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Presented by William Westra, M.D. and prepared by Hillary Elwood, M.D.
Case 2: 45 year-old woman with a white patch along the dorsal aspect of the tongue.
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1. Question
Week 483: Case 2
45 year-old woman with a white patch along the dorsal aspect of the tongueimages/1alex/06202011case1image1.jpg
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images/1alex/06202011case1image4.jpgCorrect
Answer: Reactive epithelial changes
Histology: The histopathologic findings include an irregular saw-tooth pattern of squamous hyperplasia (psoriasiform hyperplasia), a thickened parakeratin layer, and a dense mixed inflammatory infiltrate including neutrophils within the superficial layer of the squamous epithelium. The squamous cells exhibit cellular atypia including nuclear enlargement and prominent nucleoli. At high power, fungal hyphae are embedded within the parakeratin layer.
Discussion: Mucosal candidiasis is one of the more common entities that is histopathologically mistaken for oral squamous dysplasia. It tends to induce a psoriasiform hyperplasia with associated reactive epithelial changes that may show some morphologic overlap with the architectural and cellular atypia that is encountered in true squamous dysplasias. In mucosal candidiasis, the surface changes including a thickened parakeratin layer, and it is within this layer that the fungal organisms reside. The hyphae can usually be seen by routine H&E staining, but a PAS stain may be useful in identifying organisms in those cases where the background changes are typical of mucosal candidiasis but where the fungi are not readily seen. It should be emphasized that oral squamous dysplasia can be superinfected by Candida, such that the identification of fungal hyphae by itself does not exclude a neoplastic process. In those cases where the distinction between reactive atypia and squamous dysplasia cannot be made with certainty, treatment of the fungal infection with re-biopsy of any residual lesion is warranted.
Incorrect
Answer: Reactive epithelial changes
Histology: The histopathologic findings include an irregular saw-tooth pattern of squamous hyperplasia (psoriasiform hyperplasia), a thickened parakeratin layer, and a dense mixed inflammatory infiltrate including neutrophils within the superficial layer of the squamous epithelium. The squamous cells exhibit cellular atypia including nuclear enlargement and prominent nucleoli. At high power, fungal hyphae are embedded within the parakeratin layer.
Discussion: Mucosal candidiasis is one of the more common entities that is histopathologically mistaken for oral squamous dysplasia. It tends to induce a psoriasiform hyperplasia with associated reactive epithelial changes that may show some morphologic overlap with the architectural and cellular atypia that is encountered in true squamous dysplasias. In mucosal candidiasis, the surface changes including a thickened parakeratin layer, and it is within this layer that the fungal organisms reside. The hyphae can usually be seen by routine H&E staining, but a PAS stain may be useful in identifying organisms in those cases where the background changes are typical of mucosal candidiasis but where the fungi are not readily seen. It should be emphasized that oral squamous dysplasia can be superinfected by Candida, such that the identification of fungal hyphae by itself does not exclude a neoplastic process. In those cases where the distinction between reactive atypia and squamous dysplasia cannot be made with certainty, treatment of the fungal infection with re-biopsy of any residual lesion is warranted.
