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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 ¶basal 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