Neoplasia

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Neoplasia

• Chapter 7

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Vocabulary

• Neoplasia - new growththe formation of tumors by
  the uncontrolled proliferation of cells
• Neoplasm Tumora new growth of tissue in which
  growth is uncontrolled and progressive

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• 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.

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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)

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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.

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Names of Tumors-learn table 7-2 page 259

• Prefix is determined by tissue or cell of origin.
• Suffix omatumor
• 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

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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

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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

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Papilloma
 small finger-like projections on surface of
lesion    keratinized or nonkeratinized squamous
epithelium      chronic inflammatory cells in
connective tissue
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Simple columnar epithelium with very regular
line-up of nuclei.
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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

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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

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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.

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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.

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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 origin is stratified squamous epithelium
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Carcinoma-in-situ case study

• Cellular, hyperchromatic atypical mucosal
  epithelium covering focally inflamed connective
  tissue

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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.

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Carcinoma-in-situ case study

• Deeper portions of epithelium display the same
  abnormalities shown in the previous image.

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Carcinoma-in-situ case study

• Questions
• (1) What microscopic features characterize this
  lesion?
• basement membrane is still intactentire
  epithelium is dysplastic and no normal epithelial
  cells remaincarcinoma 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

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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

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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.

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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.

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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

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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.

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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
  

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Squamous Cell Carcinoma
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Squamous Cell Carcinoma
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Squamous Cell Carcinoma
Keratin Pearls
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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.

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Squamous Cell Carcinoma Case Study

• Papillary configuration to the surface.

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SCCA

• Infiltrating large bulbous rete ridges with
  uniform spinous layer.

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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?

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SCCA

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

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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

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SCCA
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SCCA
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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.
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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.
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"Classic" AppearanceThis small, round but fixed
and indurated 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.
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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.

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Verrucous Carcinoma

• Distinct, diffuse, papillary, superficial,
  nonmetastasizing form of well-differentiated
  squamous cell carcinoma.
• Snuff dippers cancer

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Basal Cell carcinoma

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

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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.
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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.

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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 (Warthins
  tumor) two types of tissue epithelial an
  lymphoid

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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.

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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
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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.

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Odontogenic Tumors

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

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Ameloblastoma

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

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Ameloblastoma

• Composed of ameloblast-like epithelial cells that
  surround areas resembling stellate reticulum

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Ameloblastoma

• Ameloblastoma is the tumor of greatest
  significance in the odontogenic group. It is a
  progressively infiltrating neoplasm that tends to
  recur if inadequately treated and may attain such
  a size that tumor becomes unmanageable.
• This shows the typical radiographic features of
  an ameloblastoma. It is a multiloculated
  expanding lesion showing root resorption and
  destruction of the cortical plates. The
  multiloculations do not indicate separate
  cavities but are the result of bony ridges on the
  inner surfaces of the cortical plates. The lesion
  is slow growing and causes mainly expansion of
  bone however, extension into adjacent soft
  tissues may occur.

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Ameloblastoma

• Occlusal view of the same mandible displays
  destruction of cortical bone with formation of
  delicate curvilinear bone spicules in response to
  tumor growth

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Hemimandibulectomy

• The opposite half of the specimen displays well
  the two large cystic cavities. Care must be taken
  that biopsy samples are not obtained from such
  cysts because it false diagnosis of dentigerous
  cyst may be made. It is important to take the
  biopsy from solid tumor. Of course, it is quite
  difficult to determine exactly where the solid
  tumor is on the basis of radiographs.

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Calcifying Epithelial Odontogenic Tumor (CEOT)

• Benign epithelial odontogenic tumor
• Less frequent that Ameloblastoma
• Majority are adults
• More often in mandible

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Adenomatoid Odontogenic Tumor (AOT)

• A well-circumscribed lesion derived from
  odontogenic epithelium that usually occurs around
  the crowns of unerupted anterior teeth of young
  patients and consists of epithelium in swirls and
  ductal patterns interspersed with spherical
  calcifications.

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Adenomatoid Odontogenic Tumor (AOT)

• usually associated with an impacted tooth
• occurs during the second decade of life, commonly
  14 to 15 years of age
• females affected more often  
• commonly presented as an area of swelling over an
  unerupted tooth  
• may be associated with cortical expansion  
• anterior maxilla is the most common site

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Adenomatoid Odontogenic Tumor (AOT)

•   well-demarcated mixed radiolucent/
  radiopaque lesion
•   often surrounds the crown of an impacted tooth
•   radiolucency usually extends apically beyond
  the cementoenamel junction

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Calcifying Odontogenic Cyst

• A rare, well-circumscribed, solid or cystic
  lesion derived from odontogenic epithelium that
  resembles a follicular ameloblastoma but contains
  "ghost cells" and spherical calcifications.

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Calcifying Odontogenic Cyst

• One can easily see the calcification in this
  larger, more destructive example of the
  calcifying odontogenic cyst. Radiographic
  findings are neither consistent nor diagnostic.
  This radiograph would also suggest fibro-osseous
  disease, osteomyelitis and certain odontogenic
  tumors.

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Mesenchymal Odontogenic Tumors

• Odontogenic Myxoma - benign nonencapsulatied
  infiltrating tumor
• High rate of recurrence (25)
• Treated by complete surgical excision

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Mesenchymal Odontogenic Tumors

• Central Cementifying Fibroma- benign
  well-circumscribed tumor composed of fibrous
  connective tissue and calcifications resembling
  cementum

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Mesenchymal Odontogenic Tumors

• Benign Cementoblastoma
• A benign, well-circumscribed neoplasm of
  cementum-like tissue growing in continuity with
  the apical cemental layer of a molar or premolar
  that produce expansion of cortical plates and
  pain

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Mixed Odontogenic Tumors

• Ameloblastic fibroma A well-circumscribed lesion
  predominantly located over unerupted molars in
  young patients
• The epithelium and connective tissue recapitulate
  the cap and bell stages of odontogenesis

• first second decades mean 14 years  
•  slightly more common in males  
•  usually in posterior mandible around 1st molar  
•  small tumors are often asymptomatic  
•  large tumors produce swelling may get quite
  large expand
• solid, soft tissue mass  
•  slight buccal and lingual cortical expansion may
  be present

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Mixed Odontogenic Tumors

• Odontoma- A rare, well-circumscribed, solid or
  cystic lesion derived from odontogenic epithelium
  that resembles follicular ameloblastoma but
  contains "ghost cells" and spherical
  calcifications
• Compound
• Complex

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Tumors of Soft Tissue

• Tumors of adipose, nerve, muscle, blood and
  lymphatic tissues
• Benign or malignant

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Lipoma

• Benign neoplasm of normal fat cells that appears
  as a soft, movable swelling, often with a slight
  yellowish coloration.

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Neurofibroma

• Well demarcated or diffuse proliferation of
  benign perineural fibroblasts that are oriented
  in either a random pattern with a myxoid
  background or a nodular (plexiform) pattern

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Granular Cell Tumor

• Submucosal mass consisting of diffuse sheets of
  large cells of either nerve or muscle origin with
  a cytoplasm of densely packed eosinophilic
  granules (lysosomal bodies) and commonly found in
  the dorsal surface of the tongue

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Hemangioma

• A proliferation of large (cavernous) or small
  (capillary) vascular channels
• Occur commonly in children
• Lesions have variable clinical courses

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Quasi pathologic condition

• Focal Melanosis
• Focal melanosis represents an increase in
  deposition of melanin pigment in the basal cell
  layer of mucosal epithelium. It is fairly common
  and is obviously a frequent normal finding in
  African-American patients. It may also occur in
  white individuals and probably can be considered
  to be the same as a freckle.
• Here is a typical example of focal melanosis
  involving the lateral border of the tongue. There
  is no mass or substance to the lesion and it is
  asymptomatic.

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Quasi pathologic condition

• Focal Melanosis
• Prominent areas of focal melanosis are often
  intense and extensive in black patients as
  illustrated here on many areas of the attached
  gingiva

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Quasi pathologic condition

• Focal Melanosis
• Sometimes patients present with multiple focal
  discrete zones of increased pigmentation as
  evidenced here where numerous fungiform papillae
  of the tongue are involved

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Quasi pathologic condition

• Focal Melanosis
• Biopsy would reveal increased deposition of
  melanin pigment in the basal cell layer of the
  epithelium. Notice there is no evidence of tumor
  mass or of nevus cell proliferation

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Quasi pathologic condition

• Amalgam Tattoo
• Other conditions must be distinguished from focal
  melanosis and the most common of these is the
  amalgam tattoo illustrated here

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Malignant Melanoma

• An extremely malignant tumor
• When involving the oral mucosa, may present as a
  variable sized and irregular melanin
  pigmentation. These are usually single lesions
  and often show areas of nodular tumor
  proliferation and/or ulceration. The dentist
  ignored this particular example until it grew to
  this size and the patient eventually succumbed to
  the tumor.

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Tumors of Bone and Cartilage

• Torus
• Exostosis
• Osteoma - benign, radiopaque (a component of
  Gardners syndrome)

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Osteosarcoma

• Most common of the malignant neoplasms derived
  from bone cells that in the jaws exhibit
  radiographic widening of periodontal membrane of
  teeth and histologically exhibit a wide spectrum
  of findings, all of which contain atypical
  osteoblasts and abnormal bone or osteoid
  formation.

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Osteosarcoma
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Tumors of Blood-Forming Tisses

• Leukemia - acute or chronic, oral involvement
  most common with monocytic leukemiadiffuse
  gingival enlargement with persistent bleeding.
• Lymphoma - malignant tumor of lymphoid tissue.
• Multiple Myeloma - systemic, malignant
  proliferation of plasma cells.

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Metastatic Tumors of the Jaws

• RARE- majority from thyroid, breast, lungs,
  prostate and kidneys
• Poorly defined and radiolucent