Premalignant Premalignant Oral LesionsOral LesionsPrecancerous Oral LesionsPrecancerous Oral Lesions

Dr Shrinivas B Dr Shrinivas B Somalwar.M.D;D.N.B.Somalwar.M.D;D.N.B.

Assistant Professor Assistant Professor

Precancerous LesionPrecancerous Lesion

It is a benign, morphologically It is a benign, morphologically altered tissue that has a greater altered tissue that has a greater than normal risk of malignant than normal risk of malignant transformation.transformation. LeukoplakiaLeukoplakia ErythroplakiaErythroplakia ErythroleukoplakiaErythroleukoplakia

LeukoplakiaLeukoplakia(leuko-white; plakia-patch)(leuko-white; plakia-patch)

Oral leukoplakia is defined by the WHO as Oral leukoplakia is defined by the WHO as “a white patch or plaque that “a white patch or plaque that cannotcannot be be characterized clinically or pathologically characterized clinically or pathologically as any other disease”. as any other disease”.

Thus a diagnosis by Thus a diagnosis by exclusionexclusion.. The term is strictly a The term is strictly a CLINICAL CLINICAL one and one and

does does notnot imply a specific histopathologic imply a specific histopathologic tissue alteration.tissue alteration.

Leukoplakia is the most common oral Leukoplakia is the most common oral precancer.precancer.

Leukoplakia: Why is it Leukoplakia: Why is it White?White?

The clinical color (white) results The clinical color (white) results from a thickened surface keratin from a thickened surface keratin layer (which appears white when layer (which appears white when wet) or a thickened spinous layer, wet) or a thickened spinous layer, which masks the normal vascularity which masks the normal vascularity (redness) of the underlying (redness) of the underlying connective tissue.connective tissue.

Leukoplakia: A Leukoplakia: A Premalignant or Premalignant or

Precancerous LesionPrecancerous Lesion Risk of malignant transformation is Risk of malignant transformation is

greater in a leukoplakic lesion than greater in a leukoplakic lesion than that associated with normal or that associated with normal or unaltered mucosa. unaltered mucosa.

LeukoplakiaLeukoplakia

In fact, dysplastic epithelium or In fact, dysplastic epithelium or invasive carcinoma is found in only 5 invasive carcinoma is found in only 5 to 25 % of the biopsy samples of to 25 % of the biopsy samples of leukoplakia.leukoplakia.

Leukoplakia: Malignant Leukoplakia: Malignant Transformation PotentialTransformation Potential

Overall, the malignant Overall, the malignant transformation potential of transformation potential of leukoplakia is 4 % (estimated leukoplakia is 4 % (estimated lifetime risk).lifetime risk).

Leukoplakia: How Common Leukoplakia: How Common Is It?Is It?

Leukoplakia is by far the most common Leukoplakia is by far the most common oral precancer, accounting for 85 % of oral precancer, accounting for 85 % of such lesions. such lesions.

Leukoplakia: Who Leukoplakia: Who Develops It?Develops It?

There is a strong male predilection There is a strong male predilection (70%), except in parts of the country (70%), except in parts of the country where females use tobacco products where females use tobacco products more than males.more than males.

In general, leukoplakia is diagnosed In general, leukoplakia is diagnosed more frequently now than in the more frequently now than in the past, probably because of enhance past, probably because of enhance awareness.awareness.

Leukoplakia: EtiologyLeukoplakia: Etiology

The cause of leukoplakia remains The cause of leukoplakia remains unknownunknown..

Over the years the following have Over the years the following have been considered: tobacco, alcohol, been considered: tobacco, alcohol, ultraviolet radiation, ultraviolet radiation, microorganisms and trauma.microorganisms and trauma.

Etiology of Leukoplakia: Etiology of Leukoplakia: The Role of TobaccoThe Role of Tobacco

The habit of tobacco smoking appears most The habit of tobacco smoking appears most closely associated with leukoplakia closely associated with leukoplakia development.development.

80 % of patients with leukoplakia are 80 % of patients with leukoplakia are smokers.smokers.

Smokers are much more likely to have Smokers are much more likely to have leukoplakia than non-smokers.leukoplakia than non-smokers.

Heavier smokers have greater numbers of Heavier smokers have greater numbers of and larger lesions than light smokers.and larger lesions than light smokers.

A large proportion of leukoplakias in persons A large proportion of leukoplakias in persons who stop smoking either disappear or become who stop smoking either disappear or become smaller soon after discontinuing the habit.smaller soon after discontinuing the habit.

Etiology of Leukoplakia: Etiology of Leukoplakia: The Role of Alcohol The Role of Alcohol

Alcohol, which seems to have a strong Alcohol, which seems to have a strong synergistic effect with tobacco in oral synergistic effect with tobacco in oral cancer development, has cancer development, has notnot been been associated with leukoplakia.associated with leukoplakia.

Etiology of Leukoplakia: Etiology of Leukoplakia: The Role of Ultraviolet The Role of Ultraviolet

RadiationRadiation Ultraviolet radiation has been Ultraviolet radiation has been

associated with leukoplakia of the associated with leukoplakia of the vermilion of the lower lip.vermilion of the lower lip.

This leukoplakia is usually This leukoplakia is usually associated with actinic cheilosis.associated with actinic cheilosis.

Etiology of Leukoplakia: Etiology of Leukoplakia: The Role of The Role of

MicroorganismsMicroorganisms Treponema pallidum Treponema pallidum has been has been

implicated in leukoplakia of the implicated in leukoplakia of the dorsal surface of the tongue in dorsal surface of the tongue in patients with syphilis.patients with syphilis.

Candida albicansCandida albicans has been has been demonstrated histologically in the demonstrated histologically in the hyperplastic/dysplastic epithelium of hyperplastic/dysplastic epithelium of lesions termed candidal leukoplakia lesions termed candidal leukoplakia and candidal hyperplasia.and candidal hyperplasia.

Etiology of Leukoplakia: Etiology of Leukoplakia: The Role of The Role of

Microorganisms ContinuedMicroorganisms Continued Human papillomavirus (HPV), Human papillomavirus (HPV),

particularly subtypes 16 and 18, particularly subtypes 16 and 18, have been identified in some oral have been identified in some oral leukoplakias.leukoplakias.

However, HPV has also been However, HPV has also been demonstrated in normal oral demonstrated in normal oral epithelial cells.epithelial cells.

Etiology of Leukoplakia: Etiology of Leukoplakia: The Role of TraumaThe Role of Trauma

Several keratotic lesions, which until Several keratotic lesions, which until recently have been viewed as variants of recently have been viewed as variants of leukoplakia, are now considered leukoplakia, are now considered notnot to to be premalignant.be premalignant.

Included in this group are lesions termed Included in this group are lesions termed nicotine stomatitis and frictional nicotine stomatitis and frictional keratosis.keratosis.

The keratoses are readily reversible The keratoses are readily reversible after the elimination of the trauma or after the elimination of the trauma or chronic irritation.chronic irritation.

Leukoplakia: Clinical Leukoplakia: Clinical FeaturesFeatures

Individual lesions vary in clinical Individual lesions vary in clinical appearance and tend to change over appearance and tend to change over time.time.

Early/mild lesions usually appear as Early/mild lesions usually appear as slightly elevated gray or gray-white slightly elevated gray or gray-white plaques, which may appear translucent, plaques, which may appear translucent, fissured or wrinkled and are typically fissured or wrinkled and are typically soft and flat.soft and flat.

Early/mild lesions are usually well Early/mild lesions are usually well demarcated but may blend into the demarcated but may blend into the surrounding normal mucosa.surrounding normal mucosa.

Leukoplakia: Leukoplakia: Histopathologic FeaturesHistopathologic Features

Leukoplakia is characterized by a Leukoplakia is characterized by a thickened keratin layer thickened keratin layer (hyperkeratosis) with or without a (hyperkeratosis) with or without a thickened spinous layer (acanthosis).thickened spinous layer (acanthosis).

Some leukoplakias show surface Some leukoplakias show surface hyperkeratosis but with atrophy or hyperkeratosis but with atrophy or thinning of the underlying epithelium.thinning of the underlying epithelium.

Variable numbers of chronic Variable numbers of chronic inflammatory cells are typically noted inflammatory cells are typically noted within the underlying connective tissue.within the underlying connective tissue.

Leukoplakia: Leukoplakia: Histopathologic Features Histopathologic Features

ContinuedContinued While most leukoplakias show no While most leukoplakias show no

dysplasia on biopsy, some 5 to 25 % dysplasia on biopsy, some 5 to 25 % of the cases do show evidence of of the cases do show evidence of epithelial dysplasia (or squamous epithelial dysplasia (or squamous cell carcinoma).cell carcinoma).

The histopathologic alterations of The histopathologic alterations of dysplastic epithelial cells are dysplastic epithelial cells are outlined in the next slide.outlined in the next slide.

Histopathologic Alterations Histopathologic Alterations of Dysplastic Epithelial of Dysplastic Epithelial

CellsCells Enlarged nuclei and cells.Enlarged nuclei and cells. Large and prominent nucleoli.Large and prominent nucleoli. Increased nuclear-cytoplasmic ratio.Increased nuclear-cytoplasmic ratio. Hyperchromatic (dark-staining) nuclei.Hyperchromatic (dark-staining) nuclei. Pleomorphic (abnormally shaped) nuclei Pleomorphic (abnormally shaped) nuclei

and cells.and cells. Dyskeratosis (premature keratinization)Dyskeratosis (premature keratinization) Increased mitotic activity and abnormal Increased mitotic activity and abnormal

mitotic figuresmitotic figures

Histopathologic Alterations Histopathologic Alterations of Dysplastic Epithelium of Dysplastic Epithelium

ContinuedContinued Bulbous or teardrop-shaped rete Bulbous or teardrop-shaped rete

ridges.ridges. Loss of polarity (lack of progressive Loss of polarity (lack of progressive

maturation toward the surface).maturation toward the surface). Keratin or epithelial pearls.Keratin or epithelial pearls. Loss of typical epithelial cell Loss of typical epithelial cell

cohesiveness.cohesiveness.

Erythroplakia: DefinitionErythroplakia: Definition

Erythroplakia is defined as a red Erythroplakia is defined as a red patch that patch that cannotcannot be clinically or be clinically or pathologically diagnosed as any pathologically diagnosed as any other condition.other condition.

Erythroplasia is occasionally used as Erythroplasia is occasionally used as a synonym for erythroplakia a synonym for erythroplakia although it was originally used by although it was originally used by Queyrat to describe a precancerous Queyrat to describe a precancerous red lesion of the penis.red lesion of the penis.

ErythroplakiaErythroplakia

Almost all true erythroplakias Almost all true erythroplakias demonstrate significant epithelial demonstrate significant epithelial dysplasia, carcinoma dysplasia, carcinoma in situin situ or or invasive squamous cell carcinoma.invasive squamous cell carcinoma.

The cause (s) of erythroplakias are The cause (s) of erythroplakias are unknown but presumed to be the unknown but presumed to be the same as those associated with same as those associated with squamous cell carcinoma.squamous cell carcinoma.

ErythroplakiaErythroplakia

Erythroplakia is far less common than Erythroplakia is far less common than leukoplakia but has a much greater leukoplakia but has a much greater potential to be severely dysplastic at potential to be severely dysplastic at the time of biopsy or to develop the time of biopsy or to develop invasive malignancy at a later time.invasive malignancy at a later time.

Erythroplakia can occur in conjunction Erythroplakia can occur in conjunction with leukoplakia and has been found with leukoplakia and has been found concurrently with a large proportion concurrently with a large proportion of early invasive oral carcinomas.of early invasive oral carcinomas.

Erythoplakia: Clinical Erythoplakia: Clinical FeaturesFeatures

It is predominantly a disease of older males It is predominantly a disease of older males with a peak prevalence between the ages of with a peak prevalence between the ages of 65 and 74 years.65 and 74 years.

The floor of the mouth, tongue and soft The floor of the mouth, tongue and soft palate are the most commonly involved sites.palate are the most commonly involved sites.

Multiple lesions may occur.Multiple lesions may occur. Early erythroplakias appear as well-Early erythroplakias appear as well-

demarcated erythematous macules or demarcated erythematous macules or plaques with a soft velvety texture.plaques with a soft velvety texture.

Unfortunately, it is usually asymptomatic.Unfortunately, it is usually asymptomatic.

Plummer-Vinson SyndromePlummer-Vinson Syndrome(Paterson-Kelly Syndrome)(Paterson-Kelly Syndrome)

This is an uncommon condition This is an uncommon condition characterized by an iron-deficiency characterized by an iron-deficiency anemia with an associated glossitis anemia with an associated glossitis and dysphagia.and dysphagia.

It is of significance because of its It is of significance because of its association with a high frequency of association with a high frequency of oral and esophageal squamous cell oral and esophageal squamous cell carcinoma.carcinoma.

Plummer-Vinson Syndrome: Plummer-Vinson Syndrome: Clinical Features ContinuedClinical Features Continued Another sign involves the nails, Another sign involves the nails,

which are often spoon-shaped which are often spoon-shaped (koilonychia) and may be brittle.(koilonychia) and may be brittle.

The symptoms of anemia such as The symptoms of anemia such as fatigue, shortness of breath and fatigue, shortness of breath and weakness often lead the patient to weakness often lead the patient to seek medical care.seek medical care.

Plummer-Vinson Syndrome: Plummer-Vinson Syndrome: Laboratory & Microscopic Laboratory & Microscopic

FeaturesFeatures Hematologic studies show a Hematologic studies show a

hypochromic, microcytic anemia hypochromic, microcytic anemia consistent with iron-deficiency anemia.consistent with iron-deficiency anemia.

Biopsy of the oral mucosa reveals Biopsy of the oral mucosa reveals epithelial atrophy with submucosal epithelial atrophy with submucosal inflammation.inflammation.

In advanced case one may see epithelial In advanced case one may see epithelial atypia, dysplasia, carcinoma atypia, dysplasia, carcinoma in situin situ or or frank squamous cell carcinoma.frank squamous cell carcinoma.

Plummer-Vinson Syndrome: Plummer-Vinson Syndrome: Treatment and Prognosis Treatment and Prognosis

Treatment centers on correcting the Treatment centers on correcting the iron-deficiency anemia and if this is iron-deficiency anemia and if this is successful, the glossodynia and successful, the glossodynia and esophageal symptoms improve.esophageal symptoms improve.

Patients should be evaluated periodically Patients should be evaluated periodically for oral, pharyngeal and esophageal for oral, pharyngeal and esophageal cancer.cancer.

The frequency of malignancy in these The frequency of malignancy in these patients has ranged from 5 to 50 % in patients has ranged from 5 to 50 % in the literature.the literature.

BENIGN TUMORSBENIGN TUMORS

pyogenic granuloma is a highly vascular pyogenic granuloma is a highly vascular pedunculated lesion, usually occurring in the pedunculated lesion, usually occurring in the gingiva of children, young adults, and, gingiva of children, young adults, and, commonly, pregnant women (pregnancy tumor). commonly, pregnant women (pregnancy tumor). The surface of the lesion is typically ulcerated The surface of the lesion is typically ulcerated and red to purple in color. and red to purple in color.

Squamous cell carcinoma

Schematic representation of the sites of origin of squamous cell carcinoma of the oral cavity, in numerical order of frequency.

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