Benign, pre-malignant (potentially malignant) and malignant epithelial lesions of oral cavity

1. EPITHELIAL PATHOLOGY
D R . S H U B H A N G I M I S H R A

3. BENIGN TUMORS OF EPITHELIAL TISSUE ORIGIN

4. SQUAMOUS PAPILLOMA

5. PATHOGENESIS
HPV
The same that is responsible for skinwarts

6. CLINICAL FEATURES

7. On the skin
VERRUCA VULGARIS

8. Multiple papilloma-like lesions
COWDEN SYNDROME

9. HISTOLOGY

10. SQUAMOUS ACANTHOMA

11. PATHOGENESIS
Reactive phenomenon of epithelium to trauma

12. CLINICAL FEATURES
ANY site in oral cavity
Usually in OLDER ADULTS
SMALL, FLAT or ELEVATED WHITE, SESSILE or PEDUNCULATED

13. HISTOLOGY

14. KERATOACANTHOMA
SELF-HEALING CARCINOMA
MOLLUSCUM PSEUDOCARCINOMATOSUM
MOLLUSCUM SEBACEUM
VERRUCOMA

15. Low-grade malignancy that originates in pilosebaceous
glands
PATHOGENESIS
• SUNLIGHT
• CHEMICAL CARCINOGENS
• GENETIC

16. CLINICAL FEAUTURES
ALL age groups
MEN twice more than women
LESS in dark-skinned
MOST on SUN-EXPOSED areas (so LIPS more)
PAINFUL
REGIONAL LYMPHADENOPATHY

18. DIFFERENTIAL DIAGNOSIS

19. HISTOLOGY

20. ORAL PREMALIGNANT LESIONS/CONDITIONS
OF EPITHELIAL ORIGIN
ORAL POTENTIALLY MALIGNANT DISORDERS

21. ORAL POTENTIALLY
MALIGNANT
DISORDERS
PREMALIGNANT
LESIONS
PREMALIGNANT
CONDITION
NORMAL MUCOSA EPITHELIAL MALIGNANCY

22. CONTINUUM OF PREINVASIVE NEOPLASIA
ORAL
POTENTIALLY
MALIGNANT
DISORDERS
NORMAL MUCOSA
HIGH-GRADE
DYSPLASIA/
CARCINOMA INSITU
RATIONALE BEHIND IDENTIFYING THEM?

23. CANCER IS A GENETIC DISORDER
CANCER
REPARATIVE ABILITY OF CELL
NORMAL
MUCOSA
MULTIPLE GENETIC
ALTERATIONS
ACCUMULATE

24. ATYPIA AT CELLULAR LEVEL
TO
DYSPLASIA AT TISSUE LEVEL

27. DYSPLASIA

30. ORAL PREMALIGNANT LESION
ORAL PREMALIGNANT CONDITION
A morphologically altered tissue in which cancer is more
likely to occur than its apparently normal counterpart
A generalized state associated with a significantly
increased risk of cancer

31. HOMEWORK
CLASSIFICATION OF ORAL POTENTIALLY MALIGNANT
DISORDERS

32. LEUKOPLAKIA

33. A predominantly white lesion of the oral mucosa that
CANNOT BE CHARACTERIZED AS ANY OTHER DEFINABLE
LESION; some oral leukoplakia will transform into cancer
- Axell 1996

34. DEFINABLE white lesions?
1. HYPERPLASTIC CANDIDIASIS

35. DEFINABLE white lesions?
2. HAIRY LEUKOPLAKIA (GREENSPAN LESION)

36. DEFINABLE white lesions?
3. TOBACCO-INDUCED WHITE LESIONS
4. TOBACCO-ASSOCIATED LEUKOPLAKIA

37. DEFINABLE white lesions?
5. IDIOPATHIC LEUKOPLAKIA

38. CLINICAL FEATURES
AFTER the age of 30 years
PEAK above 50 years
India: Male > Female
Western World: Male = Female

43. ETIOLOGY
TOBACCO
SMOKERS > NON-smokers
ALCOHOL
CANDIDA
HPV

44. LEUKOPLAKIA
HOMOGENOUS
SMOOTH FISSURED/FURROWED ULCERATED
NONHOMOGENOUS
NODULOSPECKELED

45. PROLIFERATIVE VERRUCOUS LEUKOPLAKIA

46. VERRUCOUS HYPERPLASIA

47. HISTOLOGY
HALLMARKS are
EPITHELIAL HYPERPLASIA
SURFACE HYPERKERATOSIS
EPITHELIAL DYSPLASIA, if present, MILD, MODERATE, or
SEVERE

49. MALIGNANT TRANSFORMATION
5-18%
GREATER with
NON-HOMOGENOUS LEUKOPLAKIA
PROLIFERATIVE VERRUCOUS LEUKOPLAKIA
Lesions on TONGUE, FLOOR OF MOUTH
MULTIPLE LESIONS
History of NOT SMOKING cigarettes

50. STAGING

51. Leukoedema

52. CLINICAL FEATURES NO COMPLAIN!

53. CLINICAL FEATURES

55. CARCINOMA INSITU

56. WHO ARE MORE PRONE TO DEVELOP
THIS?
MEN > women
ELDERLY

57. HOW DOES IT APPEAR?
May present as LEUKOPLAKIA,
ERYTHROPLAKIA, or an ULCERATED LESION
Most commonly on FLOOR OF MOUTH,
TONGUE, LIPS

59. ERYTHROPLAKIA

60. WHEN?
SIXTH and SEVENTH decades

61. HOW DOES IT APPEAR?
RED VELVETY PLAQUES
Unlike leukoplakia, erythroplakia is almost
always associated with PREMALIGNANT
CHANGES

62. WHY DOES IT OCCUR?

63. HISTOLOGY
80-90% of the lesions are either
SEVERE EPITHELIAL DYSPLASIA,
CARCINOMA INSITU, or
INVASIVE CARCINOMA

65. SMOKER’S PALATE

66. STOMATITIS NICOTINA
NICOTINIC STOMATITIS
LEUKOKERATOSIS NICOTINA PALATI

67. IN WHOM?
CONVENTIONAL SMOKERS

68. HOW DOES IT APPEAR?

69. PALATAL CHANGES ASSOCIATED WITH REVERSE
SMOKING

70. AMONG WHOM?
FEMALES of SRIKAKULAM district of
Andhra Pradesh

71. HOW DOES IT APPEAR?
Keratosis, excrescences, patches, red areas, ulcerated
areas, non-pigmented areas

73. TOBACCO POUCH KERATOSIS

74. IN WHOM?
QUID ABUSERS

75. HOW DOES IT APPEAR?

76. CENTRAL PAPILLARY ATROPHY OF TONGUE

77. HOW DOES IT APPEAR?
MEDIAN RHOMBOID GLOSSITIS
LOCALISED ATROPHY OF TONGUE PAPILLAE

78. WHY DOES IT OCCUR?
CANDIDAL INFECTION
SMOKING

80. ORAL SUBMUCOUS FIBROSIS

81. CLINICAL FEATURES
I am having BURNING
MOUTH, EXCESSIVE
SALIVATION, and
DEFECTIVE GUSTATION
INSIDIOUS
Now I am experiencing a
DIFFICULTY IN MOUTH OPENING,
DIFFICULTY IN SWALLOWING,
and INABILITY TO WHISTLE OR
BLOW OUT A CANDLE
ALSO
typing…
typing…
typing…
Now I am experiencing
PAIN IN THE EAR
ALSO

82. CLINICAL FEATURES
INSIDIOUS
VESICLES,
GENERALISED INFLAMMATION
PETECHIAE
PAIN IN AREAS WITH FIBROUS BANDS
BLANCHING OF MUCOSA.
WHITE FIBROUS BANDS,
REDUCTION IN MOUTH OPENING
IMPAIRMENT OF TONGUE MOVEMENT

89. ETIOLOGY

90. PATHOGENESIS
CLONAL SELECTION OF
FOBROBLASTS WITH
HIGH COLLAGEN
SECRETING CAPACITY

91. PATHOGENESIS
STIMULATION OF
FIBROBLAST
PROLIFERATION

92. PATHOGENESIS
FIBROGENIC CYTOKINES secreted by ACTIVATED
MACROPHAGES and T LYMPHOCYTES
DECREASED secretion of COLLAGENASE
PRODUCTION of more STABLE collagen
INCREASED collagen CROSSLINKING and STABILIZATION

93. SO TO SUMMARISE THE PATHOGENESIS
LOTS OF
COLLAGEN
Increased
stabilization
of collagen
Decreased
collagen
degrading
enzymes or
processes
Increased
collagen
SECRETION
•CLONAL SELECTION of
fibroblasts with high
collagen secretion capacity
•Increased PROLIFERATION o
fibroblasts

94. HISTOPATHOLOGY

95. MANAGEMENT
NUTRITIONAL SUPPORT
IMMUNOMODULATORY DRUGS
PHYSIOTHERAPY
LOCAL DRUG DELIVERY
SURGICAL

98. MALIGNANT EPITHELIAL TUMORS

99. BASAL CELL CARCINOMA

100. BASAL CELL EPITHELIOMA
RODENT ULCER

101. Grows SLOWLY
Metastasizes RARELY
Destructs LOCALLY

102. WHAT ALL CAUSES THIS?

106. OTHER CAUSES
xeroderma pigmentosum
NBCCS

107. IN WHOM DOES IT OCCUR?
FOURTH decade or later
MALE: female 3:2
WHITES

110. DIFFERENTIAL DIAGNOSIS
Actinic keratosis Keratoacanthoma Seborrheic keratosis SCC

111. HISTOPATHOLOGY

113. SQUAMOUS CELL CARCINOMA

114. EPIDERMOID CARCINOMA
malignant neoplasm exhibiting squamous differentiation:
(formation of keratin
and/or
presence of intercellular bridges)

115. ASR
6.2 per 100,000 in BANGALORE
16.1 per 100,000 in BHOPAL
3.5 per 100,000 in DELHI
7.8 per 100,000 in CHENNAI

116. IN WHOM?
Mainly after 4th decade
WHITES > blacks
MEN > women (2:1)

117. In INDIA, majority of oral cancers are associated with
TOBACO-CHEWING
and
most of them (80% as per the INDIAN house-to-house
survey) usually preceded by premalignant lesion/condition
(esp. LEUKOPLAKIA and ORAL SUBMUCOUS FIBROSIS
-NCRP 1982

118. WHY?

119. What’s so harmful in tobacco

120. What’s so harmful in Cigarrete

121. • Dehydrating effects of alcohol on the mucosa
• increasing mucosal permeability,
• Irritation of mucosa
• and it also acts as a solvent for carcinogens (especially
those in tobacco)
What’s so harmful in Alcohol

122. IN WHOM WHERE WHY APPEARANCE GOES WHERE
(metastasis)?
CLINICAL
CARCINOMA
LIP
ELDERLY MEN Mostly LOWER
LIP
Starts at VERMILLION BORDER
on one side
Small area of thickening –
induration – ulceration
Sometimes
exophytic/fungating
SLOW
Ipsilateral
SUBMENTAL
or
SUBMANDIBULAR
TOBACCO
PIPE-
SMOKING
SUN
EXPOSURE

123. IN WHOM WHERE WHY APPEARANCE GOES WHERE
(metastasis)?
CLINICAL
CARCINOMA
TONGUE
ELDERLY MEN Mostly
LATERAL
BORDER,
VENTRAL
SURFACE,
MIDDLE THIRD
ULCER (painless/painful)
Superficially indurated, raised
borders
Fungating/exophytic mass
SORE THROAT/DYSPHAGIA
HIGH
Ipsilateral,
bilateral, or
contralateral
SUBMENTAL,
SUBMANDIBULAR,
or DEEP
CERVICAL
TOBACCO
ALCOHOL
SYPHILITIC
GLOSSITIS
PLUMMER
VINSON
SYNDROME

124. IN WHOM WHERE WHY APPEARANCE GOES WHERE
(metastasis)?
CLINICAL
CARCINOMA
FLOOR OF
MOUTH
ELDERLY MEN Mostly
ANTERIOR
FLOOR
Indurated ULCER on one side
of midline (painless/painful)
Early EXTENSION to lingual
mucosa, mandible proper,
tongue, salivary glands
Esp.
contralateral
SUBMANDIBULAR,
SUBMENTAL
ALCOHOL
PIPE-
SMOKING
ILL FITTING
DENTURES

125. IN WHOM WHERE WHY APPEARANCE GOES WHERE
(metastasis)?
CLINICAL
CARCINOMA
BUCCAL
MUCOSA
ELDERLY MEN Mostly
ALONG/
INFERIOR to
a line
opposite
the plane
of occlusion
indurated painful ulcer
EXOPHYTIC/VERRUCOUS
Variable but
HIGH
IPSILTAERAL
SUBMANDIBULAR,
SUBMENTAL
TOBACCO
BETELNUT

126. IN WHOM WHERE WHY APPEARANCE GOES WHERE
(metastasis)?
CLINICAL
CARCINOMA
GINGIVA
ELDERLY MEN Mostly
MANDIBULAR
GINGIVA
FIXED
GINGIVA
Initially as ulcer,
erosive/exophytic/granular/
Verrucous (painless/painful)
Early INVASION into alveolar
bone, floor of mouth, cheek,
maxillary sinus
COMMON
MANDIBULAR
gingiva CA >
maxillary
gingiva CA
IPSILTAERAL
SUBMANDIBULAR,
SUBMENTAL
TOBACCO
CHRONIC
INFLAMMATION
DELAY in diagnosis due to similarity to common dental infections

127. IN WHOM WHERE WHY APPEARANCE GOES WHERE
(metastasis)?
CLINICAL
CARCINOMA
PALATE
ELDERLY MEN Poorly defined ulcerated and
painful lesion on one side of
midline (frequently crosses
midline)
EXTENDS laterally to palatal
gingiva/tonsillar pillar/uvula
May INVADE into the
bone/nasal cavity
COMMON
CERVICAL
lymph nodes
ULCERATION helps distinguish it from salivary gland neoplasms. It is 3 to 4 times
more common than the later.
SMOKING

128. Identify which of these can be a carcinoma and which can
be salivary gland neoplasm.

129. IN WHOM WHERE WHY APPEARANCE GOES WHERE
(metastasis)?
CLINICAL
CARCINOMA
MAXILLARY
SINUS
ELDERLY MEN CHRONIC
SINUSITIS?
SWELLING or BULGING of
maxillary alveolar ridge,
palatal or mucobuccal fold
Involvement of
Medial wall: nasal obstruction
Superior wall/roof:
displacement of eye
Lateral wall: bulging of cheek
Floor: oral manifestations
COMMON
CERVICAL,
SUBMANDIBULAR,
SUBMENTAL
lymph nodes
HOPELESSLY ADVANCED before patient gets conscious of its presence.

130. What is Metastatic Carcinoma?

132. TNM
Staging
Of
Oral
Cancer

133. WELL
DIFFERENTIATED
OSCC

134. MODERATELY
DIFFERENTIATED
OSCC

135. POORLY
DIFFERENTIATED
OSCC

136. VERRUCOUS CARCINOMA

137. Ackerman’s tumor
WARTY variant of oral squamous cell carcinoma
GROWTH generally SLOW
METASTASIS generally LATE, if at all

138. HOW TO DIFFERENTIATE IT FROM SCC?
Intact basement membrane/low chances of invasion
Infrequent dysplasia
Absence of metastases
WHAT if any of these is present?
PAPILLARY SQUAMOUS CELL CARCINOMA!

139. IN WHOM DOES IT OCCUR
ELDERLY MALES
TOBACCO CHEWERS

140. WHERE DOES IT OCCUR?
BUCCAL MUCOSA, GINGIVA/ALVEOLAR RIDGE, PALATE,
FLOOR OF MOUTH

141. WHY DOES IT OCCUR?

142. HISTOLOGY
MISDIAGNOSED AS:
papilloma
benign epithelial
hyperplasia

143. HISTOLOGY
NOTICE:
NO TRUE invasion
WELL differentiated
epithelium
LITTLE dysplasia (mitotic
activity, pleomorphism,
hyperchromatism)
INTACT basement membrane
HALLMARK
Parakeratin lining the clefts
and PARAKERATIN PLUGGING

144. BIOPSY PRECAUSTION?
GENEROUS biopsy should be taken!

145. MALIGNANT MELANOMA

146. Neoplasm of EPIDERMAL MELANOCYTES

147. FACTS and FIGURES!
THIRD most common cancer of skin
But, only 3% of the malignancies
Yet! Results in over 83% of all deaths due to skin cancer in
the USA

148. In whom?
FAIR SKINNED
1 per 100,000 in dark sinned
50 per 100,000 in light skinned Cuacasians
HIGHEST incidence in Queensland, Australia!

149. In AFRICANS and ASIANS
0.2-0.4 per 100,000

150. WHERE can it OCCUR
HEALTHY-appearing skin
Or
Acquired nevus Dysplastic nevus Congenital nevus Cellular blue nevus

151. SUN
EXPOSURE
sunburn
ARTIFICIAL
SOURCES
OF UV
High
SOCIOECO
NOMIC
STATUS
FAIR SKIN,
RED HAIR,
AND
FRECKLES
NUMBER
OF NEVI
WHY?
Xeroderma
pigmentosusm
familial

152. GROWTH PATTERNS OF MELANOMA

153. CLINICAL FEATURES:

154. ABCDE of MELANOMA

155. ORAL MANIFESTATIONS
Melanoma in BLACKS is found more on mucosa than on
skin!
MEN > women
55 years and above

156. WHERE?
PALATE, MAXILLARY GINGIVA/ALVEOLAR RIDGE

157. AMELANOTIC MELANOMA

158. Generally, FOCAL PIGMENTATION precedes the actual
neoplasm.
So,
MELANIN PIGMENTATION in mouth, with an increase in size
or depth, SHOULD BE VIEWED SERIOUSLY.

159. DIFFERENTIAL DIAGNOSIS

160. SEBORRHIC KERATOSIS
• STUCK-ON appearance
• Often MULTIPLE
• Symmetric
Traumatized or irritated nevus
• Returns back to normal in 7 to 14 days
Pigmented basal cell carcinoma
• WAXY appearance
• Telangiectasias
Lentigo
• In SUNEXPOSED areas
• Evenly pigmented
• symmetric

161. Blue nevus
• No history of change
Angiokeratoma
• Difficult to distinguish from melanoma
Traumatic hematoma
• Resolves in 7 to 14 days
Venous lake
• Blue, COMPRESSIBLE
• Found on ears and lips

162. Hemangioma
• COMPRESSIBLE, STABLE
Dermatofibroma
• “Button hole” when pinched
Pigmented actinic keratosis
• SUNEXPOSED AREA
• SANDPAPERY feel

163. HISTOLOGY

164. ANY QUERIES
CONTACT
shubhsmishra38@gmail.com