And Oropharyngeal Leukoplakia Proliferative Verrucous Leukoplakia and Erythroplakia

Both oral leukoplakia (OL) and oral erythroplakia (OE) have generally been defined as premalignant lesions, mainly on the basis of their clinical appearance [14, 371]. It seems more reasonable to disregard clinically based premalignant connotations, especially for OL, without knowing the histological features [200, 297, 342]. The risk of OL becoming malignant is relatively low and quite unpredictable [342]. In contrast, OE is a much more worrisome lesion than OL and always requires histological evaluation.

Oral leukoplakia is a clinical diagnosis of exclusion. If any oral white patch can be diagnosed as some other condition, such as candidiasis, leukoedema, white sponge naevus, lichen planus, frictional keratosis, nicotine stomatitis, etc. then the lesion should not be considered a case of OL [263]. The white appearance of OL is most often related to an increase in the surface keratin layer. OL affects approximately 3% of white adults [46]. It is most frequently seen in middle-aged and older men with an increasing prevalence with age, reaching 8% in men over 70 years [48, 49]. However, recent studies reported a tendency towards a lower prevalence of OL, compared with the past, which might be the result of the massive public health education campaign against tobacco [314].

Fig. 1.5. Leukoplakia of the dorsal tongue. The microscopic diagnosis was basal and parabasal cell hyperplasia. Courtesy of Dr. J. Fischinger, Ljubljana, Slovenia

The most common sites of lesions are the buccal and alveolar mucosa and the lower lip. Lesions in the floor of the mouth, lateral tongue and lower lip more often show epithelial atypia or even malignant growth [263]. A consensus has been attained to divide OL clinically into homogenous and non-homogenous types [14]. The former type is characterised as a uniform, flat, thin lesion with a smooth or wrinkled surface showing shallow cracks, but a constant texture throughout (Fig 1.5). The latter type is defined as a predominantly white or white and red lesion that may be irregularly flat, nodular or exophytic. Nodular lesions have slightly raised rounded, red and/or whitish excrescences. Exophytic lesions have irregular blunt or sharp projections [14]. The term non-homogenous is applicable to the aspect of both colour (a mixed white and red lesion) and texture (exophytic, papillary or verrucous) of the lesions (Fig. 1.6).

With regard to verrucous lesions, there are no reproducible clinical criteria to distinguish among verrucous hyperplasia, proliferative verrucous hyperplasia and verrucous carcinoma [371]. Any persisting lesion with no apparent aetiology should be considered suspicious [235]. A period of 2-4 weeks seems acceptable to observe the regression or disappearance of the OL after the elimination of possible causative factors. After that time a biopsy is obligatory [371].

Proliferative verrucous hyperplasia (PVL) is a special type of OL with a proven high risk of becoming malignant [32, 322]. Initially, it is relatively benign-looking, a homogenous solitary patch that turns gradually to an exophytic, diffuse or multifocal, progressive and irreversible lesion [32, 322, 390]. The diagnosis is made retrospectively after evidence of a progressive clinical course, accompanied by a particular deterioration in histological changes. Women predominate over men in PVL by 4 to 1, with a mean age at diagnosis of 62 years [322]. The epidemiology of PVL

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