Pre-cancerous lesions Flashcards
What is a precancerous lesion?
morphologically altered tissue in which cancer is more likely to occur than an apparently normal counterpart
Give an example of a precancerous lesion
leukoplakia
What is a precancerous condition?
a generalised state associated with a significantly increased risk of developing a malignancy
Give an example of a precancerous condition
oral submucous fibrosis
Give examples of clinical lesions that are commonly considered to be premalignant or that can simulate malignant lesions
- leukoplakia
- erythroplakia
- leukoerythroplakia
- smokers keratosis (nicotinic stomatitis)
- oral submucous fibrosis
- actinic keratosis/chelitis
- inherited conditions (dyskeratosis congenita)
- lichen planus/lichenoid
Give examples of non-pre-malignant white and red lesions
- frictional keratosis
- oral candidal lesions
- chemical burns (aspirin)
- thermal burns
- pericoronitis
- gingivitis
- viral papilloma
- haemangiomata
- intra-oral skin grafts restoring surgical defects
- lingual erythema migrans (geographical tongue)
- epulides
- glossitis (drug related or due to deficiency disease)
- sublingual varicosities
- intra-oral tattoos and foreign bodies
- fordyce spots
What kind of diagnosis is leukoplakia regarded as? Why is this
- as a clinical diagnosis
- a definitive pathological diagnosis can only be established following a biopsy
When and where was the definition of leukoplakia updated?
Uppsala conference in 1994
What was the definition of leukoplakia following the Uppsala conference?
“predominantly white lesion of oral mucosa which cannot be characterised clinically or pathologically as any other disease; some leukoplakias will transform into oral cancer”
What is homogenous lesion?
this is a predominantly white lesion which is uniformly flat and thin.
Some cracking may be evident
Surface may appear crinkled or corrugated but must be of a similar texture throughout
What is a non-homogenous lesion?
- predominantly white or white and red lesion (leukoerythroplakia) which may be flat, nodular or exophytic
- includes the clinincal lesion of speckled leukoplakia
Many oral cancers manifest as red patches which are asymptomatic and are found at high risk sites. True or false
True
Early oral cancer can be sometimes be used to describe…
a minimally invasive squamous cell carcinoma of the oral cavity
How does early oral cancer most commonly present?
- erythroplakia with or without patches of keratosis
Where are the commons site of early oral cancer ?
- floor of mouth
- soft palate complex
- lateral border of the tongue
Briefly compare/contrast early oral cancer lesions with more advanced lesion with regards to appearance
- EOC lesions do not tend to be ulcerated or indurated (hardened) in comparison to more advanced lesions
Hairly leukoplakia is associated almost exclusively with ________ individuals. What is usually demonstrated within the epithelial cells?
Immunocompromised individuals
Epstein Barr birus usually demonstrated within the epithelial cells
In smokers keratosis/nicotinic stomatitis, what are the red interspersed areas ?
they are minor salivary glands which have become inflammed
The continuation of the causative smoking habit that led to nicotinic stomatitis can lead to malignant transformation in the future. True or false.
Following your answer, is nicotinic stomatitis a precancerous lesion or a precancerous condition ?
true
precancerous condition
What is the cause of reverse smokers palate? What kind of lesion is produced?
results from smoking the lit end of the hand-rolled cigarette within the mouth
A premalignant lesion is produced
The signs of oral submucous fibrosis are a response to the use of …
Betel Quid
Development of oral submucous fibrosis is also due to genetic input. True or false
True
Describe the characteristic histological appearance of oral submucous fibrosis
- dense bands of fibrous tissue which replace elastic tissue in the submucosal tissues and render the mucosa rigid (due to substances that are released from the areca nut - betel quid?)
What is the characteristic appearance of the mucosa in oral submucous fibrosis ? What is the cause of this appearance
- petechiae
- melanosis
- vesicles
caused by prolonged contact with the tobacco which is often mixed with areca nut in the quid
What are the consequences of oral submucosa fibrosis in serious cases?
- severe trismus
- unable to move tongue
Cessation of the betel quid chewing habit is associated with regression of the condition. True or false
false
As such regular follow- up is necessary
State some treatment options for oral submucous fibrosis
- intralesion corticosteroids
- surgery
- both corticosteroid and surgery to release tight banding
- surgery may lead to further fibrous scarring
What is the cause of actinic keratosis ?
it is the result of a cumulative effect of ultraviolet radiation on exposed areas of skin and oral mucosa
(sun damage)
What are the clinical features of oral actinic keratosis ?
- irregular scaly plaques on an erythematous background
- keratin horn is occasionally felt on palpation
Actinic keratosis is a ____________ lesion
premalignant
What are the preferred methods of treatment for actinic keratosis ?
surgical excision
cryosurgery
What other condition is analogous to actinic keratosis ?
actinic chelitis
What is the best way to prevent actinic keratosis?
application of sunscreen to the lips
Give examples of genetically determined mucosal lesions
- white sponge naevus
- pachynochia congenita
- Xeroderma pigmentosum
- Dyskeratosis congenita
White sponge naevus may not present clinically until adulthood. True or false
true
What is pachyonychia congenita ?
- autosomal dominant benign condition
- characterised by oral keratosis and palmar- plantar keratosis
- no tendency for malignant transformation
How is xeroderma pigmentosum manifested?
- numerous cutaneous and oral malignancies in middle age
What is thought to be the pattern of inheritance of dyskeratosis congenita?
thought to be X linked due to the preponderance of males affected
How does dyskeratosis congenita present?
- tongue and buccal mucosa develop bullae which become erosions and finally leukoplakic lesion
What is the frequency/ incidence of dyskeratosis congenita lesions that undergo malignant transformation?
approximately one-third undergo malignant transformation
What conditions are often associated with dyskeratosis congenita?
- aplastic anaemia
- severe periodontal disease
What areas of the oral mucosa are affected by lichen planus?
- buccal mucosa
- tongue
- less often the gingivae
What form of lichen planus is most often associated with malignant transformation?
the more atrophic (wasting away) forms
Erosive lichen planus
Why is it important for lesions to be palpated ?
- detection of induration (hardness)
- detection of adherence (does it rub off or not?)
During a routine examination, what adjuncts/techniques can you make use of to examine the mucosa?
- drying the saliva as it may be disguised by it
- mucosal stains
Give some examples of mucosal stains
- OraScan
- Germiphene
- Canada
State an advantage and disadvantage of using mucosal stains. What is the consequence of this?
Advantage:
* high sensitivity for carcinoma
* relative sensitivity for dysplasia
Disadvantage
* low specificity in general hence ability to detect lesions that are not malignant is low but can detect lesions that are premalignant/malignant
Thus, the only feasible use is in the surveillance of high risk subjects
What should a histopathological report include following a biopsy of a lesion?
- estimation of the level of dysplasia within the lesion
- exclude the possibility that invasion has already occured
What is dysplasia?
it is a disorded maturation of mucosa in response to physical, chemical and microbiological irritants
When can dysplastic epithelium become neoplastic?
If the causative stimulus is not promptly discontinued
What is the importance/significance of determining the level of dysplasia?
It is important for the clinician with regard to appropriate management of the lesion
What sites in the oral mucosa are thought to be of greater risk of malignancy if a lesion were present?
- floor of mouth
- tongue - ventral and posterior surfaces
- retromolar areas
What investigations can be carried out with a blood testafter discovering a lesion ?
- full blood count
- vitamin B12 assay
- folic acid assay
- random glucose sample
What is the benefit of clinical photography of oral lesions?
excellent method of recording changes in the lesions
What treatment options can be considered for treatment of lesions?
- biopsy of erythematous regions
- excisional biopsy
- laser treatment
- regular observation with serial biopsy (may be best for larger lesions)
- vitamin A analogues- retinoids
What preventive advice should be give with regards to development of oral lesions/cancers?
- smoking and alcohol cessation
- their rolse in the aetiology of cancer is well documented and their synergistic effetcs are well recognised
Most cases of oral cancer are de novo. How do other oral cancer lesions present ?
some cancer lesions can mimic precancerous lesions
