Neoplasia

1. Neoplasia Chapter 7

2. Vocabulary • Neoplasia - new growth…the formation of tumors by the uncontrolled proliferation of cells • Neoplasm – Tumor…a new growth of tissue in which growth is uncontrolled and progressive

3. Oncology - The study of tumors • Irreversible change must take place in the cells and passed on to new cells for a neoplasia to occur. • Neoplasia is an abnormal process. The cells are abnormal, the proliferation of the cells is uncontrolled and unlimited.

4. Classification • Benign neoplasm remains localized, may be encapsulated (walled off by fibrous connective tissue). • Malignant neoplasm invades and destroys surrounding tissue and has the ability to metastasize. (Cancer)

5. Malignant tumors • Well-differentiated - Composed of neoplastic cells that resemble normal cells • Poorly-differentiated - cells have only some of the characteristics of the tissue from which they were derived. • Undifferentiated or anaplastic - do not resemble tissue from which they were derived at all.

6. Names of Tumors-learn table 7-2 page 259 • Prefix is determined by tissue or cell of origin. • Suffix – oma=tumor • Benign tumor of fat - lipoma • Benign tumor of bone - osteoma • Malignant tumor of epithelium -carcinoma(10x more common than sarcoma) • Malignant tumor of connective tissue - sarcoma

7. 3 types of epithelial tumors found in oral cavity • 1. tumors from squamous epithelium Example: Papilloma • 2. tumors derived from salivary gland epithelium Example: Pleomorphic adenoma • 3. tumors from odontogenic epithelium Example: Ameloblastoma

8. Papilloma • A benign exophytic papillary growth of stratified squamous epithelium. • anywhere on the oral mucosa •  adult occurrence   •  sessile or pedunculated exophytic growth    • papillary (cauliflower-like) appearance    • long duration   •  white or pink in color

9. Papilloma  small finger-like projections on surface of lesion    keratinized or nonkeratinized squamous epithelium      chronic inflammatory cells in connective tissue

10. Simple columnar epithelium with very regular line-up of nuclei.

11. Premalignant Lesions Leukoplakia • Clinical term-white plaque lesion of the oral mucosa that cannot be rubbed off and cannot be diagnosised as a specific disease. • May be hyperkeratosis

12. Premalignant LesionsErythroplakia • A clinical term that is used to describe an oral mucosal lesion that appears as a smooth red patch or a granular red and velvety patch • Much less common than leukoplakia • More serious than leukoplakia

13. Carcinoma-in-situ case study • Study Case 1 60 year-old woman presented to the USC School of Dentistry requesting dentures. Examination revealed, in addition to many periodontally involved lower teeth, a asymptomatic large erythematous lesion on the left palate. There was neither ulceration nor mass noted. For the past two years the patient had been hospitalized for hepatic cirrhosis.

14. Premalignant LesionsEpithelial Dysplasia • A histologic diagnosis that indicates disordered growth • Is considered a premalignant condition • Lesions that microscopically exhibit epithelial dysplasia frequently precede squamous cell carcinoma • May be erythematous or leukoplakic • Carcinoma in situ - the most severe stage of epithelial dysplasia, involving the entire thickness of the epithelium, with the epithelial basement membrane remaining intact.

15. Epithelial Dysplasia basal cell proliferation,   pleomorphism (cell variation),   mitotic activity, hyperchromatic nuclei,   dyskeratosis (abnormal keratosis),   premalignant (cellular change in the epithelium and no invasion into the connective tissue) tissue of originisstratified squamous epithelium

16. Carcinoma-in-situ case study • Cellular, hyperchromatic atypical mucosal epithelium covering focally inflamed connective tissue

17. Carcinoma-in-situ case study • Superficial portion of the epithelium showing increased nuclear-cytoplasmic ratio, many mitoses, minimal atypical parakeratin on the surface and lack of maturation.

18. Carcinoma-in-situ case study • Deeper portions of epithelium display the same abnormalities shown in the previous image.

19. Carcinoma-in-situ case study • Questions: (1) What microscopic features characterize this lesion? • basement membrane is still intact…entire epithelium is dysplastic and no normal epithelial cells remain…carcinoma is still confined to the epithelium. (2) How is this lesion related to mucosal dysplasia and how does it differ microscopically? • Cannot tell the difference clinically • It is an extension of the dysplastic tissue through the entire epithelium. • increased nuclear-cytoplasmic ratio, many mitoses

20. Carcinoma-in-situ case study (3) What would you expect the natural history of this disease to be? • duration varies from months to years • Etiology: usually tobacco, alcohol, irritation, or a combination (4) Is the presence of hepatic cirrhosis of any significance? • Yes, indication of the alcohol abuse

21. Squamous Cell Carcinoma • The most common malignant tumor of the oral cavity • Red and white in color • Firm to touch • Small ulcerations • Microscopically pathologists look for keratin pearl formation, loss of polarity, reversal of nuclear to cytoplasmic ratio and mitotic activity.

22. Squamous Cell Carcinoma • Accounts for more than ninety percent of the cancers of the lip and base of the tongue • Erythroplakia has a strong link to dysplasia and carcinoma • Men over 45 years of age have the highest incidence • If a vesicular lesion on the lip remains more than 3 weeks it should be biopsied • Only 30 percent with late metastatic cancer live 5 years.

23. The World Health Organization (WHO) • Predicts an increase in the number of cases of oral cancer • Projected number of new cases of oral and oral-pharyngeal cancer in the U.S. is 31,000 per year

24. RDH therapy for SCCA • Detection • Oral SCCA will occur if antecedent dysplastic oral mucosal lesions are not diagnosed and treated early • Sciubba,J.J.(2001).Oral Cancer: The importance of early diagnosis and treatment. American Journal of Clinical Dermatology, 2(4),239-252.

25. RDH therapy for SCC • Comprehensive health history • Including high risk factors, such as alcohol and tobacco use • Patients who have an increase in sunlight exposure are also at a greater risk and the hygienist may observe this fact visually or in conversation • Since time lapse after diagnosis is almost five months before the average patient is treated for these lesions, the hygienist should offer to schedule an appointment for the patient with an oral surgeon before the patient leaves the office

26. Squamous Cell Carcinoma

27. Squamous Cell Carcinoma

28. Squamous Cell Carcinoma Keratin Pearls

29. Squamous Cell Carcinoma Case Study • 40-year-old patient presented because of pain in the lower lip for the past four weeks. He claimed that he had injured it with a chicken bone two months previously and that the resulting "sore" never healed. Examination revealed an indurated, painful, ulcerated mass on the labial vestibule and gingiva. Three round, hard masses were palpated in the right neck. Incisional biopsy was performed.

30. Squamous Cell Carcinoma Case Study • Papillary configuration to the surface.

31. SCCA • Infiltrating large bulbous rete ridges with uniform spinous layer.

32. SCCA • QUESTIONS: 1. Where does this lesion occur most commonly? 2. In what age group does this disease occur most frequently? 3. Would you expect the pathologist to have much difficulty in diagnosing this disease microscopically? Why? 4. What does the lymphadenopathy in this case probably represent? 5. How should this disease be treated?

33. SCCA • Well-differentiated squamous cells with uniform nuclear morphology, slight enlargement of nuclei, easily identified nucleoli and abundant pink cytoplasm with intercellular bridges.

34. SCCA • 1.Where does this lesion occur most commonly? • floor of mouth, ventrolateral tongue, soft palate, tonsillar pillar, and retromolar areas • 2. In what age group does this disease occur most frequently? • Males over 40 years • 3. What does the lymphadenopathy in this case probably represent? • Metastasis • 4. How should this disease be treated? • surgical excision, radiation therapy or both

35. SCCA

36. SCCA

37. Lateral Border of TongueThis is a somewhat less obvious swelling on the lateral border of the tongue that is focally keratotic and ulcerated. Palpation reveals it to be quite extensive and to involve a major portion of this side of the tongue. It is markedly fixed and hard. This patient also has cervical lymph node metastasis.

38. Here again is an extremely early malignancy characterized only by thickening and erythema of the floor of the mouth. This innocuous appearing lesion could be easily overlooked or even undetected.

39. "Classic" AppearanceThis small, round but fixed andindurated keratinizing carcinoma of the soft palate should certainly be suspicious to all who visualize it. The cancer was actually not detected on initial examination and was only noted by the dentist when the patient returned for denture impressions. Again, the soft palate is one of the more common areas involved by squamous cell carcinoma.

40. SCCA • Bone resorption • considerable bone resorption of a pattern which is not typical of periodontal disease. Note the floating bone and tooth, markedly abnormal findings in inflammatory disease. This should alert one to the possibility of a serious condition and biopsy would then be indicated.

41. Verrucous Carcinoma • Distinct, diffuse, papillary, superficial, nonmetastasizing form of well-differentiated squamous cell carcinoma. • Snuff dipper’s cancer

42. Basal Cell carcinoma • Common, locally destructive, nonmetastasizing malignancy of the skin composed of medullary pattens of basaloid cells.

43. Salivary Gland Tumors • Pleomorphic Adenoma (Benign Mixed Tumor) The palate is the most common intraoral location, but these tumors may be found in any area where salivary gland tissue is present Most common salivary gland neoplasm – accounts for about 90% of all benign salivary gland tumors.

44. Pleomorphic Adenoma (Benign Mixed Tumor) • The benign mixed tumor is the most common salivary gland neoplasm. The term of mixed tumor is derived from the fact that under microscopic examination, there are areas resembling both epithelial and connective tissue components.

45. Monomorphic Adenoma • Benign encapsulated salivary gland tumor • Uniform pattern of epithelial cells • They occur most commonly in adult females • Treated by surgical excision • Papillary cystadenoma lymphomatosum – (Warthin’s tumor) – two types of tissue: epithelial an lymphoid

46. Adenoid Cystic Carcinoma • Here we have another example of the confusion in terminology. The most common designation is adenoid cystic carcinoma. These are malignant tumors that clinically may be quite deceptive as they often present with features suggestive of a benign process. They have pronounced infiltrative capacity, tend to grow around and along nerves, like to grow and infiltrate into bone and metastasize quite readily to lymph nodes and to distant organs. They must be treated by wide "radical" surgical excision.

47. Adenoid Cystic Carcinoma • The microscopic features are often described as resembling "Swiss cheese." This is because the tumor grows in such a fashion that microcysts are formed within the masses of tumor cells. Palate

48. Mucoepidermoid Carcinoma • This is a typical example of a mucoepidermoid carcinoma occurring on the palate. It was slow-growing and, in fact, had been present for three years. Clinically, it has all the features of a benign tumor; however, biopsy revealed its true nature. Clinically, these lesions are indistinguishable from other salivary gland tumors and often appear deceptively innocuous. They are not encapsulated and tend to infiltrate readily so that relatively wide surgical excision is necessary. Palate, mandibular retromolar area and buccal mucosa are most common intraoral areas of involvement.

49. Odontogenic Tumors • Tumors comprised of tooth-forming tissues • Most are benign • Malignant do occur but are rare

50. Ameloblastoma • Epithelial odontogenic tumor • Benign, slow-growing but locally aggressive • Death can occur if a tumor extends into vital structures