Effective management of smoking in an oral dysplasia clinic in London

BACKGROUND

Precancerous lesions precede the development of oral cancer; of several clinical types the most common is leukoplakia. The risk factors include tobacco and excess alcohol use and diets low in antioxidants. Studies concerning the management of risk factors related to oral precancer are meager.

OBJECTIVES

We investigated the effectiveness of smoking cessation at a dysplasia clinic among patients followed up for at least for 12 months.

METHODS

Data from case notes relating to 180 patients with white and red patches of oral mucosa (excluding other benign disorders confirmed by biopsy findings) attending a dysplasia clinic at a teaching hospital in London and seen by one consultant between 1993 and 2003 were transcribed. Effect of referring to a smoker's clinic to receive specialist help was evaluated against brief advice given at the dysplasia clinic +/- medications.

RESULTS

The mean age at the first visit was 48.5 years (+/-12.5), 65% were male, and 88% were white European. One hundred and sixty-two patients (90%) had used tobacco and 83% were current smokers. Of the smokers 95% had smoked over 10 years, the majority smoking over 10 cigarettes per day. Nine were alcohol misusers including two binge drinkers. One hundred and forty-six were diagnosed with oral leukoplakia, 16 with non-homogeneous types (speckled or nodular). Three patients were diagnosed with an erythroplakia. Nineteen per cent exhibited the presence of dysplasia and one subject had in situ carcinoma. Five patients in the sample quit smoking prior to arrival in the dysplasia clinic. Twenty-seven cases (20%) with oral leukoplakia quit smoking while registered as a patient at the dysplasia clinic: 17 of 100 subjects quit with brief advice +/- medications and 10 of 30 following referral to the smoker's clinic. The difference between the two groups was significant for point prevalence abstinence at the last visit to the clinic (minimum 12 months follow up). Out of a total of 180 precancer cases managed in the dysplasia clinic (mean follow up 4.2 years) three patients subsequently developed invasive carcinoma during follow up.

CONCLUSIONS

Smoking cessation needs to be an integral component of management of cases attending a dysplasia clinic and referring to smoker's clinics could help to improve the effectiveness of managing patients with oral precancer to quit smoking.

Oral Medicine — Update for the dental practitioner Red and pigmented lesions

This series provides an overview of current thinking in the more relevant areas of oral medicine for primary care practitioners, written by the authors while they were holding the Presidencies of the European Association for Oral Medicine and the British Society for Oral Medicine, respectively. A book containing additional material will be published. The series gives the detail necessary to assist the primary dental clinical team caring for patients with oral complaints that may be seen in general dental practice. Space precludes inclusion of illustrations of uncommon or rare disorders, or discussion of disorders affecting the hard tissues. Approaching the subject mainly by the symptomatic approach--as it largely relates to the presenting complaint--was considered to be a more helpful approach for GDPs rather than taking a diagnostic category approach. The clinical aspects of the relevant disorders are discussed, including a brief overview of the aetiology, detail on the clinical features and how the diagnosis is made. Guidance on management and when to refer is also provided, along with relevant websites which offer further detail.

Oral erythroplakia--a review

Oral erythroplakia (OE) is considered a rare potentially malignant lesion of the oral mucosa. Reports entirely devoted to OE are very few, and only two reviews none of which are of recent date have been published. Only the true, velvety, red homogeneous OE has been clearly defined while the terminology for mixed red and white lesions is complex, ill-defined and confusing. A recent case control study of OE from India reported a prevalence of 0.2%. A range of prevalences between 0.02% and 0.83% from different geographical areas has been documented. OE is predominantly seen in the middle aged and elderly. One study from India showed a female:male ratio of 1:1.04. The soft palate, the floor of the mouth and the buccal mucosa is commonly affected. A specific type of OE occurs in chutta smokers in India. Lesions of OE are typically less than 1.5 cm in diameter. The etiology of OE reveals a strong association with tobacco consumption and the use of alcohol. Histopathologically, it has been documented that in OE of the homogenous type, 51% showed invasive carcinoma, 40% carcinoma in situ and 9% mild or moderate dysplasia. Recently, genomic aberrations with DNA aneuploidy has been demonstrated. p53 mutations with different degrees of dysplasia may play a role in some cases of OE. Transformation rates are considered to be the highest among all precancerous oral lesions and conditions. Surgical excision is the treatment of choice. Data on laser excision are not available. Recurrence rates seem to be high, reliable data are, however, missing. More studies on OE are strongly needed to evaluate a number of so far unanswered questions. The natural history of OE is unknown. Do OEs develop de novo or are they developing from oral leukoplakia through several intermediate stages of white/red lesions? The possible role of fungal infection (Candida micro-organisms) is not clear as is the possible role of HPV co-infection in the development of OE. More data on incidence and prevalence, biological behaviour and adequate treatment are urgently needed.

Penile intraepithelial neoplasia: clinical spectrum and treatment of 35 cases

BACKGROUND

Penile intraepithelial neoplasia (PIN) is the term used to describe erythroplasia of Queyrat (EQ), Bowen's disease (BD) and bowenoid papulosis (BP). These conditions are distinct clinical entities and have different epidemiological and aetiological associations and prognostic implications.

OBJECTIVES

To describe the presentation and treatment of patients with PIN.

METHODS

Thirty-five patients presenting with PIN over a 7-year period are described.

RESULTS

Our observations include: (i) patients with BP are younger than those with EQ or BD and sometimes have a history of immunosuppression; (ii) patients with BP usually have a history or clinical evidence of previous genital human papillomavirus infection; (iii) patients with EQ often have a concurrent penile dermatosis (lichen sclerosus or lichen planus); (iv) patients with PIN are usually uncircumcised; and (v) response to treatment of BP depends on the integrity of the immune system.

CONCLUSIONS

We recommend vigorous treatment of all patients with PIN, including circumcision. Smoking should be actively discouraged. Patients should have life-long follow-up and partners of patients with BP should be screened for other forms of intraepithelial neoplasia (cervical and anal).

Management of potentially malignant oral mucosal lesions by consultant UK oral and maxillofacial surgeons

This paper describes the results of a recent survey carried out under the auspices of the Professional Education and Evaluation Subgroup of the UK Working Group on Screening for Oral Cancer and Precancer. The aim of this survey was to assimilate information regarding currently used management options of potentially malignant oral lesions as a basis from which to rationalise our future approach to their management. The survey has confirmed that variation exists among oral and maxillofacial consultants in their approaches and a more formal approach to management may therefore be indicated.

Erythroplakia: the dangerous red mucosa

Erythroplakia is an uncommon and subtly innocuous change of the oral mucosa, but it has very specific and identifiable clinical characteristics, therapies, and prognostic features. It is the most dangerous of all the oral cancer precursor lesions, and a search for erythroplakia should be a part of every oral soft tissue examination in persons aged 35 years and older. No erythroplakia lesions should ever be left untreated. Much has been written about the malignant potential of oral leukoplakia, but too often the dental profession has ignored the more dangerous discoloration, erythroplakia, which carries a much greater cancer risk than the white lesions. A clear understanding of this lesion may save lives by identifying oral cancers prior to invasion or at an early stage, thereby avoiding extensive surgery and spread of the disease to other parts of the body. The learning objective of this article is to review and familiarize the reader with the terminology, diagnosis, etiology, treatment, and the prognosis of this disease.

Local recurrence of squamous cell carcinoma of the penis

Given the excellent local control rates achieved with partial penectomy, it is important to consider laser treatment or radiation therapy of squamous cell carcinoma of the penis cautiously. Emotional issues surrounding preservation of a functional penis should not be allowed to compromise adequate therapy. On the other hand, some penile cancers undoubtedly can be managed adequately by techniques other than partial penectomy. The fundamental question is, then, how great a compromise laser treatment or radiation therapy introduces. In patients who present with bulky, long-neglected penile cancers, the point is moot: Partial or even total penectomy is indicated. However, other treatments are feasible in many patients, and an attempt at functional organ preservation should not be restricted simply to the rare small tumor. Lesions up to 2 cm in size can be controlled adequately without amputation. Because tumor grade correlates highly with depth of invasion, the presence of nodal metastasis, and survival, most poorly differentiated squamous cell tumors of the penis probably should be treated by amputation. As mentioned above, it may be several months after laser treatment or radiation therapy before local treatment failure is recognized. Although this is a concern, it probably does not ultimately result in therapeutic compromise in most patients. With most urologic cancers, local recurrence equates with the inability to cure the patient and, ultimately, death. With locally recurrent carcinoma of the penis, however, the situation can be salvaged by converting to partial penectomy. Thus, the patient compromises his chances for cure only if tumor dissemination occurs during the few months between the end of treatment and recognition of failure.

Vulvitis circumscripta plasmocellularis. A report of four cases

Four women were treated for erythematous lesions of the vulva, which vary from acute dermatitis to invasive cancer. Often a positive diagnosis can be made only with biopsy, and interpretation of the tissue is very important.

[A case of erythroplakia of the palate, tongue and gingiva]

A case of a 58-year-old man with erythroplakia, which occurred in the palate, tongue and gingiva, is reported. The histological diagnosis of a biopsy specimen was carcinoma in situ. The patient was treated with irradiation (60Co, 5060 cGy) and chemotherapy (5-FU, arterial infusion, 6400 mg). The erythema completely disappeared following a 6-week therapy, and no atypical cells were histologically recognized. There were no signs suggesting recurrence or metastasis during the follow-up period of 5 months.

A study of the clinical characteristics and treatment of oral carcinoma in situ

Twelve patients with oral carcinoma in situ were examined to clarify the clinical features and the most suitable therapy for this lesion. Seven cases were classified clinically as the erythroplakic type, two as the leukoplakic type, and three as the mixed type. The cumulative survival rate of ten cases, excluding two cases with lesions of the soft palate, was 100% in 10 years. Of 12 lesions of oral carcinoma in situ 50% progressed into invasive carcinoma. Erythroplakic lesions of oral carcinoma in situ were more aggressive than the other two types. The most suitable therapy for this lesion is prompt surgical treatment.

Natural history and management of keratosis, atypia, carcinoma-in situ, and microinvasive cancer of the larynx

Keratosis, atypia, carcinoma in situ, and microinvasive cancer occurring as white or red patches on the vocal cords are part of the diathesis of cancer of the aerodigestive tract and represented a sequential continuum. Excisional biopsy is the preferred treatment for identification and potential cure of the lesion. If the margins of excision are inadequate, further treatment options are either reexcision or radiotherapy. Radiotherapy should be used only when the need for voice conservation prevails. Cessation of smoking does not remove the potential for progression of the disease, therefore, all patients must be followed indefinitely. Excisional biopsy of keratosis, carcinoma in situ, and microinvasive cancer of the larynx offers an excellent prognosis for voice preservation and survival.

Cancers, precancers, and pseudocancers on the male genitalia. A review of clinical appearances, histopathology, and management

Leukoplakia penis and balanitis xerotica obliterans are precancerous lesions. Bowen's disease, erythroplasia (Queyrat), and extramammary Paget's disease are carcinomas in situ. Lesions of both types may closely mimic benign skin conditions that may occur in the genital region. Histologic examination is usually the only certain means of diagnosis. The same considerations apply to pseudomalignancies, e.g., giant condyloma acuminatum (Buschke-Loewenstein), which clinically behaves as a carcinoma but histologically appears benign, and Bowenoid papulosis, a new entity that is believed to be benign although it has histologic features of a carcinoma in situ.