The document discusses premalignant lesions and biopsy, defining premalignant lesions and conditions, and describing various types of precancerous lesions such as leukoplakia and erythroplakia. It details their etiology, clinical features, histopathology, diagnosis, differential diagnoses, and treatment. Additionally, it covers the types of biopsy and procedures involved in diagnosing and treating such lesions.

1. Premalignant lesions
and biopsy.
PRESENTED BY- DR. SUJAY PATIL
PART II MDS

2. What is a premalignant lesion?
 A premalignant lesion is "a morphologically altered tissue in which
oral cancer is more likely to occur than its apparently normal
counterpart."
 These precancerous lesions mainly include
 Leukoplakia
 erythroplakia

3. Premalignant condition
 A premalignant condition is "a generalized state associated with significantly
increased risk of cancer."
 The precancerous conditions include
 Submucous fibrosis,
 Lichen planus,
 Epidermolysis bullosa,
 Discoid lupus erythematous.

4. What is dysplasia?
• If cell division becomes poorly regulated, cells may lose some of their
morphological characteristics and/or functions. The tissue becomes
disordered in appearance, often with an increase in the numbers of
immature cells, and greater variability between cells. This appearance is
called dysplasia.
• It should be emphasized that dysplasia does not necessarily show that the
cells have become cancerous; however, it does suggest underlying changes
in the cells, which may predispose to cancer.
• In this sense dysplasia may be a stage on the way to cancer development.

5. HISTOLOGICAL VIEW

7.  Neoplasia is the term used to describe the development of tumours or
cancerous tissue.
 The development of a tumour requires a series of changes in the biology of
the cell, with progressive loss of the controls that limit cell division. Even a
cell which is undergoing uncontrolled proliferation will not necessarily be
malignant. Malignancy typically arises when the dividing cells invade the
normal tissue and move away from their site of origin.

8. Leukoplakia
 The term leukoplakia was first used by schwimmer in 1877 to describe a white
lesion of tongue
 A whitish patch or plaque that cannot be characterized clinically or pathologically
as any other disease.
 It is most common percancerious lesion ,in which between 5% and 25% of these
lesions are premalignant
 In Indian studies the rate of malignant transformation ranges from 0.13 to 2.2% per
yr.

9. Leukoplakia: Etiology
 No etiologic factor can be identified for most persistent oral leukoplakias
(idiopathic leukoplakia). Known causes of leukoplakia include the following:
– Trauma (eg, chronic trauma from a sharp or broken tooth or from mastication may
cause keratosis)
– Tobacco use: Chewing tobacco is probably worse than smoking.
– Alcohol
– Infections (eg, candidosis, syphilis, Epstein-Barr virus infection): Epstein-Barr
virus infection causes a separate and distinct non–premalignant lesion termed hairy
leukoplakia.
– Chemicals (eg, sanguinaria)
– Immune defects: Leukoplakias appear to be more common in transplant patients.

10. Classification
 There are 3 clinical forms of oral leukopliakia
1. Homogenious
2. Speckeled
3. Proliferative verrucous.

11. Clinical features..
HOMOGENOUS
White asymptomatic homogenous plaque Surface is usually smooth or
wrinkled.
It has low risk of transformation.
It is the most common form.

12. Homogeneous Leukoplakia

13.  SPECKLED
Red background with multiple small white macules.
C. Albicans infection is often present.
High risk for malignant transformation (20-30%)
Rare form.

15.  PROLIFERATIVE VERRUCOUS
White exophytic papillary surface.
Tendency for prompt extension.
High risk of malignancy transformation (30-40%).
Very rare form.

16. Verrucous or Nodular Leukoplakia

17. Leukoplakia- Histopathology
 Features highly variable
 Ranging from hyperkaratosis and hyperplasia to atrophy and severe
dysplasia.
 Significant intrapathologist and interpathologist variation in diagnosing
dysplasia.
 Molecular studies indicated.

18. Diagnosis
 Biopsy and histological examination is the key to define the nature
and relative risk of leukoplakia
 Molecular biological and immunohistochemical techniques(p53
antigen, HPV 16,18,33) are important for detection of leukoplakia
with high risk of malignant transformation.

19. Differential Diagnosis
 Lichen planus
 Discoud lupus erythematous
 Candidiasis
 Hairy leukoplakia
 Uremic stomatitis

20. Treatment plan
 Surgical excision is the mainstay of the treatment of leukoplakia
 Co2 laser surgery may be used as an alternative test.
 In wide spread or multiple leukoplakia oral administration of 13-cis
retinoic acid ( 1 mg / kg of body weight daily for 2-3 months) may be used
with limited success
 Topical application of retinoic acid has been used in the treatment of
selective cases
 Homogenous leukoplakia without epithelial dysplasia may disappear or
diminish in size with in 2-3 months after cessation of habit.

21. Erythroplakia (Erythroplasia)
 Erythroplakia or Erythroplasia of Queyrat is a rare and dangerous precancerous
lesion characterized by red non specific plaque on oral mucosa that cannot be
attributed to any other known disease.
 Red oral lesions usually are more dangerous than white oral lesions.
 Carcinomas are seen 17 times more frequently in erythroplakias than in
leukoplakias, but leukoplakias are far more common.

22. Erythroplakia

23. Etiology
 Etiology of erythroplakia is unknown.
 Predisposing factors are mainly smoking, alcohol, and HPV

24. Clinical features
 Erythroplakia mainly involves glance penis . Oral involvement is
rare
 Fiery red, slightly elevated or flat plaque of varying size
 Usually asymptomatic
 More than 90-95% of cases of erythroplakia demonstrate
histologically severe epithelial dysplasia, carcinoma in situ or
invasive squamous cell carcinoma at the times of diagnosis.

25. Erythroplakia

26. Diagnosis
 Biopsy and hispathologic examination conforms the diagnosis and
determines the risk of carcinoma
DIFFRENTIAL DIAGNOSIS
1. Speckeled leukoplakia
2. Erythematous candidiasis
3. Early sq. cell carcinoma
4. Local irritation
5. Drug reaction

27. Treatment plan
 Surgical management is the mainstay of treatement of erythroplakia.
 The extent of excision depends on histopathologic findings.
 Interventional laser surgery is an alternative treatement for oral
erythroplakia.
 Topical 5% imiquimod cream and 5- aminolevulinic acid has been
used with for success of traetement.

28. Smokeless tobacco keratosis
 Smokeless tobacco keratosis is white keratotic lesion of mandibular
vestibule encountered in user of smokeless tobacco or snuff.
 ETIOLOGY
Mucosal contact with smokeless tobacco stored in vesibular area.

29. Clinical features
 Thin gray-white translucent plaque that appers fissured or rippled
 It usually takes 1-5 yrs for the lesion to develop
 The white plaque may thicken gradually to the point of appearing
nodular
 The lesion is usually confined to the area of placement of smokeless
tobacco, and does not detach
 Gingival recession and staining of the roots of the teeth in the area
may be present as well.

30. Diagnosis
 The diagnosis is based on the history and the clinical features.
 Biopsy is occasionally necessary to rule out premalignant and
malignant changes.
DIFFRENTIAL DIAGNOSIS
1. LEUKOPLAKIA
2. CANDIDIASIS
3. LICHEN PLANUS

31. TREATEMENT
 Cessation of habit.
 Surgical excision of lesion.

32. WHAT IS A BIOPSY?
 Biopsy is the removal of tissue for the purpose of
diagnostic examination.

33. CLINICAL EVALUATION
 The anatomic location of the lesion/mass
 The physical character of the lesion/mass
 The size and shape of the lesion/mass
 Single vs. multiple lesions
 The surface of the lesion
 The color of the lesion
 The sharpness of the boundaries of the lesion
 The consistency of the lesion to palpation
 Presence of pulsation
 Lymph node examination

34. LABORATORY INVESTIGATION
 Complete heamogram
 HIV HbsAg
 BTCT
 BSL
 PTINR
 Determination of serum calcium, phosphorus, and
alkaline phosphatase and protein can be very useful in
excluding certain pathological processes.

35. INDICATIONS FOR BIOPSY
 Any lesion that persists for more than 2 weeks with no
apparent etiologic basis.
 Any inflammatory lesion that does not respond to local
treatment after 10 to 14 days.
 Persistent hyperkeratotic changes in surface tissues.
 Any lesion that has the characteristics of malignancy

36. TYPES OF BIOPSY
 Oral cytology
 Aspiration cytology
 Incisional biopsy
 Excisional biopsy
 Punch biopsy

37. WHEN TO REFER FOR BIOPSY
 When the health of the patient requires special management
that the dentist feel unprepared to handle.
 The size and surgical difficulty is beyond the level of skill that
the dentist feels he/she possesses.
 If the dentist is concerned about the possibility of malignancy.

38. ORAL CYTOLOGY
 Developed as a diagnostic screening procedure to
monitor large tissue areas for dysplastic changes.
 Most frequently used to screen for uterine cervix
malignancy
 May be helpful with monitoring post radiation changes,
herpes, pemphigus.

39. THE DISADVANTAGE OF ORAL
CYTOLOGICAL PROCEDURES
INCLUDE:
 Not very reliable with many false positives.
 Expertise in oral cytology is not widely available
 The lesion is repeatedly scraped with a moistened
tongue depressor or spatula type instrument. The cells
obtained are smeared on a glass slide and immediately
fixed with a fixative spray or solution.

40. ASPIRATION CYTOLOGY
 Aspiration cytology is the use of a needle and syringe to
penetrate a lesion for aspiration if its contents.
 Indications:
To determine the presents of fluid within a
lesion
To a certain the type of fluid within a lesion
When exploration of an intraosseous lesion
is indicated

41. ASPIRATION CYTOLOGY
 An 18 gauge needle on a 5 or 10 ml syringe is
inserted into the area under investigation after
anesthesia is obtained.
 The syringe is aspirated and the needle redirected if
necessary to find the fluid cavity.

42. INCISIONAL BIOPSY
 An incisional biopsy is a biopsy that samples only a
particular portion or representative part of a lesion.
 If a lesion is large or has different characteristics in
various locations more than one area may need to be
sampled

43.  Indications:
 Size limitations
 Hazardous location of the lesion
 Great suspicion of malignancy
 Technique:
 Representative areas are biopsied in a wedge fashion.
 Margins should extend into normal tissue on the deep
surface.
 Necrotic tissue should be avoided.
 A narrow deep specimen is better than a broad shallow
one.

44. HOW AN INCISONAL BIOPSY IS
PERFORMED

45. EXCISIONAL BIOPSY
An excisional biposy implies the complete
removal of the lesion.
 Indications:
Should be employed with small lesions.
Less than 1cm
The lesion on clinical exam appears benign.
When complete excision with a margin of
normal tissue is possible without mutilation.

46. HOW EXCISIONAL BIOPSY
IS PERFORMED

47. PUNCH BIOPSY
A punch biopsy is a type of biopsy where a
round area of skin and underlying tissue is
removed using a sharp hollow cutting
instrument.
Punch biopsy is done to diagnose certain types
of cancer that appear on or in the skin – most
common use
basal cell carcinoma
squamous cell carcinoma

48. HOW THE PUNCH BIOPSY IS
DONE

49. PRINCIPLES OF
SURGERY TO BE
PERFORMED

50. ANESTHESIA
 Block anesthesia is preferred to infiltration
 When blocks are not possible distant
infiltration may be used
 Never inject directly into the lesion

51. TISSUE STABILIZATION
 Digital stabilization
 Specialized retractors/forceps
 Retraction sutures

52. HEMOSTASIS
 Suction devices should be avoided.
 Gauze compresses are usually adequate.
 Gauze wrapped low volume suction may be
used if needed.

53. INCISION
 Incisions should be made with a scalpel.
 They should be converging
 Should extend beyond the suspected depth of the lesion
 They should parallel important structures
 Margins should include 2 to 3mm of normal appearing tissue if the
lesion is thought to be benign.
 5mm or more may be necessary with lesions that appear malignant,
vascular, pigmented, or have diffuse borders.

54. HANDLING OF THE TISSUE
SPECIMEN
 Direct handling of the lesion will expose it
to crush injury resulting in alteration the
cellular architecture.

55. SPECIMEN CARE
 The specimen should be immediately placed in
10% formalin solution, and be completely
immersed.

56. MARGINS OF THE BIOPSY
 Margins of the tissue should be identified to
orient the pathologist. A silk suture is often
adequate. Illustrations are also very helpful
and should be included.

57. SURGICAL CLOSURE
 Primary closure of the wound is usually possible
 Mucosal undermining may be necessary
 Elliptical incision on the hard palate or attached
gingiva may be left to heal by secondary intention.

58.  Incisional biopsies only require removal of a section of tissue
 Soft tissue overlying the lesion should be reapproximated
following thorough irrigation of the operative site.
 The specimen should be handled as previously described

59. NO ONE IS ALONE AGAINST THE FIGHT OF CANCER…