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Oral leukoplakia

Patient will present as → a 42-year-old male with symptoms of the flu. On social history, the patient describes drinking 2-3 beers per day as well as smoking 1 pack of cigarettes per day. He is noted on physical exam to have a white plaque-like lesion on the side of the tongue, which could not be scraped off with a tongue depressor.

Oral leukoplakia is an oral potentially malignant disorder that presents as white patches of the oral mucosa that cannot be wiped off with a gauze (compare this to oral candidiasis)

  • Tobacco use (smoked and especially smokeless), alcohol abuse, HPV infections
  • Leukoplakia is in itself a benign and asymptomatic condition. However, about 5% will eventually develop squamous cell carcinoma (SCC)
  • If there is an associated erythematous appearance (erythroplakia), there is a higher risk of dysplasia or cancer (90%)

*A separate disorder that is not premalignant is oral hairy leukoplakia, an Epstein-Barr virus-induced lesion that occurs almost entirely in HIV-infected patients

The diagnosis of leukoplakia is suspected in patients presenting with a white lesion of the oral mucosa that cannot be wiped off with gauze and that persists after eliminating potential etiologic factors, such as mechanical friction, for a six-week period

  • Excisional biopsy is indicated for any undiagnosed leukoplakia

leukoplakia - all should be treated

  • For 2–3 circumscribed lesions, surgical excision
  • For multiple or large lesions where surgery would cause unacceptable deformity, consider cryosurgery or laser surgery
  • Removal of predisposing habits (alcohol and tobacco)
  • Complete excision is the standard treatment for dysplasia or malignancy
  • After treatment, up to 30% of leukoplakia recurs, and some leukoplakia still transforms into squamous cell carcinoma

Oral Hairy Leukoplakia is unlikely to progress to squamous cell carcinoma

  • Treatment with zidovudine, acyclovir, ganciclovir, foscarnet, and topical podophyllin or isotretinoin. Therapy is usually not indicated

Question 1
A 52-year-old woman with a 20-pack-year smoking history presents with an incidental finding of white plaque on her buccal mucosa found during her routine dental examination. Biopsy shows hyperkeratosis consistent with leukoplakia. Which of the following is the strongest risk factor for the development of oral leukoplakia?
A
Alcohol consumption
Hint:
Weaker risk factor compared to smoking.
B
Areca nut chewing
Hint:
Not significantly linked.
C
Chronic gastroesophageal reflux
Hint:
Not specifically associated.
D
Smoking tobacco
E
Ultraviolet light exposure
Hint:
No evidence supporting this etiology.
Question 1 Explanation: 
The major risk factor for developing oral leukoplakia is smoking tobacco, including cigarettes, cigars, pipes, etc. Tobacco use causes mucosal irritation and hyperkeratosis. Alcohol is a weaker risk factor. Areca nut chewing, UV exposure, and acid reflux do not specifically predispose patients to oral leukoplakic changes.
Question 2
A 55-year-old man presents to your clinic with a concern about a white patch on his tongue that he first noticed two months ago. He reports that the patch has not resolved with improved oral hygiene. He has a 30-pack-year smoking history and consumes alcohol regularly. On examination, you observe a 2 cm non-removable, white plaque on the lateral aspect of his tongue. The lesion is not painful. Which of the following is the most appropriate next step in the management of this patient?
A
Prescribe antifungal medication
Hint:
While antifungal medications are used for oral candidiasis, which can also present as white plaques, the history and characteristics of this lesion suggest oral leukoplakia rather than a fungal infection. A biopsy is needed for definitive diagnosis.
B
Advise cessation of smoking and alcohol use and re-evaluate in 6 months
Hint:
While cessation of smoking and alcohol is crucial in the management of oral leukoplakia and reducing the risk of malignant transformation, the lesion requires immediate evaluation through biopsy due to the potential for cancer.
C
Perform a biopsy of the lesion
D
Prescribe a course of oral corticosteroids
Hint:
Corticosteroids are not indicated in the treatment of oral leukoplakia. The mainstay of management, after biopsy and diagnosis, may involve eliminating risk factors and monitoring or surgical excision of dysplastic lesions.
E
Recommend the use of a topical anesthetic for symptom relief
Hint:
While topical anesthetics may provide symptom relief for painful oral lesions, this lesion is asymptomatic. The priority is to biopsy the lesion to rule out malignancy, not symptom management.
Question 2 Explanation: 
Given the patient's history of tobacco and alcohol use, along with the presence of a non-removable, white plaque on the tongue, the possibility of oral leukoplakia with potential malignant transformation needs to be considered. A biopsy is essential to rule out dysplasia or squamous cell carcinoma. Oral leukoplakia is a potentially malignant disorder, and histopathological examination is necessary for diagnosis and to guide further management.
Question 3
A 67-year-old woman undergoes incisional biopsy of leukoplakia on the ventrolateral tongue concerning for severe dysplasia. Pathology returns as squamous cell carcinoma in situ. She is scheduled for resection in 2 weeks. She continues to smoke 1/2 pack daily. Which of the following is the most urgent management recommendation?
A
Broad spectrum antiviral medication
Hint:
Inappropriate treatment for oral leukoplakia or carcinoma in situ.
B
Imaging studies to evaluate involved lymph nodes
Hint:
Reserved only for invasive SCCA with basement membrane penetration, not CIS.
C
Supplemental vitamin A 25,000 units daily
Hint:
Not specifically recommended.
D
Surgical excision within 1-2 weeks
Hint:
Tobacco cessation more urgently needed for this smoker with CIS oral lesion prior to resection.
E
Strict tobacco cessation immediately
Question 3 Explanation: 
The most urgent recommendation for this patient with carcinoma in situ related to smoking is immediate and strict tobacco cessation prior to resection, as continued smoking confers a markedly increased risk of recurrence, second primaries, and malignant conversion even after excision. Resection within 2 weeks is reasonable. Imaging is appropriate for cancer staging only after histological confirmation of invasive squamous cell carcinoma invading the basement membrane rather than carcinoma in situ. Antiviral medication and vitamin A supplementation are not recommended urgent interventions.
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References: Merck Manual · UpToDate

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