Potentially Malignant Leasions

Question 1

Precancerous lesions Vs conditions

Answer 1

Precancerous lesion: an altered tissue in which cancer is more likely to form

Precancerous condition: a generalised state associated with an increased cancer risk

Question 2

Leukoplakia

Answer 2

It is idiopathic so should not include:
Tobacco related lesions
Smokers keratosis
Chronic hyperplastic candidiasis
Frictional keratosis

It is a clinical diagnosis and there is no histological connotation
Epithelial dysplasia may or may not be present

Question 3

Erythroplakia

Answer 3

Less frequent than leukoplakia
Much higher risk
More severe dysplasia
Often already carcinoma

Question 4

Clinical predictors of malignancy

Answer 4

Clinical appearance -very variable
Non-honogenous
Verrucous, speckled
Ulcerated, leuko-erythroplakia

High risk sites:
FOM, lateral border and ventral tongue, retromolar region, oro-pharynx, soft palate;buccal mucosa

Question 5

Epithelial dysplasia

Answer 5

Potentially malignant lesion
Abnormal maturation and stratification (architectural change)
Cellular atypia (cytological abnormality)

-increased and abnormal suprabasal mitoses
-basal cell hyperplasia
-drop shaped rete pegs
-disturbed polarity or basal cells
-altered nuclear/cytoplasmic ratio
-nuclear hyperchromatism
-prominent nucleoli
-irregular stratification
-abnormal keratinization
-reduction of intercellular adhesion or cohesion

Criteria for diagnosis:
Architecture then cytology

Question 6

Hyperplasia

Answer 6

Increased cell number
Architecture:
Regular stratification
Altered compartment size
NO cellular atypia

Acanthosis - hyperplasia of stratum spinosum

Question 7

Mild dysplasia

Answer 7

Architectural- change in lower third
Mild-cytologocal atypia

Question 8

Moderate dysplasia/high grade

Answer 8

Architecture - change into middle third
Marked cytological atypia

Question 9

Severe dysplasia/high grade

Answer 9

Architecture - change into middle third
Marked cytological atypia

Question 10

Carcinoma in situ

Answer 10

Theoretical concept
Cytologically malignant but not invading
Abnormal architecture - full thickness/or almost full
Severe cytological atypia
Mitotic abnormalities frequent

Question 11

Management of dysplasia

Answer 11

1. Early diagnosis and recognition of potentially malignant lesions
2. Treatment options are based on clinical features+ dysplasia grade
3. Regular examination and interval biopsy of suspicious areas
   * Disappearance of a lesson does not necessary means resolution

Question 12

Potentially malignant conditions

Answer 12

Systemic conditions
Lichen planus
Oral submucous fibrosis
Iron deficiency (syderopenic dysphagia)
Tertiary syphilis

Question 13

Oral submucous fibrosis

Answer 13

Due to chewing between quid even if tobacco free
Familiar predisposition
Mucosa becomes fibrotic and immobile (trismus)
Epithelium is smooth and atrophic
Muscles become involved
Red or white lesions at site of placement
Teeth are stained dark red
Periodontitis
Malignant transformation 4-8%

Management:
Stop the habit, corticosteroid injections, surgical excision

Histopathology:
Thinned epithelium, no rete pegs, atypia may be present. Connective tissue is thickened, hyaline, avascular. Muscle fibres undergo atrophy and replacement by fibrous tissue