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Oral Cancer - Pre-Malignant Lesions
Most oral cancers appear to arise in ‘normal’ oral mucosa
but some are preceded by
potentially malignant / pre-
malignant
clinically obvious lesions.

These include:







Conditions that MAY predispose to malignancy (ie oral
cancer
) include:

  • Lichenoid lesions + Lichenoid Dysplasia


  • Previous oral malignancy

  • Syphilitic Leukoplakia / Glossitis

  • Immunosupression

  • Dyskeratosis Congenita

  • Paterson-Kelly syndrome

  • Discoid Lupus Erythematosis

What are thought to be the lesions / conditions likely to
cause
malignancy are logically the same ones that cause
pre-malignancy.
Last Updated 20th April 2016
Actinic Cheilitis (AKA Actinic Keratosis of Lip, Solar Keratosis, Solar
Cheilosis)

  • Occurs in adults & mainly men
  • Mainly seen in persons from the Tropics
  • Chronic pre-malignant keratosis of the lip caused by long exposure to solar
    irradiation.  Most is seen:
  • on the lower lip with sparing of the commissures
  • in fair-skinned men
  • 4 – 8th decade of life
  • outdoor jobs / activities
  • Early stages – erythema & œdema; later stages, the lip becomes dry, scaly &
    wrinkled with grey / white changes in pigmentation.  Lesions appear as a
    smooth or scaly, friable patch or even the whole lip.  Later still, the lip
    becomes thickened with small greyish-white plaques with even warty nodules
    forming
  • Prevention with sunblocks
  • Treatment with topical chemo-exfoliants & surgery
Erythroplasia / Erythroplakia (AKA Red Patch)

  • Occurs in the middle aged & the elderly & mainly in men
  • Less common than leukoplakia
  • Erythroplakia contains areas of dysplasia, carcinoma in situ or invasive
    carcinoma in virtually every case

Most potentially malignant of all oral mucosal lesions.

  • Red velvety patch of variable configuration, usually level / depressed with
    surrounding mucosa, commonly on the soft palate, floor of mouth or the
    buccal mucosæ
  • Some erythroplakias are associated with white patches & hence termed,
    speckled leukoplakias
  • Any causal factor, such as tobacco, should be stopped
  • Lesions removed followed by regular follow-ups
Leukoplakia (AKA White Patch)

  • Occurs in approx 1% of the population; men > women
  • Predisposing habits – tobacco, alcohol & betel use; sanguinarine use

  • Leukoplakia has a wide range of clinical presentations, from homogenous
    white plaques (faintly white – very thick & opaque) to nodular white lesions to
    lesions admixed with red lesions.

The malignant potential depends on appearance, site & some ætiological
factors
.

  • Appearancenon-homogenous / heterogenous leukoplakias has a high risk
    of malignant transformation

  • Site – soft palate complex, ventro-lateral tongue & FOM have a high risk of
    malignant transformation

  • Ætiology – virus (HPV, EBV), bacterial (syphilis) or fungal (Candida) have a
    high risk of malignant transformation

  • Any causal factor, such as tobacco, should be stopped.
  • Lesions removed followed by regular follow-ups.
  • Surgical / Medical treatment
Photos of Leukoplakias
Photo of Speckled Leukoplakia (arrowed)
Dysplasia seems to be the most predictive marker in use for malignant
potential
.


Factors Predictive of Future Malignant Transformation may include:

  • History of cancer of upper aero-digestive tract
  • Expression of P53 tumour suppressor protein
  • Changes involving chromosomes 3p or 9p; “Loss of HeterozygosityLOH
  • Chromosomal polysomy


Principles of Management of Dysplastic Lesions:

  • Stop any associated habits, eg betel quid or smoking
  • Treat any candidal infection and / or iron deficiency if present
  • Biopsy to assess dysplasia
  • Assess risk of pre-malignant change on clinical & histological findings
  • Consider ablation of individual lesions
  • Maintain observation for signs of malignant change


Options for the Management of Pre-Malignant Lesions:

  • Observation for early detection of cancer
  • Surgical excision with grafting (if required)
  • Cryotherapy
  • Laser excision / vaporisation
  • Topical chemotherapy (eg bleomycin)
  • Retinoids

Cryotherapy heals rapidly to leave an apparently normal mucosa.  However, there
is some uncertainty about the risk of
OSCC subsequently arising in these sites.

With
laser ablation, seemingly similar concerns.

Topical chemotherapy are largely ineffective and lesions that resolve, recur on
cessation of the drugs.
Photo of Actinic Cheilitis
Photos of Actinic Cheilitis
Photos of Erythroplasia / Erythroplakia
Management of Leukoplakia

The Oral Cancer Foundation

The Mouth Cancer Foundation

Emedicine.com


Useful Articles:

BMJ 1999.  Oral Cancer

Dental Update 1999.  Update on Precancerous Lesions

CA Cancer J Clin 2002.  Oral Cancer and Precancerous Lesions

BDJ 2003.  Oral Cancer Prevention & Detection in Primary Healthcare

Preventive Dentistry 2006.  Oral Cancer - A Growing Concern

Dental Update 2006.  Current Concepts in the Management of Oral Cancer

Canadian Family Physician 2008.  Clinical Review.  Screening for and Diagnosis of
Oral Pre-Malignant Lesions and Oro-Pharyngeal Squamous Cell Carcinoma.  Role
of Primary Care Physicians

Oral Oncology 2008.  Oral Cancer Prevention and Control – The Approach of the
World Health Organization

American Academy of Oral Medicine 2008. Patient Information Sheet.  Pre-
Malignant Oral Lesions

Oral Oncology 2009.  Review.  Global Epidemiology of Oral and Oro-Pharyngeal
Cancer

Head Neck 2009.  Treatment & Follow-up of Oral Dysplasia - A Systematic Review
& Meta-Analysis

BJOMS 2011.  Management of Oral Carcinoma - Benefits of Early Pre-Cancerous
Intervention

Dent Update 2015.  Mouth Cancer for Clinicians Part 5.  Risk Factors (Other)

Dent Update 2015. Mouth Cancer for Clinicians Part 6. Potentially Malignant
Disorders
Management of Potentially Malignant Lesion
Warning Features of an Oral Lesion suggestive on Oral Cancer