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Potentially malignant disorders Flashcards

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1
Q

Define leukoplakia

A

White plaque or patch that cannot be characterized clinically or pathologically as any other disease

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2
Q

Classify leukoplakias

A
  1. Homogenous
  2. Non-homogenous
    - speckled (aka erythroleukoplakia)
    - nodulcar
    - veruccous
    - proliferative verrucous
  3. based on aetiology
    - tabacco associated
    - idiopathic
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3
Q

Aetiology of leukoplakia

A
  • Tabacco: do smoking cessation because once thats done then most leukoplakia dissapear or become smaller
  • Alcohol: not associated with leukoplakia but strong synergistic effect with tabacco in oral cancer production. Alcohol mouthwash users present with gray buccal mucosal batches, not considered true leukoplakias.
  • sanguiariaL: Pts using toothpaste or mouthwash with sanguiaria can develop true luekoplakia sanguinaria. Located on maxillary vestibule or alveolar mucosa.
  • UV radiation: lower lip vermillion leukoplakias
  • micro organisms: Treponema pallidum (syphilus tertiary stage) tongue can become stiff and has dorsal leukoplakia.
  • candida albicans: Colonizes the epithelial layers of the oral mucosa producing a thick granular plaque with mixed red and white colours. Chonric hyperplastic candida may see hpyerplastic or dysplastic histo changes
  • HPV (16 and 18) identified in some oral leukoplakia.
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4
Q

If uncertain what the white patch could be. Explain what you would do and what the results from the pathologist could say

A

If uncertain of the leukoplakia then it is called a provisional leukoplakia! Then a biopsy is definitely needed.
Biopsy can come back and say: -it is a specific lesion
-Consistent with leukoplakia without dysplasia
-consistent with leukoplakia with dysplasia
Overall term is a potentially malignant disorder.

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5
Q

Give the risk markers for carcinoma development

A

Population based: tabacco, alcohol, areco/betal quid chewing, malnutrition, genetics.
Mucosal: Leukoplakia, erythroplakia, erythroleukoplakia, submucous fibrosis.

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6
Q

Why are the lesions of leukoplakia white most of the times?

A

Hyperkeratosis and epithelium is thickened.

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7
Q

What is the most common site of leukoplakia?

A

lip vermillion, buccal mucosa and gingiva. 90% of the time lesions on the tonue lip vermillion and oral floor are the ones with dysplasia!

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8
Q

explain homogenous types of leukoplakia

A

Mild or thin leuokplakia: seldom show dysplasia. If not quit the habit then may become large and thick.

homogenous or thick leukoplakia: progession of thin leukoplakia to leathery deep a numerous fissured wihte plaque.

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9
Q

Non-homogenous type of leukoplakia explain.

A

Granular or nodular leukoplakia: progression of thick leukoplakia to more severe, more irregular surface white lesion.

verrucous or verruciform leukoplakia: demonstrates sharp or blunt projections

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10
Q

Explain proliferative verrucous leukkoplakia (PVL)

A

High risk form characterized by multiple keratotic plaques with roughened surface projection. It has a strong female predilection whom does not smoke or drink alcohol!

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11
Q

GIve the differential diagnosis of leuokplakia

A
  • LIchen planus
  • morsicatio (chronic cheekr biting)
  • frictional keratosis
  • tabacco pouch keratosis
  • nicotine stomatitis
  • leukodema
  • white sponge nevus
  • geographic tongue/geographic stomatitis
  • local hypersensitivity reaction
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12
Q

Give the treatment and prognosis of leuoplakia

A

Chemoprevention:

  • retinoids
  • relieve clinical symptoms

BIOPSY!!! histopathology is needed in most clinically severe areas.
May warrant destruction, removal and smoking cessation as conservative approach.

surgical excision, eletrocautery, cryosurgery, laser ablation are all used to remove the leukoplakia but this doesnt improve the outcome because all other tissue is affected but its not shown.
Long term follow up is necessary! Reoccurace are frequent
Those without dysplasia require follow up every 6 months!
4% leukoplakia becomes SCC this is an average and need to consider type of leukoplakia and presence of erythroleukoplakia!

Resolving it clinically means nothing.

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13
Q

Factors that may increase risk for cancer in leukoplakia lesions?

A
  1. Age/duration: older patients (immune system down) and lesions have been presentt for longtime (longer time to develop into cancer)
  2. Gender: Female predilection!
  3. idiopathic leukolakia: occuring in nonsmokers
  4. Site: leukoplakia in high risk area such as floor of mouth, soft palate, and the lateral borders of tongue.
  5. size: large lesions, especially those extend more than 1 site! higher chance to develop SCC
  6. appearance: PVL>speckled>nodular>homogenous.
  7. dysplasia: presence of mod/severe dysplasia increases risk!
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14
Q

Why do we biopsy leukoplakias?

A

Make a definitive daignosis and degree of dysplasia.

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15
Q

Give the different forms of dysplasia that can be seen in leukoplakia.

A

Mild epithelial dysplasia: seen at basal layers
Moderate epithelial dysplasia: middle portion of spinous layer involved
Severe dysplasia: basal layer to above midpoint of epithelium.
Carcinoma in situ: dysplasia involve entire thickness epithelium. Epithelium may be hyperplastic or atrophic

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16
Q

Give the histopathological alteratons of dysplastic epithelial cells (wont be asked but nice to know)

A
  • enlarged nuclei and cells
  • large and prominent nucleoi
  • hyperchromatic (dark staining) nuclei
  • Phleomorphic nuclei and cells
  • increase mitotic activity (excessive nrs of mitoses)
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17
Q

Give an explanation on what erthroplakia is

A

red patch that cannot be clinically or pathologically diagnosed as any other condition.

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18
Q

why do you want to biopsy a erythroplakia?

A

They demonstrate significant epithelial dysplasia, carcinoma in situ or invasive ssc.

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19
Q

Give the clinical features of erythroplakia

A

Mainly a disease of middle aged to elderly with no gender predilection! Floor of mouth, lateral borders tongue and soft palate are common sites. Altered mucosa appear as macule or plaque with a soft velvety texture. Usually asympomatic!

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20
Q

Give the differential diagnoses of erythroplakia

A

C.mucositis
erythemtous candidiasis
psoriasis
vascular lesions

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21
Q

what are classic clinical signs of a mlignant ulcer?

A

Indurated
Rolled borders
painless

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22
Q

define a benign neoplasm

A

localised, can b excised, does not metastasize.

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23
Q

define a malignant neoplasm

A

can invade, destroy and metastasize!

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24
Q

Define a neoplasm

Study These Flashcards
A

a new and abnormal growth of tissue in a part of the body. Has nonstop growth potential.

25
Give the pathogenesis of cancer in general
mainly a sequence of events that lead to change in tumour suppressor genes. Tumour supressor genes: they prevent uncontrolled growth and when mutated or lost they allow uncontrolled replication to occur. RB (retinoblastoma gene) causing cancer to occur if it is mutated. Also mutation of P53 gene which is guardian of the gene. Oncogenes: also called proto-oncogenes are known to cause cancers.
26
Define oral cancer
Includes the lips
27
Define intraoral cancer
Excludes the lips
28
oropharyngeal cancer
soft palate, palatine tonsils, base of tongue and posterior part of the pharynx!
29
Give the aetiology of Squamous cell carcinoma
Multifactoral! extrinsic agents such as cigarette smoke, alcohol, syphilis, radiation and sunlight. intrinsic factors are things such as malnutrition and genetics. Known that iron deficiency cause plumervinson syndrome! Tertiary syphilus can also cause SSC oncogenes HPV 16,18,32 also responsible for canccer.
30
Who is classified as a cigarette smoker?
Someone who smokes more than 100 cigarettes. Dose and time dependant. Pipe and cigar are greater risk.
31
Give the clinical features that would be found in someone who uses smokeless tabacco such as snuff
Painless loss of gingival tissues in area of tabacco contact. Destroyed facial surface of alveolar bone. Often see a white plaque (smokeless tabacco keratosis) produced on mucosa in direct contact with snuff or chew tabacco! Altered mucosa has a soft velvet feel when palpated and stretching of mucosa reveals a pouch caused by flacid stretched tissues in tabacco placed areaas.
32
What does habit cessation to for smoking patients?
Often leads to normal appearance within 2weeks in 98% of smokeless tabacco keratosis lesions that are not very white. If a lesion remains after 6 weeks without tabacco contact then its a true leukoplakia! It should then go for biopsy!
33
What effect does alcohol have in contributing to neoplasms?
Alcohol has a synergistic effect: heavy drinkers and smokers have 83x higher risk!
34
What does betel quid consist of?
Its a betel leaf wrapped around a mixture of areca nut, slaked line, tabacco usually and soemtimes sweetener and spices.
35
Oral submucous fibrosis, What is it? What is the aetiology? what is the pathogenesis? what are the clinical features?
It is a precancerous condition characterized by chronic, progressive scarring of oral mucosa. Aetiology: linked to chronic placement of betel quid or paan in the mouth. Path: Areca nut causes synthesis and degradation of extracellular matrix! Cytokines and growth factors produced by inflammatory cells promote fibrosis! Copper also found in the areca nuts and copper is known to upregulate collagen production! Clinical features: Chief complaint is trismus. Mucosal pain when eating spicy food. Buccal mucosa, retromolar area, soft palate are most commonly affected sites. Mucosa develops blotchy marble pallor and stiffness of subepithelial tissues occurs. Leukoplakia is also often noted.
36
How do we diagnose oral submucous fibrosis?
- Van gieson stain (differential staining of collagen) - procollagen type III and IV expression - immunigold silver staining - massons trichrome stain
37
Give the clinical features of squamous cell carcinoma
exophytic type: surface is irregular, fungating, papillary, verruciform, surface colour vary from red to white. The surface is often ulcerated, tumour feels indurated on pulpation. Endophytic: depressed, irregular shpae, ulcerated, central area with surrounding rolled border of normal, red or white mucosa
38
Give the different types of clinical presentation of SCC
Exophytic (mass-forming, fungating, papillary, verruciform) Endophytic (invasive, burrowing, ulcerated) Leukoplakic (white patch) erythroplakic (red patch) Erythroleukoplakic (combined red and white patch). Note that leukoplakia and erythroplakic are likely early cases that have not yet produced mass or ulceration and clinical features are same as premalignant leukoplakia and erythroplakia!!
39
Lip vermillion carcinomaa explain how you get it and how it looks.
Carcinoma of lip vermillion is found in light skin people most of the time due to UV sunlight exposure. Often assoc with actinic cheilosis and arise at site where pt holds a cigarette. 90% of the lesions are on lower lip. Typical characteristics of vermillion carcinoma is crusted, oozing, nontender, indurated, ulceration that is less than 1cm. Tumour usually grows slowly and most pts are aware of area 12-16 months before diagnosis. metastasis is a late event!
40
intra oral carcinoma explain everything you can on it.
Most common sites are tongue (lateral, posterior and ventral areas) and floor of mouth. Involvement can include the following in decending order: gingiva, buccal mucosa, labial mucosa, hard palate. 2/3 of lingual cancinomas are painless, indurated masses or ulcers of posterior lateral border. 20% occur on anterior lateral or ventral surfaces of tongue and 4% occur on dorsum of the tongue. Floor of mouth lesions are most likely to arise from preexising leukoplakia or erythroplakia! Floor of mouth carcinomas arise in midline region near frenum! Gingiva and alveolar carcinomas are painless and most frequently arise from keraintized posterior mandible mucosa.
41
Oropharyngeal carcinoma common sites?
Soft palate, base tongue, tonsillar area (tonsils, tonsillar fossa, pillars) and posterior pharyngeal wall
42
which site is most favoured for HPV associated carcinomas?
Tonsillar area
43
Hpv infection give some general information on it
More than 100 subtypes Type 16 and 18 are the high risk cancer causes E6 protein works on P53 and it degrades and inactivates it. E7 protein works on pRB
44
Name 2 ways of developing Oral pharyngeal cancer
- HPV (better prognosis) | - tabacco (worse diagnosis)
45
is there a hpv vaccine?
Yes! vaccination against oncogenic HPV done before sexual contact.
46
Give the classical clinical signs of a malignancy!
- Potential malignant disorder - non healing ulcer - indurated rolled margins (recall pt 2w later to see if not traumatic ulcer) - chronic hoarseness - exophytic or endophytic lesion - difficulty swallowing - ear pain: tongue cancer invading the glossopharyngeal nerve
47
Describe a verrucous carcinoma.
Low grade variant of oral squamous cell carcinoma. Associated with smokeless tabacco use and elderly men. Arise from oral mucosa in people who use chewing tobacco or snuff usually in areas where tabacco is placed. Cases also occur in non users! Smokeless tabacco users, SCC is much likely to develop than this low grade variant. Clinically: Site usually corresponds to site where tabacco is placed. Lesions appears as diffuse, well demarcated, painless, thick plaque with papillary or verruciform surface projections! Often occur as white or erythematous
48
Give the special investigations for SSC:
Any ulcer without a clear aetiological agent (trauma etc) or lesion that fails to heal after removing the aetiological agent should be biopsied. Biopsy site choice is important! If malignancy is suspected then should refer to specialist! If you biopsy a malignancy it may destroy clinical evidence of the site and character of the lesion. When doing an incisional biopsy need to include adjcent normal tissue!
49
Where is the mouth is metastasis most likely to occur?
Floor of the mouth due to highly vascular area
50
Give the annual incidents (in %) of second primary tumours
4% annual incidence.
51
Give the tumour staging (TNM)
Tumour size and extent of metastasis are best prognosis indicators. T (tumour size) Tx: primary tumour cannont be assessed t0: no evidence of primary tumour t1: tumour cm or less in greatest dimention t2: tumour more than 2cm but no more than 4cm t3: tumour more than 4cm t4: tumour invades adjacent tissues N: regional lymph node metastasis. N0: no regional lymph node metastasis N1: metastasis in single ipsilateral lymph node <3cm N2a: metastasis in ipsilateral lymph node >3<6cm N2b: Cancer has spread to more than 1 lymph node on the same side as the primary tumor, and none measures larger than 6 cm N2c: metastasis in bilteral or contralateral lymph nodes not more than 6cm in dimention N3: metastasis in node more than 6cm in dimention M-distant metastasis: M0: no involvement M1: involvement
52
Give the role of the dentist in Potentially malignant disorders
- ID high risk patients - early diagnoses - recognise lesions - manage these patients
53
Which patients are considerred high risk?
``` Older than 40 Tabacco users alcoholics floor of mouth lateral borders of tongue soft palate complex ```
54
Give some signs of malignancy
- non healing - indurated ulcer - rolled margins - exophytic lesions - chronic hoarseness of voice - ear pain
55
What do you do when a patient comes in and you find a white patch in the mouth?
Its fist considered a white patch. If cannot be diagnosed as any other white lesion or disorder (eg: frictional keratosis, morsicatiobaccarum, chemical injury, lichenoid reaction etc) then after clinical exam its called a provisional diagnosis of leukoplakia. Then a biopsy must be done! pathologist then finds out the definitive diagnoses.
56
How do we choose a biopsy site?
Often its the worst areas of the lesion. Not where the easiest is. So go for the red areas in erythroplakia or irregular area of a nodular leukoplakia (NB in ulcerative lesions go for the margins). Multiple biopsies can be done on large lesions because areas of dysplasia occur in different areas!
57
Give the process of using toludine blue mouth rinse to identify PMD.
- Patient rinse for 20s with 1% acetic acid solution to remove mucous and cellular debris - Patient rinses and gragle with 10mlof 1% toludine blue solution for 60s - Rinse again 20s 1% acetic acid followed by water rinse to decolourise excessively stained areas. - DNA and RNA areas are stained
58
Explain the use of velscope
Helps with biopsy. Area showing loss of flurescence in PMD lesions should be considered for inclusion in biopsy site! False positive in amalgam tattoos.

MFP 470 (9 decks)

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