Lectures 5-6

Question 1

HPV16 is strongly associated with what type of cancer?

Answer 1

Oropharyngeal

Question 2

Which cancers are the oncogenic subtypes?

Answer 2

16,18,21,33

Question 3

What are the 4 sites where H&N cancer is found?

Answer 3

Oral cavity, oropharynx, hypo pharynx, larynx.

Question 4

What triples the odds of development oropharyngeal SCC?

Answer 4

6+ oral sex partners or a high lifetime number of vaginal sex partners (>26) triples the odds of developing oropharygneal SCC.

Question 5

What is the trend of HPV and incidence of oral cancer?

Answer 5

Incidence of HPV related oral SCC increased significantly, HPV unrelated cancers decreased. Virus related cancers diagnosed earlier.

Question 6

What is the greatest risk factor of HPV and oral cancer?

Answer 6

Sexual contact with HPV+ person.

Question 7

Who tends to get HPV+ oropharyngeal cancer?

Answer 7

White, male, non-smoker, non-drinkers.

Question 8

SCC Clinical features

Answer 8

• Exophytic (fumigating, papillary, verruciform)
• Endophytic (invasive, ulcerated, burrowing)
• Leukoplakia
• Erythroplakia

Question 9

SCC Clinical features

Answer 9

SCC Clinical features

• Older males
• Vermillion of lip
• Intraoral sites: tongue PL and V, floor of mouth (more common in men), soft palate, gingiva, buccal mucosa, labial mucosa, hard palate.

Question 10

Lip vermillion SCC affects who? Why? Appearance? Typical location? Growth rate?

Answer 10

Light skinned. Long term or sudden severe exposure to UV. Crusted, oozing, non tender, indurated ulcer, <1cm. 90% located on the lower lip. Slow growth rate; metastasis occurs late.

Question 11

Where does tongue intraoral SCC occur?

Answer 11

Intraoral SCC mostly occurs on the tongue (50% of all intraoral SCC). Usually painless, indurated masses or ulcer in PL tongue. 20% anterior lateral or ventral. Dorsum rare 4%. Young patients.

Question 12

Level of danger of where SCC occurs intraorally?

Answer 12

Tongue —> floor of mouth —> gingiva

Question 13

True or False. Floor of the mouth intraoral SCC Comprises 35% of all intramural SCC. More common in males. Most likely to arise from pre-existing leukoplakia, erythroplakia.

Answer 13

True

Question 14

Intraoral gingival SCC

Answer 14

• Mimic inflammatory/reactive lesions
• May resemble inflammatory fibrous hyperplasia if edentulous
• May resemble periodontal disease or pyogenic granuloma
• Female predilection

Question 15

Verrucous carcinoma

Answer 15

• Malignancy of older individuals
• Unlike SCC: low metastatic potential, exophytic, slow growing
• Etiology: tobacco, linked to HPV 16,18

Question 16

What are the clinical features of verrucous carcinoma and what is the treatment?

Answer 16

Exophytic papillary proliferation. Location: mandibular vestibule, buccal mucosa, and hard palate. Treatment: excision and radiation.

Question 17

Specificity and Sensittivity definitions..

Answer 17

Specificity: false negative and false positive results do not occur
Sensitivity: if cancer is present it will be detected

Question 18

What are the high risk sites for a clinical exam?

Answer 18

VL tongue, lips, floor of the mouth, soft palate

Question 19

What is a disadvantage of the clinical exam?

Answer 19

It does not tell you what the lesion is, only whether further investigation is warranted.

Question 20

Oral Cdx Brush Biopsy Indications:

Answer 20

• assessment of “minimally suspicious” white lesions in low risk sites
• NOT for submucosal, pigmented, suspected inflammatory or ulcerated lesions
• Severely medically compromised pt who may be at risk for a conventional biopsy
• Monitor suspicious areas in pt with previous oral cancer
• Non-compliant pt who may not return for follow-up
• Pt with multiple lesions

Question 21

Oral Cdx Brush Biopsy

Answer 21

• Uses a special barb brush to take sample of disaggregated cells from all layers of epithelium including basal cell layer

Question 22

Which results of Cdx require surgical biopsy?

Answer 22

Atypical (abnormal epithelial cells of uncertain significance) and Positive (unequivocal evidence of dysplasia or carcinoma)

Question 23

What are the brush biopsy disadvantages?

Answer 23

• Does NOT tell you what the lesion is
• NO 2D eval of epithelial architecture
• Trauma, inflammation can produce “reactive epithelial atypia” (not sure dysplasia)
• Cost to the pt
• All “negative” lesions require same careful clinical follow up.

Question 24

Toluidine Blue (Oratest)

Answer 24

• Screening test to assess clinically suspicious lesions and used to help map biopsy sites
• NOT a diagnostic test; will not tell you what “lesion” is
• FDA approved in conjunction with Vizilite

Question 25

Indications for Toluidine Blue:

Answer 25

- Monitoring of suspicious lesions that have baseline histopathological valuation - Screening in high risk individuals - Routine follow-up of pt with history of oral cancer - Determining optimal biopsy site for large, heterogenous lesions

Question 26

What is the mechanism of toluidine blue?

Answer 26

- Selectively binds free anionic groups like phosphate groups of DNA - Actively dividing cells have more free phosphate groups - 1% toluidine stains epithelial surfaces blue - Stain is lost after treatment with 1% acetic acid solution - Premalignant and malignant lesions are not decolorized by acetic acid!!!!! - Blue = bad

Question 27

What are the disadvantages of Toluidine Blue?

Answer 27

Areas of inflammation, irritation, ulceration, and dorsum of tongue —> stain blue Screening low risk populations with no clinically suspicious areas NOT recommended. Retest areas that stain in 14 days to allow transient inflammatory lesions to heal. ONLY for epithelial lesions Negative staining does NOT: r/o presence of a cancerous lesion, preclude need for scalpel Bx if clinical presentation warrants Works well on erythroplakias but NOT leukoplakia. May be better than visual acuity but does not identify true margins of the lesion/field.

Question 28

What is Vizilite?

Answer 28

screening test “whether Bx needed”, “where to do Bx”, Detect lesions not seen under visible light?, not a diagnostic test.

Question 29

Vizilite background:

Answer 29

- Similar to colposcopy (acetowhite test): used in detection of uterine cervical dysplasias and carcinoma - Tells you which areas to Bx - May help better define areas populated by cells with increased amounts of DNA - FDA approved

Question 30

Vizilite Procedure:

Answer 30

- Examination of oral cavity with single use “chemiluminescent” light - Rinse with acetic acid solution for 1 minute (disrupts glycoprotein barrier present on mucosal surfaces) - Turn operators lights off - Activate chemiluminescent light - Examine oral cavity - Epithelium with increased keratinization and/or higher N:C ratio reflects the light!!!! - Lesions appear white “acetowhite”

Question 31

Vizlite Disadvantages

Answer 31

- Efficacy in oral cavity unknown - + readings can be caused by minor epithelial abnormalities e.g. inflammation, irritation, ulceration, linea albea. - - test does not mean that dysplasia or SCC is not present - Cost

Question 32

VELscope: fluorescence visualization in oral cavity

Answer 32

- Takes 1-2 min - Adjunct to clinical exam. Good baseline of understanding of normal is essential - For surgeon to help identify margins (clinically) - No rinses or stains - FDA approved

Question 33

VELscope procedure:

Answer 33

- Conduct thorough oral exam - Repeat oral exam with VELscope handpiece 2 inches from tissue - Normal tissue is green. Abnormal dark. - Re-evaluate suspicious areas under white light - Follow up after two weeks or refer

Question 34

VELscope Results:

Answer 34

Suspicious areas are - Very dark - High risk location - Unilateral presentation - Asymmetry, irregular shape

Question 35

VELScope Disadvantages:

Answer 35

- Inflammation/irritation - appears dark due to blood. Try blanching while viewing - Buccal mucosa, lateral tongue, hard palate, anterior tonsillar pillars, attached gingiva - Hyperkeratosis - Pigmented areas