12/28/2018 CAUTION WEETH LECTUURE • Participants should be cautioned about the potential risks of using limited knowledge when integrating new techniques. EARLY ORAL CANCERS AND PRE-CANCERS MARY RIEPMA ROSS THEATER LINCOLN NEBRASKA JANUARY 4, 2019 DONALD M. COHEN DMD, MS, MBA PROFESSOR OF ORAL & MAXILOFACIAL PATHOLOGY ACTING CHAIR DEPARTMENT OF ORAL DIAGNOSTIC SCIENCS UNIVERSITY OF FLORIDA COLLEGE OF DENTISTRY GAINESVILLE, FLORIDA [email protected] 800-500-7585 Conflicts of Interests Course Objectives • Neither my immediate family nor I have any • Upon completion of this course, participants should be able to: financial interests that would create a conflict of • Recognize and formulate a differential diagnosis, understand the etiology and interest or restrict our independent judgment management of various oral and maxillofacial conditions. with regard to the content of this course. • Better recognize early mailignacies, improve diagnostic skills for oral soft and hard tissue lesions through practice sessions utilizing the audience response devices. GENERAL DENTIST TO ORAL SURGEON ORAL SURGOEN NOT TO WORRY PLEASE TAKE OUT TWO LOOSE TEETH TWO WEEK FOLLOW UP!! 1 12/28/2018 IDIOPATHIC LEUKOPLAKIA • FEATURES TO WORRY ABOUT • Occurrence in non-smoker • Thickened often corrugated appearance • Associated erythema • High risk location-horseshoe shaped area • ??pain • Multifocal or recurrent NON-SMOKERS LEUKOPLAKIA TONSILLAR CRYPT EPITHELIUM • Stratified squamous but basaloid so virus can • 5-8 times INCREASED risk of oral cancer invade epithelium w/o surface ulceration • More frequent on tongue/floor of mouth(64 vs. 11%) • Well known localization for the replication of • More dysplasia(38 vs. 5 %) viruses • Younger patients • Tonsillar crypt epithelium serves as reservoir for • Often very subtle lesions under tongue and on lingual frenum Epstein Barr virus and also HPV • Likely high risk HPV related • Majority of OPSCCA originate from tonsillar epithelium SEVERE KOILOCYTIC DYSPLASIA 2 12/28/2018 WHY TALK TO DENTISTS ABOUT HPV??? HPV & ORAL CANCER • Dentists may be next group of providers to participate in prevention • 70% of sexually active adults are HPV positive of HPV and OPCancer • Prevalence of oral HPV in US population 7% • Improve HPV knowledge and dentists communication skills with • Oro-pharyngeal cancer most common H & N cancer shortly patients • Highlight barriers to discuss HPV with patients • Put HPV vaccination question on dentists patient health history • 47% DDS no discuss HPV with patients • 33% discuss with some patients(papilloma) • 19% Discuss with all patients • JADA 149(1) Jan 2018 pp 9-17 HPV & ORAL CANCER ® 10% male, 3.6% female ® Peak incidence: 30-34 y/o -7.37% 60-64 y/o -11.45%!!! ® HPV-16 incidence 1% (2.13 million people) ® But only 15,000 cases of oropharyngeal cancer/yr HPV & ORAL CANCER ® Oropharyngeal cancers occur in younger age group. ® Especially troubling increase in non-smoking males with oro- pharyngeal ca ® Men 45 -60 2-3 x more likely to get oro-pharyngeal cancer ® Fortunately HPV associated cancers have a better prognosis ® HPV+HNSCC: Less chromosomal mutations (compared to smoking/ drinking associated tumors) Ang KK & Sturgis EM. Seminars in Radiation Oncology Volume 22, Issue 2 2012 128 – 142A 3 12/28/2018 KOILOCYTIC DYSPLASIA TESTING FOR HPV-TISSUE SAMPLES • HPV-+ cases express high levels p16 tumor-suppressor protein • Diffuse nuclear and cytoplasmic p16 protein-staining correlates strongly with presence of HPV by in-situ hybridization, and PCR. IDIOPATHIC LEUKOPLAKIA VERRUCO-PAPILLARY HYPERKERATOSIS • FEATURES TO WORRY ABOUT • Thickened often corrugated appearance • Associated erythema • High risk location-horseshoe shaped area • ??pain • Multifocal or recurrent (ERYTHROERYTHROERYTHROERYTHRO----)) Leukoplakia ERYTHROPLAKIA • 82% of transformed leukoplakias • 4 times risk of oral cancer (23.4%) 4 12/28/2018 ERYTHROPLAKIA ERYTHROPLAKIA VERY DIFFICULT TO SEE RED ON PINK!! • HISTOLOGIC SPECTRUM: Benign keratosis – 0% Mild dysplasia - 10% Severe dysplasia or ca-in-situ - 40% Invasive carcinoma - 50% ERYTHROPLAKIA HIGH RISK LOCATIONS ORAL CANCER • Red lesions should be viewed with suspicion, biopsied. • 90% LOCATED IN: • Suspicious red lesion may be observed for 10-14 days, if persists • LATERAL OR VENTRAL TONGUE biopsy • FLOOR OF THE MOUTH • Recurrence and multifocal involvement are common • LINGUAL FRENUM • Long-term follow-up is needed • SOFT PALATE ANTERIOR PILLAR COMPLEX • FREE AND MARGINAL GINGIVA- ring around the collar LATERAL BORDER OF THE TONGUE HIGH RISK LOCATIONS ULCER, INDURATED 5 12/28/2018 VENTRAL TONGUE-ERYTHRPLPLAKIA FLOOR OF THE MOUTH LINGUAL FRENUM SOFT PALATE / TONSILLAR PILLAR RING AROUND THE COLLAR HIGH RISK LOCATION PAINPAINPAIN 6 • This 68 year old female has a three year history of recurring white lesions in her mouth. They have all been diagnosed as hyperkeratosis or atypical epithelial hyperplasia. They keep recurring and spreading to new areas in her mouth. MULTI-FOCAL CASE STUDY 4-17-13bx papilloma 09-03-14 9-4-`13 8-14-13 12/28/2018 01-20-14 What is the most likely diagnosis? 1. Chemical burn 2. Chronic lichen planus 3. Candidiasis 4. Proliferative verrucous 5. Squamousleukoplakia cell carcinoma 20% 20% 20% 1/162 20% 015 20% Chemical burn Chronic lichen planus Candidiasis Proliferative verrucous ... Squamous cell carcinoma Proliferative Verrucous • Middle aged females(4:1F>M) • Leukoplakia (PVL) Mean age 63.9( over 62) • Little relation to smoking • Little known of etiopathogenesis 7 12/28/2018 Proliferative Verrucous Leukoplakia (PVL) • Recurrent(av.71%)/persistent • Progresses to multiple sites • ??HPV 16,18 positive ( 0-80%) • High (40-100% av.64%) risk for transformation • Time to transformation 4.7-11.6 years mean 6 years • Verrucous carcinoma or squamous • 39% of 277 patients died of disease within 7 year F/U Otolaryngol Head Neck Surg 2015 Oct;153(4):504-11 PROLIFERATIVE VERRUCOUS LEUKOPLAKIA Proliferative Verrucous Leukoplakia (PVL) • No specific treatment modality has proven effective • Laser ablation rapid & high rate of recurrence • 2 not so recent papers no association with HPV • But surgery alone 18/25 recurrences within 6 months • Surgery plus antiviral (anti-HPV immunomodulatory agent) isoprinosine or methisoprinol--2/25 • 18 months post op 2 additional recurrences in anti viral group(4/25) none in surgery group(18/25) PHOTODYNAMIC THERAPY FOR PVL PHOTODYNAMIC THERAPY FOR PVL • Innovative non-invasive effective therapy • Low level energy to reactive oxygen species to kill tumor cells • Photochemical reaction induced by laser light • Complete response after 4 sessions • 20% gel of Topical 5-ALA(aminolevulinic acid) • No recurrence for 12 months(n=1) photosensitizer/metabolic precursor • Limited to superficial lesions 1-2 mm • Apply gel for 1.5 hours keep dry • Oral proliferative verrucous leukoplakia treated with photodynamic therapy: a case report. Romeo U et al Annali Stomatologia 2014;V(2);77-80. • 635 nm (low level)laser light to activate photosensitizer • 5, 3 minute and 100 second laser applications(100mW) with 3 minute breaks b/w for each session • Twice a week until resolution 8 12/28/2018 LOWER LIP NON-HEALING ULCER CASE STUDY PERIAPICAL LESION????? This 65 year old female complains of mild pain involving the area of the maxillary right first premolar. 9 12/28/2018 METASTATIC BREAST CANCER METASTATIC BREAST CANCER THREE MONTHE POST EXTRACTION THREE MONTHS POST EXTRACTION METASTATIC TUMOR TO THE TMJ BONE SCAN METASTATIC TUMOR PROSTATE TO TMJ METASTATIC TUMORS TO THE JAWS- METASTATIC TUMORS TO THE JAWS SYMPTOMS • Breast 23% Pain • • Lung 15% Swelling • • GI 8% • Loosening of teeth • Male Repro 7% • Presence of a mass • Female Repro 3% • Paresthesia • Renal 3% • Thyroid 3% 10 12/28/2018 METASTATIC TUMORS TO THE JAWS CASE STUDYCASE STUDY • Usually present as radiolucent defects. a. One of the 3 P’s • Defect well circumscribed or ill defined ("moth-eaten" appearance). b. Gingival manifestation of • Some carcinomas (prostate and breast), osteoblastic resulting in a systemic disorder radiopaque or mixed radiolucent and radiopaque lesions. c. Peripheral odontogenic neoplasm d. Malignancy GRANULOMATOSIS WITH POLYANGIITIS (Formerly Wegener Granulomatosis) 3 FLAVORS OF WEGENER'S • Unknown cause • Wide age range GRANULOMATOSIS • No gender predilection • 90% of cases in Caucasians • Generalized Wegener’s Granulomatosis • Can involve almost every organ system in the body • Initial upper & lower respiratory tract and rapid renal • Early stage (before renal involvement) = Strawberry gingivitis and enlargement of one or more major salivary glands involvement • Late stage (after renal involvement) = Oral ulcerations Limited Wegener’s Granulomatosis • Diagnosis: Respiratory tract w/o rapid kidney involvement • PR3-ANCA (previously c-ANCA): Seen in 90-95% of generalized Wegener granulomatosis Superficial Wegener’s Granulomatosis and 60% of early or localized cases Lesions primarily of skin and mucosa • ELISA test for antibodies against PR3 Systemic involvement develops slowly • Mean survival for untreated patients with disseminated disease = 5 months • 80% of patients die within 1 year and 90% die within 2 years • Treatment: Oral prednisone and cyclophosphamide • With appropriate therapy, 75% of patients have prolonged remission CASE STUDY PRETEST LP OR CANCER? Elderly FM long history of lichen planus and now burning of tongue. DDS in 2002 Dx LP. Spread ventral tongue /1st molar area to second molar all the way anterior. Bx 2007 Ulcer with reactive