GI Pathology Module 5

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What is squamous cell carcinoma?: A malignant epithelial neoplasm
Epidemiology of squamous cell cancer?: 4% of all cancers

>90% of oral cancers

male>female

5th-9th decades
Etiology of squamous cell canrcinoma?: tobacco
alcohol
(betel nut, HPV)
Precursor lesions to squamous cell carcinoma?: LEUKOPLAKIA
-- most are reactive keratosis
-- 20% are dysplastic
-- 4% are carcinoma

ERYTHROPLASIA
-- 80% in high-risk areas are carcinoma
Common sites of squamous cell carcinoma?: ventrolateral tongue - 50%

floor of mouth - 20%

soft palate-tonsillar pillar complex - 6%

gingiva-alveolar ridge
Clinical presentation of squamous cell carcinoma?: dysphagia

odynophagia

otalgia
Gross presentation of squamous cell carcinoma?: painless undurated ulcer OR

exophytic fungating mass
Histology of squamous cell carcinoma?: -- invasive neoplastic nests of squamous epithelial cells
-- pleomorphism
-- hyperchromatism
-- increased nuclear:cytoplasm
-- mitotic figures
-- intercellular bridges
-- keratinization "PEARLS"
Treatment for squamous cell carcinoma?: surgical resection

radiation therapy

chemotherapy
Prognosis for squamous cell carcinoma?: poor

overall 40-50% 5 year survival
Therapeutic morbidity of squamous cell carcinoma?: pain
dysfxn (mastication, deglutition, speech/communication)
malnutrition, esthetics
xerostomia, caries
mucositis, candidiasis
sensory deficit, trismus
osteoradionecrosis
aspiration/airway compromise
psychosocial inpact
List other cancers of the head and neck.: Adenocarcinomas

Lymphoma

Bone Sarcomas

Soft tissue sarcomas

Neuroendocrine tumors

Skin cancer/melanoma

Metastatic disease to head/neck
Name the three different types of odontogenic cysts.: 1. Radicular Cyst

2. Dentigerous Cyst

3. Odontogenic Keratocyst
Describe the radicular cyst: - inflammatory

- common incidence

- arises in periapical granuloma/abcess assoc w/ non-vital tooth

- periapical unilocular radiolucency
Treatment and prognosis for radicular cyst?: endodontic therapy

extraction/curettage

Prognosis: good
Describe the dentigerous cyst.: - developmental cyst

- common incidence

- arises from dental follicle assoc w/ impacted/unerupted tooth

- pericoronal unilocular radiolucency

- may reach destructive size
Treatment and prognosis of dentigerous cyst?: surgical removal/curettage

Prognosis: good
-- rare neoplastic transformation
Describe a odontogenic keratocyst.: - developmental vs. neoplastic cystic lesion

- incidence in 3-11% of odontogenic cysts

- arises from odontogenic epithelium

- aggressive/destructive lesion
Treatment and prognosis of odontogenic keratocyst?: Curettage w/ peripheral ostectomy, resection

High recurrence rate - assoc w/ nevoid basal cell carcinoid syndrome (Gorlin syndrome)
List the two types of odontogenic tumors.: 1. Odontoma

2. Ameloblastoma
Describe the odontoma.: - most common odontogenic tumor

- hamartomatous malformation of tooth structure

- may interfere w/ tooth eruption
Treatment and prognosis of odontomas?: surgical removal

prognosis: good
Describe an ameloblastoma.: - epithelial odontogenic neoplasm

- uncommon incidence

- found at the posterior mandible in the 4th decade

- expansile multiocular radiolucency

- locally invasive/destructive
Treatment and prognosis of ameloblastomas?: resection

prognosis: high recurrence rate, rare malignant behavior
List the common problems with salivary glands.: 1. mucocele

2. sialolithiasis

3. siadadenitis

4. xerostomia

5. sjogren's syndrome

6. salivary gland tumors
Describe a mucocele.: (mucous extravatation phenomenon)

- bluish submucosal swelling

- mucin spillage

- ruptured salivary excretory duct secondary to trauma

- very common

- found in children and young adults

- lower lip or ranula (lesion in floor of mouth)
Treatment and prognosis of a mucocele?: excision

prognosis: good
Describe sialolithiasis.: - calcium salt deposition in salivary duct system - nidus

- submandibular gland most commonly involved

- obstruciton w/ episodic pain and swelling related to meals

- salivary gland inflammation and atrophy
Treatment for sialolithiasis?: surgical removal
Describe sialadenitis.: - inflammation of salivary glands

- viral - mumps

- bacterial - acute parotitis (perioperative period)

- chronic sclerosing sialadenitis -- obstruction
Describe xerostomia.: - reduced salivary flow -- dry mouth

- common incidence
What are common causes of xerostomia?: medications

radiation therapy

Sjogren's syndrome

DM

Sarcoidosis

HIV infection

Smoking

Mouth breathing
What are complications of xerostomia?: mucositis

dental caries

candidiasis

difficulty w/ mastication

dysphagia

speech problems

altered taste

difficulty wearing denture prostheses
How do you manage xerostomia?: -- correct underlying cause

-- saliva replacement: water rinses, artificial saliva

-- sialogogues - parasympathomimetic drugs

-- dental preventive care

-- antifungal medication
Describe Sjogren's syndrome.: - autoimmune exocrinopathy

- xerostomia -- salivary glands

- keratoconjuntivitis sicca (dry eyes) -- lacrimal glands

- 0.2-0.3% of population and 80-90% of those affected are middle-aged females

- associated autoimmune disease -- RA
Complications of Sjogren's?: ocular dryness -- blindness

mucositis

dental caries

candidiasis

dysphagia

speech difficulties

altered taste

enlarged salivary glands

increased risk of lymphoma
Extraglandular manifestations of Sjogren's syndrome?: nephritis

pneumonitis

vasculitus

neuropathy

biliary cirrhosis

Reynaud's phenomenon

fatigue

depression

lymphadenopathy
How do we diagnose Sjogren's?: DRY EYES - Schirmer test, Rose Bengal staining

DRY MOUTH - reduced salivary flow rate, "cracker" sign

Labial salivary gland/parotid biopsy -- focus score >1.0

Serologic evidence of autoimmune disease -- RA, ANA, SS-A, SS-B
How do we manage Sjogren's?: rheumatologist

opthalmologist - eye care

dentist - preventive dental care

supportive care: saliva substitutes, sialogogues, antifungal therapy

Moisture Seekers support group -- Sjogren's Syndrome Foundation
List the 4 types of salivary gland tumors.: 1. Pleomorphic Adenoma (benign mixed tumor)

2. Papillary Cystadenoma Lymphomatosum (Warthin's tumor)

3. Mucoepidermoid Carcinoma

4. Adenoid Cystic Carcinoma
General features and epidemiology of pleomorphic adenoma (benign mixed tumor)?: - benign neoplasm of salivary gland origin

- most common salivary gland neoplasm (70%)

- female>male

- 3rd - 6th decade

- found on the parotid gland
Clinical presentation of the pleomorphic adenoma (benign mixed tumor)?: slow growing painless mass
Gross pathology of the pleomorphic adenoma (benign mixed tumor)?: well demarcated firm tan white solid/cystic mass
Histopathology of the pleomorphic adenoma (benign mixed tumor)?: ductal epithelial cells

myoepithelial cells

stroma -- myxoid, chondroid, fibrous, hyaline
Treatment and prognosis of the pleomorphic adenoma (benign mixed tumor)?: surgical excision (superficial parotidectomy)

Prognosis: excellent
Complications of pleomorphic adenoma (benign mixed tumor)?: recurrence -- multifocal

malignant transformation - carcinoma
General features and epidemiology of the papillary cystadenoma lymphomatosum (Warthin's tumor)?: - benign salivary gland tumor

- common incidence

- male>female

- 5th - 7th decades

- found at the parotid

- multifocal/bilateral in 14%
Symptoms and etiology of papillary cystadenoma lymphomatosum (Warthin's tumor)?: symptoms: painless mass

etiology: smoking (8x risk)
Gross pathology of the papillary cystadenoma lymphomatosum (Warthin's tumor)?: well circumscribed cystic mass - "machine oil fluid"
Histopathology of the papillary cystadenoma lymphomatosum (Warthin's tumor)?: cystic lesion w/ papillary fronds lined by bilayered oncocytic epithelial cells w/ associated lymphoid stroma
Treatment and prognosis of the papillary cystadenoma lymphomatosum (Warthin's tumor)?: surgical excision

prognosis: excellent
Complications from papillary cystadenoma lymphomatosum (Warthin's tumor)?: recurrence

malignant transformation is very rare
General features and epidemiology of mucoepidermoid carcinoma?: - malignant salivary gland neoplasm

- most common malignant salivary gland tumor (30%)

- male = female

- wide age range, 3-6th decades

- found at the parotid, palate
Gross pathology of the mucoepidermoid carcinoma?: unencapsulated tan white solid and cystic tumor
Histopathology of the mucoepidermoid carcinoma?: - epidermoid cells

- mucous cells

- intermediate cells

- cystic/solid growth patterns

- low - intermediate - high grades
Treatment of mucoepidermoid carcinoma?: surgical excision

neck dissection

radiation therapy
Prognosis of mucoepidermoid carcinoma?: Low to intermediate grade - 90% 5-year survival

High grade - 40% 5-year survival

Metastasis --> lymph nodes, lung, bone
General features and epidemiology of adenoid cystic carcinoma?: - malignant epithelial cell neoplasm

- 12% of malignant salivary gland tumors

- male = female

- 5th-7th decades

- found at parotid, submandibular gland, palate
Clinical symptoms of adenoid cystic carcinoma?: painful mass

cranial nerve deficit
Gross pathology of adenoid cystic carcinoma?: solid firm tan mass
Histopathology of adenoid cystic carcinoma?: highly infiltrative

cribriform ("swiss cheese"), tubular and solid growth patterns

perineural invasion

mucohyaline stroma
Treatment for adenoid cystic carcinoma?: surgical excision

radiation therapy
Prognosis for adenoid cystic carcinoma?: protracted relentless course

5-year survival - 75%
20-year survival - 13%

Multiple local recurrences

Metastasis - late in clinical course to lymph nodes, lung, bone

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