Prof. L. Montebugnoli - Università di Bologna

Alma Mater Studiorum
Università di Bologna
Sede di Bologna
Lesioni potenzialmente maligne
del cavo orale: aspetto clinico
Lucio Montebugnoli
Reparto Patologia Orale Clinica Odontoiatrica
Università di Bologna
Concept of precancer
1 In longitudinal studies, areas of tissue with certain
alterations in clinical appearances have undergone
malignant change during follow-up.
2 Some of these alterations, particularly red and white patches,
are seen to co-exist at the margins of oral squamous cell
carcinomas.
3 A proportion of these may share morphological and
cytological changes observed in epithelial malignancies, but
without frank invasion.
4 Some of the chromosomal, genomic and molecular
alterations found in clearly invasive oral cancers are detected
in these presumptive precancer’ or premalignant phase
WHO 1978
• precancerous lesion:
morphologically altered
tissue in which oral cancer is
more likely to occur than in
its apparently normal
counterpart
• precancerous condition: a
generalized state
associated with a
significantly increased risk
of cancer
WHO 2005
• Potentially malignant
disorders
2008
2012
Potentially malignant disorders
• Leukoplakia
• Lichen planus
•
•
•
•
Submucous fibrosis
Actinic keratosis
Discoid lupus erythematosus
Inherited cancer syndromes
Falconi’s anemia)
(xeroderma
pigmentosus,
lichen planus
• Diagnosi specifica
• Trasformazione maligna
dubbia
leucoplachia
• Diagnosi non specifica
• Evoluzione maligna
indiscussa
Lesioni bianche/rosse
LICHEN PLANUS
M.G. 54 aa
LICHEN PLANUS
M.T. 45 aa
LICHEN PLANUS
A.S. 64 aa
L.G. 51 aa
Dopo rimozione delle
amalgame
G.L. 65 aa
Dopo rimozione delle
amalgame
T.M. 56 aa
dopo rimozione dello
scheletrato
a band-like lymphocytic infiltrate filling the lamina propria,
liquefactive degeneration of basal keratinocytes,
Civatte bodies
LP at risk of malignant
transformation?
• Since the first report in 1910 of a gingival
cancer diagnosed in a patient with oral LP, a
large number of similar cases have been
published.
• WHO 1978: included lichen planus among the
potentially malignant disorders
M.S. 33 anni
femmina
C.S. 73 anni
femmina
M.G. 27 aa
Lesione
lichenoide
in GvHD
Lesione
lichenoide
in GvHD
T.G. 54 aa
Risk of malignant transformation
• On the basis of the data from the literature, the
transformation rate of oral LP appears to be
around 1% over 5 years.
• Higher risk for graft vs host disease
• Higher risk for isolated lesions
• Clinical appearance: not predictive
Ottobre 2009
M.G. 44 aa
Febbraio 2011
2006
R.S. 47 aa
2014
2005
F.S. 54 anni
femmina
2011
Oral leukoplakia
• Schwimmer (1877) coined the term leukoplakia as a white patch
• WHO (1978) defined as “ A white patch on the oral mucosa that can
neither be scrapped off nor classified as any other diagnosable disease”.
• First Int. Conference (Malmo 1984): A white patch on the oral mucosa that
can neither be scrapped off nor classified as any other diagnosable disease
and is not associated with any physical or chemical causative agent except
the use of tobacco”.
• Int Symposiun (Uppsala 1986): a predominantly white lesion of the oral
mucosa that cannot be characterized as any other definable disease.
• WHO (1997): “a predominantly white lesion of the oral mucosa that cannot
be characterized as any other definable lesion”
• WHO (2005) changed the definition of leukoplakia as “a white plaque of
questionable risk having excluded (other) known diseases or disorders that
carry no increased risk for cancer”
clinical diagnosis
• “a white plaque of questionable risk
having excluded (other) known diseases
or disorders that carry no increased risk
for cancer”
Ipercheratosi fisiologica
Lingua a carta geografica
Leucoedema
Morsicatio buccarum
Pseudomembrana
da clorexidina
Innesto gengivale 1 anno
prima
candidosi
Dopo 30 gg di
Daktarin Oral Gel
30gg dopo
molaggio…
IPERCHERATOSI
DA FRIZIONE
15 gg dopo
estrazione del 38…
IPERCHERATOSI
DA FRIZIONE
15 gg dopo
molaggio…
IPERCHERATOSI
DA FRIZIONE
IPERCHERATOSI DA
SPAZZOLAMENTO
IPERCHERATOSI
DA FUMO
30 gg dopo
astensione dal
fumo
IPERCHERATOSI
DA FUMO
30 gg dopo
modificazioni
delle abitudini di
fumo
Histological diagnosis
LEUCOPLACHIA
T.N. 34 aa
Assenza di una diagnosi
specifica alla biopsia
dopo molaggio e
posizionamento di
un bite
Diagnosi di leucoplachia
sovrastimata
Rischio di trasformazione
maligna sottostimato
Risk of malignant transformation
• rate ranging from 1% to 36%
• 1.36% annual rate (95% C.I. .69-2.03)
Scully 2003
G.B. 54 anni
femmina
M.T. 44 anni
femmina
G.s. 56 anni
maschio
Risk factor of malignant
transformation
•
•
•
•
Female gender
Long duration of leukoplakia
Leukoplakia in non-smokers
Location on the tongue and/or floor of the
mouth
• Size > 200 mm2
• clinical appearance
(non-homogeneous type)
Uppsala 1996
• Homogeneous: uniform flat, thin appearance with
shallow cracks of surface keratin, with a smooth,
wrinkled, or corrugated surface with a consistent
texture throughout
• Non-homogeneous: white and red
(erythroleukoplakia) or predominantly white,
irregularly flat, nodular (speckled), or verrucous
• Proliferative verrucous oral leukoplakia (PVL) as
a subtype of verrucous leukoplakia, characterised by
a multifocal presentation, resistance to treatment, and
high rate of malignant transformation
Leucoplachia proliferativa verrucosa
Leucoplachia proliferativa verrucosa
Leucoplachia proliferativa verrucosa
Leucoplachia proliferativa
verrucosa
Leucoplachia proliferativa verrucosa
2005
A.G. 48 aa
2010
Leucoplachia proliferativa verrucosa
2006
L.R. 51 aa
2013
2005
L.G. 56 aa
2011
2008
M.G. 64 aa
2012
Lesioni potenzialmente maligne
del cavo orale: aspetto clinico
Grazie dell’attenzione
Lucio Montebugnoli
Reparto Patologia Orale Clinica Odontoiatrica
Università di Bologna