Oral cancer differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Simrat Sarai, M.D. [2]

Overview

There are different types of cancers of the oral cavity and oropharynx. It is important that they are differentiated from one another.

Oral cancer must be differentiated from actinic keratosis, dermatologic manifestations of oral leukoplakia, erythroplasia, lichen planus and mucosal candidiasis.

Oral cancer differential diagnosis

Type of cancer Subtype ICD-O Code Epidemiology Etiology Second primary tumors Localization Clinical features Diagnostic procedures
Squamous cell carcinoma Verrucous carcinoma 8051/3 Older males
  • Chronic smokeless tobacco
  • HPV 16 and 18
Basaloid squamous cell carcinoma 8083/3
Papillary squamous cell carcinoma 8052/3
Spindle cell carcinoma 8074/3
Acantholytic squamous cell carcinoma 8075/3
Adenosquamous carcinoma 8560/3
Carcinoma cuniculatum

(epithelioma cuniculatum)

8051/3
Lymphoepithelial carcinoma
Epithelial precursor lesions
Proliferative verrucous leukoplakia and precancerous conditions
Papillomas Squamous cell papilloma and

verruca vulgaris

Condyloma acuminatum
Papillomas and papillomatosis

in immunodeficiency

Focal epithelial hyperplasia
Granular cell tumour
Keratoacanthoma
Papillary hyperplasia
Median rhomboid glossitis
Median rhomboid glossitis
Salivary gland tumours Acinic cell carcinoma 8550/3
  • 2-6.5% of all intraoral salivary gland tumors
  • Age range was from 11-77 years, with a mean of 45 years
  • Male to female ratio of 1.5:1
  • Buccal mucosa
  • Upper lip and
  • Palate
Biopsy shows:
  • Solid sheets of epithelium with secretory material
  • Ductal differentiation in tumors
Mucoepidermoid carcinoma 8430/3
Adenoid cystic carcinoma 8200/3
Polymorphous low-grade

adenocarcinoma

8525/3
Epithelial-myoepithelial

carcinoma

8562/3
Clear cell carcinoma,

NOS

8310/3
Basal cell

adenocarcinoma

8147/3
Cystadenocarcinoma 8450/3
Mucinous adenocarcinoma 8480/3
Oncocytic carcinoma 8290/3
Salivary duct carcinoma 8500/3
Myoepithelial carcinoma 8982/3
Carcinoma ex pleomorphic

adenoma

8941/3
Salivary gland adenomas Pleomorphic adenoma 8940/0 40-70% of minor gland tumors
  • Palate
  • Lips and
  • Buccal mucosa
Painless, slow growing, submucosal masses, but when

traumatized may bleed or ulcerate.

Biopsy shows cellular, and hyaline or plasmacytoid cell
Myoepithelioma 8982/0 42% of minor gland tumors
  • Palate of younger individuals
Basal cell adenoma 8147/0 20% of minor gland tumors
  • Upper lip
  • Buccal mucosa
They are histologically

similar to those in major glands.

Cystadenoma 8149/0 7% of benign minor gland tumors
  • Lips
  • Cheek
  • Palate
Kaposi sarcoma
  • Classic (elderly men of Mediterranean/EastEuropean descent)
  • Endemic ( middle-aged adults and children in Equatorial Africa who are not HIV infected)
  • Iatrogenic (Immunosuppressed, post-transplant)
  • AIDS associated (HIV-1 infected individuals)
  • HHV-8
  • Immunologic, genetic, and environmental factors
  • Skin ( most common)
  • Mucosal mem- branes such as oral mucosa, lymph nodes and visceral organs
  • Purplish, reddish blue or dark brown macules
  • Plaques and nodules that may ulcerate
Biopsy of all 4 types show:
  • Vascular slits and sparsely distributed lymphocytes.
Lymphangioma 9170/0
  • Pediatric lesions
  • Present at birth or during the first years of life.
  • Appear mostly in the head and neck area but may be found in any other part of the body
  • Developmental malformation
  • Genetic abnormalities
  • Turner's syndrome
Tongue
  • Circumscribed painless swelling
  • Soft and fluctuant on palpation
  • Irregular nodularity of the dorsum of the tongue
Biopsy shows:
  • Thin-walled, dilated lymphatic vessels of different size, which are lined by a flattened endothelium
Ectomesenchymal chondromyxoid

tumour of the anterior tongue

  • Age range varies from 9-78 years
  • No distinct sex predilection.
Asymptomatic, slow growing solitary nodule in the anterior dorsal tongue Biopsy shows:
  • Round, cup-shaped, fusiform, or polygonal cells with uniform small nuclei and moderate amounts of faintly basophilic cytoplasm
  • Some tumors may show nuclear pleomorphism, hyperchromatism, and multinucleation
Focal oral mucinosis (FOM)
  • The lesion affects all ages
  • Rare in children
  • There is no distinct sex predilection.
  • Gingiva( most common site)
  • Palate
  • Cheek mucosa and
  • Tongue
Asymptomatic fibrous or cystic-like lesion Histopathology is characterized by:
  • Well-circumscribed area of myxomatous

tissue

  • Fusiform or stellate fibroblasts
  • Absent or sparse reticular fibres
  • Mucinous material shows alcianophilia at pH 2.5
Congenital granular cell epuli
  • Affects newborns
  • Females are affected ten times more often than males
Etiology uncertain
  • Maxilla
  • Mandible
Solitary, somewhat pedunculated fibroma-like lesion attached to the alveolar

ridge near the midline

  • Ultrasound for prenatal diagnosis
  • Immuno histochemically, the tumor cells are positive for vimentin and neuron specific enolase
  • No reactivity with cytokeratin, CEA, desmin, hormone receptors or S-100
Haematolymphoid tumours Non-Hodgkin lymphoma Second most com-

mon cancer of the oral cavity

  • There is no known etiology in most patients.
  • Underlying immunodeficiency state (e.g. HIV Infection)
  • Strong association with EBV
  • Palate,
  • Tongue
  • Floor of mouth
  • Gingiva
  • Buccal mucosa
  • Lips
  • Palatine tonsils
  • Lingual tonsils or
  • Oropharynx
NHL of the lip presents with:
  • Ulcer
  • Swelling,
  • Discoloration
  • Pain
  • Paraesthesia
  • Anaesthesia, or
  • Loose teeth

Biopsy shows:

  • Large cells with predominantly round nuclei and membrane-bound nucleoli, consistent with centroblastic morphology.
  • Predominantly medium-sized cells with abundant pale cytoplasm.
  • Large cells with round or multilobated nuclei
Extramedullary plasmacytoma 9734/3
Langerhans cell histiocytosis 9751/1 Associated with:
  • Eosinophilic granulomas
  • Multifocal multisystem disease
  • Jaw bone
  • Intraoral soft tissues
  • Gingiva
  • Palate
  • Floor of mouth
  • Buccal mucosa

and

  • Tonsil
Common oral symptoms

include:

  • Swelling
  • Pain
  • Gingivitis
  • Loose teeth and
  • Ulceration
Biopsy shows ovoid Langerhans cells

with deeply grooved nuclei, thin nuclear membranes and abundant eosinophilic cytoplasm

Hodgkin lymphoma Strongly associated with Epstein- Barr Virus
  • Waldeyer ring, particularly the pala-tine tonsil
  • Oropharynx
  • Alveolar crest of mandible
  • Maxillary gingiva
Most patients present with localized disease (stage I/II), with
  • Chronic tonsillitis or tonsillar enlargement with or without enlarged cervical lymph nodes
Extramedullary myeloid

sarcoma

9930/3 History of acute myeloid leukaemia,

predominantly in the monocytic or myelomonocytic subtypes

  • Palate
  • Gingiva
Isolated tumor-forming intraoral mass Biopsy shows an Indian-file pattern of infiltration
Follicular dendritic cell

sarcoma / tumour

9758/3
  • Tumor of adulthood
  • Affects wide age range
History of underlying hya-line-vascular Castleman disease
  • Tonsil
  • Palate or
  • Oropharynx.
The patients usually

present with a painless mass

Biopsy usually exhibits

borders and comprises:

  • Fascicles
  • Whorls
  • Nodules,
  • Storiform arrays or
  • Diffuse sheets of spindly to ovoid tumour cells sprinkled with small lymphocytes
Mucosal malignant melanoma 8720/3
  • 0.5% of oral malignancies
  • Incidence 0.02 per 100,000
No known etiological factors associated with oral melanoma 80% arise:
  • Palate
  • Maxillary alveolus or gingivae
  • Mandibular

gingivae

Others:

  • Buccal mucosa
  • Floor of mouth
  • Tongue
  • Asymmetric with irregular outlines
  • Macular pigmentation
  • Nodular growth
  • Ulceration
  • Melanosis
  • Biopsy:
  • S100 positive
  • Negative for cytokeratins
  • More specific markers include:
  • HMB45,
  • Melan-A or anti-tyrosinase

References


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