Head and Neck: Biopsy Difficulties With Squamous Lesions Ilan Weinreb, MD, FRCPC
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1 Head and Neck: Biopsy Difficulties With Squamous Lesions Ilan Weinreb, MD, FRCPC Department of Pathology, University Health Network Toronto, Ontario, Canada
2 Today s Leaps of Faith There is no such thing as mild dysplasia Reactive squamous lesion/hyperplasia versus well-differentiated SCC High-grade dysplasia (moderate/severe/cis) vs. moderately differentiated SCC (microinvasion) Oropharynx lesions are NEVER in-situ Do not call something hyperplasia on a biopsy.
3 Lateral tongue biopsy, 64 yo male
4
5 Diagnosis? a. Reactive/hyperplastic squamous mucosa. b. Mild squamous dysplasia, at least. c. Severe squamous dysplasia/carcinoma in-situ. d. Squamous cell carcinoma. e. Cannot make a diagnosis.
6 Diagnosis? a. Reactive/hyperplastic squamous mucosa. b. Mild squamous dysplasia, at least. c. Severe squamous dysplasia/carcinoma in-situ. d. Squamous cell carcinoma. e. Cannot make a diagnosis.
7 PAS Atypical Squamoproliferative lesion
8 Resection of tongue: SCC, moderately differentiated
9 Ann Diag Pathol 2002;6; When I look at a malignant tumor, probably a carcinoma, and I have trouble perceiving is a SCC vs something else..., then is a poorly differentiated SCC. If I look at a squamous proliferation that is so well differentiated that I am having trouble deciding wether is malignant or not, but after struggling, I decide is malignant, then is welldifferentiated SCC. Everything else is moderately-differentiated SCC. Edwin (Ed) N. Beckman, MD
10
11 Diagnosis? a. Reactive/hyperplastic squamous mucosa. b. Mild squamous dysplasia, at least. c. Severe squamous dysplasia/carcinoma in-situ. d. Squamous cell carcinoma. e. Atypical squamoproliferative lesion.
12 Diagnosis? a. Reactive/hyperplastic squamous mucosa. b. Mild squamous dysplasia, at least. c. Severe squamous dysplasia/carcinoma in-situ. d. Squamous cell carcinoma. e. Atypical squamoproliferative lesion.
13 3.0 cm tumour subsequently resected around maxillary gingiva
14
15
16 Well-differentiated squamous cell carcinoma
17 Verrucous Carcinoma Clinical More common in elderly Most common in oral cavity and larynx Related to tobacco and poor oral hygiene
18 Verrucous Carcinoma Histology Bulbous cauliflower like surface Blunted club-shaped rete Inflammatory infiltrates Lack of cytologic atypia
19 Verrucous Carcinoma
20 Verrucous Carcinoma
21
22 On biopsy this is not overtly dysplastic
23 Verrucous Carcinoma & WD Squamous Cell Carcinoma Treatment Excision with clear margins Radiation (if difficult to treat location) Prognosis Good Extremely low risk of metastasis (unlike moderately differentiated SCC)
24 Papillary Squamous Cell Carcinoma
25 1 Tongue base - papillary squamous cell carcinoma
26 2 Tonsil bx: 52 y.o. male with neck SCC
27 Diagnosis? a. Reactive/hyperplastic squamous mucosa. b. Mild squamous dysplasia, at least. c. Severe squamous dysplasia/carcinoma in-situ, at least. d. Non-keratinizing squamous cell carcinoma. e. Cannot make a diagnosis.
28 Diagnosis? a. Reactive/hyperplastic squamous mucosa. b. Mild squamous dysplasia, at least. c. Severe squamous dysplasia/carcinoma in-situ, at least. d. Non-keratinizing squamous cell carcinoma. e. Cannot make a diagnosis.
29 3 Posterior pharyngeal wall bx: 67 y.o.
30 Oropharynx Non-Keratinizing Squamous Cell Carcinoma The vast majority of HPV driven SCCs present with the lymph node metastasis first. There is no dysplasia-carcinoma sequence in the oropharynx where most HPV driven SCCs arise. Carcinomas begin in the crypts of the tonsil and base of tongue which have incomplete basement membranes. The crypts are in direct apposition to lymphatic channels.
31 Significance of Invasion Tumour that has breached the basement membrane Access to lymphatics Potential to metastasize Oropharynx cancers have immediate access to lymphatics and potential to metastasize ie. no CIS
32 Tumor thickness or tumor depth? Exophytic Ulcerated Endophytic u Risk of lymph node metastasis: 8% in tumor with 3 mm thickness.
33 Identifying Superficial Invasion (in theory) Deep aberrant keratinization Misplaced keratin pearls Dyskeratosis Breach of basement membrane Ragged borders Single dropping off of cells Desmoplasia/reaction around tumour cells
34 Superficial Invasion: Definition Miller Friedman Padovan Crissman Barnes cells present just below the basement membrane Scattered tongues or discrete foci of invasion through the basement membrane 2 mm or less of invasion 1-2 mm of invasion (no angiolymphatic invasion) 0.5 mm of invasion, measured from basement membrane (no angiolymphatic invasion)
35 Superficial invasion drop off carcinoma
36 Carcinoma in-situ, with microinvasion
37 Benign Mimickers Squamous papilloma Morsicatio buccarum and linguarum Infectious hyperplasia eg. candidiasis Pseudoepitheliomatous hyperplasia eg. granular cell tumour - Reactive hyperplasias Necrotizing sialometaplasia Verruciform xanthoma
38 Squamous papilloma
39 Morsicatio Linguarum
40 Hyperplastic Candidiasis
41 Candida
42 Candida in H&N NOT synonymous with reactive or benign. NOT necessarily the cause of the lesion so avoid making it sound like a diagnosis. Grows well on ulcerated and keratotic surfaces eg. radiated mucosa. Ideally you should have the whole lesion to call it hyperplasia
43 5 mm Anterior dorsum of tongue: previous SCC with ORN 7 years ago
44 Verruca Vulgaris
45 Clinical Pearl Isolated midline dorsal tongue lesions are almost never malignant
46 Pseudoepitheliomatous hyperplasia
47 S100
48 Bx: mandibular gingiva,? recurrence history of SCC 7 years ago
49 Atypical squamoproliferative lesion
50 Osteoradionecrosis with reactive squamous hyperplasia
51 Retromolar trigone biopsy
52
53 Connection to duct system - necrotizing sialometaplasia
54 Verruciform Xanthoma
55 Foam cells
56 Today s Leaps of Faith and Take home messages Resist mild dysplasia DDX: Reactive/hyperplasia vs WD SCC High-grade dysplasia vs MD SCC (microinvasion) Oropharynx is NEVER an in-situ lesion Do not call something hyperplasia on an incomplete biopsy Midline dorsal tongue lesions are usually benign Candida is NOT a diagnosis!!!
According to statistics from the Department of
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