Epithelial Pathology
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This document summarizes benign and malignant epithelial tumors of the oral cavity. Regarding benign tumors, it discusses squamous papilloma caused by HPV, squamous acanthoma caused by trauma, and keratoacanthoma caused by sunlight, chemicals or genetics. It also describes leukoplakia, the most common potentially malignant oral disorder, which has a 5-18% risk of transforming into cancer, and oral submucous fibrosis, a condition caused by areca nut use associated with scarring. For malignant tumors, it outlines basal cell carcinoma, a locally destructive tumor rarely metastasizing, and squamous cell carcinoma, the most common oral cancer associated with tobacco and alcohol use and often preceded by leukop
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Epithelial Pathology
- 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
- 5. PATHOGENESIS HPV The same that is responsible for skinwarts
- 7. On the skin VERRUCA VULGARIS
- 8. Multiple papilloma-like lesions COWDEN SYNDROME
- 9. HISTOLOGY
- 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
- 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
- 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!
- 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
- 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
- 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
- 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
- 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
- 100. BASAL CELL EPITHELIOMA RODENT ULCER
- 101. Grows SLOWLY Metastasizes RARELY Destructs LOCALLY
- 102. WHAT ALL CAUSES THIS?
- 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
- 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?
- 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?
- 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.
- 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