Oral Pathology Flashcards

Question

Fibrous dysplasia

Answer 1

Normal bone being replaced by fibrous tissue associated with GNAS mutation/deletion Can involved one bone (monostotic) if late mutation or multiple (monostotic) bones if early mutation Monostotic disease: -Most common involved in craniofacial bones, ribs, femur and tibia -Slow, painful growth of jaw. Adjacent teeth may be displaced by expansion -Maxillary lesions can obliterate the antrum if extensive enough -Lesion stabilize after skeletal maturation and even regress in some cases Polystotic diseases: usually associated with syndromes that have cutaneous and endocrine abnormalities - Jaffe- Lichtenstein syndrome has cafe au lait pigmentation -McCune albright syndrome with cafe au lait pigmentation and endocrinopathies like precicious puberty, hyperparathyroidism, hyperthyroidism, and hypercortisolism -Mazabraud syndrome with intramuscular myxomas Radiographic appearance Ground glass opacity with poorly defined margins including ill-defined lamina dura Treatment Conservative management is treatment of choice Surgical controuing if severe cosmetic deformities Orthodontic treatment and orthognathic surgery for malocclusion High concern for blood loss after surgery Radiation contraindicated due to post radiation sarcoma Bisphosphonates may help relieve bone pain but risk for MRONJ

Answer 2

Black females 4-5th decade with vital teeth Radiographic and clinical findings Black female with multiquadrant or lower anterior teeth involvement where bone is replaced by cementum-like material Three variants Focal: Involves single site, posterior mandible, radiolucent to mixed to radiopaque Periapical: Anterior mandible, black, radiolucent and mimic periapical granulomas or cysts. They mature and become mixed radiopacity and radiodense Florid: Can involve all four quads, black, may develop swelling if simple bone cyst occur in long standing lesions Diagnosis: Vital teeth, radiographic and clinical findings match Treatment: No surgical removal Sclerotic lesions are hypovascular so they are prone to necrosis and infection from traumatic insults Prevent dental disease leading to tooth loss Patient with osteomyelitis should undergo debridement with saucerization

Answer 3

Unknown origin, Intraossesous lesion, nonaggressive or aggressive, mandible, routine radiographic discovery Aggressive subtypes results in pain, paresthesia, root resorption, tooth displacement 1. Major: greater than 5 cm, recurrence after treatment 2. Minor: Rapid growth, clinical displacement or loosening of teeth, cortical thinning or perforation, radiographic evidence of tooth resorption or displacement Similar to brown tumors of hyperparathyroidism. PTH assay for primary hyperparathyroidism levels (with hypercalcemia) Secondary hyperparathyroidism (with hypocalcemia) Alkaline phosphatase elevation not necessarily needed to be assayed. Histology CGCs multinucleated giant cells within a spindle mononuclear cell stroma Radiographic features Well delineated unilocular or multilocular radiolucency with displaced teeth and resorption of interradicular bone Treatment E&C with peripheral ostectomy. Recurrence 20% or higher in large lesions En bloc resection with 1 cm margins for recurrent lesions Conservative treatment for large lesions: -Intralesional corticosteroid injections - 1:1 mixture of local anesthestic and triamcinolone 10 mg/mL weekly for 6 weeks. 2 cc for every 1 cc of lesions visible on pano, high recurrence rate -Submucosal or nasal calcitonin: 100 units/day 6 months. -Subcutaneous interferon alpha-2a. In conjunction with curettage and postoperative treatment for 6 months -Imatinib - tyrosine kinase inhibitor -Bisphosphonates -Rank-L inhibitor Denosumab showing to be effective

Answer 4

Soft tissue variant caused by trauma or irritation Part of the 3 Ps 1. Pyogenic granuloma 2. Peripheral Ossifying Fibroma 3. Peripheral Giant Cell Granuloma Smaller than 2 cm with sessile or pedunculated base with blue/purple color Treatment Excision down to the bone

Answer 5

Antiresorptive medications and antiangiogenic medications with exposed bone for more than 8 weeks that can be probed through an intraoral or extraoral fistula in the maxilla or mandible. No history of radiation therapy or obvious metastatic disease to the jaws Bisphosphonates and RANK ligand inhibitors are antiresorptive medications - Diminish or alter osteoclasts - RANK ligand inhibitors prevent osteoclast differentiation Denosumab (Prolia) - for osteoporosis. Subcutaneous route Denosumab (Xgeva) - for bone metastasis. Subcutaneous route - Bisphosphonates inhibit osteoclast function and increase apoptosis of osteoclasts Alendronate (Fosamax) - Osteoporosis. Oral route Risendronate (Actonel) - Osteoporosis. Oral Route Ibandronate (Boniva) - Osteoporosis. Oral or IV route Zolendronate (Reclast) - Osteoporosis. IV route Zolendronate (Zometa) - Bone Metastases. IV route Pamidronate (Aredia) - Bone Metastases. IV route Antiangiogenic Medications reports indicate low risk for MRONJ -Tyrosine Kinase inhibitors -Monoclonal Antibodies inhibiting VEGF Radiographic Appearance Changes seen before clinical evidence of necrosis including radiopacity in areas of increased bone remodeling Periosteal hyperplasia Moth eaten radiolucency with central sequestra

Answer 6

Stage 0 - Non exposed bone variant Stage 1 - Exposed and necrotic bone or fistulae that probe to bone in asymptomatic patients with no infection Stage 2 - Exposed and necrotic bone or fistulae that probe to bone in symptomatic patients with evidence of infection Stage 3 - Exposed and necrotic bone or fistulae that probe to bone in symptomatic patients with evidence of infection and one or more of the following: - Exposed necrotic bone extending beyond alveolus -Pathologic fracutre -Extra-oral fistula -Oral antral/oral nasal communication -Osteolysis extending to inferior border of mandible or sinus floor

Answer 7

Sources of dental infection eliminated prior to starting treatments. Takes 1 month after extractions or restorations before ready for medication treatment. Bisphosphonates for 4 years or more as well as systemic corticosteroids or antiangiogenic agents, a DRUG HOLIDAY should be considered beginning 2 months prior to surgery and holding until healing complete. Drug holiday is not necessary for osteoporosis patients on bisphosphonates for less than 4 years Treatment Removal of bony sequestrum Pain management, antibiotics (penicillin, if allergic then fluoroquinolones, metronidazole, doxycycline, or erythromycin), antimicrobial rinses, debridement with possible resection for severe cases.

Answer 8

Radiation therapy for head and neck cancer. Irradiated bone exposed through a wound in overlying skin or mucosa and persists without healing for 3-4 months Diagnosis requires proven necrotic bone not related to other causes. Risk for developing following radiation ranges from 5%-15% with cases 4 months to 3 years after completion of therapy. Risk factors Radiation dose greater than 60 Gy Primary tumor located in tongue, floor of mouth, alveolar ridge, retromolar triangle or tonsil Satge III or IV cancer with mandibulectomy or ostectomy Perio disease, poor oral hygiene, dental extractions after radiation, alcohol and tobacco use, poor nutrition Clinical Findings Trauma such as tooth extractions, but some spontaneous Focal area of mucosal breakdown with exposure of bone. Progression into neuropathic pain, trismus, chronic drainage, dysgeusia, dysphagia, decreased tongue mobility Eventually lead to pathologic fracture Radiographic appearance Pano will show poorly demarcated sclerotic radiolucent with intermixed lytic areas. Pathological fracutre may be seen CT could show hypodense/hyperdense changes and interruptions in cortical margins Marx theory of ORN - 3 H's include Hypovascular, hypocellular, hypoxic tissue. Mandible is less vascularized than other bones which is why we see it more often

Answer 9

PREVENTION Avoid tooth extraction during or following radiation -Extractions prior would include: extensive decay or infection, partially impacted, pocket depths more than 5 mm -2-3 weeks healing before radiation initiation. Extractions can be done within 4 months following completion of radiation therapy if necessary. Within 5-6 months progressive fibrosis and loss of vascularity -Stress importance of oral hygiene (high fluoride tooth paste, fluoride treatment with custom tray) Hyperbaric Oxygenation -Part of Marx's theory that ORN cause by hypoxia, hypocellularity, hypovascularization -HBO therapy increases oxygenation by stimulating angiogenesis, fibroblast proliferation, collagen formation which lead to healing. TREATMENT -30 HBO dives then re-evaluated. Improvement include decrease in amount of exposed bone, granulation tissue formation, re-mucosalization. May do another 30 as needed. -No improvement after HBO dives, advanced to trans-oral debridement or sequestrectomy with primary mucosal repair. -If recurrent bone exposure after HBO and surgery, patient will require resection to bleeding bone with primary wound close and fixation. Then dives until closure or a total of 60 dives completed. -Reconstruction after disease is under control -Pentoxyfylline (improves the flow of blood through blood vessels) and tocopherol (Vitamin E) for prevention and treatment

Answer 10

Malignant neoplasm of melanocytic origin. Melanocytes are pigmented dendritic cells at base of epidermis Can arise de novo or from melanocytic nevus (benign counterpart) RISK FACTORS UV radiation fair complexion light hair or eyes Family history History of dysplastic or excessive nevi Tanning bed usage White adult around 60 Can resemble melanocytic nevus, ABCDE mneumonic A- asymmetry B- Border irregularity, scalloping, poor definition C- Color variegation D- Diameter greater than 6 mm in size E- evolving, change in size, shape or color

Answer 11

1. Superficial spreading - most common and found on trunk and extremeties. Tan, brown, pink, blue. Sharply marginated outline with peninsula-like protrusions. Papule or nodule extends above surface 2. Lentigo Maligna - Large and mostly flat, tan, black and brown flecks of color with irregular outline. Commonly on face and neck 3. Nodular - Uniform brown-black or blue-black color with smooth surface nodule, elevated plaque with irregular outlines or ulcerated tumor. Trunk and extremities 4. Acral Lentiginous Melanoma - rare on palms, soles, mucous membranes, nail beds on Africans or Asian. Most common form of Oral Melanoma. Worse prognosis than other subtypes

Answer 12

Prognosis most closely linked to primary tumor thickness Breslow depth chart measures mm of tumor cell depth from granular layer to base of melanoma Breslow chart Melanoma in-situ - 0.5 cm margin of resection < or equal to 1 - 1 cm resection 1.01 - 2.0 mm - 1-2 cm resection >2 mm - 2 cm resection -Surgical margins based on Breslow depth. If depth greater than 4 mm or with ulceration, sentinel lymph node biopsy is recommended. Radiation therapy used for tumors with high suspicion of recurrence. -TNM T- Tumor thickness N- Ulceration/mitosis M - Metastasis BRAF mutations involved in 50% of cutaneous melanomas. BRAF inhibitor treatments include. These are for metastatic melanoma - Vemurafenib - Ipilimumab

Answer 13

Rare and aggressive malignancy with primary in Head and Neck Mainly in oral cavity, nasal cavity, paranasal sinuses, pharynx, larynx RISK FACTORS No associated with UV exposure, but inhaled and ingested carcinogens such as smoking and formaldehyde may play role. DIAGNOSIS CT and MRI used to define extend of tumor - Enhancing, expansile, benign-apperaing destructive mass. May see moth-eaten irregular destructive resorption pattern on radiography PET/CT used for staging Must get chest xray to rule out metastasis Can use ABCDE to distinguish between melanoma, racial pigmentation, amalgam tattoo, Peutz-Jeghers syndrome (the combination of skin hyperpigmentation and polyps in the gastrointestinal tract. The pigmentation consists of clusters of black-brown freckles about the lips, the buccal mucosa, and the perianal and genital area), Addison disease Oral mucosal melanoma with widespread or multiple pigmented lesions with ill-defined borders. (Acral Lentiginous Melanoma most common form) - Most common locations are maxillary alveolar ridge and hard palate

Answer 14

PRIMARY TUMOR (T) starts at T3 T3- Mucosal disease limited to mucosa and immediate underlying soft tissue regardless of thickness of greatest dimension. T4 - Moderately advanced or very advanced T4a - Tumor invading deep soft tissue, cartilage, bone, or overlying skin T4b - very advanced involving brain, dura, skull base, lower cranial nerves, masticator space, carotid artery, prevertebral space, mediastinal structures REGIONAL LYMPH NODES (N) Nx - unable to assess lymph nodes N0 - No regional lymph node metastases detected N1- Regional lymph node metastases present DISTANT METASTASES M0 - no distant metastases M1 - Distant metastases

Answer 15

Complete surgical resection with wide diessection of 3 cm with Primary mucosal melanoma Lymph node dissection with evident regional metastasis. Can perform sentinel lymph node biopsy to identify patients who would benefit from elective neck dissection Radiation therapy when patient is poot surgical candidate or margins are inadequate. Chemotherapy as palliative care. No increase in 5 years survival

Answer 16

Most common cancer that rarely causes death or results in metastasis Can be locally aggressive 40+ yr old male with 80% on head and neck Risk Factors UV radiation - recreational exposure to sun during childhood and adolescence Fair complexion, red or blonde hair, light eye color Immunosuppression Radiotherapy treatment Exposure to arsenic or tar Pathogenesis Inappropriate activation of the sonic hedgehog signaling pathway. This protein binds to and inactivates the PTCH1 tumor suppressor gene on chromosome 9q22. Germline mutation of PTCH1 are found in patients with nevoid basal cell carcinoma syndrome. Gorlin syndrome is autosoma dominant disorder, but around 40% of cases represent a new mutation.

Answer 17

Nodular - most common with shiny pearlescent nodules. May be crusting with central depression or ulceration with rolled border. Superficial - well-circumscribed, scaly, pink-red macules or plaques with a crust or thin rolled border. Trunk and extremeties Morpheaform - rarest type representing 5-10%. Indurated plaques, ill defined borders. Difficult to identify, and are usually more aggressive.

Answer 18

Tx - primary tumor cannot be assessed Tis - Carcinoma in situ T1 - Tumor 2 cm or less in greatest dimension T2 - Tumor > or = 2 cm and <4 cm in greatest dimension T3 - Tumor > or = 4 cm in greatest dimension and/or perineal invasion and/or deep invasion and/or minor bone erosion T4a - Tumor with gross cortical bone/marrow invasion T4b - Tumor with skull base invasion and/or skull base foramen involvement Regional Lymph nodes (N) Nx - regional nodes cant be assessed N0 - No regional lymph node metastases N1 - Metastasis in a single ipsilateral lymph node. < or = 3cm in greatest dimension and no extranodal extension N2a - Metastases in a single ipsilateral lymph node > 3 cm but not > 6 cm in greatest dimension and no ENE N2b - Metastases in a single ipsilateral lymph node, > 6 cm in greatest dimension and no ENE N2c - Metastasis in bilateral or contralateral lymph nodes, none > 6 cm in greatest dimension and no ENE N3a - Metastasis in a lymph node > 6 cm in greatest dimension and no ENE N3b - Metastasis in single ipsilateral node > 3 cm in greatest dimension with ENE, or multiple ipsilateral, contralateral, or bilateral nodes, any with ENE; or a single contralateral node < or = 3 cm and ENE Distant Metastases (M) Mx - distant metastasis cannot be assessed M0 - No distant metastases M1 - Distant metastases TREATMENT Complete removal of tumor. Low risk of recurrence if treated with electrodessication and curettage or surgical excision. Radiation may be used for patient unable to have surgery RISK High risk features include: lesion of 6 mm or more in mask area of face Lesion more than 1 cm in head and neck Lesions poorly defined Perinerual invasion Recurrent lesions Immunosuppressed patients Aggressive growth pattern.

Answer 19

Primary lymphatic drainage of ORAL CAVITY is upper cervial lymph nodes including: Level 1a - submental nodes Level 1b - submandibular nodes Level 2 - upper jugular nodes Level 3 - Middle jugular nodes Level 4 - Lower jugular nodes: Up to 15% of tongue carcinomas can have "skip metastasis" to level 4 without involving 1,2 and 3. Selective lymphadenectomy called "Supraomohyoid Neck dissection" which includes the removal of lymph nodes levels 1-3. Some routinely include level 4 for tongue carcinomas due to possibility of skip metastasis. Primary lymphatic drainage of OROPHARYNX is upper cervial lymph nodes including: Levels 2, 3, and 4 in addition to retropharyngeal and parapharyngeal nodes.

Answer 20

Level 1a (submental lymph node group) - superior is mandible - bilaterally is anterior belly of digastric muscle - inferiorly is hyoid bone - mylohyoid forms floor Level 1b (submandibular lymph node group) - superior is mandible - anterior is anterior belly of digastric - posterior is stylohyoid/posterior belly of digastric - inferiorly is hyoid bone - mylohyoid and hypoglossus form floor Level 2 (upper jugular lymphatic chain) - superior is skull base - anteriorly is sternohyoid muscle - posterior is posterior border of sternocleidomastoid - inferiorly is carotid bifurcation Level 2a - nodes anterior to spinal accessory nerve (CN 11) Level 2b - nodes posterior to CN 11 Level 3 (middle jugular lymphatic chain extending to carotid bifurcation) - superior is carotid bifurcation - inferior is omohyoid muscle - at the level of lower border of cricoid cartilage - anterior is sternohyoid - posterior is posterior border of SCM Level 4 (Lower jugular lymphatic chain) - superior is omohyoid muscle - inferior clavicle - anterior by sternohyoid muscle - posterior is SCM Level 5 (posterior triangle of neck - posterior border is SCM - anterior border of trapezius muscle and clavicle - cricoid cartilage Level 6 (central compartment nodal group) -bilaterally by carotid artery -superiorly by hyoid bone -inferiorly by sternal notch -includes pretracheal, paratracheal, recurrent laryngeal, precricoid nodes -Drains the thyroid gland, glottic and subglottic laryn, cervical esophagus, and apex of pyriform sinuses. Not included in neck dissection for oral cavity SCC

Answer 21

Tobacco (increases risk 5-9 fold) Alcohol (increases risk 3-9 fold) Tobacco and alcohol together increase chances 100x Betel nut and other carcinogens Immunosuppresion Malnutrition Excessive sun exposure of lips Can develop SCC from premalignant lesions such as: - Leukoplakia (white patch or plaque. remove and follow) - Erythroplakia (red patch or plaque. remove with adequate margins due to higher malignancy potential than leukoplakia) - Oral Lichen Planus (mucocutaneous disease characterized by T cell mediated degeneration of basal cell layer with low malignant potential. There is erosive and atrophic subtypes) - Oral Submucous fibrosis (progressive fibrosis of submucosal layer and atrophy)

Answer 22

HPV more than 80% of oropharyngeal SCC, as opposed to 3-5% in oral cavity cancers

Answer 23

-Stage 0: Tis N0 M0 -Stage 1: T1 N0 M0 -Stage 2: T2 N0 M0 -Stage 3: T3 N0 M0, T(1-3) N1 M0 -Stage 4a: T4a N(0-1) M0, T(1-4a) N2 M0 -Stage 4b: T4b AnyN M0 -Stage 4c: AnyT AnyN M1

Answer 24

T3/T4 tumors Positive or close (< 5 mm) resection margins 2 or more cervical lymph nodes containing metastatic cancer Perineural or lymphovascular invasion Extracapsular spread Should be given within 6 weeks after surgery based on studies that showed poorer outcome with delayed treatment radiation mucositis, dermatitis, tirmus, dysphagia, xerostomia, osteoradionecrosis, dental caries

Answer 25

Positive resection margins Extracapsular spread Cisplatin is chemotherapeutic drug of choice. Commonly given weekly or every 3 weeks. Cetuximab (monoclonal antibody targeting the EGFR) as alternative to those who cant use Cisplatin

Answer 26

Negative N0 with >20% chance of having occult regional metastasis (clinically and radiographically unidentifiable cancerous node due to small quantity of cancer cells present in the node) receive Selective Neck Dissection (SND) Oral tongue SCC with depth invasion > 4 mm believed to have >20% chance of occult regional metastasis and warrants selective neck dissection for N0 neck. If lesion approaches within 1 cm of midline then bilateral neck dissection. - Oral cavity SCC, SND involves removal of lymph node levels 1-3 and is called supraomohyoid neck dissection. Level 4 is often included for tongue carcinomas due to skip metastases N0 oropharyngeal SCC requires removal of level 2-4 if surgery is selected as primary treatment. Patient with nodal positive (N+) neck generally received removal of lymph nodes level 1-5.

Answer 27

Radical neck dissection - includes levels 1-5 along with SCM, IJV and CN11. Reserved for N3 for extensive cervical involvement Modified radical neck dissection - same as RND except preservation of one or more non-lymphatic structures (SCM, IJV, and/or CN 11) not invaded by cancer MRND Type 1 - CN 11 preserved MRND Type 2: CN 11, IJV preserved MRND Type 3: CN 11, IJV, and SCM preserved Extended neck dissection - RND and MRND and also removes carotid artery, hypoglossal nerve, or level 6 or 7 nodes. END reserved for cancer spread to these extended location

Answer 28

STANDARD UTILITY INCISION for exposure to level 1-4. -Patient is placed supine on OR table with a shoulder roll to allow slight extension of the neck. -Incision marked from mastoid process in a gentle curve over the mid-portion of the neck up to the contralateral submental region -Infiltrate with local anesthetic with epi for hemostasis -Incision with scalpel through skin and subq -Bovie electrocautery to dissect through subq exposing platysma -Platysma sharply divided with care taken to preserve clean edge for closure -Subplatysmal flaps elevated superiorly until inferior border of mandible and inferiorly until the clavicle - External jugular vein and greater auricular nerve are found coursing transversely over the SCM from inferior to superior, and during elevation of platysmal flap, structures preserved. Will encounter marginal mandibular branch of facial nerve - Divide muscle over SCM and then retract muscle exposing levels 2,3,4 -CN11 identified and dissected from surrounding fascia to level of posterior belly of digastric -CN 11 can be retracted and lymph node tissues from levels 2a and 2b can be dissected off over the splenius capitis muscle. -Dissect inferiorly staying medial to transverse cervical nerves. Allows adequate dissection of level III lymph nodes off of the internal jugular vein -Dissect lymph nodes off carotid artery, and retracted medially. Lymph nodes can then be dissected from levels 1A and 1B. -Contralateral anterior belly of digastric, level 1A lymph nodes are dissected from mylohyoid muscle and digastric muscles. Care for submental branch of facial artery -Dissect to level 1B, posterior edge of mylohyoid muscle is retracted anteriorly and sailvary gland is retracted out of submandibular fossa. Lingual nerve is identified along with submandibular ganglion and submandibular duct. -Duct can be ligated and divided and gland dissected. Deep to digastric muscle is hypoglossal nerve and ranine veins. Care to not injure hypoglossal nerve or damage veins -Lymph node specimen elevated from fascial attachment and oriented for pathological evaluation -Close with 1-2 large suction drains and close platysma and then skin in separate layers.

Oral Pathology Flashcards

(52 cards)