Pre cancerous lesion and condition

Morphologically altered tissue in which cancer is more likely to occur than its apparently normal counter part.
-WHO(1978)
Definition

Leukoplakia is defined as ‘white patch’ or ‘plaque’ in the oral cavity, which cannot be scraped off or stripped off easily and more over which cannot be charectarized clinically or pathologically as any other disease. –WHO

Redefined as a “ predominantly white lesion of oral mucosa that cannot be characterized as any other definable lesion; some oral leukoplakia will transform into cancer” (Axell T, 1996)
Homogenous Leukoplakia

Non-Homogenous Leukoplakia
Granular or Nodular Leukoplakia
Speckled or Erythroleukoplakia
Verruciform Leukoplakia
Proliferative Verrucous Leukoplakia

1. Leukoplakia Dr Amitha

2. White lesions: Lesions of the oral mucosa, which are white, results from Thickened layer of keratin Epithelial hyperplasia Intercellular epithelial edema Reduced vacularity of subjacent connective tissue. White or yellow lesion may also be due to Fibrin exudate covering an ulcer Submucosal deposit or fungal colonies.

3. Classification: Hereditary : Reactive or inflammatory: Leukoedema White sponge nevus Hereditary benign intraepithelial dyskeratosis Follicular keratosis Frictional [traumatic] keratosis White lesions associated with smokeless tobacco Nicotine stomatitis Hairy leukoplakia Hairy tongue

4. Actinic chellitis Idiopathic leukoplakia Candidiasis Mucosal burns Fordyce's granules Parulis Regezi 5 th edition Geographic Tongue Lichen planus Lupus erythematosus Pre neoplastic and neoplastic lesions: Other white lesion: Non epithelial white lesion:

5. White lesion classification : Scrapable white lesion : Pseudo membraneus candidiasis Thermal burn Sloughing traumatic burn Tooth paste or mouth wash reaction Chemical burn Secondary syphilis Diphtheria Nonscrapable white lesion: Linea alba Leukoedema Leukoplakia Tobacco pouch keratosis Lichen planus Nicotine stomatitis Hairy leukoplakia White sponge nevus Hereditary benign intraepithelial dysfunction Tertiary syphilis

6. Premalignant Lesions Definition Morphologically altered tissue in which cancer is more likely to occur than its apparently normal counter part. -WHO(1978) Leukoplakia Erythroplakia Palatal changes associated with reverse smoking

7. Definition Generalized state or condition associated with significantly increased Risk for cancer Development. -WHO(1978 ) Oral Sub Mucous Fibrosis Oral Lichen Planus Lupus Erythematous Dyskeratosis Congenita Xeroderma pigmentosum Tertiary syphilis Premalignant Conditions

8. Also known as Leukokeratosis; Leuko= white Plakia = patch ( Leukoplakia

9. Leukoplakia Definition Leukoplakia is defined as ‘ white patch’ or ‘plaque’ in the oral cavity, which cannot be scraped off or stripped off easily and more over which cannot be charectarized clinically or pathologically as any other disease. –WHO Redefined as a “ predominantly white lesion of oral mucosa that cannot be characterized as any other definable lesion; some oral leukoplakia will transform into cancer” (Axell T, 1996)

10. Definition : Leukoplakia should be used to recognize white plaques of questionable risk having excluded(other) known disease or disorder that carry no increased risk for cancer. - Warnakulasuriya (2007)

11. Etiology : Tobacco - widely used in two forms; Smoking tobacco ( cigarette,bidi ) Smokeless tobacco Alcohol Has a strong synergistic effect with tobacco relative to oral cancer production. Sanguinaria

12. Ultraviolet radiation Causative factor for leukoplakia of the lower lip vermilion Usually associated with actinic cheilosis Microorganisms Treponema pallidum Candida albicans-candidal leukoplakia Human papilloma virus- subtypes 16 and 18

13. Trauma Several keratotic lesions had been viewed as variants of leukoplakia, but now are considered not to be a precancers

14. Site of Occurence Vestibule Buccal Palate Alveolar Ridge Lip Tongue Floor

15. Lateral aspect of the tongue was most common lesion site(25.9% of patients) Gums (18.5%) Buccal mucosa (16.7%) Floor of the mouth (9.3%) Palate, lip, and ventral surface of the tongue (each 7.4%) Dorsal surface of the tongue and commissures (each, 3.7%).

16. Clinical features:- Age : Occurs more commonly in older age group (>50 yrs ). Prevalence increases with age. Gender : Males > Females. Extent - May vary from small, localized, irregular patches to diffuse lesions. Color - May be white/ yellowish in color. Surface - The surface of the lesion is finely wrinkled in appearance, may feel rough on palpation. Symptoms - The patients may complain of increase thickness of mucosa. may be totally asymptomatic to burning sensation with ulcerated or nodular type.

17. Forms of leukoplakia :

18. Leukoplakia- TYPES Homogenous Leukoplakia Non-Homogenous Leukoplakia Granular or Nodular Leukoplakia Speckled or Erythroleukoplakia Verruciform Leukoplakia Proliferative Verrucous Leukoplakia

19. Homogenous Leukoplakia Clinical features Homogenous white patch/ plaque No red component Fine, white, grainy texture. Low risk malignant transformation rate Localized or extensive “cracked mud appearance” Histopathological features Hyperkeratosis Acanthosis Lymphocytes Dysplasia

20. Non Homogenous/ Heterogenous Leukoplakia/ Speckled Leukoplakia Clinical features Red and white mixed lesion White lesions interspersed with red or atrophic areas Higher risk of malignant transformation Histopathological features Irregular hyperkeratosis Bulbous and crowded rete pegs Epithelial atrophy Lymphocytes Severe dysplasia

21. Non homogenous/ Nodular Leukoplakia Clinical features White lesion with raised, pebbly surface with polypoid outgrowths (nodules) on an erythematous base Very fine, pin head sized or larger, rounded, red or white Associated with high malignant transformation rate showing carcinoma. Appearance often similar to Candidiasis Mild complaints of localized pain/ discomfort Histopathological features Irregular hyperkeratosis Bulbous rete pegs Lymphocytes Moderate/Severe dysplasia

22. Histopathological features Irregular hyperkeratosis- verruciform hyperkeratosis Bulbous rete pegs Lymphocytes Moderate/Severe dysplasia Congested vessels

23. Verrucous Leukoplakia Clinical features White lesion with raised corrugated surface White component is thicker than red & protrudes over surface mucosa The surface exhibits multiple papillary projections which are heavily keratinized 60 – 80 years Histopathological features Irregular hyperkeratosis Bulbous rete pegs Lymphocytes Moderate/Severe dysplasia Congested vessels

24. Proliferative Verrucous Leukoplakia Clinical features Persistent , extensive verrucoid/ wart like appearance Begins as simple hyperkeratosis, slow-growing, persistent & irreversible, but tends to spread, becomes multifocal with an exophytic surface. Most commonly resistant to all forms of therapy as recurrence is common. Strong female predilection > 60 years Highest risk of malignant transformation. Site- often bilateral & affects mandibular alveolar &buccal mucosa

25. Candidal Leukoplakia Clinical features Lesion: Firm, white leathery plaques Site: Cheeks, lips, palate, tongue Diagnosis: PAS (Periodic Acid Schiff) +. Histopathological features Epithelial proliferation (inflammatory/ reactive changes in epithelium) Epithelial Dysplasia Hyphae in leukoplakic lesions

26. Differential diagnosis Lichen planus Frictional keratosis Chronic hyperplastic candidiasis Leukoedema White sponge nevus Tobacco pouch keratosis

27. Blood investigation Tolidine blue staining or lugol’s iodine Exfoliative cytology Biopsy Investigations

28. Histopathologic features Hallmarks of histological aspects of leukoplakia is- epithelial hyperplasia and surface hyperkeratosis . The keratin layer may consist of : Parakeratin (hyperparakeratosis) with no granular cell layer and epithelial nuclei are retained in keratin layer. Orthokeratin ( hyperorthokeratosis) with granular cell layer and the nuclei are lost in the keratin layer. Combination of both Evidence of epithelial dysplasia is found in only 5% to 25% of the cases.

29. Leuokoplakia diagnosed as moderate dysplasia Leukoplakia diagnosed as severe dysplasia

30. MANAGEMENT Elimination of etiological factors Surgical management Cyrosurgery : Use of extreme cold to destroy the abnormal or diseased tissue. Eg : liquid nitrogen, argon CO2- laser surgery Retinoid Photodynamic therapy : It ’ s a treatment that uses drug, called photosensitizing agent and particular type of light. when photosensitizer are exposed to certain wavelength of light, they produce a form of oxygen that kills nearby cells (1-3).

31. Dysplasia It comprises a loss in the uniformity of the individual cells as well as loss in their architectural orientation. Dysplastic features : Increased mitotic activity Abnormal mitotic figures Increased nuclear-cytoplasmic ratio Enlarged nuclei and cells Hyperchromatic nuclei Pleomorphic nuclei and cells Large and prominent nucleoli Dyskeratosis Bulbous or teardrop shaped rete rigdes. Loss of polarity Keratin or epithelial pearls Loss of typical epithelial cell cohesiveness.

32. Histopathological features of epithelial dysplasia :

33. Loss of polarity Reduction in cellular cohesion Increased mitotic figures

34. Drop shaped rete processes Nuclear hyperchromatism Basal cell hyperplasia Dyskeratosis

35. Increased nuclear cytoplasm ratio Enlarged nucleoli Cellular pleomorphism

36. Staging system of leukoplakia : According to van der wall et al, 2000 Size of the leukoplakia and presence or absence of epithelial

37. Thank You!!! Thankyou And Subscribe for more presentation updates Dr Amitha