Chapter 10: Epithelial Pathology PART 3 Flashcards
1
Q
___ is a chronic, progressive, scarring, high-risk precancerous condition of the oral mucosa
A
oral submucous fibrosis
2
Q
oral submucous fibrosis is linked to chronic placement of ___ or ___
A
betel quid or paan
- quid - areca nut from a palm tree
- slaked lime
- betel leaf
- +/- tobacco
- +/- sweeteners
3
Q
betel quid is seen primarily in the ___ subcontinent, but ___ million people worldwide use it regularly
A
- india
- 600
4
Q
___ releases alkaloids from the areca nut, which results in ___
A
- slaked lime
- euphoria
5
Q
how often do betel quid users typically use it?
A
16-24 hours/day
6
Q
betel quid ingredients can be purchased in the US. they have a higher concentration of ___ and cause ___
A
- areca nut
- lesions more rapidly than conventional
7
Q
oral submucous fibrosis is characterized by ___
A
mucosal rigidity
8
Q
T or F:
a few patients developed oral submucous fibrosis after only a few contacts with areca nut
A
true
9
Q
what is the first chief complaint of patients with oral submucous fibrosis?
A
trismus and mucosal pain from eating spicy foods
10
Q
what sites are most commonly affected by oral submucous fibrosis?
A
buccal mucosa, retromolar areas, soft palate
11
Q
the surface of oral submucous fibrosis lesions is typically what color?
A
white
12
Q
___% of oral submucous fibrosis lesions show frank malignancy
A
5%
13
Q
do oral submucous fibrosis lesions regress with habit cessation?
A
no
14
Q
___ is mandatory in the management of oral submucous fibrosis lesions
A
frequent follow-up
15
Q
___% of oral submucous fibrosis lesions undergo malignant transformation
A
10%
16
Q
A
oral submucous fibrosis
17
Q
nicotine stomatitis produces a ___ change on the palate
A
white keratotic
(can be diffusely gray or white)
18
Q
nicotine stomatitis is due to ___
A
heat (long-term hot beverage use can cause the same clinical changes)
19
Q
is nicotine stomatitis premalignant?
A
no
20
Q
what is reverse smoking?
A
the lit end is held in the mouth
21
Q
describe nicotine stomatitis that results from reverse smoking
A
significant potential for malignant transformation, requires a biopsy
22
Q
nicotine stomatitis is most commonly found in males or females? of what age?
A
white males older than age 45
23
Q
how does nicotine stomatitis present clinically?
A
- numerous, slightly elevated papules
- typically have punctuate red centers
- may appear like dried mud
24
Q
the punctuate red centers in nicotine stomatitis lesions represent what?
A
inflamed minor salivary glands and their ductal orifices
25
is nicotine stomatitis reversible?
yes - palate returns to normal within 2 weeks of habit cessation
26
nicotine stomatitis
27
nicotine stomatitis
28
actinic keratosis is a common ___ lesion
cutaneous premalignant
29
what is actinic keratosis caused by?
cumulative UV radiation
30
actinic keratosis develops in over half of white adults with significant lifetime ___ exposure, and is seldom found in patients younger than age \_\_\_
* sun
* 40
31
actinic keratosis lesions are \_\_\_, ___ plaques that vary in color from ___ to ___ to \_\_\_
* scaly, irregular
* white, gray, brown
32
actinic keratosis lesions have a ___ texture
sandpaper
33
what happens if keratotic scales from actinic keratosis are peeled off?
the lesion will recur
34
is dysplasia present on biopsy of actinic keratosis?
yes, by definition
35
actinic keratosis should be destroyed or excised due to \_\_\_
its precancerous nature
36
approximately \_\_\_% of actinic keratosis will progress to squamous cell carcinoma in ___ years
* 10%
* 2 years
37
actinic keratosis
38
\_\_\_ is a common premalignant alteration of the lower lip vermillion that results from long-term exposure to \_\_\_
* actinic cheilosis
* UV light
39
\_\_\_ is associated with actinic cheilosis
outdoor occupation
* farmer's lip
* sailor's lip
40
actinic cheilosis is similar to actinic keratosis in ___ and \_\_\_
pathophysiologic and biologic behavior
41
actinic cheilosis is rare in persons under what age?
45
42
what is the male:female prevalence of actinic cheilosis?
M:F is 10:1
43
actinic cheilosis is slowly developing, and the patient is usually not aware of the lesion. what are the earliest clinical changes in actinic cheilosis?
* atrophy of the lower lip vermillion border, characterized by a smooth surface and blotchy pale areas
* blurring of the margin between the vermillion zone and cutaneous portion of the lip
44
after the earliest clinical changes seen in actinic cheilosis, as the lesion progresses, scaly areas develop on the \_\_\_. further progression leads to \_\_\_, which suggests \_\_\_
* drier portions of the vermillion
* ulceration
* transformation into squamous cell carcinoma
45
are changes seen in actinic cheilosis reversible? what should patients be instructed to do to prevent further damage?
* no
* patients should use lip balms
46
actinic cheilosis lesions that exhibit which characteristics should be submitted for biopsy? \_\_\_% of patients with these characteristics will develop squamous cell carcinoma
* induration (firm to touch), thickening (leukoplakia), and/or ulceration
* 10%
47
actinic cheilosis
48
actinic cheilosis
49
keratoacanthoma is also known as \_\_\_
squamous cell carcinoma, keratoacanthoma type
50
keratoacanthoma is a \_\_\_, ___ proliferation
self-limiting, epithelial
51
keratoacanthoma has a strong clinical and histopathological similarity to well-differentiated \_\_\_
SCCA
52
patients with ___ have a hereditary predisposition for multiple keratoacanthoma lesions
muir-torre syndrome
53
keratoacanthoma has a predilection for males or females? over what age?
males over the age of 45
54
10% of keratoacanthoma cases occur where?
on the outer edge of the vermillion border of the lips
55
how does keratoacanthoma present clinically?
a firm, well-demarcated, painless, sessile, dome-shaped nodule with a central plug of keratin
56
what are the 3 phases of keratoacanthoma?
* growth - rapidly grows up to 2cm in 6weeks; distinguishes from SCCA
* stationary
* involution - within 1 year of onset
57
surgical excision of ___ lesions is recommended, despite the propensity to involute
keratoacanthoma
58
keratoacanthoma
59
keratoacanthoma
60
keratoacanthoma
61
keratoacanthoma
62
1 in ___ americans develop a malignancy. of those, how many survive?
* 3
* 2/3
63
cancer accounts for \_\_\_% of all deaths in the US; oral cancer accounts for \_\_\_%; \_\_\_% of these are SCCA
* 20%
* 3%
* 95%
64
the cause of SCCA is \_\_\_
multifactoral
there are many contributing factors
65
what are the possible contributors to the development of SCCA?
* tobacco
* betel quid
* alcohol
* phenolic agents
* radiation
* iron deficiency
* vitamin-A deficiency
* syphilis
* oncogenic viruses
* immunosuppression
* oncogenes
* tumor suppressor genes
66
\_\_\_% of US adults smoke, and \_\_\_% of patients with oral SCCA have a history of smoking
* 20%
* 80%
67
\_\_\_ and ___ smoking carries a greater oral cancer risk than ___ smoking
* pipe and cigar
* cigarette
68
the smoker's risk for oral SCCA compared with that of a nonsmoker is dependent on what?
* dose
* 2 ppd = 5x increase risk
* 4 ppd = 17x increase risk
* risk increases the longer the person smokes
69
\_\_\_ results in the greatest risk of SCCA development from tobacco
reverse smoking
70
can alcohol alone initiate carcinogenesis?
it is uncertain, but in combination with tobacco, it is a significant risk factor for SCCA
71
what is the indirect evidence provided that suggests alcohol in combination with tobacco is a significant risk factor for SCCA?
1/3 of men with oral SCCA are heavy drinkers compared to 10% of the general population (nutritional deficiencies may contribute)
72
which population is at increased risk for SCCA caused by phenolic agents?
workers in the wood industry who are chronically exposed to phenoxyacetic acids
73
describe SCCA development risks relative to radiation
* effects of UV radiation are well known
* x-irradiation (for cancer treatment) also increases the risk
74
\_\_\_ is required for normal function of the epithelial cells in the upper digestive tract, and can produce esophageal webs, resulting in an increased risk for SCCA development
iron
75
patients with severe, chronic forms of what syndrome, characterized by difficulty swallowing and iron deficiency, are at increased risk for SCCA?
plummer vinson syndrome
76
patients that are iron deficient tend to have impaired \_\_\_
cell-mediated immunity
77
describe the relationship between vitamin A deficiency and SCCA
* deficiency produces excessive keratinization
* researchers believe normal levels are protective
78
which stage of syphilis can cause SCCA, and on what location in the mouth? what is it possibly due to?
* tertiary stage
* dorsal tongue SCCA
* may be due to old treatment with aresenical agents and heavy metals
79
which oncogenic viruses can cause SCCA?
HPV 16, 18, 31, 33
80
describe the relationship between immunosuppression and the development of SCCA
* immune reaction to malignant cells is diminished
* patients at risk include AIDS patients and patients undergoing immunosuppressive therapy for other malignancy or organ transplantation
81
\_\_\_ are chromosomal components capable of being acted on by a variety of causative agents
oncogenes
normal genes are proto-oncogenes
82
proto-oncogenes can be transformed into activated oncogenes via what 3 things?
viruses, irradiation, or chemical carcinogens
83
once oncogenes are activated, they may stimulate the production of an excessive amount of \_\_\_
new genetic material
84
\_\_\_ allow tumor production when they become inactivated or mutated
tumor suppressor genes
85
SCCA may have what 5 possible characteristics?
* exophytic (mass forming, fungating)
* endophytic (invasive, burrowing, ulcerated)
* leukoplakic
* erythroplakic
* erythroleukoplakic
86
what is the most common site of intraoral SCCA? what is the second most common site? third? fourth?
* most common site is the posterior lateral or ventral tongue
* second most common site is the floor of the mouth
* third most common site is the soft palate
* fourth most common site is the gingiva
87
the majority of lingual SCCAs are \_\_\_, ___ masses or ulcers on the ___ border of the tongue
* painless, indurated
* posterior lateral
88
floor of mouth SCCA lesions are most likely to be associated with prior ___ or \_\_\_
leukoplakia or erythroplakia
89
floor of mouth SCCA lesions are typically located where?
midline, near the frenum
90
\_\_\_ and ___ intraoral SCCAs are usually painless
gingival and alveolar
91
gingival and alveolar SCCAs have a propensity to mimic ___ or \_\_\_
benign lesions or periodontal disease
92
of all intraoral SCCA lesions, gingival and alveolar carcinomas are least associated with ___ use and is more common in males or females?
* tobacco
* females
93
oropharyngeal SCCAs develop where?
on the soft palate or tonsillar area
94
oropharyngeal SCCAs have the same appearance as SCCAs located more anteriorly, except \_\_\_. therefore when it is doscovered, ___ is more likely
* the patient is usually unaware of its presence
* metastasis
95
80% of oropharyngeal wall SCCA lesions have ___ or ___ at the time of diagnosis
metastasized or extensively involved surrounding structures
96
metastatic spread of SCCA is largely via \_\_\_, and tends to spread to \_\_\_
* lymphatics
* ipsilateral lymph nodes
97
in cases of SCCA metastasis, how will cervical lymph nodes present?
* firm to stony hard
* painless
* enlarged
* fixed - if the cells have perforated the capsule of the node and invaded into surrounding tissues
98
distant metastasis of SCCA is below the \_\_\_, and most commonly found where?
* below the clavicles
* most commonly found in the lungs, liver, and bones
99
what is the best indicator of patient prognosis in cases of SCCA?
stages
100
SCCA staging is determined by ___ and \_\_\_
tumor size and extent of metastatic spread (TNM system)
101
what is the TNM system for staging?
* T = size of primary local tumor in sontimeters
* N = involvement of local lymph nodes
* M = distant metastasis
102
what does it mean if any TNM is followed by an X? what about if it is followed by a 0?
* X = no available information
* ex. Nx = nodes could not be or were not assessed
* 0 = no evidence of primary tumor
* ex. M0 = no evidence of distant metastasis
103
in the TNM system, T indicates \_\_\_. what do the following indicate?
Tis
T1
T2
3
T4a
T4b
primary tumor size
* Tis = carcinoma in situ
* T1 = tumor is 2cm or less
* T2 = tumor is 2-4cm
* T3 = tumor is more than 4cm
* T4a = tumor is resectable and doesn't involve major anatomy
* T4b = unresectable tumor; involves major anatomy
104
in the TNM system, N indicates \_\_\_. what do the following indicate?
N1, N2, N3
regional node involvement
* N1 = single ipsilateral node, 3cm or less
* N2 = ipsilateral or contralateral node or nodes; 6cm or less
* N3 = any metastasis in a node more than 6cm
105
in the TNM system, M indicates \_\_\_. what do the following indicate?
M0, M1
involvement by distant metastases
* M0 = not present
* M1 = present
106
what are the TNM classifications that accompany stage I?
T1, N0, M0
107
what are the TNM classifications that accompany stage II?
T2, N0, M0
108
what are the TNM classifications that accompany stage III?
T3, N0, M0 or any T, N1, M0
109
what are the TNM classifications that accompany stage IV?
any M, any T4, any N3
110
what allows for tumor grading?
histologic features
111
tumors that most closely resemble their parent tissue seem to grow at a lower rate. which grade does this describe?
* grade I
* low-grade
* well-differentiated
112
tumors that less resemble their parent tissue are which grade?
* grade II
* intermediate-grade
* moderately-differentiated
113
tumors that show little resemblance to their parent tissue tend to enlarge rapidly and metastasize early. which grade is this?
* grade III (or IV, depending on scale)
* high-grade
* poorly-defferentiated
114
\_\_\_ staging is a better prognostic indicator than histologic grading
clinical
115
lip carcinoma is typicaly treated with ___ with excellent results. what percent recurs? what is the 5-year survival?
* wedge resection
* 10%
* reaches 100% on the lower lip
116
\_\_\_ guides treatment for intraoral carcinoma
clinical stage
117
what is the treatment for SCCAs?
* wide surgical excision and/or radiation therapy
* chemotherapy is sometimes administered
* does not improve survival time
118
patients with intraoral tumors larger than 3mm depth of invasion receive \_\_\_
radical neck dissection
119
patients with one carcinoma of the mouth or throat are at an increased risk for \_\_\_
additional SCC
* concurrently (synchronous)
* different time (metachronous)
120
\_\_\_ is the tendency toward development of multiple mucosal cancers
field cancerization
121
verrucous carcinoma is also called \_\_\_
snuff dipper's cancer
122
\_\_\_ is a low-grade variant of oral SCC that can be caused by smokeless tobacco
verruccous carcinoma
123
verruccous carcinoma is found predominantly in men or women? over what age?
men older than 55
124
what are the most common sites of involvement of verruccous carcinoma?
mandibular vestibule and gingiva
125
verruccous carcinoma is typically ___ by the time of diagnosis and is present for ___ years before diagnosis
* extensive
* 2
126
verruccous carcinoma appears as \_\_\_
a diffuse, well-demarcated, painless, thick plaque with papillary or verruciform surface projections
127
verruccous carcinoma has a ___ microscopic appearance
deceptively benign
128
why is adequate sampling of a verrucous carcinoma biopsy is important?
because up to 20% have a SCCA developing within the verrucous carcinoma
129
what is the treatment of verrucous carcinoma? what percent of patients survive disease-free?
* surgical excision without neck dissection
* 90%
130
what is the malignant transformation potential, from most to least, of the following pathologies?
oral submucous fibrosis, erythroleukoplakia, proliferative verrucous leukoplakia, erythroplakia, actinic cheilosis, granular leukoplakia, nicotine stomatitis in reverse smokers
1. proliferative verrucous leukoplakia
2. nicotine stomatitis in reverse smokers
3. erythroplakia
4. oral submucous fibrosis
5. erythroleukoplakia
6. granular leukoplakia
7. actinic cheilosis
131
nicotine stomatitis in reverse smokers
132
verrucous carcinoma
133
verrucous carcinoma
134
actinic keratosis
135
actinic keratosis
136
\_\_\_ refers to a group of malignancies that arise from the lining epithelium of the nasopharynx
nasopharyngeal carcinoma
137
nasopharyngeal carcinoma is most prevalent in what population?
chinese men
138
what are the possible contributory factors of nasopharyngeal carcinoma?
* EBV infection (strongly associated)
* vitamin C deficiency
* consumption of salt fish with N-nitrosamines
* +/- tobacco
139
what age patient does nasopharyngeal carcinoma occur most commonly in?
all ages, but most commonly age 50
140
what is the M:F prevalence of nasopharyngeal carcinoma?
3:1 M:F
141
the primary lesion of nasopharyngeal carcinoma is usually found where?
on the lateral nasopharyngeal wall
142
what is the first sign of disease in nasopharyngeal carcinoma cases?
in half of patients, it is cervical lymph node metastasis
143
what is the treatment for nasopharyngeal carcinoma?
* radiotherapy
* +/- chemotherapy
144
what is the prognosis of nasopharyngeal carcinoma?
* ranges from good to poor depending on the stage of disease
* stage I = 100% 5-yr
* stage IV = 35% 5-yr
* patients with 2+ clinical symptoms have a worse prognosis
145
nasopharyngeal carcinoma
146
what is the most common of all cancers?
basal cell carcinoma
147
\_\_\_ is a locally invasive and slowly spreading epithelial malignancy
basal cell carcinoma
148
80% of basal cell carcinomas are found where?
in the head and neck regions
149
basal cell carcinoma results from what?
UV radiation
* frequent sunburns and freckling in childhood increase risk
* occupational sun exposure and sunburns as an adult are not significant risk factors
150
what is the most common form of basal cell carcinoma?
nodular (noduloulcerative)
151
nodular (noduloulcerative) basal cell carcinoma begins as a \_\_\_, and slowly enlarges, gradually developing into a \_\_\_. one or more ___ are typically seen, and ___ borders are usually present
* firm, painless papule
* central depression and unbilicated appearance
* telangiectatic blood vessels
* rolled
152
is metastasis common in basal cell carcinoma?
no, it is extremely rare
153
what are the 4 other clinicopathologic varieties of basal cell carcinoma?
* pigmented - same as nodular, but clinically brown or black
* sclerosing (morpheaform) - mimics scar tissue; deeply invasive before discovery
* superficial - skin of trunk; appear as multiple scaly red patches that somewhat resemble psoriasis
* those associated with nevoid basal cell carcinoma
154
treatment of basal cell carcinoma depends on what? what is the treatment?
* depends on size and location of the lesion
* Mohs micrographic surgery - essentially uses frozen-sections to evaluate margins during surgery
155
treatment of basal cell carcinoma have a \_\_\_% cure rate
98%
156
is recurrence of basal cell carcinoma common after treatment? is metastasis common?
* recurrence is uncommon with properly treated disease
* metastasis is exceptionally rare
157
describe death associated with basal cell carcinoma
death is usually the result of local invasion into vital structures, though it is unusual to have such uncontrollable disease
158
nodular basal cell carcinoma
notice the telangiectatic blood vessels and the central depression
159
nodular basal cell carcinoma
notice the telangiectasia and central depression
160
basal cell carcinoma
161
\_\_\_ is a malignant neoplasm of melanocytic origin
melanoma
162
melanoma arises from a ___ or \_\_\_
* benign melanocytic lesion
* de novo from melanocytes within otherwise normal skin or mucosa
163
most melanoma lesions develop where?
on the skin, but can develop anywhere melanocytes are present
164
what is a major causative factor of melanoma?
* damage from UV radiation
* **chronic sun exposure is not a significant factor; acute sun exposure is**
165
the risk of melanoma increases 2-8x with what?
a family history of disease
166
other than family history and acute UV radiation, what are additional risk factors of melanoma?
* fair complexion
* light hair
* tendency to sunburn easily
* history of painful/blistering sunburns in childhood
* personal history of melanoma
* personal history of dysplastic or congenital nevus
167
melanoma is the ___ most common skin cancer, but accounts for the most \_\_\_
* 3rd (1/60 will be diagnosed)
* deaths
168
\_\_\_% of melanomas arise on the skin, \_\_\_% of which are in the head and neck region
* 90%
* 25%
169
50% of ___ melanomas occur in the head and neck region
mucosal
* oral cavity
* sinuses
170
1/3 people with oral melanoma have a history of \_\_\_
a pigmented macule in the region
171
mucosal melanoma presents at a ___ state and is more \_\_\_
* advanced
* aggressive
this is why oral melanoma is really bad
172
melanoma exhibits two directional patterns of growth. describe them
1. radical - malignant melanocytes spread horizontally through the basal layer (flat lesion)
2. vertical - malignant cells invade underlying connective tissue (tumor)
173
\_\_\_ is melanoma's benign counterpart
melanocytic nevus
174
what is the ABCDE system used to distinguish between melanoma and melanocytic nevus that has been developed to describe the clinical features of melanoma?
* **A**symmetry
* **B**order irregularity
* **C**olor variation
* **D**iameter greater than 6mm
* **E**volving lesions
175
what is the treatment of choice for melanoma?
* surgical excision with a 3-5cm margin
* 1cm margins are now being used for cutaneous tumors less than 2mm in thickness
176
melanomas are traditionally considered \_\_\_
radioresistant
177
\_\_\_ has promise in the treatment of melanoma
newer chemo therapy
178
what are the locations of melanoma associated with a worse prognosis?
BANS
* intrascapular area of the **B**ack
* posterior upper **A**rm
* posterior and lateral **N**eck
* **S**calp
179
what is the prognosis for oral melanoma?
extremely poor
* 5-year survival is 15-20% due to inability for wide resection and a tendency for early hematogenous metastasis
180
nasopharyngeal carcinoma
181
which patients have a better survival from melanoma?
younger patients
182
patients with ___ melanoma have a very poor prognosis
amelanotic
183
patients with melanoma usually die from ___ rather than lack of local control
distant metastasis
184
melanoma
185
oral melanoma
186
oral melanoma
187
oral melanoma
188
\_\_\_ correlates with prognosis of melanoma
depth of invasian - clark's classification
189
\_\_\_ is an adverse prognostic indicator for cutaneous melanomas
ulceration
190
ulceration has not been proven to be a prognostic indicator in ___ melanomas
mucosal
191
any invasion more than \_\_\_mm in oral mucosal melanoma has a poor prognosis
0.5mm
