Potentially Malignant Lesions and Oral Cancer

Question 1

What are the steps in describing a lesion clinically?

Answer 1

Location

Size

Colour

Texture

Question 2

What is penducnulated?

Answer 2

Has a stem or stalk attaching main bulk of lesion underlying tissue

Question 3

What is sessile?

Answer 3

Flat

Question 4

What questions should you ask patient when investigating a potentially malignant lesion?

Answer 4

How long has it been there?
Have you ever had anything like this before?
General Hx
Symptoms- change size/colour, swell, bleed, pain

Question 5

What are fordyce spots?

Answer 5

White and yellow spots- ectopic sebaceous glands

Question 6

What are the types of candidiasis?

Answer 6

 Chronic hyperplastic candidiasis (candida leucoplakia)- WHITE
 Acute pseudomembranous- WHITE
 Chronic denture stomatitis- poor OH in denture wearers (red outline of the denture)- RED
 Acute Erythematous- disturbance of microflora in oral cavity (candida becomes favoured), associated with long term broad spectrum antibiotic use/steroid inhaler without rinsing- RED

Question 7

Why is biopsy taken for chronic hyper plastic?

Answer 7

As dysplasia can be present

Question 8

What are the types of inflammatory cells?

Answer 8

CHRONIC
 Lymphocytes- T cells and B cells
 Macrophages- act as antigen presenting cells, phagocytosis (removes pathogens, foreign objects etc, but cannot remove amalgam)
 Plasma cells- produce immunoglobulins
ACUTE
 Granulocytes
 Neutrophils- if infection causes a lot of neutrophils we get pus (caused by damage through enzymes)
 Basophils
 Eosinophils

Question 9

What are the features of macrophages?

Answer 9

 clear/pale cytoplasm containing vesicles which helps them engulf
 Large cells
 Kidney shaped nucleus

Question 10

What are the features of lymphocytes?

Answer 10

Large nucleus

Small rim like cytoplasm

Question 11

What are the features of plasma cells?

Answer 11

Large

Oval shaped

Big nucleus- pushed to one side

Question 12

What stain has affinity for carbohydrates?

Answer 12

PAS- glycogen in epithelium is removed
-> candida appears pink as it contains gluco-polysaccharide (not removed)

Question 13

How do neutrophils appear?

Answer 13

Look as If they have more than one nucleus
-> they don’t, they have one held together by chromatin

Question 14

How does smokers keratosis present?

Answer 14

White patches (excessive keratisation due to trauma)
 Can be in buccal mucosa or areas corresponding to where cigarette is smoked
 Not caused by asthma inhalers

Question 15

What is smokers melanosis?

Answer 15

Occurs where as a result of trauma- melanocytes produce melanin

Question 16

What are the histological features of Smokers/reactive melanosis?

Answer 16

 Cells have empty spaces- contain glycogen
 Cells are not tightly bound-as muscles move a lot so needs to be flexible
 Thick pink layer- keratin (Orthokeratinisation- no nuclei present)- would not usually be present here
 Thin epithelium- lower third displays cellular atypia (cells with darker nuclei, more crowded, has mitotic figures, increased basal cells and altered shape/size of cells)
Grade (microscope): MILD epithelial dysplasia- not all cells affected, only a third
 Melanin- brown spots (produced by melanocytes- generally found in basal layer)

Question 17

What should we look at when determining whether a mitoses is abnormal?

Answer 17

Location

Number

Appearance- is it tripolar

Question 18

What happens to rete pegs in dysplasia?

Answer 18

They become pear shaped

Question 19

What is pigmentary incontinence in melanocytes?

Answer 19

When melanin leaks into lamina propria and has to be removed by macrophages

Question 20

What are the features of dysplasia?

Answer 20

Large nucleus

Pleomorphism

Hyperchromatism

Altered stratification

Increased mitotic figures in abnormal position

Becoming broad and thick at base

Keratinisation in stratum spinosum

Question 21

What is the difference between carcinoma in situ and invasive carcinoma?

Answer 21

All cells are affected in all layers- CIS

If a few cells go over basement membrane into connective tissue- invasive carcinoma

Question 22

What causes the inflammatory/immune response in connective tissue underneath dysplastic epithelium?

Answer 22

Genetic changes/mutation which produces altered protein to be produced triggering reaction against non-self-protein
 The same thing occurs in malignancy
 Indicates good immune response (if this did not occur it suggests that patient is immunocompromised)
 This is a cell mediated immune reaction caused by T lymphocytes

Question 23

What are the different types of hypersensitivity immune reactions?

Answer 23

T1. Allergic
T2. cytotoxic (LP- antigen antibody reaction results in destruction of cell
T3. Antigen-antibody complex- can cause glomerular nephritis
T4. Cell mediated or Delayed- T cells

Question 24

What may be required if there is malignancy in mouth and pharynx?

Answer 24

Endoscopy- to check if other areas are affected

Question 25

What functional disturbances can occur in patients with cancerous lesions on the tongue?

Answer 25

Difficulty swallowing, eating, speaking, wearing dentures

Question 26

What is meant by indurated?

Answer 26

Lesion is harder and firmer than surrounding tissue

Question 27

What are the different grades for a carcinoma?

Answer 27

 Well differentiated- cells are easy to recognise as epithelium, can carry out function (produce keratin- as pearls)
 Moderately- no production of keratin
 Poorly- difficult to tell which cells are present (different stains required)
 Anaplastic- cannot tell where cells came from (metastatic tumour- if tumour came from other part of body)

Question 28

What are the positives about well differentiated tumours?

Answer 28

Respond to tx

Less likely to reoccur

Better prognosis

Question 29

What features indicate LN involvement of a cancer?

Answer 29

Perineural spread

Non-cohesive advancing front

Presence of malignant cells in lymphatic vessels and BV

Question 30

What are the causes of swelling in neck?

Answer 30

Goitre- more to front of neck

Lymphadenopathy due to infection (painful, mobile- return to normal following treatment)

Abscess- infection passing from mandibular teeth

Lymphoma

Salivary gland tumours- parotid can extend to below angle of mandible

Question 31

What is done to test a swelling?

Answer 31

Fne needle aspirate
 Can identify what type of cells are present
 Does not provide enough information for diagnosis

Question 32

What are the different classifications in T part of TMN staging?

Answer 32

T1- diameter is<2cm
T2- >2cm but <4cm
T3- > 4cm

Question 33

What is it called when cancer in LNs spreads outwith them?

Answer 33

Extra-capsular spread

Question 34

What are the reasons for epithelial cells being present within LNs?

Answer 34

 Metastases of cancer- epithelial cells may be out of place producing keratin pearls

 Developmental anomaly- epithelial cells remain inside LN statically

Question 35

What word do we use to describe a cell/tissue that is smaller/thinner than normal?

Answer 35

Atrophy

Question 36

How would you manage a patient with smoker’s melanosis?

Answer 36

Strongly advise the patient to give up smoking

Keep lesion under observation as only mild dysplasia is present and if patient stops smoking then lesion will probably regress (review)

Question 37

How does a metastatic tumour spread form primary site to neck LN?

Answer 37

Tumour grows into lymphatics
-> Small clumps of tumour cells break free and spread as emboli into the draining lymph nodes
-> Spread may also be by means of permeation by growth into the lymphatics

** Spread of intra-oral cancer is usually by the first mechanism