Quiz 2 Flashcards
1
Q
“Textbook” progression of leukoplakias (3 steps)
A
- Thin LPs
- Thick/homogeneous
- Granular/nodular or verrucous/verruciform
2
Q
Pts with oral submucous fibrosis are ____x more likely to develop SCC
A
19x more likely
This is why it is a high risk lesion
3
Q
What is the 1 cell in the body that shows reverse polarization
A
Ameloblast
4
Q
Actinic cheilitis (cheilosis)
A
PREMALIGNANT lesions on lip due to chronic UV exposure
5
Q
6 histologic features of Granular, Verruciform Leukoplakia
A
- Irregular (verruciform) hyperkeratosis
- Bulbous rete pegs
- Lymphocytes (mod #s)
- Mod/severe dysplasia
- Congested vessels
- Candida hyphae (maybe)
6
Q
Of the 95% of leukoplakias that are NOT malignant at 1st biopsy, about ___% undergo subsequent malignant transformation
A
5%
7
Q
In TNM staging, what does TNM stand for?
A
T = tumor size in cm N = regional lymph node involvement M = distant metastasis
8
Q
What is the main diagnostic feature (microscopically) of focal epithelial hyperplasia (hecks disease)
A
Mitosoid bodies
9
Q
Erythroleukoplakia (speckled leukoplakia)
A
Leukoplakia with patches of redness
10
Q
Incidence of proliferative verrucous leukoplakia
A
4x more in females
11
Q
Cause of verruciform xanthoma
A
Unknown
Most likely reactive or immune response to trauma
12
Q
The risk for oral SCC in smokeless tobacco users is ____ compared to smoking
A
Less
13
Q
4 other symptoms associated with smokeless tobacco keratosis
A
- Gingival recession
- Periodontitis
- Caries
- Tooth wear
14
Q
Idiopathic leukoplakia incidence
A
Pts >40 yrs
15
Q
What role does smoking play in proliferative verrucous leukoplakia
A
No/minor role
16
Q
Which HPV subtypes may be causative factors for proliferative verrucous leukoplakia?
A
HPV 16 + 18
17
Q
Acanthosis
A
Diffuse epidermal hyperplasia
Aka thicker epithelium
18
Q
Betel quid/Guthka
A
*cause of oral submucous fibrosis
Betel leaf, areca nut, slaked lime, catechu, tobacco? Sweeteners?
19
Q
4 features of Muir Torre syndrome
A
- Autosomal dominant
- Cutaneous tumors of sebaceous origin
- Visceral malignant diseases
- Multiple keratoacanthomas
20
Q
Definition of idiopathic leukoplakia
A
Clinical white lesion that does not rub off + cannot be characterized clinically as any other disease
21
Q
Leukoplakia is _______
A
PREMALIGNANT
22
Q
Incidence of oral submucous fibrosis
A
India, South East Asia (where ppl use betel quid)
Young pts
23
Q
HPV associated oral cancers are different from the others how?
A
Better prognosis
24
Q
The single most effective measure to lower the risk for oral cancer is…
A
Reduce exposure to tobacco + alcohol
25
Actinic cheilitis (cheilosis) has the same pathology as ______ but in a different location
Actinic keratosis
26
____% of the dysplasia that present as clinical leukoplakias (thick + granular) will undergo malignant transformation
10-15%
27
Where do you see sanguinaria associated keratosis
Mx buccal vestibule
| Mx alveolar ridge
28
Names for a raised lesion
Papule
| Nodule
29
3 high risk sites of erythroplakia
1. Floor of mouth
2. Tongue
3. RMP
30
6 danger signals of malignant transformation
1. No cause (risk factors)
2. Causative agent carcinogen
3. Location (high risk sites)
4. Ulceration
5. Induration
6. Redness (erythroplakia)
31
10 signs of epithelial dysplasia
1. Hyperchromatism (dark nuclei)
2. Pleomorphism (abnormal shape nuc)
3. Increased nuclear/cytoplasmic ratio
4. Dyskeratosis (prematrue keratinization)
5. Increased mitotic activity
6. Abnormal mitotic figures
7. Loss of polarity
8. Bulbous rete pegs
9. Keratin pearls
10. Loss of epithelial cell cohesiveness
32
7 intrinsic risk factors for oral cancer
1. Iron deficiency (plummer vinson syndrome)
2. Vitamin A defiency
3. Bacteria (tertiary stage syphilis)
4. Candida
5. HPV 16 + 18
6. Immunosuppression (HIV, drugs)
7. Oncogenes + tumor suppressor genes
33
HPV positive tumors have a better prognosis bc...
Respond v well to radiation + chemo
34
Red lesions are red because
Epithelium is thin = close to blood vessels
35
What are the 2 clinical forms of focal epithelial hyperplasia (hecks disease) and how many/where are the lesions
Papulonodular
Papillomatous
Multiple lesions on lips, tongue, gingiva, tonsils (typically in anterior)
36
What cancer can develop from smokeless tobacco keratosis? Risk?
Oral squamous cell carcinoma (verrucous)
4x more risk vs. non users (but NOT as high as smoking)
37
3 microscopic features of focal epithelial hyperplasia (hecks disease)
1. Nodular broad based mass of oral mucosa
2. Numerous mitosoid bodies
3. Viral like cytopathic change
38
4 histologic features of verruciform xanthoma
1. Papillary acanthotic epithelium
2. Hyperparakeratosis
3. Clefts + crypts noted
4. Xanthoma (foam) cells in CT papilla
39
Metastasis from the posterior mouth occurs through...
Superior jugular nodes
| Digastric nodes
40
HPV positive tumors are diagnosed...(6) (compared to HPV negative tumors)
1. Dx @ younger age
2. Low prevalence of amoking/alch use
3. Dx @ more advanced TNM stage
4. Dx @ smaller tumor size
5. With lumph node positivity
6. Presence of metastases
41
Name for a lesion with an irregular surface
Papillary
42
Does every cancer have a precancerous lesion?
No
43
Which 2 conditions increase the risk for development of actinic cheilitis (cheilosis)
Xeroderma pigmentation
| Albinism
44
3 histologic features of Thin, Smooth Leukoplakia
1. Hyperkeratosis
2. Acanthosis (thick epi)
3. Lymphocytes (sometimes)
45
Which parts of the tongue are high risk for oral cancer
Lateral border
| Ventral
46
What are the 3 theories that explain why HPV positive oropharyngeal cancers respond better to chemo?
1. Low rates of genomic damage
2. Absence of field cancerization
3. Presence of immune responses to HPV antigens
47
8 premalignant + related lesions of the oral mucosa
1. Leukoplakia
2. Proliferative verrucous leukoplakia
3. Erythroplakia
4. Smokeless tobacco keratosis
5. Oral submucous fibrosis
6. Nicotine stomatitis
7. Actinic cheilitis/keratosis
8. Keratoacanthoma
48
Nicotine stomatitis clincal presentation
Diffuse grey/white mucosa with red punctate papules (= inflamed minor salivary glands + their ductal orifices) on PALATE
49
Incidence of nicotine stomatitis
Men >45 yrs
| Pipe + cigar smokers
50
Hyperchromatism
Dark staining nuclei
*sign of epithelial dysplasia
51
Plummer vinson syndrome
Iron deficiency
Risk factor for oral cancer
52
HPV positive tumors are ____ differentiated
Poorly differentaited
53
What are molluscum bodies
Histo feature of molluscum contagiosum
Large intranuclear inclusions inside bloated keratinocytes
54
How does transmission of molluscum contagiosum vary in different populations
Teens/adults = sexual
Kids = nonsexual contact
Immunocompetent pts = warm + humid environments
55
Are smokeless tobacco keratosis lesions reversible?
Yes
56
Explain the theory that HPV+ tumors respond better to chemo bc of the presence of immune responses to HPV antigens
Immune responses to E6 + E7 oncoproteins help in improved tx responses + px
57
Where do Keratoacanthomas originate from in the skin? Oral mucosa?
Skin = pilosebaceous apparatus
| Oral mucosa = ectopic sebaceous glands? (FG)
58
Explain the theory that HPV+ tumors are more responsive to chemo because they have an absence of field cancerization
HPV believed to arise from limited foci of infection = less 2nd malignancies
59
3 high risk sites for oral cancer
1. Floor of mouth
2. Tongue (lateral border + ventral)
3. Soft palate
60
What is the most common malignancy in the mouth
Squamous cell carcinoma
61
4 histologic features of Thick, Fissured Leukoplakia
1. Hyperkeratosis
2. Acanthosis (thick epi)
3. Lymphocytes (sometimes)
4. Mild/mod dysplasia
62
Why are white lesions white?
Because the epithelium is thickened = further away from blood vessels
63
Types of HPV assoc with Focal Epithelial Hyperplasia (Heck's disease)
HPV 13 + 32
64
90% of leukoplakias show dysplasia or carcinoma in these 3 locations
1. Tongue
2. Lip vermillion
3. Floor of mouth
65
2 Tx's for focal epithelial hyperplasia (hecks disease)
Spontaneous regression
| Conservative excision
66
Why must all erythroplakias be biopsied?
Can't distinguish clinically
ALMOST ALWAYS squamous cell carcinoma or in situ carcinoma
67
3 reasons why proliferative verrucous leukoplakia is a high risk oral lesion
1. No absolutely predictive histologic pattern
2. No tests to prove likely progression
3. Must be re-evel v often + totally removed in recurs
68
How does metastasis of oral squamous cell carcinoma occur?
Through the lymphatics to the ipsilateral cervical lymph nodes
69
Cases of molluscum contagiosum are _____ in HIV pts (5-18%)
Florid
70
Clinical differential diagnoses of verruciform xanthoma (3)
Papilloma
Condyloma
Early carcinoma
71
Multiple keratoacanthomas are a feature of what syndrome?
Muir Torre syndrome
72
7 histologic features of Erythroleukoplakia (speckled LP)
1. Irregular hyperkeratosis
2. Bulbous + crowded rete pegs
3. Epithelial atrophy
4. Lymphocytes (mod-numerous)
5. Severe dysplasia
6. Carcinoma in situ?
7. Congested vessels
73
What is different about nicotine stomatitis caused by 'reverse smoking'
Severe keratosis
| PREMALIGNANT (otherwise isn't)
74
Is nicotine stomatitis premalignant?
By itself = not premalignant
If caused by 'reverse smoking' it IS premalignant
75
Speckled erythroplakia is ALMOST ALWAYS...
Carcinoma in situ or squamous cell carcinoma
76
Almost all of oropharyhngeal carcinomas are related to...
HPV
77
Traumatic (frictional) hyperkeratosis
Hyperplastic response (similar to callus) to chronic mechanical irritation
Reversible after stopping trauma
78
3 histologic features of nicotine stomatitis
1. Hyperkeratosis
2. Chronic inflammation
3. Salivary duct metaplasia
79
Pleomorphism
Abnormal shaped nuclei
*sign of epithelial dysplasia
80
Cause of nicotine stomatitis
Develops in response to HEAT (from pipe/cigars)
81
Symptoms of oral submucous fibrosis
Trismus (can't open) + burning followed by v stiff + blotchy mucosa
Tongue can be stiff + immobile
Leukoplakic lesions can develop
82
What are the 2 things that the MDH says about oral cancer?
1. Most cases are preventable
| 2. The single most effective measure to lower the risk is to reduce exposure to tobacco and alcohol
83
3 different histologic presentations of erythroplakia (in order from most common to least)
1. 50% Squamous cell carcinoma
2. 40% severe dysplasia or in situ carcinoma
3. 10% mild/mod dysplasia
84
Verruciform xanthoma presents in ____ much more than any other site as small lesions <2 cm
Gingiva
85
Erythroplakia is usually seen in which pts
50-70 yrs
86
Metastasis from the lower lip + floor of mouth happens through...
Submental nodes
87
How does molluscum contagiosum present clinically
Little papules on skin of face, neck, trunk + genetalia
Less often on mucous membranes
88
__% of leukoplakias are malignant at 1st biopsy
5%
89
There are wide ranges of risk of transformation from 1 anatomic site to another. How is the floor of the mouth an example of this?
In the floor of the mouth, the transformation rates are HIGH but show only minimal dysplasia
90
Sanguinaria associated keratosis
TRUE leukoplakia caused by sanguinaria (herb used in certain toothpaste + mouth rinses)
Persist for years even after stopping use
91
2 features of the histology of molluscum contagiosum
1. Lobular proliferation of epithelium
| 2. Bloated keratinocytes containing large intranuclear inclusions (molluscum bodies)
92
3 histologic features of actinic cheilitis (cheilosis)
1. Epithelium might show dysplasia
2. CT shows solar elastosis (sun damage)
3. Chronic inflammation
93
Describe keratoacanthoma lesions
1(+)
Always raised with central depression (cup shaped symmetry)
Verruciform surface
94
Describe Smokeless tobacco keratosis lesion
Characteristic white/grey lesion
Velvety feel
Blends w surrounding tissues
Rippled mucosa
95
Molluscum contagiosum can be mistaken for a more localized version of _______
Fordyce granules
But FG usually more generalized
96
Clinical presentation of early leukoplakia lesions
Thin leukoplakias
Flat/slightly elevated
Greyish white plaque
97
In the US, the majority of oral idiopathic leukoplakias are...
Benign + probably will never become malignant
98
Proliferative verrucous leukoplakia is what kind of lesion
High risk oral white lesion
99
Does traumatic (frictional) hyperkeratosis, cheek chewing (morsiciatio), or toothbrush trauma of gingiva transform to malignancy?
No
100
Verruciform xanthoma is a primarily ____ disease
Oral
101
Dyskeratosis
Premature keratinization of individual cells (keratin being made before they go up to the cell surface)
*sign of epithelial dysplasia
102
70% of idiopathic leukoplakias happen where? (3)
1. Lower lip vermillion
2. Buccal mucosa
3. Gingiva
103
Location of keratoacanthoma
Sun exposed skin
Less commonly on mucocutaneous jxn
Rarely intraoral mucosa
104
Keratoacanthoma is a ____ process
Squamoproliferative process
105
Erythroleukoplakia (speckled leukoplakia) has a ______ change of dysplasia
MUCH higher
106
Clinical term for erythroplakia
Idiopathic mucosal red patch
107
What are the 7 high risk sites for malignant transformation (in order)
1. Floor of mouth
2. Tongue
3. Lip
4. Palate
5. Buccal
6. Vestibule
7. Retromolar
108
2% of cases of oral SCC distantly metastasize. What are the 3 common locations?
1. Lung
2. Liver
3. Bones
109
Metastasis from the oropharyngeal region occurs through...
Jugulodigastric nodes
| Retropharyngeal nodes
110
Actinic cheilitis (cheilosis) lesions that show _____ are suspicious for SCC
Ulceration
111
Oral cancer is the __ most common cancer in men + ___ most common in women
11th most common in men
| 16th most common in women
112
Progression of proliferative verrucous leukoplakia (5 steps)
*different stages can be present in different sites within the same lesion
1. Clinical leukoplakia
2. Verrucous hyperplasia
3. Verrucous carcinoma
4. Papillary squamous cell carcinoma
5. Less differentiated squamous carcinoma
113
3 locations for oropharyngeal carcinoma
1. Lateral soft palate
2. Tonsillar region
3. Base of tongue
114
6 extrinsic risk factors for oral cancer
1. Smoking
2. Smokeless tobacco
3. Betal quid
4. Alcohol
5. Occupational exposures (heavy metals)
6. UV exposure (lip)
115
What 5 diseases must be excluded before you dx leukoplakia
1. Hyperkeratosis (incl frictional)
2. Candidiasis
3. Lichen planus
4. Tobacco pouch keratosis
5. Hairy leukoplakia
116
Does molluscum contagiosum have malignant transformation?
No
117
Thick (homogenous) leukoplakia clinical presentation
Progression of thin leukoplakias
Leather like white lesion with distinct borders
⅓ regress
118
Progression of actinic cheilitis (cheilosis) - 4 stages
1. Blotchy, smooth
2. Dryness + fissures
3. Blurring of vermillion border
4. Later stages = scaling, leukoplakic areas, redness, ulceration
119
What organism causes molluscum contagiosum
Molluscum contagiosum virus (DNA pox virus)
120
Name for a flat lesion
Macule
121
Definition of dysplasia
Defect in cell maturation pattern
122
Actinic cheilitis (cheilosis) incidence
Men 10x more
UV light exposure
More risk with Xeroderma pigmentation + albinism
123
Sanguinaria associated keratosis is a TRUE leukoplakia, which means it is ____ (although questionable)
Premalignant
May show dysplasia
124
Proliferative verrucous leukoplakia is usually multifocal (multiple sites), but the most likely location is...
Gingiva
125
Management of oral submucous fibrosis
```
Mild = steroids
Mod/severe = surgical splitting/excision of fibrous bands
```
Relapse common
126
Malignant transformation risk of idiopathic LP varies from study to study because...
Differences in the underlying pathology
| Differences in the use of putative carcinogens (e.g. tobacco)
127
8 anatomic sites for oral cancer (3 HIGH RISK)
1. Lip
2. Buccal mucosa
3. Retromolar trigone
4. FLOOR OF MOUTH
5. Hard palate
6. TONGUE (LATERAL BORDER + VENTRAL)
7. SOFT PALATE
128
Symptoms associated with oropharyngeal carcinoma (3)
1. Dysphagia
2. Odynophagia (pain during swallowing)
3. Otalgia (ear pain)
129
Leukoplakia may become _________________ WITHOUT change in clinical appearance
Dysplastic or even malignant
130
How can you tell if a lymph node is metastatic?
Firm
| Feel "fixed"
131
Erythroplakia
Red lesions (thinned epithelium, atrophic)
132
Cause of erythroplakia
Unknown
| Some related to tobacco
133
Induration
Localized hardening of soft tissue
Feels thick, firm, like something is underneath in the CT
*danger signal for malignant transformation
134
How does the incidence of oral cancer compare in white men vs. black men >65? Mortality rates? Why?
Oral cancer is more common in white men >65 (bc more HPV assoc cases)
Black men >65 have a higher mortality rate (bc of access, socioeconomic)
135
Is verruciform xanthoma malignant?
No
136
5 risk factors for idiopathic leukoplakia
1. Tobacco
2. Alcohol
3. UV light
4. HPV
5. Unknown
137
Incidence of verruciform xanthoma
40-70 years
Mostly whites
Slight male predeliction
138
Heck's disease is also called
Focal epithelial hyperplasia
139
Oral cancer is more common in men or women?
Men
140
Oral submucous fibrosis
High risk premalignant condition caused by betel quid
141
Explanation behind the theory that HPV+ tumors respond better to chemo because of low rates of genomic damage
Low frequency of TP53 mutations
Low rates of LOH + microsatellite instability
= intact apoptotic responses (= better response to chemo)
142
Incidence of Focal epithelial hyperplasia (heck's disease)
Children
Immuncompromised
Native americans (high prevalence)
Multiple members of same family (genetic +or infectious)
