UPFRONT

Updates from the 5th edition of the World Health

Organisation Classification of head and neck tumours
By Manas Dave, Manchester and Keith Hunter, Liverpool, UK

T
he World Health Organisation
classifications of tumours (often
referred to as the ‘Blue Book’ series)
provides the internationally recognised
standard for diagnosis and research in
neoplastic lesions. The 5th edition of the
Classification of head and neck tumours,1
which will be published in 2022, updates
current knowledge and integrates developing
understanding of these conditions, including
insights from molecular pathology techniques.
There are several changes from the 4th edition
(2017) which bring a more logical hierarchical
classification, consensus definitions and

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provide greater insight into advances in our
understanding of the pathogenesis of these
varied lesions.2,3 Whilst there are 17 chapters
in the 5th edition, covering different tumours
and sites within the head and neck, this update
will focus on the main changes of relevance to
dental professionals working in primary and
secondary care.
For oral potentially malignant disorders
(OPMDs), chronic candidiasis, syphilitic
glossitis and actinic keratosis have been
removed from the table of OPMDs, whilst
oral lichenoid lesions (resemble oral lichen
planus but lack the classical clinical or
histopathological features; please note –
lichen planus remains an OPMD), oral
graft versus host disease and familial cancer
syndromes have been added. Smokeless
tobacco keratosis has been updated to note
that the risk varies with tobacco type.
There is greater clarity in the new edition
for grading of oral epithelial dysplasia
(OED), taking into account numerous
studies highlighting challenges in reaching
diagnostic agreement. The grading system is
still three-tiered (mild, moderate and severe
epithelial dysplasia) and there is increased
recognition of a lichenoid response against
dysplastic epithelium. HPV-associated
dysplasia has been described under a
separate heading with defined diagnostic
criteria, and which is not graded like classical
OED. Molecular techniques may be useful:
demonstration of p16 overexpression is
desirable, but the positivity threshold has not
been validated for diagnosis.
‘Greater detail has been provided for rare variants
of oral squamous cell carcinoma with separate
sections for verrucous carcinoma’
Greater detail has been provided for rare
variants of oral squamous cell carcinoma
with separate sections for verrucous
carcinoma (pushing border interface
with a proliferative verrucous exophytic
architecture) and carcinoma cuniculatum
(which has a burrowing invasive pattern).4
In terms of lesions of the maxillofacial
bones, the surgical ciliated cyst is a new entity
in the cysts of the jaws section. This is caused
by traumatic implantation (usually surgical)
of respiratory (sinus lining) epithelium in the
gnathic bones. Risk factors include Caldwell-
Luc and Le Fort I procedures amongst
other sinus and facial surgeries. Another
new entity is the adenoid ameloblastoma
which is an epithelial odontogenic neoplasm
characterised by cribriform architecture,
duct-like structures and an ameloblastoma-
like component. Dentinoid, clear cells
and ghost cells can also be present. These
tumours have a recurrence rate of up to 70%.
Metastasising ameloblastoma is also discussed
in a separate section.
The beta version of the 5th edition of the
WHO classification1 is currently live to
allow early access; however, the content may
change during further editing. The book
is anticipated to be published in 2022. We
hope this brief update and link to references
signposts readers to further reading.
References
1. World Health Organisation. WHO Classification
of Tumours Online. Available at: https://
tumourclassification.iarc.who.int/chapters/52 (accessed
July 2022).
2. Thompson L D R, Bishop J A. Update from the 5th Edition
of the World Health Organization Classification of Head
and Neck Tumors: Nasal Cavity, Paranasal Sinuses and
Skull Base. Head Neck Pathol 2022; 16: 1–18.
3. Vered M, Wright J M. Update from the 5th Edition of
the World Health Organization Classification of Head
and Neck Tumors: Odontogenic and Maxillofacial Bone
Tumours. Head Neck Pathol 2022; 16: 63–75.
4. Muller S, Tilakaratne W M. Update from the 5th Edition
of the World Health Organization Classification of Head
and Neck Tumors: Tumours of the Oral Cavity and Mobile
Tongue. Head Neck Pathol 2022; 16: 54–62. ª

BRITISH DENTAL JOURNAL | VOLUME 233 NO. 2 | July 22 2022 79

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© 2022, British Dental Association. © 2022 The Author(s), under exclusive licence to British Dental Association.
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