Oral Leukoplakia — MCQs
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
A 50-year-old female presents with blisters and erosions on the skin and mucous membranes, most commonly inside the mouth. What is the most likely diagnosis?
Oral Leukoplakia Indian Medical PG Practice Questions and MCQs
Question 1: 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 2: 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 3: 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 4: 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 5: 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 6: 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 7: 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 8: 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 9: 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.
Question 10: A 50-year-old female presents with blisters and erosions on the skin and mucous membranes, most commonly inside the mouth. What is the most likely diagnosis?
- A. Pemphigus vulgaris (Correct Answer)
- B. Dermatitis herpetiformis
- C. Bullous pemphigoid
- D. Erythema multiforme
Explanation: ***Pemphigus vulgaris*** - This condition is characterized by **flaccid blisters** that easily rupture, leading to painful erosions, often starting in the **oral mucosa** (50-70% of cases). - It is an **autoimmune disease** with antibodies against **desmoglein 3 (mucous membranes) and desmoglein 1 (skin)**, causing **intraepidermal blistering**. - **Nikolsky sign positive** - lateral pressure causes sloughing of skin. *Dermatitis herpetiformis* - This presents with intensely **pruritic (itchy) grouped vesicles** on extensor surfaces (elbows, knees, buttocks), not flaccid blisters with oral involvement. - It is strongly associated with **celiac disease** and characterized by **IgA deposition in the dermal papillae**. *Bullous pemphigoid* - Presents with **tense blisters** on an erythematous base, typically in **elderly patients (>60 years)**. - **Oral mucosa usually spared** or involved late in the disease course. - Involves autoantibodies against **hemidesmosomal proteins (BP180 and BP230)**, leading to **subepidermal blistering**. *Erythema multiforme* - Characterized by **target lesions** and can involve mucous membranes, but typically presents acutely with symmetrical distribution. - Often triggered by **infections (HSV) or medications**, not an autoimmune blistering disease. - Lacks the chronic, progressive oral erosions typical of pemphigus vulgaris.
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