Premalignant conditions Flashcards
What is a pre-malignant lesion?
Morphologically altered tissue in which cancer is more likely to occur than in its apparently normal counterpart
What is leukoplakia?
Predominantly white lesion of the oral mucosa that cannot be characterised as any other definable lesion (disease) & which is not associated with any physical or chemical causative agent except tobacco
What is erythroplakia?
Bright red velvety plaque which cannot be characterised as any other definable lesion (disease)
Normal anatomy causes of white patches?
o Fordyce spots
o Leucoedema
Developmental causes of white patches
o White sponge naevus
Traumatic causes of white patches?
o Frictional keratosis
o Cheek biting, trauma from dentures, cusps, fillings, orthodontic appliances
Chemical causes of white patches?
o Aspirin burns
o Smoker’s keratosis (on palate)
Autoimmune causes of white patches?
o Lichen planus
o Lupus erythematosus
Infective causes of white patches?
o Chronic hyperplastic candidosis
o Oral hairy leukoplakia
What is oral hairy leukoplakia associated with?
- Associated with EBV
- If associated with AIDS, resolves with HAART
Clinical features of OHL?
- Painless
- May mimic other oral mucosal diseases
- Not premalignant
Clinical features & prevalence of Fordyce spots?
- Common, benign
- AKA Fordyce granules
- Sebaceous glands
- Creamy-yellow papules may coalesce
- Buccal/labial mucosa
- Appear in childhood
- Increase at late puberty & adult life
Management of Fordyce spots?
- Reassurance
What is leucoedema?
- Variation of normal
- Bilateral, diffuse, translucent, greyish appearance to oral mucosa
- Typically present in black people may also occur in white
- Disappears on spreading affected mucosa
What are the 2 types of appearance of leukoplakia?
Homogenous
Non-homogenous
What is the appearance of homogenous leukoplakia?
Uniform, flat appearance that may exhibit shallow cracks & has a smooth, wrinkled or corrugated surface with a consistent texture throughout
What is the appearance of non-homogenous leukoplakia?
o Predominantly white or white & red lesion (erythroleukoplakia)
o Irregularly flat, nodular & exophytic:
- Nodular lesions have raised, rounded, red and/or white excrescences (protrusion)
- Exophytic (outward growth) lesions have irregular blunt or sharp projections
Epidemiology of leukoplakia?
- Most diagnosed in middle age, increase with age
- 10% of oral leukoplakias idiopathic
- 90% associated with use of tobacco/areca nut
- M>F (maybe due to greater prevalence of tobacco use by males)
- Buccal mucosa affected in 25% cases, mandibular gingiva in 20%, tongue in 10% & floor of mouth in 10%
What surface features of leukoplakia is suggestive of an increased risk of malignant transformation?
Raised/nodular
Gender & age with increased risk of malignant transformation?
Advanced age
Females
What features of the colour of leukoplakia is suggestive of an increased risk of malignant transformation?
Red/white (speckled)
Which sites of leukoplakia are suggestive of malignant transformation?
o Floor of mouth
o Lateral border of tongue
o Retromolar region
o Buccal sulcus (paan chewers)
o Labial commissure
What is the rate of malignant change of leukoplakia & erythroplakia?
- Leukoplakia – overall 1-5% (UK 4%)
Homogenous 0%
Non-homogenous 26% - Erythroplakia – overall 80%
What is the risk of erythroplakia?
- High risk lesion & ALWAYS associated with dysplasia or carcinoma
Which premalignant conditions is erythroplakia associated with?
Syphilis
Sideropenic dysphagia (Patterson Kelly or Plummer Vinson Syndrome)
Oral submucous fibrosis
Actinic keratosis (cheilitis)
Lichen planus
Chronic hyperplastic candidosis
Presentation of syphilis orally?
Leukoplakias on central dorsum of tongue
Glossitis with mucosal atrophy
Clinical features of Sideropenic dysphagia (Patterson Kelly or Plummer Vinson Syndrome)
Fe deficiency anaemia
Generalised mucosal atrophy
Oesophageal web
Middle aged women
Where do we see oral submucous fibrosis? And what is the risk of OSCC?
Fibrosis of oral mucosa & difficulty opening mouth
Paan, betel chewers
30% may develop OSCC
What is actinic keratosis (cheilitis)?
Sunlight induced changes on the lip
Increased risk of carcinoma
Risk of OSCC developing in long-standing OLP?
0.5-2% rate over 5-year period
When would OLP need further specialist opinion & possible biopsy?
- Isolated areas of increasing whiteness, speckling (areas of redness & whiteness)/ solitary ulceration unlikely to reflect local trauma
What must all pts with OLP be advised of?
Controversial malignant potential
To avoid tobacco & alcohol
Have diet rich in vitamins A, C & E/antioxidants
Maintain good OH with regular dental care
What is chronic hyperplastic candidosis related to?
- Uncommon
- Associated with tobacco use
- Occasionally related to immunodeficient states
- Resistant to anti-fungal therapy
What does histology tell us in regard to malignancy of lesion?
More reliable indication than clinical exam
But dependent on site of lesion biopsied
Definition of keratosis?
Keratinisation in an epithelium that is not normally keratinised
What is hyperkeratosis?
Increased thickness of the keratinised layer
What is orthokeratosis?
Flat, anucleate superficial cells with homogenous eosinophilic cytoplasm
What is parakeratosis?
Flat, homogenous eosinophilic superficial cells BUT with pyknotic nuclei
What is acanthosis?
o Increased number of cells in prickle layer
o Broadening of rete ridges
o Thicker epithelium
What is atrophy?
o Decreased epithelial thickness
o Loss of rete ridges
o Epithelium may be roughly equal thickness throughout
What is atypia?
Changes to individual cell
What is dysplasia?
Changes in whole epithelium
Histological features of oral dysplasia
- Nuclear hyperchromatism (increased DNA content)
- Nuclear & cellular pleomorphism (variation in size & shape)
- Increased nuclear to cytoplasmic ratio
- Increased number & bizarre mitoses
- Mitosis in prickle cell layer
- Premature keratinisation in the prickle cell layer
- Loss of polarity of basal cells
- Loss of epithelial stratification
- Drop shaped rete ridges
- Loss of cell adherence
Grading of dysplasia
- None - epithelial cells appear normal
- Mild - few epithelial cells in the basal layers show atypia
- Moderate - Most cells in the basal layers & some suprabasally show atypia
- Severe - Almost all cells show atypia but there is no evidence of invasion into the underlying tissues; ‘carcinoma in situ’
What makes leukoplakias appear white clinically?
Hyperkeratosis or parakeratosis
Why are erythroplakias red?
Atrophy
Histological features of leukoplakia?
- Hyperkeratosis or parakeratosis
- Variable hyperplasia & acanthosis (increased thickness of prickle cell layer)
- Atrophy
- Candidal hyphae – up to 30% of leukoplakias
- Inflammation
- Some leukoplakias may show one or more features of dysplasia
Histological features of erythroplakia?
- Atrophy
- Dysplasia
- Inflammation
Risk of malignant change in epithelial dysplasia?
10-36%
Aetiology of leukoplakia?
Tobacco - chewing tobacco (paan - betel quid), reverse smoking, pipe smoking, smoking (bidi smoking, cigarettes)
Smokeless tobacco & oral epithelial dysplasia (snuff, tobacco chewing)
Candida albicans (30% of leukoplakias may contain candida)
Management of leukoplakia in gdp?
- Determine the level of risk – site, size, colour, surface, habits
- Refer to local oral & maxillofacial department – don’t biopsy yourself!
- If lesion very suspicious, mark the letter as urgent or treat within 2 week rule & phone relevant consultant; fax letter & send through post
What is survival rate of oral cancer?
40%
Hospital setting management of leukoplakias?
- Biopsy lesion to establish the level of risk
- Incisional biopsy for a large lesion, multiple biopsies if necessary
- Always biopsy most suspicious part & include margin of normal tissue
- Multiple biopsies may be required
- Excisional biopsy if the lesion is small
How to manage erythroplakia in gdp/hospital?
Refer urgently from gdp
In hospital, these lesions are always biopsied & excised
Management of mild/moderate dysplasia?
- Keep under review – every 3-6 months
- Advice on tobacco, alcohol cessation
- Nutritional assessment – Fe/B12/folate deficiency
- Biopsy at 3 months to reassess dysplasia
- Further biopsy within 2-3 years
Management of moderate dysplasia?
Surgical excision
- If lesion is small
- If patient if unlikely to modify risk habits
Candidal leukoplakia
- Fluconazole up to 6 weeks treatment
- Smoking cessation advice
- Re-biopsy after 3 months & reassess dysplasia
Management of severe dysplasia?
Surgical excision
- Scalpel, laser or cryotherapy
Photodynamic therapy
- 5 aminolaevulinic acid
- Multiple lesions
- Topical
- Systemic - Patient will need to stay in darkened room
