Oral Leukoplakia — MCQs
Which of the following is not directly implicated as a cause of squamous cell carcinoma of the head and neck?
What is the most common oral cancer?
Treatment of erythroplakia
Which of the following is classified as a non-premalignant oral lesion?
A patient presents with a cheek cancer of 2.5 cm size, which is close to and involves the alveolus, and is associated with a single mobile cervical lymph node of 6 cm size. What is the TNM staging?
Which of the following is a precancerous lesion?
Statement 1 - A 59-year-old patient presents with flaccid bullae. Histopathology shows a suprabasal acantholytic split. Statement 2 - The row of tombstones appearance is diagnostic of Pemphigus vulgaris.
A 60-year-old tobacco chewer and heavy bidi smoker comes with diminished mouth opening and occasional spitting of blood mixed with saliva. Oral examination revealed a white buccal mucosa with a bright red velvety plaque. The most likely diagnosis is :
A 22 year old male addicted to alcohol and abused with pan-masala-arecanut comes to the clinic with limited mouth opening and restricted tongue movement. The clinical suspicion will be of:
Tongue fixation in a patient with carcinoma tongue is staged as
Oral Leukoplakia Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is not directly implicated as a cause of squamous cell carcinoma of the head and neck?
- A. EBV
- B. HPV
- C. Betel Nut
- D. Vitamin A deficiency (Correct Answer)
Explanation: ***Vitamin A*** - Vitamin A deficiency is associated with increased risk of squamous metaplasia but not a direct cause of squamous cell carcinoma in the head and neck. - Adequate levels of Vitamin A are actually protective against various epithelial cancers. *EBV* - Epstein-Barr Virus (EBV) is linked to certain types of cancers, including nasopharyngeal carcinoma, but is not a major causative factor for squamous cell carcinoma [1]. - It can contribute to **lymphoproliferative disorders** but not primarily to squamous cell carcinoma of the head and neck [1]. *HPV* - Human Papillomavirus (HPV), particularly types 16 and 18, are recognized as significant contributors to oropharyngeal squamous cell carcinoma [1]. - HPV infection can lead to **malignant transformation** of epithelial cells [1]. *Betel Nut* - Betel nut chewing is a well-established risk factor for oral squamous cell carcinoma, associated with its carcinogenic properties [2]. - It can cause **oral lesions** and dysplasia, contributing significantly to the etiology of head and neck cancers [2].
Question 2: What is the most common oral cancer?
- A. Transition cell ca
- B. Mucoepidermoid
- C. Adenocarcinoma
- D. Squamous cell ca (Correct Answer)
Explanation: ***Squamous cell ca*** - **Squamous cell carcinoma (SCC)** accounts for over **90% of all oral cancers**, making it the most prevalent type. - It arises from the **stratified squamous epithelium** lining the oral cavity. *Transition cell ca* - This term is more commonly associated with tumors of the **urinary tract**, such as transitional cell carcinoma of the bladder. - **Transitional cell carcinomas** are not typically found in the oral cavity. *Mucoepidermoid* - **Mucoepidermoid carcinoma** is the most common primary malignant tumor of **salivary glands**, not the oral cavity lining. - While salivary glands are in the oral region, this type of cancer originates specifically from these glands. *Adenocarcinoma* - **Adenocarcinoma** originates from **glandular tissue** and represents a small percentage of oral cancers. - It is much **less common** than squamous cell carcinoma in the oral cavity.
Question 3: Treatment of erythroplakia
- A. Radiotherapy
- B. Excision and regular follow up (Correct Answer)
- C. Excision
- D. Steroid injection
Explanation: ***Excision and regular follow up*** - **Erythroplakia** has a high rate of **malignant transformation** (up to 90% are severe dysplasia or carcinoma), making complete surgical excision essential to prevent progression. - **Regular follow-up** is critical due to the risk of recurrence and the development of new lesions, monitoring for any further malignant changes after excision. *Radiotherapy* - **Radiotherapy** is generally reserved for **malignancies** or situations where surgery is not feasible, not typically for the initial treatment of erythroplakia which is a precancerous lesion. - Its use for erythroplakia could lead to unnecessary side effects and may not remove all dysplastic tissue, increasing the risk of recurrence. *Excision* - While **excision** is a necessary part of the treatment, performing it without **regular follow-up** is insufficient due to the high risk of recurrence and new lesion development. - Failure to monitor the patient closely after initial excision could lead to delayed detection of malignant transformation or new areas of dysplasia. *Steroid injection* - **Steroid injections** are used to treat inflammatory conditions or reduce scarring, and have **no role** in the management of erythroplakia, which is a precancerous lesion. - This treatment would not address the underlying dysplastic changes and would allow for potential malignant transformation to continue unchecked.
Question 4: Which of the following is classified as a non-premalignant oral lesion?
- A. Submucous fibrosis
- B. Oral lichen planus (Correct Answer)
- C. Erythroplakia
- D. Leukoplakia
Explanation: ***Oral lichen planus*** - While chronic inflammatory conditions like **oral lichen planus** can increase the risk of squamous cell carcinoma, it is generally considered a **non-premalignant lesion** itself. - The malignant transformation rate for oral lichen planus is relatively low, estimated between 0.5% and 2.5%, and it's classified as a **potentially malignant disorder** rather than a primary premalignant condition. *Erythroplakia* - **Erythroplakia** is characterized by a **red velvety patch** that cannot be rubbed off and is considered one of the oral lesions with the **highest malignant transformation potential** (up to 50%). - The red color is due to **angiogenesis** and a lack of keratinization, allowing underlying vascular tissue to show through, often indicating severe dysplasia or carcinoma in situ. *Leukoplakia* - **Leukoplakia** appears as a **white patch or plaque** that cannot be characterized clinically or pathologically as any other disease, and it has a significant potential for malignant transformation. - Approximately 5-10% of leukoplakias eventually transform into **squamous cell carcinoma**, making it a major premalignant lesion. *Submucous fibrosis* - **Oral submucous fibrosis** is a chronic, progressive, and **irreversible scarring disease** of the oral mucosa, primarily associated with the chewing of areca nut (betel quid). - It is classified as a highly premalignant condition with a documented **malignant transformation rate** ranging from 7.6% to 30% over 10 years, leading to squamous cell carcinoma.
Question 5: A patient presents with a cheek cancer of 2.5 cm size, which is close to and involves the alveolus, and is associated with a single mobile cervical lymph node of 6 cm size. What is the TNM staging?
- A. T3 N2
- B. T4 N2 (Correct Answer)
- C. T3 N3
- D. T4 N3
Explanation: ***T4 N2*** - The primary tumor involving the **alveolus (cortical bone invasion)** is classified as **T4a** regardless of size according to AJCC TNM staging for oral cavity cancers. - A single mobile ipsilateral cervical lymph node of **6 cm** is classified as **N2a** (single ipsilateral node, 3-6 cm in greatest dimension). - Therefore, the correct staging is **T4 N2**. *T3 N2* - **T3 classification is incorrect** as alveolar involvement (cortical bone invasion) automatically upgrades the tumor to T4a. - While N2 is correct for a single 6 cm node, the T-stage is underestimated. *T4 N3* - While **T4 is correct** due to alveolar bone involvement, **N3 is incorrect**. - **N3a requires lymph nodes >6 cm** (greater than 6 cm), not equal to 6 cm. - A single 6 cm node falls within the N2a category (3-6 cm range). *T3 N3* - **Both T3 and N3 are incorrect** for this presentation. - Alveolar involvement mandates T4 staging, and a 6 cm node is N2a, not N3.
Question 6: Which of the following is a precancerous lesion?
- A. Keratosis of larynx (Correct Answer)
- B. Laryngitis sicca
- C. Scleroma larynx
- D. Pachydermia of larynx
Explanation: ***Keratosis of larynx*** - **Keratosis of the larynx**, particularly with **dysplasia**, is considered a **precancerous lesion** due to the potential for malignant transformation into squamous cell carcinoma [1]. - It involves abnormal thickening and keratinization of the laryngeal mucosa, often linked to irritants like **smoking** and **alcohol** [1]. *Laryngitis sicca* - This condition involves **dryness and crusting of the laryngeal mucosa**, typically due to environmental factors or systemic drying conditions. - While uncomfortable, it is generally an **inflammatory** condition and not considered precancerous. *Scleroma larynx* - **Laryngeal scleroma** is a chronic inflammatory condition caused by infection with **Klebsiella rhinoscleromatis**, leading to granulomatous changes and fibrosis. - It results in progressive airway obstruction but is a bacterial infection and **not a precancerous lesion**. *Pachydermia of larynx* - **Pachydermia of the larynx** refers to a benign thickening of the laryngeal mucosa, often in the interarytenoid region, typically due to **chronic irritation** or reflux. - Although it indicates chronic inflammation and hyperkeratosis, it is generally considered a **benign reactive change** rather than a true precancerous condition, unless significant dysplasia is also present (which would classify it under keratosis). **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Head and Neck, pp. 746-747.
Question 7: Statement 1 - A 59-year-old patient presents with flaccid bullae. Histopathology shows a suprabasal acantholytic split. Statement 2 - The row of tombstones appearance is diagnostic of Pemphigus vulgaris.
- A. Statements 1 & 2 are correct, 2 is not explaining 1 (Correct Answer)
- B. Statements 1 and 2 are correct and 2 is the correct explanation for 1
- C. Statements 1 and 2 are incorrect
- D. Statement 1 is incorrect
Explanation: ***Correct: Statements 1 & 2 are correct, 2 is not explaining 1*** **Analysis of Statement 1:** - A 59-year-old patient with **flaccid bullae** and **suprabasal acantholytic split** on histopathology is the classic presentation of **Pemphigus vulgaris** - The flaccid (easily ruptured) nature of bullae distinguishes it from tense bullae seen in bullous pemphigoid - The suprabasal location of the split (just above the basal layer) with acantholysis (loss of cell-to-cell adhesion) is pathognomonic - **Statement 1 is CORRECT** ✓ **Analysis of Statement 2:** - The **"row of tombstones" or "tombstone appearance"** is indeed a diagnostic histopathological feature of Pemphigus vulgaris - This appearance results from basal keratinocytes remaining attached to the basement membrane while suprabasal cells separate due to acantholysis - The intact basal cells standing upright resemble a row of tombstones - **Statement 2 is CORRECT** ✓ **Does Statement 2 explain Statement 1?** - Statement 2 describes a **histopathological appearance** (tombstone pattern) that is a **consequence** of the suprabasal split - However, it does NOT explain the **underlying cause** of the flaccid bullae or the suprabasal split - The true explanation involves **IgG autoantibodies against desmoglein 3 (and desmoglein 1)**, which attack intercellular adhesion structures (desmosomes), causing **acantholysis** - Therefore, **Statement 2 does NOT explain Statement 1** ✗ *Incorrect: Statement 2 is the correct explanation for Statement 1* - While both statements describe features of Pemphigus vulgaris, the tombstone appearance is a descriptive finding, not an explanatory mechanism *Incorrect: Statements 1 and 2 are incorrect* - Both statements are medically accurate descriptions of Pemphigus vulgaris features *Incorrect: Statement 1 is incorrect* - Statement 1 correctly describes the cardinal clinical and histopathological features of Pemphigus vulgaris
Question 8: A 60-year-old tobacco chewer and heavy bidi smoker comes with diminished mouth opening and occasional spitting of blood mixed with saliva. Oral examination revealed a white buccal mucosa with a bright red velvety plaque. The most likely diagnosis is :
- A. Erythroplakia
- B. Oral candidiasis
- C. Leukoplakia
- D. Speckled leucoplakia (Correct Answer)
Explanation: ***Speckled leucoplakia*** - This patient, a **tobacco chewer** and **bidi smoker**, has risk factors and presents with a "white buccal mucosa with a bright red velvety plaque" (known as **speckled leukoplakia**), which is a highly suspicious lesion for **oral squamous cell carcinoma (OSCC)**, especially with symptoms like diminished mouth opening and occasional spitting of blood. - **Speckled leukoplakia** combines features of both leukoplakia (white areas) and erythroplakia (red velvety areas), and is considered the **highest risk precancerous lesion** for malignant transformation. *Erythroplakia* - Characterized by a **bright red velvety patch** that is flat or slightly depressed. - While highly suspicious for malignancy (with a 90% chance of being dysplastic or malignant), the description also includes a "white buccal mucosa," indicating a mixed white and red lesion. *Oral candidiasis* - Presents as **white, curdy patches** that can be scraped off, often revealing an erythematous base, and is typically associated with immunosuppression or antibiotic use. - It does not usually present with a persistent **red velvety component** or symptoms of diminished mouth opening indicative of malignancy. *Leukoplakia* - Defined as a **white plaque** that cannot be rubbed off and cannot be characterized as any other diagnosable disease. - Only describes the white component, while the patient's lesion also has a significant **red, velvety component**, classifying it more accurately as speckled leukoplakia.
Question 9: A 22 year old male addicted to alcohol and abused with pan-masala-arecanut comes to the clinic with limited mouth opening and restricted tongue movement. The clinical suspicion will be of:
- A. Leukoplakia
- B. Sub-mucous fibrosis (Correct Answer)
- C. Sideropenic dysphagia
- D. Chronic hyperplastic candidiasis
Explanation: ***Sub-mucous fibrosis*** - The combination of **pan-masala-arecanut** use and clinical symptoms like **limited mouth opening (trismus)** and **restricted tongue movement** are classic signs of **oral submucous fibrosis (OSMF)**, a precancerous condition. - OSMF is characterized by **progressive fibrosis** of the oral submucosa, leading to rigidity and loss of tissue elasticity, which impairs normal oral functions. *Leukoplakia* - **Leukoplakia** appears as a **white patch or plaque** that cannot be wiped away and is not attributable to any other known disease, often associated with tobacco use. - While it is also a **precancerous lesion**, it typically does not present with the severe **limited mouth opening** and **restricted tongue movement** seen in this patient. *Sideropenic dysphagia* - **Sideropenic dysphagia**, also known as **Plummer-Vinson syndrome**, is characterized by **iron deficiency anemia**, **dysphagia (difficulty swallowing)**, and esophageal webs. - It does not involve **limited mouth opening** or effects of betel nut chewing on oral mucosa. *Chronic hyperplastic candidiasis* - **Chronic hyperplastic candidiasis** (CHC) is a persistent white lesion caused by **Candida albicans**, often found in smokers and presenting as a non-scrapable white patch. - Although it can be chronic, CHC is a fungal infection that does not cause the **fibrotic changes** that lead to the severe **mouth opening restriction** observed here.
Question 10: Tongue fixation in a patient with carcinoma tongue is staged as
- A. T1
- B. T2
- C. T3
- D. T4 (Correct Answer)
Explanation: ***T4*** - **Tongue fixation** in carcinoma of the tongue indicates advanced local disease classified as **T4a stage** according to AJCC TNM staging. - This finding suggests invasion of **extrinsic tongue muscles**, which causes loss of tongue mobility and represents moderately advanced local disease. - T4a tumors invade through cortical bone, involve the inferior alveolar nerve, floor of mouth, or skin of face, or in the case of tongue, involve deep extrinsic muscles causing fixation. *T1* - **T1 tumors** are small lesions measuring **≤2 cm** in greatest dimension with **depth of invasion (DOI) ≤5 mm**. - They are superficial without invasion of deep structures or causing any functional impairment like tongue fixation. *T2* - **T2 tumors** measure **≤2 cm with DOI >5 mm and ≤10 mm**, OR **>2 cm but ≤4 cm with DOI ≤10 mm**. - While larger than T1, they do not involve deep extrinsic muscles or cause tongue fixation. *T3* - **T3 tumors** are defined as tumors **>4 cm** OR **any tumor with DOI >10 mm**. - Although T3 indicates larger tumor size and deeper invasion, **tongue fixation** specifically indicates T4a stage due to involvement of extrinsic tongue musculature.
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