Dent 355 Oral PathologyDent 355 Oral PathologyLaboratory Session Laboratory Session

Oral Epithelial Tumors, Oral Epithelial Tumors, Melanocytic Nevi, and Melanocytic Nevi, and

MelanomaMelanomaDr. Rima SafadiDr. Rima Safadi

Oral and Maxillofacial Oral and Maxillofacial PathologistPathologist

Modified from Dr. Huda Hammad Modified from Dr. Huda Hammad

CISOSCC

Oral squamous cell carcinoma

Human Papilloma Virus-Associated Human Papilloma Virus-Associated Lesions:Lesions:Squamous Cell PapillomaSquamous Cell Papilloma

Human Papilloma Virus-Associated Human Papilloma Virus-Associated Lesions:Lesions:Squamous Cell PapillomaSquamous Cell Papilloma

Histopathologic Histopathologic Features:Features:

Finger-like epithelial Finger-like epithelial proliferation proliferation

thin fibrovascular thin fibrovascular cores.cores.

Hecks disease

Koilocytes

Human Papilloma Virus-Associated Human Papilloma Virus-Associated Lesions:Lesions:Verruca Vulgaris (Common Wart)Verruca Vulgaris (Common Wart)

Human Papilloma Virus-Associated Human Papilloma Virus-Associated Lesions:Lesions:Verruca Vulgaris (Common Wart)Verruca Vulgaris (Common Wart)Histopathologic Features:Histopathologic Features:

Papillary finger-like epithelial Papillary finger-like epithelial proliferation supported by proliferation supported by thin fibrovascular cores.thin fibrovascular cores.

Acanthosis and Acanthosis and hyperkeratosis.hyperkeratosis.

Hyperplastic rete ridges Hyperplastic rete ridges around margins slope around margins slope inwards towards center.inwards towards center.

Large vacuolated cells Large vacuolated cells (koilocytes) with prominent (koilocytes) with prominent keratohyalin granules.keratohyalin granules.

Verruca vulgaris

Human Papilloma Virus-Associated Human Papilloma Virus-Associated Lesions:Lesions:Condyloma Acuminatum (Venereal Condyloma Acuminatum (Venereal Wart)Wart)

Human Papilloma Virus-Associated Human Papilloma Virus-Associated Lesions:Lesions:Condyloma Acuminatum (Venereal Condyloma Acuminatum (Venereal Wart)Wart)Histopathologic Features:Histopathologic Features: Prominent acanthosis with Prominent acanthosis with

marked broadening and marked broadening and elongation of rete ridges.elongation of rete ridges.

Keratinization is not a Keratinization is not a prominent feature.prominent feature.

Koilocytosis.Koilocytosis.

Squamous Cell Carcinoma:Squamous Cell Carcinoma:Clinical Presentation, Early LesionsClinical Presentation, Early Lesions

1. White patch.1. White patch. 2. Small exophytic growth 2. Small exophytic growth which in early stages which in early stages shows no ulceration or shows no ulceration or erythemaerythema

Squamous Cell Carcinoma:Squamous Cell Carcinoma:Clinical Presentation, Early LesionsClinical Presentation, Early Lesions

3. Small indolent ulcer.3. Small indolent ulcer. 4. Erythroplakia.4. Erythroplakia.

Squamous Cell Carcinoma:Squamous Cell Carcinoma:Clinical Presentation, Early LesionsClinical Presentation, Early Lesions

5. Carcinoma of vermilion border of lip: slightly 5. Carcinoma of vermilion border of lip: slightly raised swelling, or crusty, inconspicuous lesion raised swelling, or crusty, inconspicuous lesion resembling delayed healing of herpes labialis.resembling delayed healing of herpes labialis.

Squamous Cell Carcinoma:Squamous Cell Carcinoma:Clinical Presentation, Advanced Clinical Presentation, Advanced LesionsLesions

Advanced lesions may Advanced lesions may present as:present as:

1. Broad-based, 1. Broad-based, exophytic mass with exophytic mass with rough, nodular, warty, rough, nodular, warty, hemorrhagic, or hemorrhagic, or necrotic surface.necrotic surface.

Squamous Cell Carcinoma:Squamous Cell Carcinoma:Clinical Presentation, Advanced Clinical Presentation, Advanced lesionslesions

2. Deeply destructive, 2. Deeply destructive, crater-like ulcer with crater-like ulcer with raised, rolled everted raised, rolled everted edges.edges.

Squamous Cell Carcinoma:Squamous Cell Carcinoma:Clinical Presentation, Advanced Clinical Presentation, Advanced LesionsLesions3. Infiltration of musculature may 3. Infiltration of musculature may

result in functional disturbances result in functional disturbances including impaired speech and including impaired speech and difficult swallowing.difficult swallowing.

4. Pain may be a feature.4. Pain may be a feature.

Squamous Cell Carcinoma:Squamous Cell Carcinoma:Clinical Presentation, Advanced Clinical Presentation, Advanced LesionsLesions5. Radiographic 5. Radiographic

evidence of bone evidence of bone destruction.destruction.

6. Mobility of teeth.6. Mobility of teeth.

7. Altered sensation over 7. Altered sensation over distribution of mental distribution of mental nerve.nerve.

8. Pathologic fracture of 8. Pathologic fracture of mandible.mandible.

Squamous Cell Carcinoma:Squamous Cell Carcinoma:Clinical PresentationClinical Presentation

9. Metastatic spread to 9. Metastatic spread to regional lymph nodes.regional lymph nodes.

Size of surface lesion does Size of surface lesion does not indicate extent of not indicate extent of underlying invasion.underlying invasion.

Squamous Cell Carcinoma:Squamous Cell Carcinoma:Clinical PresentationClinical Presentation

Squamous Cell Carcinoma:Squamous Cell Carcinoma:PathologyPathology

Considerable variation.Considerable variation.

Invasion and destruction of Invasion and destruction of local tissues accounts for local tissues accounts for induration and fixation induration and fixation detected clinically.detected clinically.

Cytologically malignant Cytologically malignant squamous epithelium with squamous epithelium with variable degrees of variable degrees of differentiation.differentiation.

Keratinization variesKeratinization varies with with degree of differentiation.degree of differentiation.

Keratin pearl

Invasive malignant epithelium

Squamous Cell Carcinoma:Squamous Cell Carcinoma:PathologyPathology

Well-differentiated tumors:Well-differentiated tumors:- Obvious squamous - Obvious squamous

differentiation.differentiation.- Masses of prickle cells with - Masses of prickle cells with

limiting layer of basal cells limiting layer of basal cells around them.around them.

- Recognizable intercellular - Recognizable intercellular bridges.bridges.

- Central keratin pearl - Central keratin pearl formation.formation.

- Nuclear and cellular - Nuclear and cellular pleomorphism is not pleomorphism is not prominnemt.prominnemt.

- Relatively few mitotic - Relatively few mitotic figures.figures.

Keratin pearl

Squamous Cell Carcinoma:Squamous Cell Carcinoma:PathologyPathology

Moderately Moderately differentiated tumors:differentiated tumors:

- Less keratinization.- Less keratinization.

- More pleomorphism of - More pleomorphism of cells and nuclei.cells and nuclei.

- Abundant and atypical - Abundant and atypical mitotic figures.mitotic figures.

- Still readily identified - Still readily identified as squamous type.as squamous type.

Squamous Cell Carcinoma:Squamous Cell Carcinoma:PathologyPathology

Poorly differentiated Poorly differentiated tumors:tumors:

- Keratinization usually - Keratinization usually absent.absent.

- Marked atypical features.- Marked atypical features.

- Cells may be hardly - Cells may be hardly recognizable as epithelial.recognizable as epithelial.

Poorly differentiated OSCC

Squamous Cell Carcinoma:Squamous Cell Carcinoma:PathologyPathology

Squamous Cell Carcinoma:Squamous Cell Carcinoma:Verrucous CarcinomaVerrucous Carcinoma

Squamous Cell Carcinoma:Squamous Cell Carcinoma:Verrucous CarcinomaVerrucous Carcinoma

Histopathologic Features:Histopathologic Features:

Very well differentiated, Very well differentiated, heavily keratinized SCC with heavily keratinized SCC with little or no cytological atypia.little or no cytological atypia.

Mitoses are rare.Mitoses are rare.

Squamous Cell Carcinoma:Squamous Cell Carcinoma:Verrucous CarcinomaVerrucous Carcinoma

Histopathologic Features:Histopathologic Features:

Although it is an exophytic tumor, it also has a Although it is an exophytic tumor, it also has a slowly advancing, slowly advancing, pushing, cohesive invasive pushing, cohesive invasive frontfront causing local destruction. causing local destruction.

Squamous Cell Carcinoma:Squamous Cell Carcinoma:Carcinoma-Carcinoma-In-SituIn-Situ

A term used to describe A term used to describe severe epithelial severe epithelial dysplasia in which the dysplasia in which the whole, or almost the whole, or almost the whole thickness of whole thickness of epithelium is involved, epithelium is involved, but basement but basement membrane is intact and membrane is intact and there is no invasion of there is no invasion of lamina propria.lamina propria.

Carcinoma in Situ

Squamous Cell Carcinoma:Squamous Cell Carcinoma:Carcinoma-Carcinoma-In-SituIn-Situ

Usually presents Usually presents clinically as clinically as leukoplakia or leukoplakia or erythroplakia.erythroplakia.

In some patients it In some patients it may progress to may progress to invasive carcinoma, invasive carcinoma, but in others it may but in others it may remain static or even remain static or even regress.regress.

Oral Premalignant Lesions and Oral Premalignant Lesions and ConditionsConditions

The following may be The following may be considered premalignant considered premalignant lesions or conditions:lesions or conditions:

1. Precancerous lesions:1. Precancerous lesions:a)a) Leukoplakia- Leukoplakia-

homogeneous, non-homogeneous, non-homogeneous, nodular, homogeneous, nodular, and speckled types, and speckled types, including chronic including chronic hyperplastic candidosis hyperplastic candidosis and proliferative verrucous and proliferative verrucous leukoplakia.leukoplakia.

b)b) erythroplakiaerythroplakiac)c) carcinoma carcinoma in situin situ..

Oral Premalignant Lesions and Oral Premalignant Lesions and ConditionsConditions

2. Precancerous conditions:2. Precancerous conditions:

a)a) oral submucous fibrosisoral submucous fibrosis

b)b) lichen planuslichen planus

c)c) actinic keratosis or cheilitis.actinic keratosis or cheilitis.

d)d) other conditions associated other conditions associated with oral epithelial atrophy, with oral epithelial atrophy, e.g. sideropenic dysphagia.e.g. sideropenic dysphagia.

Basal Cell Carcinoma (Rodent Ulcer):Basal Cell Carcinoma (Rodent Ulcer):Clinical FeaturesClinical Features

Basal Cell Carcinoma (Rodent Ulcer):Basal Cell Carcinoma (Rodent Ulcer): Clinical Features Clinical Features

Basal cell nevus Basal cell nevus syndrome.syndrome.

Basal Cell Carcinoma (Rodent Basal Cell Carcinoma (Rodent Ulcer):Ulcer):Histopathologic FeaturesHistopathologic Features Histologically consists Histologically consists

of malignant basaloid of malignant basaloid cells arranged in cells arranged in various patterns , various patterns , invading adjacent invading adjacent tissues.tissues.

Melanocytes

Acquired Melanocytic Nevi:Acquired Melanocytic Nevi:Clinical FeaturesClinical Features

Acquired Melanocytic Nevi:Acquired Melanocytic Nevi: Histopathologic Features Histopathologic Features

Junctional NevusJunctional Nevus

Acquired Melanocytic Nevi:Acquired Melanocytic Nevi: Histopathologic Features Histopathologic Features

Compound nevusCompound nevus

Acquired Melanocytic Nevi:Acquired Melanocytic Nevi: Histopathologic Features Histopathologic Features

Intramucosal Intramucosal (intradermal) nevus(intradermal) nevus

Malignant Melanoma:Malignant Melanoma:Clinical FeaturesClinical Features

ABCD Clinical Features:ABCD Clinical Features:

1.1. AAsymmetry (uncontrolled symmetry (uncontrolled growth pattern)        growth pattern)        

2.2. BBorder irregularity        order irregularity        

3.3. CColor variation       olor variation       

4.4. DDiameter greater than 6 iameter greater than 6 mmmm

Malignant Melanoma:Malignant Melanoma:Histopathologic FeaturesHistopathologic Features

Highly pleomorphic Highly pleomorphic neoplasms.neoplasms.

Variable melanin Variable melanin production, may be absent production, may be absent (amelanotic melanoma).(amelanotic melanoma).

Immunohistochemical Immunohistochemical studies using specific studies using specific markers for malignant markers for malignant melanocytes (S-100 and melanocytes (S-100 and HMB-45) are useful.HMB-45) are useful.

Ultrastructural examination Ultrastructural examination to identify immature to identify immature melanosomes can be used.melanosomes can be used.

Oral Malignant MelanomaOral Malignant Melanoma