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3rd lecture

BY

DR. IMAN METWALY

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5-Idiopathic leukoplakia

Defined by the World Health Organization {WHO} as :

"A white patch that cannot be characterized clinically or

pathologically as any other disease ."

N.B. Leuko = white ; plakia = patch

The term is strictly a clinical one & does not imply aspecific histopathologic tissue alteration

The diagnosis depend on the exclusion of other entitiesthat appear white

It is considered a premalignant lesion because :The frequency of transformation into malignancy is greater

than the risk associated with normal mucosa

EtiologyThe cause of leukoplakia remains unknown but hypothesis

abound {exist}

Many cases are related to:

1.Tobacco use2.Alcohol abuse3.Chronic irritation4.Nutritional deficiency5.Sun light or actinic radiation

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Clinical features

Age : middle aged & older population

Site : may occur anywhere on the oral cavity

Mandibular buccal mucosa account for almost halfof theleukoplakias

The floor of the mouth & the ventral surface of the tongueaccount for a relatively small percentage but they account

for the high malignant potential

Leukoplakic lesions are classified according to the surface

texture into :

1-Homogeneous leukoplakia :

White plaque on a base of uninflammed ,normal appearing tissue with smooth or

wrinkled surface

2 -Speckled leukoplakia :

White flecks or fine nodules on anatrophic base

It can be regarded as a combinationbetween leukoplakia & erythroplakia

Spekled lesions show dysplasia more thanlesions with a homogeneous surface

3- Proliferative verrucous leukoplakia

This type begins as a simple keratosis &eventually becomes verrucous in nature

It is persistent Multifocal Has the potential to recur Some may be associated with HPV Malignant transformation to verrucous

carcinoma or squamous carcinoma hasbeen reported in 15% of the cases

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Histopathologic features :

Histologic changes varies from hyperkeratosis, dysplasia , &

carcinoma in situ to invasive carcinoma

1.Hyperkeratosis :{hyperorthokeratosis orhyperparakeratosis or a combination of both } with or

without acanthosis

2.Dysplasia : indicates abnormal epithelium & disorderedgrowth .Dysplasia is graded as mild, moderate & severe

Mild epithelial dysplasia refers to alteration limitedto the basal &parabasal layers

Moderate demonstrates involvement from basallayer to mid portion of the prickle cell layer

Severe epithelial dysplasia demonstratesinvolvement from the basal layer to a level above the

midpoint of the epithelium

3.Carcinoma in situ : the most severe dysplasia whereabnormalities extend throughout the thickness of the

epithelium

Carcinoma in situ spreads in a lateral direction4.Invasive carcinoma : begins when a focus of epithelial

cell invades the lamina propria 1 to 2mm beyond the basal

lamina

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Features of dysplastic epithelial cells1)Enlarged nuclei & cells2)Large &prominent nucleoli3)Pleomorphic nuclei & cells {abnormally shaped}4)Increases nuclear cytoplasmic ratio5)Hyprchromatic nuclei {excessively dark staining nuclei}6)Dyskeratosis {premature keratinization of individual

cells }

7)Increased mitotic activity{excessive number of mitosis }8)Abnormal mitotic figures{ tripolar or star-shaped

Features of dysplastic epithelium which are evident at low

power magnification1)Bulbous or teardrop-shaped rete ridges& basal cells hyperplasia

2) Loss of polarity{lack of progressive maturation towards the surface}3) Keratin or epithelial pearl {focal, round collections of

concentrically layered keratinized cells}

4) Loss of epithelial cell cohesiveness

normal

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Differential diagnosis:

White lesions which can be removed by a gauze or tongue

blade

1.Pseudomembraneous candidiasis2.Thermal burn3.Chemical burn4.White furred tongue

White lesions which are not removable

1.Leukoplakia2.Tobacco keratosis3.Leukodema4.Lichen planus5.Nicotinic stomatitis6.hairy leukoplakia7.white spongy nevus

White lesions showing bilateral distribution

1.Hereditary conditions2.Cheek chewing3.Lichen planus4.Lupus erythematosus

White lesions with cutaneous lesions

1.Lichen panus2.Lupus erythematosus

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Premalignant lesions of the oral mucosa

Premalignant lesion is a morphologically altered tissue that has

a great risk than normal tissue for malignant transformation

Premalignant lesions include :

1.Idiopathic Leukoplakia2.Candidal leukoplakia3.Erythroplakia4.Oral epithelial atrophy

N.B.Toluidine blue is a stain used to detect the

premalignant lesions

It stains the premalignant lesions in blueErythroplakia

Definition

Erythroplakia is a clinical term that refers to a red patch on the

oral mucosa which cannot be attributed, clinically or

microscopically, to any other diagnosable disease

Etiology :

The causes of this lesion are the same to those of oral cancer

Tobacco has a significant role in the induction of many ofthese lesions

AlcoholNutitional difficiencyAnd other factors may also have modifying roles

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Clinical featuresAge : between 50 & 70 years

Common sites : the floor of the mouth & the ventral surface of

the tongue

Bright red plaque of velvety textureHomogeneous irregular outlineFocal white areas representing keratosis intermingling the

red patches speckled leukoplakia

Histopathologic features

40% of erythroplakias shows severe dysplastic changes orcarcinoma in situ

50% of the cases are squamous carcinomaA relative reduction in keratin production & relative

increase in vascularity account for the red color of these

lesions

Differential diagnosisA differential diagnosis should include :

Kaposi s sarcomaContact allergic reactionVascular malformation

Treatment :

Surgical excision is the treatment of choice

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Oral epithelial atrophy

Conditions which predispose to oral epithelial atrophy

1.Plummer-Vinson syndrome {Patterson-kelly syndrome}2.Submucous fibrosis

1-Plummer-Vinson syndromeIt is a condition characterized by :

1.Iron deficiency anemia2.Post-cricoid carcinoma3.Oral manifestations

i. Glossitis &dysphagiaii. Burning sensation in the tongue &oral mucosa

iii. Severe angular cheilitisiv. Marked atrophy of the lingual papillae producing

smooth red appearance of the dorsal tongue surface

2-Oral submucous fibrosis

Etiology :1.Chronic exposure to chilly peppers2.Frequent chewing of betel nut3.Chronic & prolonged deficiency of iron &B-complex

vitamin , especially folic acid

Such factors alter the oral mucosa & increases the

hypersensitivity to many potential irritant such as dietary spices

& tobacco with an inflammatory reaction & fibrotic response

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Clinical features

1.Age : 20 to40 years2.Occurring almost exclusively in Indians3.Site : the soft palate & the buccal mucosa but may extend

into the pharynx& oesophagus

4.The affected mucosa loses its resilience & elasticity withresultant trismus & difficulty in eating

Treatment and prognosis

Includes elimination of the causative factor

Intralesional injections of steroids

The primary importance of submucous fibrosis relates to its

reported premalignant nature

The development of squamous cell carcinoma has been noted in

one third of the affected patients