A 52-year-old woman with a 15-year history of betel quid chewing presents with a 6-week history of a white patch on the floor of the mouth that does not blanch with scraping. She denies pain but reports mild difficulty in swallowing. Oral examination reveals a 1.5 cm × 1 cm area of leukoplakia with induration. There is no cervical lymphadenopathy. Incisional biopsy shows dysplasia with high-grade intraepithelial neoplasia (HGIN). What is the most appropriate management?

Explanation

## Management of Oral Dysplasia and High-Grade Intraepithelial Neoplasia ### Pathologic Classification **Key Point:** High-grade intraepithelial neoplasia (HGIN) is a precancerous lesion with significant malignant potential (10–40% risk of progression to invasive carcinoma within 5 years). **Mnemonic:** WHO Oral Dysplasia Grades — **MILD-MOD-SEVERE** - Mild: Dysplasia confined to basal 1/3 of epithelium - Moderate: Extends to middle 1/3 - Severe/HGIN: Extends to upper 1/3 or full thickness (carcinoma in situ) ### Surgical Management of HGIN **High-Yield:** The standard of care for oral dysplasia, especially HGIN, is: 1. **Wide local excision** with adequate margins (5–10 mm) 2. **En bloc removal** of the lesion with surrounding normal mucosa 3. **Histopathologic examination** of all margins to ensure complete excision 4. **Margin assessment** is critical — positive margins require re-excision **Clinical Pearl:** Unlike low-grade dysplasia (which may be observed), HGIN requires definitive surgical excision because of its high malignant transformation risk. Observation alone is inadequate. ### Why Wide Excision Is Mandatory | Feature | Significance | |---------|-------------| | HGIN status | 10–40% malignant transformation risk | | Induration | Suggests invasion or field change | | Betel quid use | Chronic carcinogen exposure; field cancerization risk | | Margin assessment | Positive margins → re-excision; negative margins → surveillance | ### Postoperative Management **Key Point:** After wide excision: - If margins are **negative:** 3–6 monthly clinical surveillance for 2 years, then annual review - If margins are **positive or close (<5 mm):** Re-excision or adjuvant radiotherapy - Patient counselling on cessation of betel quid and tobacco use is essential ### Rationale Against Other Options **Topical corticosteroids:** These may reduce inflammation but do not address dysplasia or prevent malignant transformation. They are not indicated for HGIN. **Observation alone:** HGIN has a 10–40% malignant transformation rate. Observation without excision is inappropriate and delays definitive treatment. Repeat biopsy cannot replace excision as it does not remove the lesion. **Laser ablation + radiotherapy:** Laser ablation alone does not allow histopathologic assessment of margins and may miss invasive disease. Adjuvant radiotherapy is not indicated for excised HGIN without invasion; it is reserved for invasive carcinoma or positive margins after surgery. [cite:Shah's ENT Ch 8, Oral Dysplasia and Carcinoma] [cite:WHO Classification of Head and Neck Tumours 2022]