosis
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
Oral submucous fibrosis
What does leukoplakia mean?
White patch
(leuko = white; plakia = patch)
A white patch or plaque that cannot be characterized clinically or pathologically as any other disease
Leukoplakia
A clinical term only. Should be used after exclusion of known entities that produce white patches/plaques
Leukoplakia
When defined this way (i.e. other clinical entities are excluded), it can be considered a premalignant lesion
Leukoplakia
Which diagnoses must be excluded? (not leukoplakia) (9)
Leukoedema
Cheek chewing
Frictional keratosis
Nicotine stomatitis
Tobacco pouch keratosis
Chemical burn
Candidiasis
Lichen planus
Contact rxn (like cinnamon)
What type of lesion?
Most common oral premalignant lesion
Leukoplakia
What type of lesion?
1.5-4.3% prevalence worldwide
Leukoplakia
What type of lesion?
Male predilection, usually > 40 years (increases with age, average is 60 years)
Leukoplakia
What type of lesion?
Sharply demarcated white patch or plaque
Leukoplakia
What type of lesion?
Variable surface texture:
Thin or thick
Smooth or rough
Granular/nodular or verrucous
Homogenous or non-homogenous
Leukoplakia
What is leukoplakia called if a red component is present?
Speckled leukoplakia
Erythroleukoplakia
What type of lesion?
Some degree of hyperkeratosis (wet keratin looks white) and thickening of the spinous cell layer (acanthosis)
Leukoplakia
What type of lesion?
Demonstration of epithelial dysplasia histologically proves lesion is premalignant
Leukoplakia
What type of lesion?
If dysplasia is not seen, it does not mean that it doesn’t have premalignant potential. Clinical correlation is needed
Leukoplakia
What type of lesion?
Tx for moderate dysplasia or worse: remove by the most convenient means available (excision, laser, electrocautery, cryosurgery)
Leukoplakia
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
Leukoplakia
What is the malignant transformation risk for:
Thin leukoplakia
Thick, homogeneous leukoplakia
Granular/verruciform leukoplakia
Non-homogeneous leukoplakia
Erythroleukoplakia
Thin: Sseldom transforms w/o clinical alteration
Thick, homogeneous: 1-7%
Granular/verruciform: 4-15%
Non-homogeneous: > 4-15%
Erythroleukoplakia: 28%
Rank the leukoplakia phases from lowest to highest malignant transformation risk
Thin
Thick, homogenous
Granular or verruciform
Non-homogeneous
Erythroleukoplakia
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
True
What are the high risk sites for dysplasia or squamous cell carcinoma?
Lateroventral tongue
Floor of mouth
Soft palate/tonsillar pillar
Lip vermillion
What are the intermediate risk sites for dysplasia or squamous cell carcinoma?
Gingiva
What are the low risk sites for dysplasia or squamous cell carcinoma?
Buccal mucosa (if pt doesn’t use betel quid)
Hard palate
Dorsal tongue
What is the malignant transformation risk for:
Non-dysplastic leukoplakia
Mild dysplastic leukoplakia
Moderate dysplastic leukoplakia
Severe dysplastic leukoplakia
Non-dysplastic: 0.85-2%
Mild: 4%
Moderate: 4-11%
Severe: 20-43%
What is the malignant transformation risk for all dysplastic leukoplakia combined?
<2% per year
12% over time
What are other risk factors to determine malignant transformation of leukoplakia? (6)
Female
Age
Non-smoking status
Lesion persistence
Large size
Ventrolateral tongue/FOM
What are the features that increase the risk that leukoplakia will progress to cancer? (4)
Site
Appearance
Presence of dysplasia
Increasing dysplasia grade
Which 3 features involving the appearance of leukoplakia are predictors of higher risk for malignant transformation?
Non-homogeneous
Red/speckled
Ulcerated
How many leukoplakias recur after excision?
1/3
Transformation of leukoplakia usually occurs within ___________, but can be variable, so you need to follow closely
2-4 years
How often should you follow-up on a patient that has had an excised leukoplakia with dysplasia?
Every 3 months
How often should you follow-up on a patient that has had an excised leukoplakia without dysplasia?
Every 6 months
(but if other risk factors are present, then every 3 months)
What does erythroplakia mean?
Erythro = red
Plakia = patch/plaque
A red patch/plaque that cannot be clinically or pathologically be diagnosed as any other condition
Erythroplakia
What is the prevalence of erythroplakia?
< 1%
What type of lesion?
Velvety red, well-demarcated patch, usually affecting the lateral tongue, floor of the mouth or soft palate
Erythroplakia
What type of lesion?
Red appearance is due to the lack of surface keratin production and epithelial atrophy
Erythroplakia
What type of lesion?
Same risk factors are leukoplakia, but usually more advanced when detected
Erythroplakia
What type of lesion?
90% of these lesions are severe epithelial dysplasia or worse at time of biopsy
Erythroplakia
What type of lesion?
Tx and prognosis are similar for that of leukoplakia having a similar degree of epithelial dysplasia
Erythroplakia
What type of lesion?
Surgical excision often preferred to rule out cancer
Erythroplakia
