Oral Cavity and Salivary Glands Pathology

Oral Cavity and Salivary Glands Pathology

Learning Outcomes

• Compare the pathogenesis and morphology of leukoplakia, erythroplakia, carcinoma in-situ, and oral cavity carcinoma.
• Describe the pathologic features of pleomorphic adenoma.
• Relate the etiopathogenesis and morphology of salivary gland inflammatory lesions and benign and malignant tumors.

Aphthous Ulcers

• Common, recurrent, and painful superficial oral mucosal ulcerations with unknown cause.
• Most common in the first 2 decades of life.
• May be associated with immunologic disorders, including celiac disease, inflammatory bowel disease, and Behçet disease.
• Single or multiple, shallow, hyperemic ulcers with a thin exudate and narrow zone of erythema.
• The inflammatory infiltrate is initially mononuclear and can become neutrophilic with secondary bacterial infection.
• Typically resolves spontaneously in 7 to 10 days.

Irritation Fibroma (Traumatic Fibroma)

• A focal fibrous hyperplasia.
• Submucosal nodular mass of fibrous connective tissue stroma that occurs mainly on the buccal mucosa along the bite line or gingiva.
• Believed to be a reactive proliferation caused by repetitive trauma.
• Treatment involves complete surgical excision.

Pyogenic Granuloma

• Inflammatory lesion typically found on the gingiva of children, young adults, and pregnant women (pregnancy tumor).
• The lesion surface is often ulcerated and appears red-purple.
• Growth can be rapid, raising fears of malignancy.
• Histologically, it is a highly vascular proliferation of organizing granulation tissue.
• Can regress, mature into dense fibrous masses, or develop into a peripheral ossifying fibroma.
• Complete surgical excision is the definitive treatment.

Hairy Leukoplakia

• A distinctive oral lesion on the lateral border of the tongue.
• Typically seen in immunocompromised patients (HIV and cancer therapy) and caused by EBV.
• Presents as white, confluent patches of fluffy ("hairy"), hyperkeratotic thickenings.
• Unlike thrush, it cannot be scraped off.
• Microscopically, a hyperparakeratosis and acanthosis with "balloon cells" in the upper spinous layer.

Precancerous and Cancerous Lesions

• Leukoplakia is defined by the WHO as a white patch or plaque that cannot be scraped off and cannot be characterized clinically or pathologically as any other disease.
• Patches caused by obvious irritation such as lichen planus and candidiasis are not leukoplakias.
• About 3% of the population has it, with 5% to 25% of these lesions being premalignant; thus, leukoplakias must be considered precancerous until proven otherwise by histology.
• Erythroplakia is less common and more ominous than leukoplakia.
• It is a red, velvety, possibly eroded area within the oral cavity, usually level or slightly depressed than surrounding mucosa.

Speckled Leukoerythroplakia

• Has characteristics of both leukoplakia and erythroplakia.
• Can be seen in adults aged 40 to 70, with a 2:1 male preponderance.
• Originates from various causes, but is often associated with tobacco use.
• Can occur anywhere in the oral cavity, such as the buccal mucosa, floor of the mouth, ventral surface of the tongue, palate, and gingiva.
• Appears as solitary or multiple white patches or plaques, often with sharply demarcated borders.
• Can be thickened, smooth, wrinkled, fissured, raised, corrugated, or verrucous plaques.
• Microscopically, it presents a spectrum of epithelial changes.
• Erythroplakia only rarely demonstrates orderly epidermal maturation, with approximately 90% displaying severe dysplasia, carcinoma in situ, or minimally invasive carcinoma.

Squamous Cell Carcinoma (SCC)

• Approximately 95% of head and neck cancers are SCCs, with adenocarcinomas of salivary gland origin making up most of the remaining cancers.
• The 6th most common neoplasm in the world.
• Associated with smoked tobacco and alcohol, betel quid and paan, radiation, Pipe, and HPV-16 in 80% of oropharynx SCCs.
• Oral cavity SCC incidence is rising in individuals younger than 40 with no known risk factors.
• HPV-positive patients have greater long-term survival vs HPV-negative tumors.
• The 5-year survival rate of "classic" early-stage SCC is approximately 80%.
• Survival is markedly reduced due to late diagnosis and primary tumors at 3% to 7%/year.
• Oral cavity SCC (particularly the tongue) presents showing ulceration and induration.
• Favored locations include oral mucosa, the ventral surface of the tongue, floor of the mouth, lower lip, soft palate, and gingiva.
• Early stages appear as raised, firm, pearly plaques.
• Microscopically, numerous islands of malignant keratinocytes with keratin invade the underlying connective tissue stroma.

Salivary Glands

• There are a number of diseases associated with the salivary glands.
• Sialadenitis is inflammation of the salivary glands caused by trauma, viral or bacterial infection, or autoimmune disease like Sjögren syndrome.
• Mucoceles are common inflammatory lesions from blockage or rupture of the duct, with saliva leakage into surrounding tissues.
• Ranulas are epithelial-lined cysts arising from damage to the sublingual gland duct.
• Duct obstruction causes bacterial infection, Sialolithiasis, and Nonspecific Sialadenitis.

Neoplasms

• Represent less than 2% of all tumors in humans.
• 65% to 80% of salivary gland tumors arise within the parotid, 10% in the submandibular gland, and the remainder in the minor salivary glands.
• Most of the salivary gland tumors in the parotid are benign.
• The malignant potential of salivary gland tumors is inversely proportional to gland size.
• Usually occur in adults, with a slight female predominance (except Warthin tumors), about 5% occur in children younger than age 16 years

Pleomorphic Adenoma (Mixed Tumors)

• Benign tumors with remarkable histologic diversity.
• Among the most common salivary gland neoplasms.
• Represent about 60% of tumors in the parotid, less common in the submandibular and rare in minor salivary glands
• Radiation exposure increases the risk.
• Derived from myoepithelial or ductal reserve cells (stem cell).
• Well-demarcated, encapsulated masses rarely exceeding 6 cm.
• Surface is gray-white with blue translucent areas of chondroid.
• Histologically heterogeneous; epithelial cells are arranged in ducts, acini, irregular tubules, strands, or sheets.
• No epithelial dysplasia or evident mitotic activity.
• Tumors behave similarly whether they are primarily composed of epithelial or mesenchymal elements.
• Presents as painless, slow-growing, mobile, masses within the parotid.
• Recurrence rate of 4% with parotidectomy, and ~ 25% with simple enucleation.
• The incidence of malignant transformation increases with time to 2% after 5 years.
• Carcinoma ex pleomorphic adenoma is adenocarcinoma or undifferentiated carcinoma, with high mortality rates of 30% to 50% at 5 years.

Warthin Tumor (Papillary Cystadenoma Lymphomatosum)

• The 2nd most common salivary gland neoplasm, arising almost exclusively in the parotid gland.
• More common in males, usually in the 5th -7th decades with 8x greater risk in Smokers
• 10% are multifocal & 10% bilateral.
• Round -oval masses, 2-5 cm in diameter, arising in the superficial parotid.
• On cut section, it shows pale gray narrow cystic spaces with mucinous secretions and polypoid projections.
• Histogenesis of the epithelial component is unknown, with the release of factors that attract cells.
• Benign behavior with low recurrence of only 2% after resection
• Microscopically contains double layer of oncocytic resting on stroma with germinal centers.

Mucoepidermoid Carcinoma

• Is the most common primary malignant tumor of the salivary glands.
• 15% of all salivary gland tumors; 60%-70% occur in the parotids.
• The tumor grows up to 8 cm that often infiltrative at the margins.
• Composed of squamous, mucous, or intermediate cells that contain squamous features with mucin-filled vacuoles.
• Classified into low, intermediate, or high grade depending on degree of anaplasia.
• The clinical course is dependent on the grade of the neoplasm.
• In high-grade neoplasms recurrence and metastasis occur at 30%, year survival rate is 50% .

Adenoid Cystic Carcinoma

• A relatively uncommon tumor in minor salivary glands/ the palatine.
• The parotid and submandibular glands are common sites.
• In the nose, sinuses, upper airways, breast, and elsewhere
• It causes perineural invasion and high recurrence rate and metastasis to bone, liver, and brain.
• Survival rate of about 60% to 70% drops after attempted removal.
• The minor salivary glands have a poorer prognosis than the parotid glands.
• It is small, poorly encapsulated, lesions: composed of cells with dark nuclei & cytoplasm, arranged with swiss cheese patterns.
• Can be arranged in tubular, solid, or cribriform patterns, often filled w/ excess basement membrane.

Acinic Cell Carcinoma

• A relatively uncommon (2%-3%) tumor that frequently appears in the parotid, and rarely near the minor glands.
• The lesions small and discrete and contained.
• Appears small, discrete, encapsulate.
• Cells that resemble the acinar ones in cytoplasm with purple (zymogen) granules.
• Uncommon for recurrence and lymph occurance.

Pathology of Esophagus

• A review of main features of esophagus, esophagus related disease, and carcinoma

Learning Outcomes

• Correlate of pathogenesis with esophageal varices to related complications.
• Discuss types of classification with esophagitis and clinicopathologic and complications.
• Discuss esophageal and carcinoma origin, and risks factors .

Congenital Esophageal Atresia, Tracheoesophageal Fistula, & Stenosis

• Atresia occurs as a noncanalized segment in cord replaces a segment in esophagus that leads to mechanical obstruction.
• Stenosis: lumen is lowered results by fibrous thickness leads partial obstruction.

Motor Dysfunction

• Includes diseases such as Achalasia, Hiatal Hernia, Diverticula, Lacerations ,Mallory-Weiss

Esophageal Varices

• Associated with collateral channels between a face of portal hypertension.
• Seen in approx. 50% of cirrhotic patients are often associated with alcoholics or hepatic schistosomiasis .
• Ruptured results hemorrhage may occur in esophageal.
• Despite Interventions each variceal hemorrhage confers 15%. Mortality may reach 20%
• With recurring hemorrhage there is a low survival with more than 50% recurring in about a year.

Esophagitis

• In reflux of leads to reflux as gastric contents
• Can be caused by chemicals such as alcohol and corrosives acids or fluid and bacterial.
• Symptoms include pain and hemorrhage.

Reflux Esophagitis

• Reflux of gastric causes as the reason of for esophageal illness.
• Pathogenesis has many pathways as gastric distention that is triggered.
• Conditions that decline pressure, alcohol , tobacco.

GERD Morphology

• Shows inflammation is also simple hyperemia.
• Erosion are visible with amounts of eosinophias increase within squamous .

GERD CLINICAL

• The most age group occurs around 40 years Old .
• The most clinical symptoms include regurgitation, pain, etc.

Barrett Esophagus

• Characterized and metaplasia within mucosa.
• 10% in individuals that affect population and the incidence range is up to 2%.
• Mostly affect men with age ranges from 40-60.

Tumors

• Adenocarcinoma and squamous are very frequent and major esopageal cancers.

Adenocarcimona

• Affects the growth.

Morphology

• At the esophagus and cardia. Alternately shows the layers of mass that is up to 5cm.

Adenocarcimona Clinicals

• Vomitting and chest pains with swallowing aliments becomes an issue.
• Spreads that are lymphatic.
• The survival rate on overall scale for five year is over 25%.

Squamos Cell Carcinoma

• In USA can happen older than 45 , 4 times more.
• Injuries are one of the key risk factors. Consumption ,very hot beverages over 10 years, radiation.
• Contain fungal contaminated material and HPV.