Pathology of the Oral Cavity - SRS Flashcards
What process causes dental caries?
Focal demineralization of tooth structure by acidic metabolites of fermenting sugars that are produced by bacteria.
What is gingivitis?
Inflammation of the oral mucosa surrounding the teeth.
What is dental plaque?
Sticky colorless biofilm that collects between and on the surface of the teeth.
Plaque contains a mixture of what 3 things?
Bacteria
salivary proteins
desquamated epithelial cells
What is this?
Periodontitis.
Perodontitis is an inflammatory process that affects the teeth including what things?
Periodontal ligaments
Alveolar bone
cementum
What was the causative agent in this patient’s dental pathology?
Methamphetamines
What is shown here?
Apthous Ulcers (canker sores)
What is shown here?
Fibrous proliferative lesion
What is shown here?
Aphthous ulcer
If you see a single oral ulceration with an erythematous halo surrounding a yellowish fibrinopurulent membrane, what are you looking at?
Aphthous ulcer
Aphthous ulcers are common often recurrent, exceedingly painful superficial oral mucosal ulcerations due to what etiology?
Unknown
What is shown here?
An irritation fibroma - smooth pink exophytic nodule on the buccal mucosa.
What is shown here?
Pyogenic granuloma
What three patient populations tend to get pyogenic granulomas?
- Children
- Young adults
- Pregnant women (pregnancy tumor)
Your patient presents with the lesion shown. The biopsy is also attached. What do you see in the biopsy?
What is this lesion?
Peripheral ossifying fibroma
Histo reveals white areas of osteoid formation
What is shown here?
What is visible in the histology?
Peripheral giant cell granuloma
granuloma
What color is a pyogenic granuloma?
red
What color is a peripheral ossifying fibroma?
White
What color is a peripheral giant cell granuloma?
Purple
What is shown here?
What is a stain we might have to use on this?
What is a better way of identifying it?
Acute herpetic gingivostomatitis
Tzank stain
Immunohistochem for HSV
This patient presents with a white coated tongue. You are able to scrape off a sample and stain it with PAS, which is shown at right. What does this patient have?
What would you likely prescribe first?
Oral candidiasis (Thrush)
Treat with nystatin
What has infected this patient?
Why the black coloration?
Aspergillosis
Black = fruiting bodies of aspergillus
What patients are prone to oral aspergillus infections?
Immunocompromised
What is a medication known to cause this?
Also, what is it?
Gingival hyperplasia
- Dilantin (phenytoin)
What did this person with gingival hyperplasia develop?
Acute monocytic leukemia
M5
What does this person have?
(These lesions are also found down their throat)
Osler-Weber-Rendu Syndrome
Your patient presents with characteristic dirty white fibrinosuppurative, tough inflammatory membrane over the tonsils and retropharynx.
What does this patient have?
Diptheria
You find your patient with gingival enlargement has leukemic infiltration with accompanying periodontitis. What does this patient have?
Monocytic leukemia
M5
What should you educate your patient with epilepsy on as far as a possibe ADR associated with the phenytoin (Dilantin) you are prescribing them, within the context of the oral cavity?
For bonus point how about hematologically?
Striking fibrous enlargement of the gingivae. (Gingival hyperplasia)
What is described here?
Autosomal dominant disorder with multiple congeital aneurysmal telangiectasias beneath mucosal surfaces of the oral cavity and lips.
Osler-Weber-Rendu syndrome
You see this lesion on the lateral border of the tongue. What is it?
What patients is this typically seen in?
Hairy leukoplakia
Immunocompromised, HIV patients, caused by EBV
Where are most oral tumors found?
UNDER the tongue
What does this patient have on their buccal mucosa?
Speckled leukoplakia
What is this here?
How can you tell
Probably: Squamous cell carcinoma
Can’t tell for sure on inspection, must biopsy
What is the WHO definition of leukoplakia?
A white patch or plaque that cannot be scraped off and cannot be characterized clinically or pathologically as any other disease.
Until proven otherwise by histological evaluation, what must leukoplakias be considered?
Precancerous
In general are white or red oral lesions worse?
Red
What is this red, non-raised lesion?
Erthythroplakia - since not raised, most likely carcinoma in situ
Your patient presents with the lesion shown in the photo. On the right is the histological image of the biopsy.
What do you see going on in the histo?
Full thickness dysplasia
What are ~95% of cancers of the head and neck?
What are the remainder?
- Squamous cell carcinomas (SCC)
- The remainder are adenocarcinomas of salivary gland origin.
Within north america and europe, oral cavity SCC has classically been a disease of what population?
Middle-aged individuals who have been chronic abusers of smoked tobacco and alcohol.
In india and asia, what is a major regional predisposing influence that leads to SCC?
Chewing of betel quid and paan
What are some predisposing influences for cancer of the lower lip?
2
- Actinic radiation (sunlight)
- pipe smoking
The incidence of oral cavity SCC (particularly the tongue) in individuals under age 40 has been on the rise. What is driving this increase?
Not known.
These patients are nonsmokers, not infected with HPV, and have no known risk factors.
Biopsy of a lesion in the oropharynx of your patient revealed the attached images. What do you see in the histology?
As a hint, this is one of the 70% of cases of this that harbors what organism?
Squamous cell carcinoma
Histology: Squamous cell pearls
Immunoperoxidase reveals oncogenic variants of HPV (particularly HPV-16.
Which typically has a better prognosis, HPV associated SCC or non-HPV associated SCC?
HPV associated, since the body mounts an immune response to the organism, and the tumor gets caught up in the ensuing shitstorm.
You biopsy the lesion shown at left and obtain the sample shown on the right. What is going on here?
Keratin pearls are visible below the mucosa, invading the underlying connective tissue stroma and skeletal muscle.
Thus, this is an invasive squamous cell carcinoma.
This panorex is of a patient with an oral lesion that had a corrugated squamous epithelium.
What does this patient have?
What kind of outcome is expected?
Odontogenic keratocyst (OKC)
Even with resection, good chance of regrowth
This patient presented with a cystic mass in their oral cavity. A biopsy revealed disorganized cellular detritus in the cyst.
Based on the panorex and the biopsy findings, what is this lesion?
What is causing the cyst in this case?
Dentigerous cyst
Impacted tooth is the root cause of the cyst
This patient presented with a radicular/root abcess, and a FNA of the cyst revealed disorganized cellular debris.
What does this patient have?
Periapical cyst
What is the most common cause of tooth loss in persons under the age of 35?
Dental caries - destruction of tooth structure by acid end products of bacterial sugar fermentation.
What is a common and reversible inflammation of the mucosa around the teeth?
Gingivitis
Periodontitis is a chronic inflammatory condition that results in the destruction of the supporting structures of the teeth with eventual loss of teeth. What is it associated with?
Poor oral hygeine and altered oral microflora
What are two common reactive lesions of the oral mucosa?
Fibromas and pyogenic granulomas
What can lead to appearance of aphthous ulcers in patients prone to them?
Stress largely.
What can be a long term consequence of leukoplakias and erythroplakias?
May undergo malignant transformation
What are the majority of oral cavity and oropharyngeal cancers?
Squamous cell carcinomas
What are three things that oral cavity squamous cell carcinomas are linked to?
Tobacco
ETOH
HPV
In a child, what is a unilateral cervical lymphadenopathy likely to be d/t?
Benign reactive process
Your patient presents with the shown bulge on their lateral neck. Palpation reveals a soft squishy mass. CT scan is shown at right.
What is this? (give two names for it)
In what patients is it most commonly observed?
What causes it?
Branchial cyst (Cervical lymphoepithelial cyst)
Young adults between ages 20 and 40
2nd Branchial arch remnant
What is this?
What do you see in the histo?
How would it feel on palpation?
Thyroglossal duct cyst
Histo = thyroid follicles
Would feel soft/squishy
What are paraganglia?
Clusters of neuroendocrine cells associated with the sympathetic and parasympathetic nervous system.
Paravertebral paraganglioma have what type of connections?
What stain can you use to identify them?
Sympathetic connections
Chromaffin positive - this stain detects catecholamines
Paraganglioma can also be parasympathetic in nature. Where do these types of neoplasms show up typically?
Great vessels of the head and neck
aorticopulmonary chain
carotid bodies - most common
aortic bodies
jugulotympanic ganglia
ganglion nodosum of the vagus
clusters around the oral cavity, nose, nasopharynx, larynx, orbit
Your attending physician hands you the attached images from a mass identified at the T7 vertebrae and demands that you interpret the findings. Being as you obtained an exceptional histology education at RVU, you correctly identify what key characteristics in the top image?
Based on those findings, what is the immunohistochem staining for?
What is the diagnosis?
This low power view shows tumor clusters seperated by septa (Zellballen). Also there are sustentacular cells.
This indicates a likely paraganglioma.
Consequently the immunohistochem is staining positively for chromagranin.
70% of paragangliomas are observed in the fifth decade of life. While often sporadic in appearance, they may be associated with what condition?
Multiple endocrine neoplasia syndrome type 2
What are the three major salivary glands?
PArotid
Submandibular
sublingual
What are six general categories that causes of xerostomia can be lumped into?
- Drugs
- Chemotherapy
- Radiotherapy
- systemic diseases
- salivary gland diseases
- psychosomatic/psychological
What are 4 common causes of sialadenitis (inflammation of the salivary gland)?
4
- Trauma
- Viral (mumps especially)
- bacterial infection
- Autoimmune disease
What are the most common type of inflammatory salivary gland lesion?
Mucoceles
You biopsy this xerostomia patients parotid gland and find the sample shown here to have a primary lymphocytosis, indicated by the star sign.
What does this indicate the patient likely has?
Sjogrens
This cyst ended up being lined with epithelial cells, and happened after traumatic injury to the sublingual gland. What is this called?
Ranula - pseudocyst mucocele
*** according to radiopedia and some dentistry sites this would be lined with granulation tissue, not epithelial cells, as Hertz described in his slide ***
What does this patient have, based on your physical findings and the histology?
Mucocele
Histo reveals a cystlike cavity filled with mucinous material and lined by organizing granulation tissue
What are two common causative agents of the pathology shown in the image below?
S. aureus
S. viridans
What is the most common site of salivary gland neoplasms?
Parotid gland
What is the relationship between the likeliehood of a salivary gland neoplasm being malignant vs. its size (size of the salivary gland preneoplasm)?
Larger gland = less likely malignant
Smaller gland = more likely malignant
Likeliehood of malignancy is more or less inversely proportional to the size of the gland.
Which is more likely to be malignant… tumor of a serous gland or of a mucinous gland?
Mucinous gland more likely to be malignant.
Of the following sites of possible neoplasia, what are the percentages of malignant cancers that arise in each?
- Submandibular
- minor salivary gland
- sublingual
- Submandibular - ~40%
- Minor salivary gland - ~50%
- Sublingual gland - ~70-90%
This specimen demonstrates both epithelial and mesenchymal differentiation with a stroma. What is this?
Pleomorphic adenoma
This was excised from the parotid gland of a patient. Based on what you see here, what is it?
Pleomorphic adenoma
Findings include…
Low power: well demarcated tumor with cartilagenous development, and adjacent normal salivary gland parenchyma.
High Power: Epithelial and myoepithelial cells within a chondroid matrix material.
Describe the clinical presentation of a pleomorphic adenoma.
Painless, slow growing, mobile, discrete masses.
Pleomorphic adenomae most commonly appear in the parotid, submandibular gland or in the buccal cavity. What is the recurraance rate?
With parotidectomy = 4%
With simple enucleation = 25%
What would a carcinoma arising in a pleomorphic adenoma be referred to?
Carcinoma ex pleomorphic adenoma
or
Malignant mixed tumor
This is an example of the second most common salivary gland neoplasm which arises almost exclusively in the parotid gland. It has both cystic and noncystic characteristics.
What is this neoplasm and is it malignant?
Warthin Tumor
(papillary cystadenoma lymphomatosum)
Benign
Warthin tumors typically present in the fifth to seventh decade of life, and more commonly in males than females. Roughly 10% are multifocal, and 10% bilateral.
What patients are especially at risk for these neoplasms?
Smokers have roughly an eight times greater chance of getting these than non smokers.
Your patient with a parotid tumor comes in and you take a biopsy. It reveals epithelial and lymphoid elements, with follicular germinal centers beneath the epithelium.
On higher power you can see cystic spaces seperating lobules of neoplastic epithelium consisting of a double layer of eosinophilic epithelial cells based on a reactive lymphoid stroma.
What is this tumor?
Warthin tumor
Your dickish attending physcician hands you the histology images but not the write up for the parotid gland biopsy you did on the patient in room 8. You see the image attached and tell the attending that this patient has a?
Warthin tumor
Low power: epithelial and lymphoid elements with a follicular germinal center below the epithelium
High power: cystic spaces separate lobules of neoplastic epithelium consisting of a double layer of eosinophilic epithelial cells based on a reactive lymphoid stroma.
You encounter a neoplasm composed of variable mixtures of squamous cells, mucus-secreting cells, and intermediate cells.
What type of tumor is this?
Malignant?
Mucoepidermoid carcinoma
Yes, malignant
Where do mucoepidermoid carcinomae typically appear?
Parotid 60-70%
also a large fraction of neoplasms in other salivary glands.
What stain do we use for mucin?
What color does it turn?
Mucicarmine
Turns pink
The clinical course and prognosis of mucoepidermoid carcinoma depend on the grade of the neoplasm. What is the prognosis for a low grade mucoepidermoid carcinoma?
Recurrance?
5 year survival rate of 90% d/t rare metastasis.
Recur in about 15% of cases
What is the prognosis for a high-grade mucoepidermal carcinoma?
Recurrance rate?
5 year survival is only 50%, d/t 30% metastasis and difficulty in excision.
Recurrance in 25-30% of cases
Is this example of mucoepidermoid carcinoma obtained from a sublingual salivary gland high grade or low?
High grade
Is this mucoepidermoid carcinoma high or low grade?
Low
This salivary gland tumor shows perineural invasion, indicated by the star. What is this type of tumor?
Adenoid cystic carcinoma
What is this low grade serous tumor of the parotid?
Acinic Carcinoma
This tumor on histo shows tumor cells with a cribriform pattern enclosing secretions, and perineural invasion by tumor cells.
What is it?
What might be a component of this patients CC?
Adenoid cystic carcinoma
very painful d/t the nerve invasion
Although slow growing, adenoid cystic carcinomas are unpredictable tumors with a tendincy to invade perineural spaces, and they are stubbornly recurrent.
How often do they metastasize?
50% or more disseminate widely to distant sites.
Where do adenoid cystic carcinomae tend to disseminate to?
When?
- Bone
- Brain
- Liver
Sometimes more than a decade after the primary lesion is removed.
What is the prognosis for an adenoid cystic carcinoma at 5, 10 and 15 years?
5 year survival rate is 60-70%
10 year = 30%
15 year = 15%
You find a tumor that resembles the normal serous acinar cells of the salivary glands. What is it?
Acinic cell carcinoma
The clinical course of acinic cell carcinoma is dependant upon what?
The degree of pleomorphism
Acinic cell carcinoma rarely recurs after resection, but about 10 to 15% of these neoplasms metastasize to lymph nodes.
What are the 5 year and 20 year survival rates?
5 years = 90%
20 years = 60%
Inflammation of the salivary glands d/t trauma, infection or autoimmune rxn, describes what?
Sialadenitis
What are mucoceles caused by?
Trauma to or blockage of a a salivary gland duct with consequent leakage of saliva into the surrounding connective tissue stroma.
A pleomorphic adenoma is a benign, slow-growing neoplasm composed what?
A heterogenous mix of epithelial and mesenchymal cells.
A Mucoepidermoid carcinoma is a malignant neoplasm of variable biological aggressiveness that is composed of?
A mixture of squamous and mucous cells.
