Mitosoid figures

found in early lesions of

MULTIFOCAL EPITHELIAL HYPERPLASIA

- viral cytopathy from HPV 13 &32

- elongated rete ridges

- poverty, immune suppression; children & HIV adults

the majority of oral nevi are this type

Intramucosal

- nevus cells confined to lamina propria

How often to melanocytic nevi undergo malignant transformation?

Acquired: 1 in 1 million

Congenital: 3-15%

Lipid-filled macrophages

Xanthoma cells

- found in lamina propria between rete ridges in

VERRUCIFORM XANTHOMA

- papillomatous

- most on alveolar ridge or gingiva of elderly

- etiology likely trauma

Benign salivary gland tumors usually have well-defined borders, a slow growth rate, and are freely moveable.

Where in the mouth are they not freely moveable?

hard palate

treatment and malignant transformation rate for

PLEOMORPHIC ADENOMAS

surgical excission must include rim of normal tissue

(these adenomas often poorly encapsulated and can extend beyond capsule)

- malignant transformation <5%

- recurrence more often for parotid gland than minor sg

[image]

single row of cells often form canals with central lumina

CANALICULAR MONOMORPHIC ADENOMA

smokers have an increased risk for this benign salivary gland tumor

WARTHIN'S TUMOR

(papillary cystadenoma lymphomatosum)

- asymptomatic swelling in lower pole of parotid

- unilateral or bilateral

- fluctuant

- in males >50 yrs old

This is the most common type of malignant salivary gland tumor in the US. It can be mistaken for a mucocele when fluctuant.

MUCOEPIDERMOID CARCINOMA

This type of minor salivary gland malignancy may exhibit mucoid or hyalinized material within cyst-like spaces or surrounding them.

ADENOID CYSTIC CARCINOMA

treatment and prognosis for adenoid cystic carcinoma

- solid histology pattern has worse prognosis than tubular/swiss cheese pattern

- worst prognosis for tumors arising in submandibular gland or maxillary sinus

- surgery and/or radiation therapy

- 5 yr survival rate is 80% but 20 yr is only 20%

The likely etiology of leukoplakia of the lower vermillion

UV radiation

- actinic cheilosis also on lower lip from UV radiation

(tobacco smoking most closely linked to leukoplakia in general)

What are 6 diagnoses that must be excluded before calling a clinical impression "leukoplakia"?

• white sponge nevus
• leukoedema
• frictional keratosis
• chronic cheek biting
• lichen planus
• nicotine stomatitis

Where in the mouth does leukoplakia most commonly occur?

lower vermillion

buccal mucosa

gingiva

What is the clinical variant of leukoplakia most likely to be premalignant or malignant?

speckled variant/erythroleukoplakia

More than 90% of leukoplakias with dysplasia or carcinoma are found on what 3 locations in the mouth?

tongue

lower vermillion

floor of mouth

Sublingual Keratosis

HIGH RISK for malignant transformation!

- leukoplakias on floor of mouth, ventral tongue, or lingual gingiva

Tobacco is the #1 risk factor for oral squamous cell carcinoma. What 3 major components of tobacco smoke contribute to its carcinogenicity?

polycyclic aromatic hydrocarbons

hetercyclic amines

nitrosamines

(contains over 60 carcinogens)

Which type of lymphoma is more likely to appear in Waldeyer's ring: NHL or HL?

NHL

non-hodgkin lymphoma

- should be included in diff diagnosis for palatal swelling in older adult

- extra-nodal involvement is uncommon in hodgkin lymphoma

True or False?

cigar and pipe smoke carry a greater risk for oral cancer than cigarretes.

True.

along with UV light, all major contributors to cancer of lower lip

Sever chronic iron deficiency in Northern European middle aged women can be a risk factor for oral and esophogeal cancer. What 3 names does this collection of symptoms (esophageal webs, glossitis, dysphagea) go by?

Sideropenic Dysphagia

Plummer-Vinson Syndrome

Patterson-Kelly Syndrome

Which HPV type is found in 95% of all HPV positive oro-pharyngeal cancers?

HPV16

True or False?

HPV+ cancers have a better prognosis than HPV- ones.

True

Dyskeratosis Congenita

(progression to SCC in 1/3 of cases)

- also AD and AR forms

Xeroderma Pigmentosum is an AR condition that predisposes people to what type of oral cancer?

cancer of skin, lower lip, and tongue tip

- can include SCC, BCC, melanoma

Which play a bigger role in oral cancer: tumor suppressor genes or oncogenes?

Tumor suppressor genes (particularly their inactivation)

i.e. p53 gene inactivated in up to half of oral cancers

Name 2 proteins that are commonly overexpressed in oral cancers, causing, or as a result of, p53 inactivation.

MDM2 protein (inhibits p53)

Cyclin D1 protein (p53 activates CDK inhibitors)

Loss of an HPV16 protein leads to overexpression of other HPV16 proteins, which promotes cancer. What proteins are involved?

E2 is not expressed when HPV16 integrates into host

E2 normally inhibits expression of E6 and E7,

causing overexpression of these proteins associated with cancer.

E6 - binds and promotes degredation of p53

E7 - binds RB, promoting its degredation and hence cell cycling

In histologic examination of which type(s) of cysts would you find germinal centers in the cyst wall?

A. Oral lymphoepithelial cyst

B. Thyroglossal duct cyst

C. Epstein's pearls

D. Branchial cleft cyst

E. Epidermoid cyst of skin

A. Oral lymphoepithelial cyst

&

D. Branchial cleft cyst

What site for oral SCC has the greatest predilection for females and the least association with tobacco smoking?

Gingivae/Alveolar mucosa

- associated with smokeless tobacco

- may be mistaken for chronic perio disease or pyogenic granuloma

Which oral cancer site has highest mortality rate?

Which has the lowest?

highest - tongue

lowest - lower lip

What staging criteria (T,N,M) represent stage IV cancer?

any of the following:

T4, N3, M1

T4 = invasion of deep adjacent structures

N3 = metastasis in node > 6mm

M1 = distant metastasis

3 methods for metastasis imaging?

CT (main)

MRI (for extranodal spread)

PET (for occult metastases)

3 types of surgical resection of the jaw?

Resection: removal of tumor involving bone w/ 2cm margin of radiographically normal bone

Marginal: inferior border of mandible preserved

Segmental: full height of mandible is lost

Composite: removal of hard & soft tissue; usually monobloc of primary tumor, mandible and neck nodes

Internal jugular vein,

Sternocleidomastoid, and

Spinal accessory nerve

are all removed in what cancer treatment?

Radical neck dissection

- indicated for positive lymphadenopathy

- lymph node levels 1-4 also removed

The most important factor in the development of Osteoradionecrosis?

tooth extraction after radiation therapy

3 cystic forms of teratomas?

Epidermoid: lined by SSE

Dermoid: lined by SSE with cyst wall containing skin appendages

Teratoid: may contain elements from variety of germ layers (skin, muscle, bone, GI)

Sistrunk procedure

 removal of thyroglossal duct cyst

- cyst removed as well as midsegment of hyoid bone and musle along tract

- less than 10% recur

- rarely can transform into papillary adenocarcinoma

True or False?

Keratoacanthoma is benign

True

- surgical removal is still treatment of choice, even though they can spontaneosly regress

- removal improves cosmesis on healing and provides bioposy to rule out SCC

Antoni A areas and Antoni B areas

- found in biopsy of Neurilemoma

- Antoni A areas contain Verocay bodies (palisaded Schwann cell nuclei surroinding a nuclear free zone), and are solid and cellular

Antoni B areas contain looser, myxoid tissue

Definitive diagnosis requires IHC identification of antigenic actin filaments.

Leiomyoma

- spindle cells with cigar-shaped nuclei

- normally covered by normal colored mucosa

- blue variants arise from vascular smooth muscle; angioleiomyomas or vascular leiomyomas

Pseudoepitheliomatous hyperplasia

Granular cell tumor

- may arise from Schwann cells

- firm, uneven surface, most often found on the tongue

* Congenital gingival granular cell epulis is neonate version, bu does NOT have pseudoepitheliomatous hyperplasia

PEH may also occur in extensive palatal papillary hyperplasia of denture wearers

wavy or comma-shaped nuclei

NEUROFIBROMA

- well circumscribed spindle-cell benign nodule, non-specific cellular proliferation pattern

- composed of Schwann cells with wavy or comma nuclei

- mast cells, collagen, myxoid also present

tubules with eosinophilic coagulum

pleomorphic adenoma

- most comon type of salivary gland tumor

- most occur in the parotid, although this is the most common type of minor salivary gland tumor, with these occuring most often in the palate and upper lip

Pregnancy tumor is a version of this?

Pyogenic granuloma

- soft and red

- made up of granulation tissue

- may become fibrotic post-partum

Epulis granulomatosum

Post-extraction granuloma

- represents exuberant granulation tissue

- tooth extraction "removes a cork from a bottle"

Leaf-like structure found under a denture?

Fibro-epithelial polyp

- collagenous fibrous connective tissue covered by hyperplastic/hyperkeratotic SSE

Sometimes the calcified material in Peripheral Ossifying fibroma allows it to be distinguished radiographically from which 3 clinically similar, benign lesions?

Irritation fibroma

Pyogenic granuloma

Peripheral giant cell lesion

Most likely location for Adenoid Cystic Carcinoma?

For Mucoepidermoid Carcinoma?

Adenoid Cystic Carcinoma - palate

Mucoepidermoid - parotid

Which of the following factors is/are not strongly linked to leukoplakia?

A. Trauma

B. Smoking

C. Sanguinara

D. UV radiation

E. Microorganisms

F. Alcohol

A. Trauma

&

F. Alcohol

Order the following types of leukoplakia from unlikely malignant transformation to likely malignant transformation:

Granular/nodular

Speckled

Verrucous

Thin

Homogenous/thick

Thin

Homogenous/thick

Granular/nodular

Verrucous

Speckled

This high risk leukoplakia often occurs in elderly women without any predisposing risk factors for SSC.

Proliferative verrucous leukoplakia

Keratosis from which form of smokeless tobacco is strongly associated with dysplasia and SCC:

Snuff or Betel Quid?

Betel Quid

- whereas the tobacco component is responsible for dysplasia, the areca nut component causes oral submucous fibrosis, mainly in young users

This represents more than 90% of oral cancers

Squamous Cell Carcinoma of the oral mucosa

Which does not have a female predilection?

A. SCC

B. Nasolabial cyst

C. Proliferative verrucous leukoplakia

D. Melanoacanthosis

E. Pregnancy tumor

A. SCC

- more common in males, though females are catching up with increased rates of smoking

What would you use to rinse the patient's mouth before and after using Toluidine blue?

1% acetic acid

- not diagnostic for oral cancer; strongly positive stains require follow up with biopsy.

What would you use to test for field cancerization in someone with oral cancer?

A. MRI

B. PET
C. CT

D. indirect mirror laryngoscopy and/or flexible fiberoptic laryngoscopy

D. indirect mirror laryngoscopy and/or flexible fiberoptic laryngoscopy

field cancerization = additional primary cancers in predisposed area of body

Which is not used alone as an oral SSC treatment?

A. Radiation

B. Chemo

C. Surgery

B. Chemo

- usually part of combined treatment for palliative effects

- agents: cisplatin, carboplatin, 5-fluoruracil, taxanes

Which type of radiotherapy can include radioactive sources within the tumor bed?

A. External beam

B. Brachytherapy

C. Fractionation

B. Brachytherapy

Which of the following does not affect children?

A. Rhabdomyosarcoma

B. Oral verrucous vulgaris

C. Multifocal epithelial hyperplasia

D. Angiocentric T cell lymphoma

E. Nasopharyngeal angiofibroma

F. Oral lymphangioma

D. Angiocentric T cell lymphoma

aka Extranodal NK/T cell lymphoma

- rare disease affecting mainly adults

- relentless destruction of midline stuctures of palate and nasal fossa

- eventual oral-nasal fistula

*include in diff diagnosis for palatal ulcers

Irregular, fluid-filled grey and pink papillations are almost pathognomonic for this neonatal malformation when it occurs on the anterior dorsal surface of the tongue.

Oral lymphangiomas