Smokeless Tobacco Lesions Workup

Updated: Jun 25, 2018
  • Author: Carol E Cheng, MD; Chief Editor: William D James, MD  more...
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Workup

Laboratory Studies

No blood tests are available to help diagnose cancers of the oral cavity.

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Imaging Studies

Typically, imaging studies are reserved for staging purposes once oral cancer has been diagnosed. Chest radiography, barium swallow, MRI, and positron emission tomography scanning may be used to rule out the involvement of other organ systems.

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Other Tests

A thorough history, including an assessment of the risk factors, and a careful examination of the oral cavity are the most important clinical tools in diagnosing oral lesions. The physical examination must include an assessment of the cervical lymph nodes. 

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Procedures

In order to better visualize lesions of the throat, base of the tongue, and larynx, indirect pharyngoscopy and laryngoscopy may be performed. In addition, if suspicion for a head or neck cancer is strong, endoscopy may be performed to more thoroughly examine the oral cavity, oropharynx, larynx, esophagus, trachea, and bronchi.

Exfoliative cytology of a suggestive lesion may be performed, but oral cancer can only be definitively diagnosed based on findings from an incisional biopsy.

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Histologic Findings

Tobacco-associated keratosis appears as epidermal thickening or hyperkeratosis and acanthosis. Dysplasia is uncommon in this lesion.

Leukoplakia appears as hyperkeratosis due to chronic irritation in approximately 80% of cases. A minority of lesions shows precancerous changes with varying degrees of dysplasia.

Speckled leukoplakia exhibits both epithelial hyperplasia and epithelial atrophy. Dysplasia occurs in 50-70% of all lesions, but carcinoma is rarely diagnosed. Candidal infection may be a common finding, with an inflammatory infiltrate of lymphocytes and plasma cells in the underlying connective tissue. The role of candidal species in causation of the lesion is unclear.

Erythroplasia shows mild-to-moderate epithelial dysplasia in only 9% of lesions obtained from biopsy samples. Severe dysplasia, carcinoma in situ (CIS), or squamous cell carcinoma (SCC) is often apparent. The clinical size of the lesion is not correlated with microscopic severity.

CIS refers to severe dysplasia extending the full thickness of the epithelium. Grossly, CIS may appear as leukoplakia, speckled leukoplakia, erythroplasia, or keratosis.

At histologic examination, SCC shows increased cellular proliferation, atypical mitotic figures, loss of cell cohesion, and/or atypical keratinization. Invasive growth is indicated by the invasion of tumor cells into the epithelial basement membrane. Verrucous carcinoma is a specific form of SCC that exhibits a high level of differentiation.

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Staging

See the American Cancer Society detailed guide on oral cavity and oropharyngeal cancer: "How Are Oral Cavity and Oropharyngeal Cancers Staged."

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