THE LARGEST DENTAL MEETING/EXHIBITION/CONGRESS IN THE UNITED STATES When, Why and How to Biopsy Oral Lesions Mark A. Lerman, D.M.D. Wednesday December 4, 2013 Welcome to the Greater New York Dental Mee ng 6 Days of Educa on Seminars, Hands-on Workshops & Essays Friday - Wednesday th Friday, November 29 12:00 Noon - 4:30 P.M. Saturday, November 30th 8:00 A.M. - 4:30 P.M. Sunday, December 1st - Tuesday, December 3rd 8:00 A.M. - 5:30 P.M. Wednesday, December 4th 8:00 A.M. - 4:30 P.M. 4 Days of Exhibits Exhibit Hall Hours Sunday Sunday, December 1st - Tuesday, December 3rd 9:30 A.M. - 5:30 P.M. Wednesday, December 4th 9:30 A.M. - 5:00 P.M. 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Schlesinger Implants Dr. Alex Touchstone Restora ve Watch us Dr. Aeklavya Panjali Implants Blog with us Connect with us When, Why, and How to Biopsy Oral Mucosal Lesions Mark A. Lerman, D.M.D. Diplomate, American Board of Oral and Maxillofacial Pathology Contact Information • Mark A. Lerman, D.M.D. • [email protected] • 617-732-6974 (clinical appointments) • www.brighamandwomens.org Leading Causes of Death in USA • • • • • • • Heart Disease 25% Cancer 23% Cerebrovascular Disease 6% Respiratory Disease 5% Accidents 5% Alzheimer Disease 3% Diabetes Mellitus 3% US Mortality Data 2007, National Center for Health Statistics, Centers for Disease Control and Prevention, 2010 Oral/Pharyngeal Cancer 41,380 ESTIMATED NEW CASES in 2013 • 7,890 estimated deaths • Incidence more than twice as high in men • 3% of all cancers • 8th most common type of cancer diagnosed • Overall 5 year survival rate = 61% • Mortality rate improved slightly in last 50 years American Cancer Society, Cancer Facts and Figures 2013 Clinical Staging Stage Stage I Stage II Stage III Stage IV 5 year survival T1N0M0 T2N0M0 T3 or any T w/ N1 T4 or any T w/ N2 or M1 85% 66% 41% 9% The patient’s best chance for improved survival is early detection Oral Cancer • Squamous cell carcinoma • Everything else – – – – – – Lymphoma Salivary gland malignancies Bone and soft tissue sarcomas Melanoma Odontogenic tumors Metastasis Clinical Presentation of Oral Squamous Cell Carcinoma • Leukoplakia • Erythroplakia • Non-healing ulceration • Exophytic mass White Lesions May appear white due to: – Membrane or plaque covering mucosa – Accumulation of fluid within epithelium – Thickened epithelium – Alteration of epithelium Etiology of White Lesions • Developmental • Infectious • Immunemediated • Reactive • Neoplastic/ Dysplastic Leukoplakia White patch or plaque that cannot be characterized clinically or pathologically as any other disease Leukoplakia Localized vs. Multi-focal Homogenous Non-homogenous Speckled Nodular Verrucous Leukoplakia Waldron & Shafer analyzed 3,256 cases: Hyperkeratosis or hyperplasia Mild or moderate dysplasia Severe dysplasia or ca-in-situ Squamous cell carcinoma 80% 12% 4% 3% Verrucous Hyperplasia Proliferative Leukoplakia • Proliferative verrucous leukoplakia • Multifocal leukoplakia that recurs with a tendency to undergo malignant transformation • Female predilection • Less often associated with a history of tobacco or alcohol use Lichen Planus Oral Lichen Planus • Clinical Features – Reticular – Erosive/erythematous – Ulcerative Lichenoid Mucositis Associated with: • • • • • • • NSAIDs anti-hypertensive agents cholesterol lowering agents anti-hyperglycemic agents cinnamon flavoring agents herbal remedies amalgam restorations Lichen Planus Treatment • Fluocinonide gel 0.05% • Warn patient • Dexamethasone elixir • Follow-up Erythroplakia Erythroplakia Waldron & Shafer analyzed 58 cases Mild to moderate dysplasia Severe dysplasia or ca-in-situ Squamous cell carcinoma 9% 40% 51% Leukoplakia and Erythroplakia • Non-specific benign diagnoses (esp. in high risk sites) warrant close follow-up and/or complete removal when clinically appropriate • Biopsy-proven dysplasias require complete removal and long term follow-up Ulcers Recurrent Aphthous Ulcers Immune-mediated disorder characterized by RECURRENT ulcers Recurrent Aphthous Ulcers Subtypes • Minor (canker sores) • <0.5cm, heal <2 weeks, no scarring • Major • >0.5cm, heal >2 weeks, scarring • Herpetiform • Multiple crops of pinpoint ulcers, may involve hard palate • Complex • Continuous ulcers Recurrent Aphthous Ulcers Diagnosis • History and clinical presentation • Cultures/cytology/biopsy may be necessary in atypical cases or for variants excluding minor aphthous ulcers Recurrent Aphthous Ulcers Treatment • Topical steroids are first line of treatment • Intra-lesional triamcinolone for major aphthous ulcers Recurrent Aphthous Ulcers Systemic conditions • • • • • • Bechet syndrome Immunocompromise Nutritional deficiencies Celiac disease Inflammatory bowel disease Cyclic neutropenia Herpetic Ulcers Aphthous Ulcers vs. Herpetic Ulcers • Etiology – Immune-mediated vs. viral • Morphology – Ulcers vs. vesicles • Location – Non-keratinized vs. keratinized mucosa Herpetic Ulcers • Primary herpetic gingivostomatitis • Secondary recrudescent herpetic reactivation Secondary Herpetic Eruptions Diagnosis • • • • History and clinical presentation Cultures Cytology Biopsy Herpetic Ulcers Treatment • Topical acyclovir ointment 5% • Systemic valacyclovir tablets • 500mg • 2g stat, then 500mg BID for 5 days, starting as soon as prodromal signs appear Oral Squamous Cell Carcinoma Risk Factors Tobacco Alcohol Immune suppression History of cancer Family history of cancer • Human papillomavirus infection • Areca nut • Actinic damage • • • • • Oral Squamous Cell Carcinoma • Male:female ratio = 2.5:1 • Average age at diagnosis = 62 • Increasing incidence before age 40 Oral Squamous Cell Carcinoma Field cancerization • Patients with one oral carcinoma have an increased risk for additional oro-pharyngeal carcinomas • 35% of patients with oral cancer develop another primary tumor within five years of initial diagnosis Oral Squamous Cell Carcinoma High-risk locations – Ventro-lateral tongue – Floor of mouth – Soft palate Clinical Staging T1S- Ca-in-situ T1 - Primary <2 cm T2 - Primary between 2-4cm T3 - Primary >4cm T4 - Invasion of contiguous tissue N0 N1 N2 N3 - No LN mets - One ipsilateral node <3cm - One node >3-6cm or multiple nodes - node >6cm M0 - no distant metastasis M1 - evidence of distant metastasis Clinical Staging Stage Stage I Stage II Stage III Stage IV 5 year survival T1N0M0 T2N0M0 T3 or any T w/ N1 T4 or any T w/ N2 or M1 85% 66% 41% 9% For the patient with a mucosal lesion • Take a good history • Formulate a differential diagnosis • Arrive at a definitive diagnosis Exfoliative Cytology Indications • Herpetic lesions • Candidiasis • Oral hairy leukoplakia Where do I biopsy? Areas to avoid • Ulcers • Thickly keratinized sites Biopsy • Informed consent; sequelae • pain, infection, bleeding, swelling, scar • 2% lidocaine with 1:50,000 epinephrine • Perform biopsy • Hemostasis • Post-operative instructions • Written and oral • Send to pathology Requisition Form Essential data to include • Date of procedure • Clinician name • Patient information • • • • • • Name (ALSO ON SPECIMEN JAR) Date of birth MEDICAL insurance History and clinical information Biopsy site Clinical diagnosis •Duration •Symptoms •Description •Number •Location •Color •Size •Shape •Morphology •Other habits •Clinical diagnosis •Biopsy site Additional Information • Provide as much information as possible to the pathologist along with the specimen to aid in the diagnosis • History • Clinical photographs • Radiographs Diagnostic Aids • Cytology • Light-based detection • Fluorescence-based detection Nomenclature • Predictive values – Refer to the likelihood that patients with positive test results (PPV) or negative test results (NPV) actually have or do not have disease • Sensitivity – Associated with a LOW FALSE NEGATIVE rate – Of the people tested who ACTUALLY HAVE a disease, a sensitive test will report that most are + • Specificity – Associated with a LOW FALSE POSITIVE rate – Of the people tested who are DISEASE-FREE, a specific test will report that most are negative Nomenclature • Screening – Technique applied to patients without signs or symptoms • Case-Finding – Technique applied to patients with abnormal signs or symptoms to confirm a diagnosis Cytology • OralCDx BrushTest – Introduced in 1999 – Designed for evaluation of clinically-innocuous lesions – Does NOT provide a definitive diagnosis Tolonium Chloride • Toluidine Blue – Dye designed to stain nucleic acids and abnormal tissues – False positives in reactive lesions – Sensitivity ranges from 78-100% – Specificity ranges from 31-100% Light-Based Detection • Designed for evaluation of cervical lesions • Removes debris and dehydrates cells to better visualize nuclei Vizilite+ • Disposable light packet • Tolonium chloride – Mehrotra et al. • 102 biopsies • 24 false positives • All 4 dysplasias false negatives – Awan • 77% sensitivity • 28% specificity Narrow Emission Tissue Fluorescence • Velscope – Normal mucosa emits a pale green color under 400-460nm Narrow Emission Tissue Fluorescence • Velscope – Mehrotra et al. • 156 biopsies • 50% sensitivity • 6% PPV – Awan et al. • 116 biopsies • 84% sensitivity; 15% specificity • 7 false negatives; NPV= 61% Narrow Emission Tissue Fluorescence • Velscope – November 2012: McNamara et al. • 130 patients • 42 DVL – 41 false positives • 1 false negative Oral Cancer • Oral cancer clinical presentations – Leukoplakia – Erythroplakia – Non-healing ulceration – Exophytic mass lesions • High risk locations – Ventro-lateral tongue – Floor of mouth – Soft palate Thank You