Pre-cancerous lesions

Question 1

What is a precancerous lesion?

Answer 1

morphologically altered tissue in which cancer is more likely to occur than an apparently normal counterpart

Question 2

Give an example of a precancerous lesion

Answer 2

leukoplakia

Question 3

What is a precancerous condition?

Answer 3

a generalised state associated with a significantly increased risk of developing a malignancy

Question 4

Give an example of a precancerous condition

Answer 4

oral submucous fibrosis

Question 5

Give examples of clinical lesions that are commonly considered to be premalignant or that can simulate malignant lesions

Answer 5

• leukoplakia
• erythroplakia
• leukoerythroplakia
• smokers keratosis (nicotinic stomatitis)
• oral submucous fibrosis
• actinic keratosis/chelitis
• inherited conditions (dyskeratosis congenita)
• lichen planus/lichenoid

Question 6

Give examples of non-pre-malignant white and red lesions

Answer 6

• frictional keratosis
• oral candidal lesions
• chemical burns (aspirin)
• thermal burns
• pericoronitis
• gingivitis
• viral papilloma
• haemangiomata
• intra-oral skin grafts restoring surgical defects
• lingual erythema migrans (geographical tongue)
• epulides
• glossitis (drug related or due to deficiency disease)
• sublingual varicosities
• intra-oral tattoos and foreign bodies
• fordyce spots

Question 7

What kind of diagnosis is leukoplakia regarded as? Why is this

Answer 7

• as a clinical diagnosis
• a definitive pathological diagnosis can only be established following a biopsy

Question 8

When and where was the definition of leukoplakia updated?

Answer 8

Uppsala conference in 1994

Question 9

What was the definition of leukoplakia following the Uppsala conference?

Answer 9

“predominantly white lesion of oral mucosa which cannot be characterised clinically or pathologically as any other disease; some leukoplakias will transform into oral cancer”

Question 10

What is homogenous lesion?

Answer 10

this is a predominantly white lesion which is uniformly flat and thin.

Some cracking may be evident
Surface may appear crinkled or corrugated but must be of a similar texture throughout

Question 11

What is a non-homogenous lesion?

Answer 11

• predominantly white or white and red lesion (leukoerythroplakia) which may be flat, nodular or exophytic
• includes the clinincal lesion of speckled leukoplakia

Question 12

Many oral cancers manifest as red patches which are asymptomatic and are found at high risk sites. True or false

Answer 12

True

Question 13

Early oral cancer can be sometimes be used to describe…

Answer 13

a minimally invasive squamous cell carcinoma of the oral cavity

Question 14

How does early oral cancer most commonly present?

Answer 14

• erythroplakia with or without patches of keratosis

Question 15

Where are the commons site of early oral cancer ?

Answer 15

• floor of mouth
• soft palate complex
• lateral border of the tongue

Question 16

Briefly compare/contrast early oral cancer lesions with more advanced lesion with regards to appearance

Answer 16

• EOC lesions do not tend to be ulcerated or indurated (hardened) in comparison to more advanced lesions

Question 17

Hairly leukoplakia is associated almost exclusively with ________ individuals. What is usually demonstrated within the epithelial cells?

Answer 17

Immunocompromised individuals
Epstein Barr birus usually demonstrated within the epithelial cells

Question 18

In smokers keratosis/nicotinic stomatitis, what are the red interspersed areas ?

Answer 18

they are minor salivary glands which have become inflammed

Question 19

The continuation of the causative smoking habit that led to nicotinic stomatitis can lead to malignant transformation in the future. True or false.
Following your answer, is nicotinic stomatitis a precancerous lesion or a precancerous condition ?

Answer 19

true

precancerous condition

Question 20

What is the cause of reverse smokers palate? What kind of lesion is produced?

Answer 20

results from smoking the lit end of the hand-rolled cigarette within the mouth

A premalignant lesion is produced

Question 21

The signs of oral submucous fibrosis are a response to the use of …

Answer 21

Betel Quid

Question 22

Development of oral submucous fibrosis is also due to genetic input. True or false

Answer 22

True

Question 23

Describe the characteristic histological appearance of oral submucous fibrosis

Answer 23

• dense bands of fibrous tissue which replace elastic tissue in the submucosal tissues and render the mucosa rigid (due to substances that are released from the areca nut - betel quid?)

Question 24

What is the characteristic appearance of the mucosa in oral submucous fibrosis ? What is the cause of this appearance

Answer 24

• petechiae
• melanosis
• vesicles

caused by prolonged contact with the tobacco which is often mixed with areca nut in the quid

Question 25

What are the consequences of oral submucosa fibrosis in serious cases?

Answer 25

* severe trismus * unable to move tongue

Question 26

Cessation of the betel quid chewing habit is associated with regression of the condition. True or false

Answer 26

false As such regular follow- up is necessary

Question 27

State some treatment options for oral submucous fibrosis

Answer 27

* intralesion corticosteroids * surgery * both corticosteroid and surgery to release tight banding * surgery may lead to further fibrous scarring

Question 28

What is the cause of actinic keratosis ?

Answer 28

it is the result of a cumulative effect of ultraviolet radiation on exposed areas of skin and oral mucosa (sun damage)

Question 29

What are the clinical features of oral actinic keratosis ?

Answer 29

* irregular scaly plaques on an erythematous background * keratin horn is occasionally felt on palpation

Question 30

Actinic keratosis is a ____________ lesion

Answer 30

premalignant

Question 31

What are the preferred methods of treatment for actinic keratosis ?

Answer 31

surgical excision cryosurgery

Question 32

What other condition is analogous to actinic keratosis ?

Answer 32

actinic chelitis

Question 33

What is the best way to prevent actinic keratosis?

Answer 33

application of sunscreen to the lips

Question 34

Give examples of genetically determined mucosal lesions

Answer 34

* white sponge naevus * pachynochia congenita * Xeroderma pigmentosum * Dyskeratosis congenita

Question 35

White sponge naevus may not present clinically until adulthood. True or false

Answer 35

true

Question 36

What is pachyonychia congenita ?

Answer 36

* autosomal dominant benign condition * characterised by oral keratosis and palmar- plantar keratosis * no tendency for malignant transformation

Question 37

How is xeroderma pigmentosum manifested?

Answer 37

* numerous cutaneous and oral malignancies in middle age

Question 38

What is thought to be the pattern of inheritance of dyskeratosis congenita?

Answer 38

thought to be X linked due to the preponderance of males affected

Question 39

How does dyskeratosis congenita present?

Answer 39

* tongue and buccal mucosa develop bullae which become erosions and finally leukoplakic lesion

Question 40

What is the frequency/ incidence of dyskeratosis congenita lesions that undergo malignant transformation?

Answer 40

approximately one-third undergo malignant transformation

Question 41

What conditions are often associated with dyskeratosis congenita?

Answer 41

* aplastic anaemia * severe periodontal disease

Question 42

What areas of the oral mucosa are affected by lichen planus?

Answer 42

* buccal mucosa * tongue * less often the gingivae

Question 43

What form of lichen planus is most often associated with malignant transformation?

Answer 43

the more atrophic (wasting away) forms Erosive lichen planus

Question 44

Why is it important for lesions to be palpated ?

Answer 44

* detection of induration (hardness) * detection of adherence (does it rub off or not?)

Question 45

During a routine examination, what adjuncts/techniques can you make use of to examine the mucosa?

Answer 45

* drying the saliva as it may be disguised by it * mucosal stains

Question 46

Give some examples of mucosal stains

Answer 46

* OraScan * Germiphene * Canada

Question 47

State an advantage and disadvantage of using mucosal stains. What is the consequence of this?

Answer 47

Advantage: * high sensitivity for carcinoma * relative sensitivity for dysplasia Disadvantage * low specificity in general hence ability to detect lesions that are not malignant is low but can detect lesions that are premalignant/malignant Thus, the only feasible use is in the surveillance of high risk subjects

Question 48

What should a histopathological report include following a biopsy of a lesion?

Answer 48

* estimation of the level of dysplasia within the lesion * exclude the possibility that invasion has already occured

Question 49

What is dysplasia?

Answer 49

it is a disorded maturation of mucosa in response to physical, chemical and microbiological irritants

Question 50

When can dysplastic epithelium become neoplastic?

Answer 50

If the causative stimulus is not promptly discontinued

Question 51

What is the importance/significance of determining the level of dysplasia?

Answer 51

It is important for the clinician with regard to appropriate management of the lesion

Question 52

What sites in the oral mucosa are thought to be of greater risk of malignancy if a lesion were present?

Answer 52

* floor of mouth * tongue - ventral and posterior surfaces * retromolar areas

Question 53

What investigations can be carried out with a blood testafter discovering a lesion ?

Answer 53

* full blood count * vitamin B12 assay * folic acid assay * random glucose sample

Question 54

What is the benefit of clinical photography of oral lesions?

Answer 54

excellent method of recording changes in the lesions

Question 55

What treatment options can be considered for treatment of lesions?

Answer 55

* biopsy of erythematous regions * excisional biopsy * laser treatment * regular observation with serial biopsy (may be best for larger lesions) * vitamin A analogues- retinoids

Question 56

What preventive advice should be give with regards to development of oral lesions/cancers?

Answer 56

* smoking and alcohol cessation * their rolse in the aetiology of cancer is well documented and their synergistic effetcs are well recognised

Question 57

Most cases of oral cancer are *de novo*. How do other oral cancer lesions present ?

Answer 57

some cancer lesions can mimic precancerous lesions