Orathon3: Adventures in Pathology Flashcards
A white patch or plaque that Won’t rub off and which can’t be diagnosed as any specific condition. A Clinically descriptive term.
Leukoplakia
2 etiologies of Leukoplakia:
Frictional Keratosis (physical)
Tobacco (most)
80% of Leukoplakia is _____, _____, and ______
17% is ______
3% is _____
Hyperparakeratosis, Hyperorthokeratosis, Acanthosis (increased thickness)
Epithelial dysplasia/carcinoma in situ (pre-malignant)
Superficially invasive squamous cell carcinoma
Superficially Invasive Squamous Cell Carcinoma makes up ____% of __________,
3%, Leukoplakia
Superficialy invasive squamous cell carcinoma (3% of Leukoplakia), a single incisional biopsy will underdiagnose ___%, and surgical excision will display carcinoma ___%
Multiple biopsies will underdiagnose ____%, carcinoma __%
30%, 12%
12%, 2.4%
3 most common anatomic sites for Leukoplakia:
% of time Dysplastic/Invasive for each
Floor mouth/ventral tongue (50%)
Lateral Tongue (25%)
Lower lip (35%)
There is homogenous Leukoplakia and Non-homogenous leukoplakia, which makes up ____ % of dysplastic/invasive
50-80%
3 types of Non-homogenous Leukoplakia:
Erythroleukoplakia (Erosive)
Nodular leukoplakia (Speckled)
Verrucous leukoplakia
The Rare form of progressive leukoplakia that is characterized by progression, multifocality, verrucous morphology, recurrence after excision, progression to SCC and death
Proliferative Verrucous Leukoplakia
Leukoplakia Malignant trasfromation _____ overall:
____% if dysplastic
____% if NOT dysplastic
4-6%
15%
1-3.5%
A red patch which can’t be diagnosed as a specific condition
clinically descriptive term considerable less common than leukoplakia
Erythroplakia
T/F
Erythroplakia has a tendency for high risk sites and may produce symptoms
True
Histology of Erythroplakia
Dysplasia
Carcinomainsitu/carcinoma
*almost 100%
Tx of Erythroplakia depends on presence/absence of what?
dysplasia
*severity
% if Erythroplakia resolves with Smoked tobacco cessation:
spit/topical tobacco cessation:
50%
95%
4 Premalignant conditions of Erythroplakia:
Sideropenic dysphagia
Submucous fibrosis
Lichen planus (controversial)
Immunosuppression
Oral Cancer: (known as what 2 things)
Squamous Cell Carcinoma
Epidermoid Carcinoma
SCC represents greater than ___% of all oral cancer
90%
90% of Oral Cancer is SCC. 10% is made up of what 3 types?
carcinoma/adenocarcinoma (salivary, metastatic)
Sarcoma
Leukemia/Lymphoma
How many new cases of SCC diagnosed/year?
How many will die?
30,000
9,000
Average 5 yr survival rate for oral SCC is less than
50%
Oropharyngeal cancer survival is (represents 1/3):
Oral cavity cancer survival is (represents 2/3):
*these 2 are computed together = 63%
90%
49.5%
Oral cavity cancer (SCC) has the __th lowest survival rate of any cancer
6th
T/F
Survival rates of oral cancer aren’t improving
Represent 4th most common cancer in black males
6th most common cancer in white males
True
T/F
oral cavity cancer has a higher death rate than Melanoma, Cervical Cancer, Breast Cancer
True
Peak age of incidence of Oral Cancer:
Increasing incidence:
50-70
under 40
male:female ratio for Oral Cancer
males 2:1
Risk Factors of Oral Cancer:
radiation (lip only) tobacco alcohol immune genetic environmental
In __% of cases, Oral Cancer pt is/was a Smoker
75%
T/F
The risk for cigars/pipe smoking = risk for cigarettes for intraoral SCC
True
T/F
Smokeless tobacco has the same incidence of oral SCC as smoked
False
*smokeless much lower
T/F
Typically, oral SCC SMOKELESS pts have been exposed to tobacco for 20-30 years
True
*site of quid, cancer develops
Statistically, what is a greater risk factor for Oral SCC than tobacco?
Alcohol
Risk for use of Alcohol developing oral SCC is greater than 2 pack/day smokers
True
Alcohol has what 3 effects that contribute to SCC
drying agent
solvent
contaminant
Alcoholics have nutritional deficiencies and liver disease (increase of carcinogens) that lead to oral SCC
True
Abuse of Alcohol is considered to be ___ alcohol equivalents/day
6
Risk min smoking/drinking:
heavy smoking/minimum drinking:
heavy drinking/ minimum smoking
heavy smoking/drinking:
1
8
23
100
Aging, chronic nutritional deficiency, disease states, and therapeutic interventions can all affect the Immune System and are risk factors for Oral SCC
True
4 types of Chronic Nutritional Deficiencies
*risk factors for Oral SCC
Iron deficiency (Plummer-Vinson)
Vitamin A deficiency (protective/preventive)
Vitamin C deficiency
Vitamin E deficiency (antioxidant)
Chronic candidal infection can lead to what 2 conditions (increasing risk factor for Oral SCC)
Epithelial hyperplasia
Persistent/continuous inflammatory cell response
Several types of HPV are oncogenic and produce ____ of cell cycle regulation that compromise immune system _____
inhibition
surveillance
T/F
Significant increase of Oral SCC due to HPV
True
30 years ago HPV cause ___% of throat cancer
today it is ___%
15%
80%
2 types of Herpes associated with Oral SCC
EBV (HHV 4)
KSAV (HHV 8)
*both inhibit immune surveillance
Chronic conditions stimulate the immune system can accumulate what?
Genetic defects of affected cells
*diabetes, perio, lichen planus - leads to Oral SCC
3 Types of Therapeutic interventions that can increase risk for Oral SCC
Chemo
Radiation
Routine meds (anti-rejection)
Genetic defects associated with what 2 Syndromes increase risk for genetic defects:
*but, not particularly Oral SCC
Basal Cell Nevus Syndrome
Gardner’s Syndrome
Though basal cell nevus syndrome and Gardner’s syndrome are associated with Genetic Defects, specific syndromes are NOT reported associated with Oral SCC
True
Family Hx of Oral SCC is a risk factor
True
3 Environmental factors increase risk for Oral SCC:
Carcinogenic chemicals
Foods/additives
Heat
Only ____% of US adults can correctly identify early signs of Oral Cancer
Only ___% of US adults know risk of alcohol
Only ___% of US adults have had an Oral Cancer exam
25%
13%
14%
In ___% of new Oral SCC cases, the Pts have absolutely no evident risk factors
25%
Warning Signs for Oral SCC (H/N)
C hange in sensation A sore will not heal U nexplained hoarseness/difficulty swallowing T hickening/lump I nability to pronounce O bvious change in mole, wart, etc N agging cough
4 things Oral SCC can look like:
Leukoplakia (white plaque)
Erythroplakia (red plaque)
Ulcer
Exophytic Mass
T/F
Earliest lesions do NOT show characteristic features that increase index of suspicion for Oral SCC
True
Advances lesions for Oral SCC have 5 characteristics:
firm/hard (indurated)
non-moveable
Irregular, exophytic growth
Non-healing ulcer (rolled borders very ominous)
Pain
T/F
An oral cavity site of Origin for Oral SCC is decreasing
it can, however, occur anywhere
True
2 areas rarely affected by Oral SCC
3 high risk sites:
Dorsum tongue, Anterior hard palate
lower lip, posterior lateral tongue, floor mouth
T/F
Males are 2:1 Oral SCC, though females are increasing
True
Increasing incidence of Oral SCC in Females is in what 2 areas?
This has minimal association with what?
tonsillar pillars/soft palate margins
HPV
T/F
Oropharynx cancers are decreasing in frequency
False
What 2 areas comprise the vase majority of Oropharynx Cancers?
Base of tongue
Tonsillar regions
Oropharynx cancers are highly associated with what?
HPV
The risk factors for Oropharynx Cancers are different than Oral Cavity - 4 Factors:
non-smokers
non alcohol abusers
early sex
multiple sex partners!!!
T/F
Majority of Oral Cancers diagnosed after they have metastasized to neck nodes
*directly related to survival
True
True
Squamous Cell Carcinoma in Young Adults defined as before what age?
*alarming increase in incidence
40
What area is SCC of Young Adults most associated with?
Lateral border tongue
T/F
There is conflicting data if SCC under 40 is more aggressive and higher recurrence
True
3 subsets of young tongue cancer cohort
Natl Cancer Data Base Report
less than 35% = female, few risk factors, aggressive, bad prognosis
less than 40% = male, tobacco/alcohol, prognosis depends on stage
less than 40% = slight male, tobacco, differentiated, Tx response good
2 Staging Systems:
TNM
STNMP
TNM:
Tumor Size
Nodal Metastasis
Metastatic Spread
STNMP:
Site of primary tumor
Tumor size
Nodal metastasis
Metastatic spread
Pathologic Grade of Tumor
TNM: T1 - T4:
T1: < 2 cm
T2: between 2 and 4 cm
T3: > 4 cm
T4: >4 and in Antrum, Skin, Pterygoids, Base of Tongue
TNM: N0 - N3:
N0: no lymph node
N1: only node, same side, < 3cm
N2: one node, same side, 3-6 cm (multiple nodes, same side, < 6cm)
N3: Contralateral/bilateral OR same side > 6 cm
TNM: M:
M0: no distant metastasis
M1: Distant metastasis
Stage 1 TNM:
T1, N0, M0
Stage 2 TNM:
T2, N0, M0
Stage 3 TNM:
T3, N0, MO
T1, N1, M0
T2, N1, M0
T3, N1, M0
Stage 4 TNM:
Any T4
Any N2 or N3
Any M1
Stage 1 survival (5 year):
Stage 2
Stage 3
Stage 4
77-85%
66-76%
41-44%
9-20%
Document abnormalities (draw it out), include color size, surface characteristics, feel
True
Eliminate possible causes (noxious habits), smooth rough teeth (restore)
True
If you think a Pt has an abnormality _________
Schedule Appointment
Tx of SCC dependent on what 2 things?
Stage
Location
Chemo is curative
False
Drooling, speech impairment, facial deformity, all are potential complications of Surgical Tx
True
4 potential complications of Chemo:
*also Nausea, Neurotoxicity
Mucositis/ulceration
Xerostomia
Infection
Bleeding
5 potential complications of Radiation:
Dermatitis
Mucositis/ulceration
decreased salivation
taste alteration
Infection
4 Long term complications of Tx for SCC
Xerostomia
Osteoradionecrosis
Trismus/figrosis
Alopecia
80% of all skin cancer
Basal Cell Carcinoma
Basal Cell Carcinoma (80% skin cancer) cases/yr?
90% sun exposure, proportion of US people will develop?
1 million
1/5 (1/3 Texans)
Etiology for Basal Cell Carcinoma
describe:
UV
low grade, slow growing, almost never metastasize
Most common clinical form of Basal Cell Carcinoma:
noduloulcerative
Basal Cell Carcinoma is usually noduloulcerative, with the center _____ with ______ borders and _____ vessels
cratered ulceration
rolled
telangiectatic (dilated)
Histologically, what is Basal Cell Carcinoma?
Islands of Basaloid Epithelial cells showing invasive growth
Tx Basal Cell Carcinoma:
Excision, curettage w/ electrodessication
Radiation
Prognosis BCC:
90-95% 5 year survival
Syndrome associated with Nasopharyngeal Carcinoma?
Trotter’s syndrome
Trotter’s Syndrome (nasopharyngeal carcinoma) has pain referred where?
includes what nerve exiting the Foramen Ovale?
tongue/jaw (secondary to invasion of carcinoma)
trigeminal
Bulky or Fleshy mass under the surface skin or mucosa
This comprises 1% H/N malignancies and affect what age?
Mesenchymal Sarcoma
broad age range
3 types of Mesenchymal Sarcoma:
CT
Muscle
Nerve
4 kinds of CT Mesenchymal Sarcoma:
Fibrosarcoma
Liposarcoma
Angiosarcoma
Kaposi’s Sarcoma
Malignancy of the vascular endothelium
*more in H/N, scalp and forehead
Angiosarcoma
Malignancy of Vascular Endothelium
Kaposi’s Sarcoma
Kaposi’s Sarcoma associated with what Herpes?
Lesiona reddish/purple, patch or mass, ______
50% HIV+KS has ____ lesions
More prevalent in what 2 areas?
HHV 8
macula
oral
gingiva, palate
Histology of KS, variable but most include ____ cell proliferation with slit like vascular spaces and prominent _____ extravasation
spindle
RBC
Tx KS (4 options)
Radiation
Chemo
Excise
Intralesion Vinblastine (vinblastine sulfate)
2 types of Muscle (mesenchymal sarcoma):
Leiomyosarcoma
Rhabdomyosarcoma
What is the most common soft tissue malignancy in children?
2 areas increased prevalence?
Graplike clusters called…
Rhabdomyosarcoma
H/N, urogenital tract
sarcoma botryoides
Malignant peripheral nerve sheath tumor, aka…
may arise from what?
Mass lesion w/ pain and ____ deficit
Neurogenic Sarcoma
neurofibromatosis
nerve
Tx Sarcomas (mesenchymal - that’s CT, muscle, nerve):
Prognosis:
Surgery +- radiation +- chemo
variable
What is the most common malignancy in bone of Oral Cavity?
Mx?
Mn?
Mx/Mn represent 2/3, other 1/3 found where?
Metastatic Disease
20%
80%
soft tissue/gingiva
Primary site of Metastatic Disease found in Oral Cavity for Males includes:
Females:
lung, kidney, liver, prostate
breast, genitals, kidney, colorectal
What % of Metastatic Disease found in the Oral Cavity Precede the Primary Diagnosis?
23%
4 Clinical Signs of Metastases to the Oral Cavity:
although may be asymptomatic
pain
paresthesia
swelling
loosening of teeth
How does Metastases to the Oral Cavity look Radiographically?
destructive, invasive, POORLY MARGINATED Lucency
*rarely stimulated production of bone/osteosclerosis
Osteosclerosis/production of bone is indicative of what Metastatic Disease?
Prostate
Histology of Mestastases to the Oral cavity, is usually what form of cancer?
Tx:
carcinoma
palliation (often)
Malignancies of the immune system, mostly lymphocytes
Lymphoma
Lymphoma is divided into what 2 categories?
Hodgkins
Non-Hodgkins
Lymphomas tend to have lymphadenopathy where nodes are firm, rubbery, painless, moveable or fixed
and Multifocal
True
Hodgkins cases/yr:
malignant Cell:
80% of malignant cells have what marker?
Classic presentation:
Spread:
Oral involvement?
8000
Reid-Sternberg
B-cell
lymphadenopathy
predictable/contiguous
rare
___% of Hodgkin’s disease is cervical or supraclavicular
75%
Clinical staging of Hodgkin’s Lymphoma determine the Anatomic Sites Involved
By what means?
PE, chest film, CT, MRI, lymphangiography, laparotomy
Histologic classification of 4 subtypes of Hodgkin’s Lymphoma:
Ann Arbor System
Ann Arbor System (Hodgkin’s Lymphoma) 4 Stages:
*Histologic
I single lymph node (I), single estralymphatic (IE)
II 2 or more nodes, same side diaphragm (II), extralymphatic site (IIE)
III nodes both sides diaphragm (III), extralymphatic (IIIE), spleen (IIIS)
IV Diffuse/disseminated extralymphatic organs (with or without associated node involvement)
Ann Arbor (Hodgkins) A =
B =
absence of systemic signs
fever, night sweats, 10% body weight loss 6 months prior to diagnosis
Tx of Hodgkins via Ann Arbor System:
Stage I/II = radiation therapy
Stage III/IV = chemo +/- radiation
Most pts survive Hodgkins Lymphoma, Stage I/II survival is…
90%
Non-Hodgkins Lymphoma are a diverse group of ______ malignancies
Usually what cell in origin?
immune system
B-cell (some T cell)
Non-Hodgkins lymphoma represent ____ cases/yr
affect lymphoid tissues, compared to Hodgkins, spread…
lymphadenopathy/mass lesion orally, commonly affects _____ (can affect bone)
80,000
unpredictably (often to non-lymphoid)
palate
3 subtypes, Non-Hodgkin’s Lymphoma:
low, intermediate, high grades
1 specific type of Non-Hodgkin’s Lymphoma:
Burkitt’s lymphoma
Burkitt’s lymphoma is a _______ lymphoma
aka…
non-Hodgkins B-cell
African jaw lymphoma (affects jaws of childres)
90% Burkitt’s lymphoma associated with ______
80% show translocation of protooncogene from _______to ______
Very rapidly growing destructive ______
American Burkitt’s has less _____ involvement and is in older pts (increase CNS/abdominal involvement)
EBV
C8 to C14
lucency
jaw
Starry Sky
Burkitt’s lymphoma
*phagocytic cells in sea of malignant lymphoid cells
Tx Burkitt’s Lymphoma:
*what drug?
aggressive chemo
*cyclophosphamide
Tx and Prognosis Burkitt’s lymphoma is Radiation +/- chemo, and prognosis is highly variable
True
Group of monoclonal malignant proliferative diseases affecting Plasma Cells where cells remain functional and produce whole antibody molecule or part of it
Plasma cell dyscrasias
Bence Jones proteinuria:
Plasma Cell Dyscrasias
*light chain of antibody of functional but malignant plasma cell
Light chain of Ab of functional but malignant plasma cell:
Bence Jones proteinuria
*plasma cell dyscrasia
2 types of Plasma Cell Dyscrasia:
Multiple Myeloma
Extramedullary plasmacytoma
The most common malignancy of the bone:
cases/yr?
Multiple Myeloma
30,000
*plasma cell dyscrasia
Multiple Myeloma 2 risk factors:
age
male
Multiple Myeloma affect bones with _______
includes vertebrae, ribs, skull, pelvis, and ___% in the jaw
active marrow
10%
Bone pain, anemia, infection renal insufficiency, fatigue
Multiple myeloma
IgA, IgG, IgM, IgE, IgD in the serum
Multiple myeloma
- monoclonal gammopathy
- may or may not have light chains (Kappa/Lambda)
Multiple Myeloma will present how orally?
Skull?
destructive lucencies
punched out lucencies
Tx Multiple myeloma
Prognosis
survival at 5 yrs:
chemo, immunomodulating agents, stem cell/marrow transplant
poor
33%
Single lesion of myeloma in the bone
*many progress to multiple
Solitary myeloma
Soft tissue lesions
*isolated or with multiple myeloma
Extramedullary plasmacytoma
Malignancies of bone marrow stem cells
Leukemia
3 types of Leukemia:
aside from acute/chronic
myelocytic
lymphocytic
monocytic
Primary oral manifestation of Leukemia:
Secondary (3):
gingival enlargement
anemia, thrombocytopenia (bleeding), immunosuppression
