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Flashcards in Oral cavity and GI tract - DONE Deck (81):
1

Salivary glands general description:

- Capsule
- Tubuloalveolar
- Exocrine function

2

Parotid gland:

predominantly serous

3

Submandibular gland:

mucous

4

Minor salivary glands location:

numerous (hundreds) in lips, in the submucosa of oral cavity

5

Salivary glands % of all tumors:

- Parotid -> 65-80% of all tumors
- Submandibular - > 10% of all tumors
- Minor salivary glands -> remainder

6

Salivary glands % of tumors are malignant:

- Parotid -> 15-30%
- Submandibular - > 40%
- Minor salivary glands -> 50% (70-90% of sublingual)

7

Who usually get Salivary gland tumors?

F > M (Wärthin in males)

8

When does the Salivary gland tumors appear?

- Benign appear in 5th-7th decade
- Malignant later

Parotid: swelling in front and below the ear

9

How are the Salivary gland tumors upon diagnosis?

4-6 cm in diameter, mobile in palpation (exception: neglected malignant)
- Generally malignant grow faster

10

Mixed tumor =

Pleomorphic adenoma

11

Where does most of the Pleomorphic adenoma (Mixed tumor) appear?

60% of tumors in the parotid
* Rare in minor salivary glands

12

What increases the risk of Pleomorphic adenoma (Mixed tumor)?

Radiation increases the risk

13

Pleomorphic adenoma (Mixed tumor) - Macroscopically:

• Rounded, well-demarcated, firm mass
• <6 cm in greatest dimension
• Encapsulated (in small salivary glands capsule not fully developed)
• Expansile growth with small protrusions into surroundings -> enucleation difficult

14

Pleomorphic adenoma (Mixed tumor) - Microscopically:

- Mixture of ductal (epithelial) and myoepithelial cells, (both epithelial and mesenchymal differentiation)
- Epithelial elements dispersed throughout the matrix along with varying degrees of myxoid, hyaline, chondroid (cartilaginous), and even osseous tissue
- In some tumors the epithelial elements predominate; in others they are present only in widely dispersed foci
- Islands of well-differentiated squamous epithelium may also be present
- No difference in biologic behavior between the tumors composed largely of epithelial elements and those composed largely of seemingly mesenchymal elements

15

Warthin tumor =

Adenolymphoma

16

Where does the Adenolymphoma (Warthin tumor) occur?

Almost exclusively in the parotid gland
* 10% are multifocal
* 10% bilateral

17

What is the 2nd most common salivary gland neoplasm?

Adenolymphoma (Warthin tumor)

18

Risk factors of Adenolymphoma (Warthin tumor):

Smokers have eight times the risk of nonsmokers for developing these tumors

19

Adenolymphoma (Warthin tumor) - Macroscopically:

- Round to oval, encapsulated, pale gray mass
- Narrow cystic spaces filled with a mucinous/serous secretion
- 2 to 5 cm in diameter
- Usually arising in the superficial parotid gland (palpable)

20

Adenolymphoma (Warthin tumor) - Microscopically:

- Spaces lined by a double layer of neoplastic epithelial cells resting on a dense lymphoid stroma (sometimes germinal centers)
- Polypoid projections of the lymphoepithelial elements
- Surface palisade of columnar cells having an oncocytic appearance; Deep layer of cuboidal to polygonal cells
- Sometimes foci of squamous metaplasia

21

Where can Warthin tumors arise?

Warthin tumors can arise within cervical lymph nodes - a finding that should not be mistaken for metastases.

22

Recurrence rates of Warthin tumors after resection?

Recurrence rates of only 2% after resection

23

Who usually gets Esophageal squamous cell carcinoma?

- In adults over age 45
- M:F = 4:1

24

What are the risk factors of Esophageal squamous cell carcinoma?

- alcohol and tobacco use
- poverty
- caustic esophageal injury
- achalasia, tylosis (95% in age of 70)
- Plummer Vinson syndrome
- frequent consumption of very hot beverages
- previous radiation

25

When do people usually get Esophageal squamous cell carcinoma?

50% of ESCC occur in the middle third

26

How does Esophageal squamous cell carcinoma begin?

Begins as an in situ lesion termed squamous dysplasia

27

What does the early lesions of Esophageal squamous cell carcinoma appear like?

Early lesions appear as small, gray-white, plaque-like thickenings

28

What is the level of differentiation of Esophageal squamous cell carcinoma?

Most squamous cell carcinomas are moderately to
well-differentiated

29

Describe the symptomatic tumors of Esophageal squamous cell carcinoma?

Symptomatic tumors are generally very large at diagnosis and have already invaded the esophageal wall

30

Esophageal squamous cell carcinoma - Clinical features

• Dysphagia, odynophagia (pain on swallowing), and obstruction
• Progressively increasing obstruction by altering patients diet from solid to liquid foods -> extreme weight loss and debilitation
• Hemorrhage and sepsis may accompany tumor ulceration

31

What is the survival rate of Esophageal squamous cell carcinoma?

Overall 5-year survival: 9%

32

What causes the first symptoms of Esophageal squamous cell carcinoma

Occasionally, the first symptoms are caused by aspiration of food via a tracheoesophageal fistula

33

What is the lifetime risk of getting Chronic gastric ulcer, peptic ulcer disease

Lifetime risk: 10% males, 4% females

34

What causes Chronic gastric ulcer, peptic ulcer disease?

Develops on the basis of chronic gastitis

35

What are the main risk factors of Chronic gastric ulcer, peptic ulcer disease?

- Helicobacter pylori infection:
* 85-100% of duodenal ulcers
* 65% of gastric ulcers

- NSAIDs (aspirin, ibuprofen)

36

What are the other risk factors of Chronic gastric ulcer, peptic ulcer disease?

- Zollinger-Ellison syndrome
- cigarette smoking
- high-dose corticosteroids
- alcoholic cirrhosis
- chronic obstructive pulmonary disease
- chronic renal failure
- hyperparathyroidism (hypercalcemia: ↑gastrin)

37

Where is the localization of Chronic gastric ulcer, peptic ulcer disease?

- 95-98% proximal duodenum and stomach (3-4:1)
* Duodenum: bulb
* Stomach: lesser curvature (interface of body and antrum)

38

Is the Chronic gastric ulcer, peptic ulcer disease solitary or not?

80% solitary

39

Describe the classic peptic ulcer:

The classic peptic ulcer is a round to oval, sharply punched-out defect (heaped-up margins: cancers)

40

Chronic gastric ulcer, peptic ulcer disease (alot)

- The base of peptic ulcers is smooth and clean as a result of peptic digestion of exudate (blood vessels may be evident)
- In active ulcers the base may have a thin layer of fibrinoid debris underlaid by a predominantly neutrophilic inflammatory infiltrate
- Beneath this, active granulation tissue infiltrated with mononuclear leukocytes and a fibrous or collagenous scar forms the ulcer base
- Vessel walls within the scarred area are typically thickened and are occasionally thrombosed
- Scarring may involve the entire thickness of the wall and pucker the surrounding mucosa into folds that radiate outward

41

Chronic gastric ulcer, peptic ulcer disease - Clinical features (alot)

• Epigastric burning or aching pain
• The pain tends to occur 1 to 3 hours after meals during the day, is worse at night, and is relieved by alkali or food
• Iron deficiency anemia
• Nausea, vomiting, bloating, and significant weight loss
• Penetrating ulcers: the pain is occasionally referred to the back, the left upper quadrant, or the chest (may be misinterpreted as cardiac!)

42

Chronic gastric ulcer, peptic ulcer disease - Complications:

- Hemorrhage (15-20%)
* In almost 1/3 of patients a first sign
- Perforation (5-10%)
- Obstruction
- Cancer ???

43

What comprises over 90% of all gastric cancers?

Adenocarcinoma

44

Gastric cancer / Carcinoma ventriculi - symptoms:

Early symptoms resemble those of chronic gastritis
including:
- dyspepsia
- dysphagia
- nausea which leads to late diagnosis

45

Gastric cancer / Carcinoma ventriculi - symptoms:

Early symptoms resemble those of chronic gastritis
including:
- dyspepsia
- dysphagia
- nausea which leads to late diagnosis

46

Gastric cancer / Carcinoma ventriculi - survival:

The overall 5-year survival is less than 30%

47

Gastric cancer - types:

• Diffuse (M:F=1:1, incidence similar in different countries)

• Intestinal (M:F=2:1, 2nd most common cancer death cause worldwide)

48

Diffuse type of stomach cancer - risk factors?

- Germline mutationsin CDH1, which encodes Ecadherin, a protein that contributes to epithelial intercellular adhesion

- BRCA2 (breast cancer type 2 susceptibility gene) mutations

49

Intestinal type of gastric cancer - risk factors:

- Helicobacter pylori infection
- Smoking
- Alcohol consumption
- Autoimmune atrophic gastitis
- Genetic factors (FAP, others)
- Partial gastrectomies

50

Gastric adenocarcinomas classification depends on:

- most importantly, gross and histologic morphology
- location in the stomach

51

Most gastric adenocarcinomas involve.......

- the gastric antrum
- lesser curvature > greater curvature

52

Intestinal type:

- bulky tumors (exophytic mass or an ulcerated)
- glandular structures

53

Diffuse type:

- diffuse infiltrative growth pattern
- signet-ring cells
- desmoplastic reaction (thickened wall - linitis plastica)

54

Ileitis terminalis Crohn

Inflammatory bowel disease
- Crohn disease and ulcerative colitis

55

Ileitis terminalis Crohn - Pathogenesis:

- Genetic factors. (family members; in Crohn disease the concordance rate for monozygotic twins is approximately 50%)
- Mucosal immune responses. Immunosuppression - basic IBD therapy
- Epithelial defects
- Microbiota: metronidazole can be helpful in management of Crohn disease

56

What has:
- skip lesions
- transmural inflammation
- ulcerations
- fissures

Crohns disease

57

What has:
- continous colonic involvment, beginning in rectum
- pseudopolyp, ulcer

Ulcerative colitis

58

TABLE PAGE 7

difference between CD and UC

59

What causes CD and UC?

CD and UC result probably from a combination of defects in host interactions with intestinal microbiota, intestinal epithelial dysfunction, and aberrant mucosal immune responses

60

CD =

Crohns disease

61

UC =

Ulcerative colitis

62

Crohns disease - Clinical features:

• Clinical manifestations – extremely variable
• Most patients: mild diarrhea, fever, abdominal pain (20% pain in lower right quadrant – mimics appendicitis)
• Active disease – asymptomatic periods of weeks months
• Reactivation – stress, dietary change, smoking (strong association of onset, but cessation does not cause remission)
• Anemia, protein loss, vitamin B12 malabsorption
• Perforations, fistulas

63

Ulcerative colitis - Clinical features:

- Extra-intestinal manifestation
- Uveitis, polyarthritis, ankylosing spondylitis, erythrema nodosum, clubbing of fingertips (may develop before disease is recognized)
- Pericholangitis, primary sclerosing cholangitis (more commonly associated with UC)
- Increased risk of colonic adenocarcinoma

64

Which one of CD and UC has an increased risk of colonic adenocarcinoma?

Ulcerative colitis (UC)

65

Crohn disease:

- Terminal ileum, ileocecal valve, cecum
- Fissures, thickenning of wall, mesenteric fat extends on serosal surface (creeping fat)
- Ulcerations, Paneth cell metaplasia
- Noncaseating granulomas (35%)

66

Crohn disease - earliest lesion:

Earliest lesion: aphthous lesion

67

Crohn disease - appearance:

Patchy distribution: cobblestone appearance

68

Crohn disease - Microcopic feature of active process:

Microcopic feature of active process:
abundant neutrophils in crypts epithelium (crypt abscesses)

69

What has a cobblestone appearance?

Crohn disease

70

What has aphthous lesion in early lesions?

Crohn disease

71

What is the 2nd cause of cancer related death in western countries?

Colonic adenocarcinoma

72

Colonic adenocarcinoma - Risk factors - diet:

- Low fiber intake, high carbohydrates and fat intake

73

Who usually gets Colonic adenocarcinoma (risk factors)?

M slightly higher incidence than F

74

Colonic adenocarcinoma - Risk factors:

- Genetic disorders (~5%) : familial adenomatous polyposis –all patients develop colon cancer), hereditary non-polyposis colorectal cancer (Lynch syndrome)
- Inflammatory bowel disease

75

Sporadic colon cancers (90-95%) (alot):

- APC/WNT/β-katenin pathway: left side of colon. Tubular, villous adenoma -> typical adenocarcinoma

- MSH2,MLH1 pathway: right side of colon. Sessile serrated adenoma -> mucinous carcinoma (poorer prognosis)

76

Location for colon cancer:

- Rectosigmoid (50% of cases)
- Ascending colon (15% of cases)
- Descending colon (15% of cases)
- Transverse colon and cecum (each 10%)

77

Screening tests for colon cancer:

- Fecal occult blood test (NOT very sensitive or specific)

- colonoscopy

- Serum carcinoembryonic antigen (CEA) – used to detect recurrences

78

Which screening tests is used to detect recurrences?

Serum carcinoembryonic antigen (CEA)

79

Clinical findings in colon cancer (Left-sided):

Left-sided: change in bowel habits; constipation or diarrhea with or without bleeding

80

Clinical findings in colon cancer (Right-sided):

Right-sided: tend to bleed; blood in the stool and iron deficiency ANEMIA are more likely

81

Clinical findings in colon cancer (Sites of metastasis):

Sites of metastasis: liver and lungs or bone