Oral Path Exam III

neoplasia
Click the card to flip 👆
1 / 54
Terms in this set (54)
neoplasia
- abnormal process whereby cells exhibit uncontrolled proliferation
- initial stimulus that triggers cell change is not known
- tumors exhibit unlimited and unregulated growth
causes of neoplasia
• Chemicals
• Viruses (EBV, HPV)
• Radiation: sunlight, x-rays, nuclear fission
• Genetic mutation
benign
- remains localized
- encapsulated; slow growing
- does not spread to distant sites
- cells resemble normal cells (well differentiated)
- Mitotic figures are rare
- No metastasis
malignant
- invades and destroys surrounding tissue
- slow to rapid growth
- may spread throughout the body
- can be well differentiated, poorly differentiated, or undifferentiated (anaplastic)
- Mitotic figures may be numerous
- Invasive and unencapsulated
- Metastasis is likely

• Well differentiated
-Cells resemble normal cells
• Poorly differentiated
-Cells have some characteristics of the
tissue from which they were derived
• Undifferentiated (anaplastic)
-Cells do not resemble the tissue from
which they were derived
malignant histopathology
- cells vary in size and shape (pleomorphic)
- nuclei are darker than normal (hyperchromatic)
- cells exhibit increased nuclear cytoplasmic ratios (very little cytoplasm around the nucleus)
- cells demonstrate normal and abnormal mitotic figures
papilloma
- benign tumor of squamous epithelium
- exophytic pedunculated (stocks) or sessile (flat) growth
- composed of numerous papillary projections that are white or mucosal colored
- most cases arise on the soft palate or tongue
- no sex predilection

• Microscopic features
-Numerous fingerlike or papillary
projections composed of stratified
squamous epithelium and surfaced by
keratin
-Central core of fibrous connective tissue

Treatment:
- surgical excision
-Does not recur
Image: papilloma
premalignant lesions (stratified squamous epithelium)
• Leukoplakia
• Erythroplakia
• Epithelial dysplasia
Leukoplakia
clinical term used to define a white plaque-like lesion that cannot be rubbed off or diagnosed as a specific disease
- cause should be identified and removed
- high risk areas: floor of the mouth, lip, ventrolateral tongue, soft palate

• Microscopic features
-Most cases represent hyperkeratosis or
epithelial hyperplasia and hyperkeratosis
-5%-25% show epithelial dysplasia
(premalignant process)
-May show squamous cell carcinoma
(malignant process)

Treatment:
-Dependent on the microscopic findings
-Surgical excision of all cases of epithelial
dysplasia
Image: Leukoplakia
Erythroplakia
• Clinical term used to describe a smooth red
patch or a granular red and velvety patch
• Speckled leukoplakia: mixture of red and
white areas
• Most common locations
-Floor of mouth
-Tongue
-Soft palate
• Leukoplakia > erythroplakia (60:1)

• Microscopic features
-90% of cases demonstrate epithelial
dysplasia or squamous cell carcinoma

• Treatment
-Depends on the microscopic findings
Image: Erythroplakia
epithelial dysplasia
• Microscopic diagnosis that indicates disordered
growth
• Considered a premalignant process; frequently
precedes squamous cell carcinoma
• Abnormal changes may revert to normal if the
stimulus (tobacco smoking) is removed
• May present as a red or a white lesion
• Often arises in the floor of the mouth or tongue

• Microscopic features
-Abnormal maturation of the epithelial cells
-Hyperplasia of the basal cell layer
-Enlarged, pleomorphic nuclei
-Increased nuclear cytoplasmic ratios
-Abnormal keratinization
-Increased numbers of normal and abnormal
mitotic figures
-Abnormal cells have not invaded through
the basement membrane
-Carcinoma in situ: full thickness dysplasia
(severe dysplasia)

• Treatment
-Surgical excision
-Close long-term follow-up examinations
Image: epithelial dysplasia
squamous cell carcinoma• Malignant tumor of squamous epithelium • Most common primary malignancy of the oral cavity • Can present as leukoplakia, erythroplakia, speckled leukoplakia, or an exophytic ulcerative mass • Can infiltrate and destroy underlying bone • May occur anywhere in the oral cavity • Most common locations -Floor of the mouth -Ventrolateral tongue -Soft palate -Tonsillar pillar • Risk factors -Tobacco products -Alcohol -HPV • Majority of patients are > 40; M > F • Microscopic features -Invasion of tumor cells through the basement membrane into the underlying connective tissue -Sheets and nests of neoplastic squamous cells -Keratin production is variable -Neoplastic cells contain hyperchromatic nuclei and numerous mitotic figures • Treatment -Surgical excision -Radiation therapy and chemotherapy may be used in combination with surgery • Prognosis -Related to the size and location of the tumor and the presence or absence of metastases -Assessed using the TNM staging systemTNM Staging System for Oral Squamous Cell Carcinoma• T - Tumor -T1 - Tumor less than 2 cm in diameter -T2 - Tumor 2-4 cm in diameter -T3 - Tumor greater than 4 cm in diameter -T4 - Tumor invades adjacent structures • N - Node -N0 - No palpable nodes -N1 - Ipsilateral palpable nodes -N2 - Contralateral or bilateral nodes -N3 - Fixed palpable nodes • M - Metastasis -M0 - No distant metastasis -M1 - Clinical or radiographic evidence of distant metastasis TNM Staging System Stage I T1N0M0 Stage II T2N0M0 Stage III T3N0M0 T1,T2,T3 N1M0 Stage IV T1,T2,T3 N2M0 T1,T2,T3 N3M0 T4N0M0 Any patient with M1verrucous carcinoma• Specific type of squamous cell carcinoma • Presents as a slow-growing exophytic tumor with a white surface; M > F • Occurs in older men • Typically involves the vestibule and buccal mucosa • Microscopic features -Well-differentiated epithelium arranged in numerous papillary projections *-Keratin plugging* -Broad-based rete pegs that penetrate into the connective tissue -Basement membrane is intact • Treatment -Surgical excision -Does not metastasize but can cause significant local damage -Prognosis is better than prognosis of squamous cell carcinomabasal cell carcinoma• Malignant skin tumor • Associated with excessive sun exposure • Often occurs on the face • Presents as a non-healing ulcer with rolled borders - no sex predilection • Microscopic features -Proliferation of basal cells into the underlying connective tissue -Tumor cells are well-differentiated • Treatment -Surgical excision -Rarely metastasizes -Locally invasive and may be disfiguringsquamous epithelium tumors- papilloma - premalignant lesions - leukoplakia - erythroplakia - epithelial dysplasia - squamous cell carcinoma - verrucous carcinoma - basal cell carcinomasalivary gland tumors- pleomorphic adenoma - monomorphic adenomas - adenoid cystic carcinoma - mucoepidermoid carcinomapleomorphic adenoma• Also known as benign mixed tumor • Benign salivary gland tumor *• Most common salivary gland tumor (90%)* • Most common extraoral location: parotid gland • Most common intraoral location: palate • Slowly enlarging, non-ulcerated, painless, dome -shaped mass • Adults > 40; F > M • Microscopic features -Encapsulated tumor -Tissue is composed of a mixture of epithelium and tissue that resembles connective tissue -Connective tissue may contain cartilage -Connective tissue is derived from myoepithelial cells • Treatment -Surgical excision -Recurrence rates vary depending on location and type of surgery -May undergo malignant transformationmonomorphic adenomas• Benign salivary gland tumor • Less common than the pleomorphic adenoma • Adults; F > M • Most common locations: *upper lip and buccal mucosa* • Slowly enlarging, non-ulcerated, painless, dome-shaped mass • Microscopic features -Encapsulated -Varies markedly but composed of a uniform pattern of epithelial cells -No connective tissue-like component • Treatment -Surgical excision -Recurrence is rareadenoid cystic carcinoma• Malignant salivary gland tumor • Most common extraoral location: parotid gland • Most common intraoral location: palate • Adults; F > M • Slowly growing mass that may exhibit surface ulceration *• Pain is common since these tumor surround nerves* • Microscopic features -Looks like Swiss cheese -Cylinders composed of small, darkly staining epithelial cells -Mitotic figures are rare • Treatment -Complete surgical excision -Recurrence and persistent local invasion are common -30% of patients have cervical lymph node involvement -Distant metastasis can occur - lungsmucoepidermoid carcinoma• Malignant salivary gland tumor • Most common extraoral location: parotid gland • Most common intraoral location: palate • Wide age range: children to adults; F > M *• Most common malignant salivary gland tumor in children* • Slowly enlarging mass • May occur centrally in bone • Mandibular premolar and molar region • Unilocular or multilocular radiolucency Microscopic features -Unencapsulated -Infiltrating -Composed of a combination of mucous cells interspersed with squamous-like epithelial cells • Treatment -Complete surgical excision -Low-grade tumors: 92% 5-year survival rate -High-grade tumors: 49% 5-year survival rateOdontogenic Epithelial Tumors- ameloblastoma - adenomatoid odontogenic tumorameloblastoma• Benign, slow-growing but locally aggressive • Infiltrates into surrounding tissue and can cause extensive destruction • Asymptomatic swelling of the affected bone • Adults; M = F • 80% arise in the mandible - molar and ramus area • Radiographic features -Unilocular or multilocular radiolucency -May be associated with impacted teeth -May resemble a dentigerous cyst • Microscopic features -Ameloblast-like epithelial cells that surround areas resembling stellate reticulum -Ameloblast-like epithelial cells are arranged in islands or interconnecting strands • Treatment -Complete surgical excision -Recurrence is commonAdenomatoid Odontogenic Tumor• Benign epithelial odontogenic tumor • 70% rule: -Females -Under 20 years of age -Anterior jaws - maxilla -Impacted tooth • Asymptomatic; localized swelling • Radiographic features -Well-circumscribed radiolucency -May simulate a dentigerous cyst since it is often associated with an impacted tooth -Calcifications - radiopaque areas • Microscopic features -Encapsulated -Duct-like structures, whorls, and masses of cuboidal and spindle-shaped epithelial cells -Calcifications • Treatment -Enucleation -Recurrence is raremesenchymal odontogenic tumors- odontogenic myxoma - cementoblastomaodontogenic myxoma• Benign *unencapsulated* infiltrating tumor • Occurs in young people between 10-29 years of age • F = M • Mandible > maxilla • Radiographic features -Multilocular radiolucency with poorly defined margins -May cause tooth displacement • Microscopic features -Composed of pale-staining mucopolysaccharide ground substance that contains cells with long cytoplasmic processes -Resembles the dental papilla • Treatment -Complete surgical excision -Recurrence rate = 25% -Most cases recur within 2 years of treatmentcementoblastoma• Cementum-producing tumor found in *young adults* • Pain is common • May cause localized bone expansion • Radiographic features -Well-defined radiopaque mass with a surrounding radiolucent halo -Attached to the root or roots of a mandibular premolar or molar • Microscopic features -Proliferation of cellular cementum fused to the root or roots of the affected tooth • Treatment -Enucleation of the tumor and removal of the tooth -Does not recurmixed odontogenic tumorsOdontomaOdontoma*• Most common odontogenic tumor* • Adolescents and young adults; M = F • Most cases are identified because of failure of a permanent tooth to erupt • Large lesions may cause swelling and displacement of erupted teeth • Often associated with impacted or unerupted teeth • Two types: compound and complex • Compound -Collection of numerous small teeth *-Anterior maxilla* • Complex -Calcified mass that does not resemble a normal tooth -Posterior mandible • Radiographic features -Compound odontoma •Cluster of numerous miniature teeth surrounded by a radiolucent halo -Complex odontoma •Radiopaque mass surrounded by a radiolucent halo • Microscopic features -Compound odontoma •Multiple teeth composed of enamel, dentin, cementum, and pulp tissue -Complex odontoma •Disorder mass of enamel, dentin, cementum, and pulp tissue • Treatment -Surgical excision -Does not recurradiopaque tumors- cementoblastoma - odontomaradiolucent tumors- mucoepidermoid carcinoma - ameloblastoma - Adenomatoid Odontogenic Tumor - myxomaMixed Radiolucent/Radiopaque tumorsAOTtumors of soft tissue- Lipoma - Neurofibroma and schwannoma - Granular cell tumor - Hemangioma - LymphangiomaLipoma• Benign tumor of mature fat cells • Yellowish mass with delicate blood vessels on the surface • Adults; F = M • Most common intraoral locations: buccal mucosa and vestibule • Microscopic features -Well-delineated tumor composed of lobules of mature fat cells -Fat cells are of uniform size and shape • Treatment -Surgical excision -Does not recurtumors of nerve tissue- neurofibroma and schwannoma - granular cell tumorneurofibroma and schwannoma• Benign tumors derived from nerve tissue • Schwannoma = neurilemmoma • Schwannomas are derived from Schwann cells • Neurofibromas are derived from Schwann cells and perineural fibroblasts • Most common intraoral location: tongue • May cause macroglossia • Any age; M=F • Multiple neurofibromas are associated with neurofibromatosis • Microscopic features -Neurofibroma •Diffuse proliferation of spindle-shaped Schwann cells and perineural fibroblasts -Schwannoma •Spindle-shaped Schwann cells arranged in palisaded whorls around a central pink zone •Encapsulated • Treatment -Surgical excision -Generally do not recur -Neurofibroma may undergo malignant degeneration but is extremely rareGranular cell tumor• Benign tumor derived from neural or primitive mesenchymal cells • Presents as a painless, non-ulcerated nodule • Most common intraoral locations: tongue > buccal mucosa • Adults; F > M • Microscopic features -Composed of large oval-shaped cells with a granular cytoplasm -Overlying surface epithelium may show Pseudoepitheliomatous hyperplasia and be mistaken for squamous cell carcinoma • Treatment -Surgical excision -Does not recurvascular tumors- hemangioma - lymphangiomaHemangioma• Benign vascular tumor • May represent a developmental lesion rather than a true tumor since it does not exhibit an unlimited growth potential • Present at birth or arises shortly thereafter • At least 50% of cases occur in the head and neck area • Most common intraoral location: tongue • May lead to marked macroglossia • F > M • May occur in adults as a response to trauma (vascular malformation) -Deep-red to blue lesions that blanch when pressure is applied • Two subtypes: capillary and cavernous • Microscopic features: -Capillary •Numerous small capillaries -Cavernous •Numerous large blood vessels • Treatment -Most cases undergo spontaneous remission -Surgery -Injection of a sclerosing solutionLymphangioma• Benign tumor of lymphatic vessels • Less common than the hemangioma • Most are present at birth • 50% arise in the head and neck area; M = F • Most common intraoral location: tongue -May cause macroglossia • Ill-defined mass with a pebbly surface • Cystic hygroma: lymphangioma in the neck • Microscopic features -Numerous lymphatic vessels containing lymph fluid -Vessels are close to the overlying surface epithelium • Treatment -Surgical excision -Does not respond to a sclerosing solution -Tends to recurTumors of Melanin-Producing Cells1. Melanocytic Nevi 2. Melanomamelanocytic nevi• Nevus (singular) (nevi - plural): congenital lesion • Developmental tumor of melanocytes (nevus cells) • Skin or oral mucosa • Tan to brown macules or papules • Most common intraoral locations: hard palate > buccal mucosa • 20-50 years of age; F > M • Treatment -Biopsy to establish the diagnosis -Surgical excision -Recurrence is rareMelanoma• Malignant tumor of melanocytes • Most cases arise on the skin as a result of prolonged sun exposure • Involvement of the oral mucosa is rare • Rapidly enlarging blue-to-black mass • Most common intraoral locations: palate and maxillary gingiva • Adults > 40 years of age • ABCDE's of melanoma -A: Asymmetry (one half different from the other) -B: Border (irregular) -C: Color (multicolored) -D: Diameter (larger than 6 mm) -E: Evolving (changing in size, shape, or color) • Treatment -Surgical excision -Chemotherapy (in conjunction with surgery) -Rapidly and early metastasis -Prognosis is poorTumors of Bone and CartilageOsteoma ExostosisExostosis• Bony hard nodule on the buccal aspect of the maxillary or mandibular alveolar ridges • Asymptomatic • Tend to occur in individuals who have a grinding or bruxing habit • Adults; M = F • Microscopic features -Normal compact bone • Treatment -None unless a prosthetic appliance needs to be constructedOsteoma• Asymptomatic benign bone tumor • Slow-growing; M = F • Radiographic features -Sharply defined radiopaque mass within bone (endosteal) -Delineated mass attached to the outer surface of the bone (periosteal) -May cause expansion of bone • Most common location in the jaws: posterior mandible • Common in the frontal sinuses • Multiple osteomas are a component of Gardner syndrome Microscopic features -Normal compact bone Treatment -Surgical excision -Does not recurTumors of Blood-Forming TissueslymphomaLymphoma (non-hodgkin lymphoma)• Malignant tumor of lymphoid tissue • Numerous types exist • Gradual enlargement of involved lymph nodes • May present as a primary lesion in the oral soft tissues or bone • Most common intraoral location: tonsillar area and posterior hard palate • Adults; M > F • May arise centrally in bone -Destructive, poorly defined radiolucency • Treatment -Radiotherapy, chemotherapy, or a combination of these therapies -Surgery is not a good option since patients often have systemic involvement -Prognosis depends on the type of lymphoma and extent of involvementMetastatic Tumors of the Jaws• Rare • Most cases arise from the thyroid, breast, lungs, prostate, and kidneys • Adults; M > F • Most frequent intraoral site: mandible • Pain, paresthesia, swelling, expansion of bone, loosening of teeth • Typically appears several years after the primary lesion is discovered • Occasionally the oral metastatic tumor may be the first manifestation of a primary tumor elsewhere • Radiographic features -Variable -Poorly defined and radiolucent -Spiked appearance to roots -Some case are radiopaque: breast, prostate, and lungs • Microscopic features -Resembles the primary malignancy -Majority of cases are epithelial in origin - adenocarcinoma • Treatment -Chemotherapy and radiation therapy -Prognosis is poorBenign Fibro-Osseous Lesions• Periapical cemento-osseous dysplasia • Focal cemento-osseous dysplasia • Florid cemento-osseous dysplasia • Fibrous dysplasiaPeriapical cemento-osseous dysplasia• Common disease of unknown cause • Asymptomatic; discovered on routine radiographic examination • Anterior mandible • Adults > 30 years of age; F > M • Blacks > whites • Associated teeth are vital • Radiographic features -Early lesions: well circumscribed and radiolucent -Older lesions: radiolucent with central opacifications • Microscopic features -Combination of fibrous tissue and calcifications -Early lesions: mainly fibrous tissue with scattered calcifications -Older lesions: fibrous tissue with numerous calcifications • Treatment -Diagnosis is established based on characteristic clinical and radiographic features -Once a diagnosis has been made, no treatment is necessaryFlorid cemento-osseous dysplasia• Asymptomatic fibro-osseous lesion • Involves multiple quadrants in maxilla and mandible (usually posterior areas) • Middle-aged (> 40) black women • Cause is unknown • Radiographic features -Irregular radiopaque masses -Occasionally demonstrates an early radiolucent phase -No bone expansion • Microscopic features -Sclerotic masses of bone, cementum, or both • Diagnosis -Based on characteristic clinical and radiographic features • Treatment -Unnecessary -If sclerotic bone becomes exposed to the oral environment, osteomyelitis may occur •Surgical intervention and antibioticsFocal cemento-osseous dysplasia• Asymptomatic fibro-osseous lesion • Women between 30-50 years of age • Whites > blacks • Posterior mandible • Radiographic features -Isolated -Well-delineated radiolucent to radiopaque lesion less than 1.5 cm. in size • Diagnosis -Biopsy -Numerous gritty pieces of soft and hard tissue • Treatment -Once a diagnosis has been made, no treatment is necessary -Prognosis is excellentfibrous dysplasia• Developmental disease characterized by the replacement of normal bone with abnormal fibrous connective tissue and calcified material (benign fibro-osseous lesion) • Genetic mutation has been identified as the underlying cause (GNAS gene) • Two forms: monostotic and polyostotic • Monostotic fibrous dysplasia -Most common type of fibrous dysplasia (85%) -Involves a single bone -Maxilla (posterior) > mandible • May involve the ribs, femur, and tibia • Children and young adults; M = F • Painless swelling or bulging of the affected bone • May lead to malocclusion, tipping, or displacement of adjacent teeth • Polyostotic fibrous dysplasia -Involvement of more than one bone -Children; F > M -Skull, clavicles, and long bones are often affected -Long bone involvement may cause bowing, fractures, pain • Polyostotic fibrous dysplasia -Café au lait spots - light brown macules on skin -Three forms *•Craniofacial* -Involves the maxilla with extension into the sinuses, zygoma, sphenoid, and occipital bones *•Jaffe (Jaffe-Lichtenstein) type* -Involves multiple bones along with café au lait skin macules *•Albright (McCune-Albright) syndrome* -Involves multiple bones -Endocrine abnormalities •Precocious puberty in females -Stunting of skeletal growth •Early epiphyseal plate closure -Café au lait skin macules • Radiographic features -Diffuse radiopacity that blends into the surrounding normal bone - "ground glass" -May vary from radiolucent to radiopaque depending on the degree of calcification present • Microscopic features -Cellular fibrous connective tissue interspersed with irregularly shaped bone trabeculae • Diagnosis -Correlate clinical and radiographic features • Treatment -Recontour affected bone for cosmetic reasons -Radiation therapy is contraindicated - may lead to osteosarcomaPaget disease of bone (osteitis deformans)• Also called osteitis deformans • Chronic metabolic bone disease • Cause is unknown but thought to be caused by a virus • Men > 50 years of age • Typically involves the pelvis, spinal column, tibia, and skull • Maxilla > mandible • Enlargement of the affected bone; pain • Spacing between the teeth increases as bone enlarges • Dentures do not fit • Headache, dizziness, deafness - enlarging bone impinges on cranial nerves • Radiographic features -Patchy radiolucency and radiopacity - "cotton wool" appearance (late stages) -Early stages are nonspecific -Hypercementosis -Loss of the lamina dura -Obliteration of the PDL • Laboratory findings -Markedly elevated serum alkaline phosphatase -Serum calcium and phosphorus are normal • Microscopic features -Bone trabeculae surfaced by numerous osteoclasts and osteoblasts -Prominent reversal lines - mosaic bone -Well vascularized connective tissue • Treatment -Bisphosphonates -Slowly progressive -Complications include fracture, development of osteosarcoma, and heart disease