Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 8-16: Leukoplakia, Erythroplakia, Oral Lichen Planus, & Oral Cancer + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis +++ LEUKOPLAKIA ++ A white lesion that cannot be removed by rubbing the mucosal surface +++ HAIRY LEUKOPLAKIA ++ Found in patients with HIV infection Occurs on lateral border of tongue Develops quickly Appears as slightly raised leukoplakic areas with corrugated surface +++ ERYTHROPLAKIA ++ Similar to leukoplakia except that it has a definite erythematous component +++ ORAL LICHEN PLANUS ++ Most commonly presents as lacy leukoplakia but may be erosive Definitive diagnosis requires biopsy +++ ORAL CANCER ++ Early lesions appear as leukoplakia or erythroplakia More advanced lesions are larger, with invasion into tongue producing a palpable mass lesion; ulceration may be present +++ OROPHARYNX CANCER ++ Unilateral throat masses, typically presenting with painful swallowing and weight loss +++ General Considerations +++ LEUKOPLAKIA ++ About 2–6% represent either dysplasia or early invasive squamous cell carcinoma (SCC) Histologically, there is often hyperkeratoses, occurring in response to chronic irritation +++ HAIRY LEUKOPLAKIA ++ Seen in about 19% of HIV-positive patients with oral lesions Can occur following solid organ transplantation Associated with Epstein-Barr virus infection and long-term systemic corticosteroid use +++ ERYTHROPLAKIA ++ About 90% of cases are either dysplasia or carcinoma, so distinction from leukoplakia is important +++ ORAL LICHEN PLANUS ++ An inflammatory pruritic disease of the skin and mucous membranes Mucosal lichen planus must be differentiated from leukoplakia Erosive oral lesions require biopsy and often direct immunofluorescence for diagnosis because lichen planus may simulate other erosive diseases There is a low risk (1%) of SCC arising within lichen planus +++ ORAL CANCER ++ Alcohol and tobacco use are the major etiologic risk factors +++ OROPHARYNX CANCER ++ Generally presents later than oral cavity squamous cell carcinoma Typically associated with known carcinogens such as tobacco and alcohol The human papillomavirus (HPV)—most commonly, type 16—is believed to cause up to 70% of oropharyngeal squamous cell carcinoma cases HPV-related tumors often present in advanced stages of the disease with regional cervical lymph node metastases (stages III and IV) but have a better prognosis than similarly staged lesions in tobacco and alcohol users + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ Intraoral examination (lateral tongue, floor of the mouth, gingiva, buccal area, palate, and tonsillar fossae) and palpation of the neck for enlarged lymph nodes in patients over age 45 who smoke tobacco or drink immoderately +++ LEUKOPLAKIA ++ Any white lesion that cannot be removed by rubbing the mucosal surface Usually small +++ HAIRY LEUKOPLAKIA ++ Appears as slightly raised leukoplakic areas with corrugated or "hairy" surface Parakeratosis and koilocytes are seen with little or no underlying inflammation Waxes and wanes over time with generally modest irritative symptoms +++ ERYTHROPLAKIA ++ A white lesion with an erythematous component that cannot be removed by rubbing the mucosal surface +++ ORAL LICHEN PLANUS ++ Lacy leukoplakia but may be erosive Reticular pattern mimics candidiasis or hyperkeratosis Erosive pattern mimics carcinoma +++ ORAL CANCER ++ Raised, firm, white lesions with ulcers at the base are highly suspicious and generally quite painful on even gentle palpation Lesions < 4 mm in depth have a low propensity to metastasize Invasion into tongue leads to palpable mass; ulceration may be present Biopsy essential for diagnosis Metastases to submandibular and jugulodigastric neck nodes are common +++ OROPHARYNX CANCER ++ Large lesions that are often buried within the lymphoid tissue of the palatine or lingual tonsils Unilateral odynophagia Weight loss Ipsilateral cervical lymphadenopathy +++ Differential Diagnosis +++ ORAL LEUKOPLAKIA ++ Hyperkeratosis resulting from irritation Dysplasia or carcinoma Lichen planus Oral candidiasis Oral hairy leukoplakia +++ ERYTHROPLAKIA ++ Dysplasia or carcinoma Necrotizing sialometaplasia (when on hard palate) Ulcerative lichen planus +++ ORAL LICHEN PLANUS ++ Oral cancer Candidiasis Erythema multiforme Pemphigus vulgaris Bullous pemphigoid Inflammatory bowel disease + Diagnosis Download Section PDF Listen +++ +++ Imaging Studies ++ If SCC is suspected, then metastatic evaluation of neck and imaging to determine the deep extent in the oral cavity are warranted Both PET and MRI scans are useful +++ Diagnostic Procedures ++ Oral lichen planus may be difficult to diagnose clinically. Exfoliative cytology or a small incisional or excisional biopsy is indicated, especially if SCC is suspected Any area of erythroplakia, any enlarging area of leukoplakia, or any lesion that has submucosal depth on palpation should have an incisional biopsy or an exfoliative cytologic examination HPV-positive tumors are readily distinguished by immunostaining of primary tumor or fine-needle aspiration biopsy specimens for the p16 protein, a tumor suppressor protein that is highly correlated with the presence of HPV + Treatment Download Section PDF Listen +++ +++ Medications +++ LICHEN PLANUS ++ Pain management for confirmed diagnoses Daily topical corticosteroid remains the most effective treatment Cyclosporine, retinoids, and tacrolimus also have been used +++ LEUKOPLAKIA & ERYTHROPLAKIA ++ Clinical trials have suggested a role for beta-carotene, celecoxib, vitamin E, and retinoids in producing regression of leukoplakia and reducing the incidence of recurrent squamous cell carcinomas +++ HAIRY LEUKOPLAKIA ++ Acyclovir, valacyclovir, and famciclovir have been used for treatment but produce only temporary resolution +++ Surgery +++ ORAL CANCER ++ Most patients in whom the tumor is detected before it is 2 cm in diameter are cured by local resection Larger tumors of the oral cavity are usually treated with resection of the primary tumor, neck dissection, and postoperative irradiation Reconstruction, when needed, is done at the time of initial surgery Vascularized free flaps, with bone if needed, are commonly used Myocutaneous flaps may also be used +++ Therapeutic Procedures +++ LEUKOPLAKIA & ERYTHROPLAKIA ++ Mainstays of management Surveillance following elimination of carcinogenic irritants (eg, smoking tobacco, chewing tobacco or betel nut, drinking alcohol) Serial biopsies and excisions +++ ORAL CANCER ++ Radiation is reserved for patients with positive margins or metastatic disease Tumors of the tonsillar fossa and base of tongue are usually best treated with radiation, often with concomitant chemotherapy, reserving surgery for salvage + Outcome Download Section PDF Listen +++ +++ Follow-Up ++ Leukoplakia, erythroplakia, lichen planus, and oral cancer require monitoring; early diagnosis of recurrent SCC or a new primary lesion is key to management It is common for a patient with a prior malignancy to be examined Every 4–6 weeks in the first year Every 8–10 weeks in the second year Every 3–4 months thereafter for several additional years The incidence of second tumors is about 3–4% annually, likely associated with prior use of tobacco or alcohol, or both Periodic PET scans and baseline posttreatment MRIs are frequently used in subsequent tumor surveillance +++ Complications ++ Failure to recognize early tumors contributes to the need for more extensive intervention +++ Prognosis ++ Lesions < 4 mm in depth have a low propensity to metastasize Floor of mouth and alveolar ridge are associated with neck metastases Base of tongue and tonsillar fossa are usually associated with nodal metastases; late distant metastases may occur in as many as 30% Early-stage tumors (< 2 cm without nodal involvement) have cure rates above 90% +++ Prevention ++ Smoking cessation and alcohol abatement programs +++ When to Refer ++ Specialty referral should be sought early for both diagnosis and treatment Consider indirect or fiberoptic examination of the nasopharynx, oropharynx, hypopharynx, and larynx by an otolaryngologist–head and neck surgeon when there is oral erythroplakia, unexplained throat or ear pain, or unexplained oral or nasal bleeding + References Download Section PDF Listen +++ + +Awadallah M et al. Management update of potentially premalignant oral epithelial lesions. Oral Surg Oral Med Oral Pathol Oral Radiol. 2018 Jun;125(6):628–36. [PubMed: 29656948] + +Chera BS et al. Current status and future directions of treatment deintensification in human papilloma virus–associated oropharyngeal squamous cell carcinoma. Semin Radiat Oncol. 2018 Jan;28(1):27–34. [PubMed: 29173753] + +Gooi Z et al. The epidemiology of the human papillomavirus related to oropharyngeal head and neck cancer. Laryngoscope. 2016 Apr;126(4):894–900. [PubMed: 26845348] + +Gupta S et al. Interventions for the management of oral lichen planus: a review of the conventional and novel therapies. Oral Dis. 2017 Nov;23(8):1029–42. [PubMed: 28055124] + +Huang SH et al. Overview of the 8th edition TNM classification for head and neck cancer. Curr Treat Options Oncol. 2017 Jul;18(7):40. [PubMed: 28555375] + +Lowy DR et al. Preventing cancer and other diseases caused by human papillomavirus infection: 2017 Lasker-DeBakey Clinical Research Award. JAMA. 2017 Sep 12;318(10):901–2. [PubMed: 28876435] + +Mello FW et al. Prevalence of oral potentially malignant disorders: a systematic review and meta-analysis. J Oral Pathol Med. 2018 Aug;47(7):633–40. [PubMed: 29738071] + +Nadeau C et al. Evaluation and management of oral potentially malignant disorders. Dent Clin North Am. 2018 Jan;62(1):1–27. [PubMed: 29126487]