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Y2 Clinical Pathology > Pathology of the Head & Neck > Flashcards

Pathology of the Head & Neck Flashcards

1
Q

How does the most common aetiology cause the changes described in the stroma?

A

trauma damaging tissue which can feasibly both directly make vessels leak by structural damage or trigger an inflammatory response which leads to increased vascular permeability

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2
Q

What is the significance of a polyp becoming fibrotic?

A

rather than being potentially reversible like oedema and fibrin deposition could be, fibrosis is likely to be permanent

it may only be remedied by a surgical procedure

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3
Q

What is the main factor influencing the severity of a polyp?

A

there are different implications of inflammation and fibrosis depending on the location

it is more life threating in organs such as the heart, liver, kidney or lungs

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4
Q

What are the 3 main lesions of voice abuse?

A
  • vocal cord nodules
  • vocal cord polyp
  • contact ulcer

these are due to overuse or abuse and are more common in people who use their voice a lot (e.g. professional singers)

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5
Q

What are the main differences between vocal cord polyps and nodules?

A

nodules:

  • usually bilateral
  • present on opposing surfaces of the vocal fold, usually on the middle third

polyps:

  • >90% are unilateral
  • usually in Reinke’s space / ventricular space, usually on the anterior half of the vocal cord

they are clinically different, but histologically similar

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6
Q

What is Reinke’s space?

A

the part of the vocal cord that lies beneath the elastic lamina

some mucosa in this area is capable of almost intimate expansion

it is a potential space between the vocal ligament and the overlying mucosa

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7
Q

What is a vocal cord polyp?

Who is more commonly affected?

A

a reactive change of laryngeal mucosa and stroma resulting in benign polypoid or nodular growth

it is caused by vocal abuse and phonation changes

it can occur at any age but is more common in young women

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8
Q

What does a vocal cord polyp look like?

A

it has a smooth surface and affects the anterior half / anterior third of the vocal cord

it has a translucent appearance (can almost see through it)

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9
Q

What are the histological features of nodules & polyps?

A
  • epithelium is usually unremarkable (normal)
  • initially the stroma is edematous, with myxoid matrix
  • later the stroma may demonstrate a spectrum of vascular proliferation, hyaline change, or fibrosis
    • blood vessels and lymphatics become leaky
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10
Q

What is shown here?

A

vocal cord polyp

it is recognised by markedly oedematous stroma underlying a normal epithelium

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11
Q

What is shown here?

A

vocal cord polyp (late stage)

the polyp may progress to form fibrosis and a solid nodule

fibrin is present

this is plasma that has leaked out of damaged vessels and clotted to form the pink masses

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12
Q

What is the most common aetiology of vocal cord nodules and polyps?

A

voice abuse, in particular people who use their voice a lot

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13
Q

How can continuous trauma affect the vocal cords?

A
  • trauma can directly damage structures or damage them enough to trigger an inflammatory response
  • this leads to vessels becoming more leaky (reversible process as oedema becomes reabsorbed again)
  • continuous trauma and inflammation leads to fibrosis
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14
Q

What is the definition of “precursor lesions of laryngeal squamous cell carcinoma”?

What is the problem with identifying these lesions?

A

squamous lesions with an increased risk of progression to squamous carcinoma

some histologically normal squamous mucosa can be a precursor for dysplasia and invasive squamous cell carcinoma

only 10% of precursor lesions progress to carcinoma

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15
Q

Who is more likely to be affected by precursor lesions of laryngeal squamous carcinoma?

Where are they usually found?

A

the supraglottic and glottis region are most affected

  • peaks in 6th decade
  • more common in males than females
  • associated with carcinogen exposure - tobacco and alcohol abuse
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16
Q

What is shown here?

A

low grade dysplasia

abnormal but there is a definite risk of developing invasive carcinoma

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17
Q

What is shown here?

A

high grade dysplasia

malignant appearing epithelium is confined to the epithelium

there is no evidence of breach of the basement membrane and invasion of underlying tissues

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18
Q

What is a squamous cell carcinoma of the larynx?

What % of cancers does it account for?

A

a malignant tumour characterised by squamous differentiation

the supraglottic and glottic regions are most affected

it is 1% of all cancers but 90% of all head and neck cancers

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19
Q

Where is squamous epithelium found?

A

it covers the skin and most of the mucous membranes in the body

it keratinises, flattens off and becomes anucleate and impermeable to water as it becomes more superficial

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20
Q

Who is more likely to get squamous cell carcinoma?

A

males are much more commonly affected than females

it is associated with tobacco and alcohol abuse

these factors work synergistically

(much more likely to get it if you smoke and drink than if you just smoke and don’t drink)

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21
Q

What is the prognosis like for squamous cell carcinoma of the larynx?

A

prognosis is dependent on size, site, stage and differentiation

early lesions that are confined to the vocal cord (T1) have a 90% 5 year survival

there is a less than 50% 5 year survival for a T4 lesion

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22
Q

What is shown here?

A

squamous cell carcinoma

islands of squamous epithelium inflitrating into fibrous connective tissue

it is keratinizing (pink areas are keratin)

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23
Q

How do the 2 most common predisposing factors for laryngeal dysplasia act on the epithelium?

A

alcohol and tobacco smoke act as carcinogens (synergistically) and the mechanisms for carcinogenesis include:

  • activating oncogenes (“foot on the accelerator”)
  • inactivating tumour suppressor genes (foot off the brake)
  • inhibiting apoptosis (“stopping the car from crashing”)
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24
Q

Why is inhibiting apoptosis a mechanism of carcinogenesis?

A

when cells show uncontrolled proliferation they may be confined to the basement membrane (“in situ”)

if they keep on proliferating in an uncontrolled way, there is more chance of acquisition of further mutations to enable further “bad” capabilities

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25
Q

What is the significance of grade in laryngeal epithelial dysplasia?

A

low and high grade make it more reproducible between pathology opinions (rather than having many grades)

low grade progression to invasion is 5-10% and management is to observe

high grade progress in 30-50% and management is treatment through excision or irradiation

26
Q

What capabilities have invasive cells developing compared to those of non-invasive dysplastic cells?

A
  • break down the basement membrane, stroma and other structures
  • break apart from neighbours if adhesion molecules do not work as well
  • move to allow invasion
  • adhere to stroma to enable movement
  • evade host immune response
  • survive in vessels
  • adhere to vessel lining at distant sites
  • survive at distant sites
  • produce own blood supply
27
Q

What are sinonasal polyps and where do they develop?

A

polypoid lesions formed by expansion of the lamina propria of nasal mucosa by fluids, protein and fibrosis

found in the nasal cavity and paranasal sinuses

28
Q

What are the clinical features and aetiology of sinonasal polyps?

A

clinical features:

  • rhinorrhoea (runny nose)
  • nasal stuffiness
  • obstruction
  • chronic headache

aetiology:

  • allergy
  • infection
  • diabetes
  • triad including aspirin sensitivity, asthma & cystic fibrosis
29
Q

What is the prognosis of sinonasal polyps like?

A

they have no malignant potential

prognosis is excellent but they are often recurrent if the aetiological factors are not removed

30
Q

What is shown here and how can it be recognised?

A

sinonasal polyp

underlying the epithelium is very oedematous

the submucosa is full of fluid and eosinophils / mast cells, highlighting the allergic aetiology

31
Q

Who is most commonly affected by sinonasal polyps?

A

they equally affect males and females

most are over 20 and they are rare under 5 years

stromal atypia has no clinical significance and DDx is rhabdomyosarc

32
Q

What is allergic fungal sinusitis?

Who is more commonly affected?

A

an allergic response to fungal allergens

(inhaled fungi sit within the sinuses - predominantly maxillary, but also frontal & sphenoid)

it is more common in warmer climates

it has an equal sex ration, but is more common in third to seventh decade

33
Q

What are the clinical features of allergic fungal sinusitis?

What most commonly causes it?

A

may often find fungal hyphae, most commonly Aspergillus

clinical features:

  • allergic symptoms
  • nasal discharge
  • rinorrhoea (runny nose)
  • may be associated with peripheral eosinophilia and elevated antifungal IgG
34
Q

What is shown here?

A

allergic fungal sinusitis

hypersensitivity to fungal antigens causes headaches & obstruction

lots of eosinophils are present and occasionally fungal hyphae are visible within the mucus

35
Q

What is the treatment for allergic fungal sinusitis?

A

it is mainly treated with surgery (evacuation) but also with inhaled steroids

36
Q

What is shown here?

What is a particularly dominant feature?

A

allergic fungal sinusitis

  • mucin
  • eosinophils
  • Charcot-Leyden crystals

crystals are formed by the degranulation of eosinophils

37
Q

What is shown here?

A

allergic fungal sinusitis

fungal hyphae are stained with a silver stain

cultures:

  • aspergillus
  • curvularia
  • dreshella
  • bipolaris
  • exserohilum
38
Q

What proportion of the adult population develop sinonasal polyps?

A

10%

39
Q

How can sinonasal polyps lead to chronic headaches?

A

they obstruct the sinuses

sinuses are constantly draining mucus out of them and if they are blocked, pressure builds up

40
Q

Which chronic self limiting inflammatory condition is common in the oral cavity?

A

oral lichen planus

41
Q

In what group of patients is the prognosis better in oropharyngeal cancer?

A

those with HPV infection but no smoking and drinking history

the smoking and drinking makes the prognosis much worse

42
Q

What is oral lichen planus?

Who is more likely to be affected?

A

common and chronic self-limited inflammatory mucocutaneous disorder of unknown aetiology

  • 1-2% of world population
  • more common in females
  • peak in middle aged adults
43
Q

What are the clinical features of oral lichen planus?

What is it associated with?

A

reticular variant:

  • white patches consisting of fine white lace-like striae on the buccal mucosa

erosive variant:

  • atrophic oedematous mucosa with ulcerations

it is associated with increased risk of malignant disease

44
Q

What is squamous cell carcinoma of the oral cavity?

Where does it most commonly arise from?

A

malignant neoplasm arising from squamous epithelium lining the oral cavity

most common malignancy of the oral cavity and anterior 2/3 of the tongue

most commonly arises from the lip, tongue, floor of mouth, gingiva, palate and buccal mucosa

45
Q

What is squamous cell carcinoma of the oral cavity often preceeded by?

What is the prognosis like?

A

often preceded by white (leukoplakia) or red (erythroplakia) mucosal patches

prognosis is stage dependent, but advanced stages have poor survival

46
Q

What is squamous cell carcinoma of the oropharynx?

What is it commonly associated with?

A

usually a poorly differentiated squamous cell carcinoma with minimal keratinisation

most common at the tonsil and base of tongue

commonly associated with HPV 16 and 18

47
Q

In what types of patients is the prognosis of squamous cell carcinoma of the oropharynx better?

A

prognosis is better in patients who do not have a carcinogen history (e.g. smoking / drinking) as well as HPV

prognosis is better in HPV-associated cases

48
Q

What are the 4 main benign neoplasms of the salivary gland?

A
  • pleomorphic adenoma
  • basal cell adenoma
  • canalicular adenoma
  • warthin’s tumour
49
Q

What is a pleomorphic adenoma?

A

a benign neoplasm composed of ductal epithelial cells and myoepithelial cells within a mesenchymal stroma

it shows divergent differentiation derived from a common stem cell

it is the most common salivary gland neoplasm

50
Q

What is meant by a major and minor salivary gland?

A

major glands are the parotid, submandibular and sublingual

minor glands are distributed in the palate, oral cavity, tongue and also in the larynx, bronchi and trachea

51
Q

Who is most commonly affected by pleomorphic adenoma?

What does it develop from and what are the clinical features?

A

peak age in fourth to fifth decade

disease in minor salivary glands is rare and 60% are in the parotid gland

it is an asymptomatic slow-growing mass

52
Q

What are the 2 major clinical problems associated with pleomorphic adenoma?

A

if they are not excised completely then they recur

they tend to recur multifocally and they are not curable at this stage

they may undergo malignant transformation at a rate of 1% per year

53
Q

What is meant by carcinoma ex pleomorphic adenoma?

What is the risk of carcinoma developing?

A

carcinoma arising in association with pleomorphic adenoma

risk of carcinoma development is dependent on the length of history of pleomorphic adenoma

non-invasive carcinoma has the same prognosis as pleomorphic adenoma

54
Q

What is the prognosis like for non-invasive and invasive tumours in carcinoma ex pleomorphic adenoma?

A

non-invasive / minimally invasive:

  • non-invasive carcinomas live within the same capsule as the pleomorphic adenoma
  • minimally invasive are less than 1.5mm beyond capsule
  • good prognosis

invasive:

  • greater than 1.5mm beyond the capsule
  • poor prognosis with < 50% alive at 5 years
  • aggressive with systemic metastases to the bone, liver, lung and brain
55
Q

What are the different malignant neoplasms of the salivary gland?

A
  • adenoid cystic carcinoma
  • mucoepidermoid carcinoma
  • acinic cell carcinoma
  • polymorphous low-grade adenocarcinoma
  • carcinoma ex pleomorphic adenoma
56
Q

What is an adenoid cystic carcinoma?

What % of neoplasms does it account for?

A

basaloid tumour consisting of epithelial and myoepithelial cells

(divergent differentiation)

accounts for 10% of salivary gland neoplasms with 75% arising in minor salivary glands

57
Q

Who is most likely to be affected by adenoid cystic carcinoma?

What is significant about the outcome?

A

peak age instance fifth to seventh decade

it is an incurable epithelial neoplasm and most patients die of or with the tumour

metastasis to lung, bone, brain and liver seen in up to 60% of cases

58
Q

In what anatomical location are pleomorphic adenomas most common?

A

usually in the major salivary glands

60% occur in parotid gland and they are rare in minor salivary glands

59
Q

What sort of malignancy can arise in a pleomorphic adenoma?

A

carcinoma ex pleomorphic adenoma

the most important prognostic factor is whether it is confined within the capsule, minimally invading (<1.5mm) or invading beyond this

60
Q

What is notable about the clinical progression of adenoid cystic carcinoma?

A

all patients will either die of it or with it

it is incurable and is one of the more common malignant tumours of the salivary glands

61
Q
A

Y2 Clinical Pathology (76 decks)

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