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A digital manual for the early diagnosis of oral neoplasia

Erythroplakia  Search in Medline for Erythroplakia



Erythroplakia is defined as a fiery red patch that cannot be characterized either clinically or pathologically as any other definable lesion  Pindborg JJ, Reichart PA, Smith CJ, van der Waal I, (1997). World Health Organisation International Histological Classification of Tumours.Histological Typing of Cancer and Precancer of the Oral Mucosa. 2 ed. Berlin: Springer..These may appear as smooth, velvety, granular or nodular lesions often with a well-defined margins adjacent to normal looking mucosa.The soft palate, the floor of mouth, the ventral surface of tongue and the retromolar area are the most common sites of involvement  Pindborg JJ, Reichart PA, Smith CJ, van der Waal I, (1997). World Health Organisation International Histological Classification of Tumours.Histological Typing of Cancer and Precancer of the Oral Mucosa. 2 ed. Berlin: Springer.. Erythroplakia is more common among middle aged to elderly persons and, especially among men  Scully C, Sudbo J, Speight PM (2003). Progress in determining the malignant potential of oral lesions. J Oral Pathol Med 32: 251-256.Reichart PA, Philipsen HP (2005). Oral erythroplakia--a review. Oral Oncol 41: 551-561.. The prevalence of these lesions range from 0.02-0.83% in different regions Reichart PA, Philipsen HP (2005). Oral erythroplakia--a review. Oral Oncol 41: 551-561.. Erythroplakia is strongly associated with tobacco habits and alcohol drinking(52;53). The risk factors for erythroplakia are the same as for oral squamous cell carcinomaMelrose RJ (2001). Premalignant oral mucosal diseases. J Calif Dent Assoc 29: 593-600..

Diagnosis:

Erythroplakia is seldom multicentric and rarely covers extensive areas of the mouth. It is soft on palpation and does not become indurated until an invasive carcinoma develops in it Reichart PA, Philipsen HP (2005). Oral erythroplakia--a review. Oral Oncol 41: 551-561.Bouquot JE, Ephros H (1995). Erythroplakia: the dangerous red mucosa. Pract Periodontics Aesthet Dent 7: 59-67.. It is often asymptomatic, although some patients may complain of a sore, burning or metallic sensation. Oral erythroplakia has the highest risk of malignant transformation compared to all other mucosal lesions. Histological examination of clinically diagnosed erythroplakia often shows severe epithelial dysplasia, carcinoma in-situ or micro-invasive cancer Shafer WG, Waldron CA (1975). Erythroplakia of the oral cavity. Cancer 36: 1021-1028.Lapthanasupkul P, Poomsawat S, Punyasingh J (2007). A clinicopathologic study of oral leukoplakia and erythroplakia in a Thai population. Quintessence Int 38: e448-e455..

All erythroplakias should be viewed with extreme clinical suspicion for malignancy, as they are more likely to harbour histological foci of severe dysplasia, carcinoma in-situ (CIS) or invasive cancer. We advise excision biopsy and histological examination as a mandatory procedure whenever an erythroplakia is clinically diagnosed.

Histopathology:

Erythroplakia harbours carcinoma in about 51% of cases, severe dysplasia or CIS in 40% and mild to moderate dysplasia in 9% Reichart PA, Philipsen HP (2005). Oral erythroplakia--a review. Oral Oncol 41: 551-561.. The red appearance is due to the thin atrophic epithelium with prominent subepithelial vascularity and inflammation. Almost all erythroplakic lesions contain dysplastic cells. The histopathology may be mild or moderate epithelial dysplasia, severe dysplasia or carcinoma in-situ. Carcinoma in-situ is characterized by a complete disorganization of cells throughout all layers of the epithelium, with no keratin pearls. In other words, the entire thickness of the epithelium is occupied by dysplastic cells, with an intact and well-defined basement membrane. Rete pegs are frequently bulbous or tear-drop shaped, often with secondary proliferations or projections of abnormal cells. Nuclei are typically hyperchromatic and enlarged, with the amount of cytoplasm diminished. Mitotic activity is pronounced and abnormal mitotic figures may be noted. The basement membrane should be carefully examined for areas of micro-invasion.

Differential diagnosis:

The following conditions should be considered before making a diagnosis of erythroplakia:

Management:

Management of oral erythroplakia focuses on the prevention of malignant transformation and early detection of occult malignancy. Persons with erythroplakia should be advised to stop tobacco/alcohol habits, and should be encouraged to take a diet rich in vegetables and fruits. In view of the high malignant potential of these lesions the recommended treatment is surgical excision, including laser Reichart PA, Philipsen HP (2005). Oral erythroplakia--a review. Oral Oncol 41: 551-561.Vedtofte P, Holmstrup P, Hjorting-Hansen E, Pindborg JJ (1987). Surgical treatment of premalignant lesions of the oral mucosa. Int J Oral Maxillofac Surg 16: 656-664.. However, even after surgical excision, the recurrences and development of malignancy at the same site are high Vedtofte P, Holmstrup P, Hjorting-Hansen E, Pindborg JJ (1987). Surgical treatment of premalignant lesions of the oral mucosa. Int J Oral Maxillofac Surg 16: 656-664.. In view of this, long-term follow-up is essential even after surgical removal.

Image

Caption

Figure 1: Erythroplakia. A 53-year-old heavy smoker with 2x3 cm erythematous lesion (arrow) on the left side of the posterior aspect of the hard palate.
Figure 2: Erythroplakia. Note the red patch on the right buccal mucosa with white areas posteriorly.
Figure 3: Oral submucous fibrosis with erythroplakia of the tongue.
Figure 4: Erythroplakia. Note the red velvety lesion involving the posterior aspect of the right side of the hard palate. Note the raised irregular area along the anterolateral aspect of the lesion which is clinically suspicious of malignant transformation.
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