BENIGN SOFT TISSUE LESIONS & tumors and malignancy (kerr) Flashcards
1
Q
Irritation Fibromas
Composed of
Etiology
Clinical features ;Color
Location
Treatment
A
- AKA – Fibroma, Traumatic Fibroma
- Composed of dense, scar-like, fibrous connective tissue
- Occurs as a result of chronic trauma
- Clinical Features: Exophytic lesion
- Usually less than a centimeter in diameter
- Color: lighter pink than surrounding mucosa,the surface can be white sometimes bc it’s rubbing and bumping into other oral structures (like teeth), so they get surface keratinization
- Locations: buccal mucosa, tongue, lips, gingiva
- Very common; totally benign soft lesion
- Treatment: You don’t have to remove them, but the surgical Tx = to excise them bc pts will stop biting them and they’ll heal and stop the irritation
2
Q
What is this clinical finding?
A
Irritation Fibromas
3
Q
What is this clinical finding?
A
Irritation Fibromas
4
Q
Chronic Hyperplastic Pulpitis
What is it?
Location?
Age?
Clinical Appearance?
Treatment?
A
• AKA: pulp polyp
• An e_xcessive proliferation of chronically inflamed dental pulp tissue_ – granulation tissue/ fibrous tissue with inflammatory cells (like a little fibroma that
occurs from pulp tissue) ( benign soft tissue leasion)
• Location:
• Teeth with large, open carious lesions
• Primary or permanent molars
• Age: Children & young adults
• Clinical Appearance: A red or pink nodule of soft tissue protruding from the
pulp chamber and fills the entire cavity of the tooth
• Treatment: RCT or extraction of tooth
5
Q
What is this clinical finding?
A
Chronic Hyperplastic Pulpitis (pulp polyp)
6
Q
Giant Cell Fibroma
A
- Very small form of fibrous tumour that show giant cells
- Age: relatively rare in paediatric patients.
- Clinically it is presented as a painless, sessile, or pedunculated growth which is usually confused with other fibrous lesions like irritation fibromas or Retrocuspid papilla
- Location: Largely occur on lower gingivae and on palate\
7
Q
A
Giant Cell Fibroma
8
Q
Cowden Syndrome
A
- (multiple hamartoma and neoplasia syndrome)
- • Autosomal dominant disorder affecting multiple organ systems
- • Caused by mutations in the phosphatase and tensin homolog gene (PTEN, a tumor suppressor gene)
- • Oral and perioral findings include
- *multiple papules on the lips and gingivae,**
- papillomatosis (benign fibromatosis) of the buccal, palatal, faucial, and oropharyngeal
- mucosae often producing a “cobblestone” effect, and the tongue may also present as pebbly or fissured.
- • Multiple papillomatous nodules (histologically inverted follicular keratoses or
- trichilemmomas) are often present on the perioral, periorbital, and perinasal skin, the pinnae of the ears, and neck.
- • These nodules are often accompanied by lipomas, hemangiomas, neuromas, vitiligo, café au lait spots, and acromelanosis .
- • A variety of neoplastic changes occur in the organs exhibiting hamartomatous lesions,with an increased rate of breast and thyroid carcinoma and gastrointestinal malignancy.
- Squamous cell carcinoma of the tongue and basal cell tumors of the perioral skin have also been reported.
- Incredibly rare ( board loves it)
9
Q
What is these clinical findings? (what is the name of the syndrome or complex?)
A
Cowden Syndrome
Very rare!
10
Q
Tuberous sclerosis complex
A
• is an inherited disorder caused by mutations in the tuberous sclerosis complex (TSC1 or TSC2) genes
• Characterized by seizures and mental retardation associated with hamartomatous glial proliferations and neuronal deformity in the central nervous system.
• Fine wart-like lesions (adenoma sebaceum) occur in a butterfly distribution over the cheeks and forehead, and histologically similar lesions (vascular fibromas) have been described intraorally.
• Characteristic hypoplastic enamel defects (pitted enamel hypoplasia)
occur in 40 to 100% of those affected.
• Rhabdomyoma of the heart and other hamartomas of the kidney,
11
Q
What are these clinical findings (what is the name of the syndrome or complex?)
A
Tuberous sclerosis complex
we see A lot of gingival enlargement – is this overgrowth from disease or from seizure medication? Multi organ system involvement
12
Q
Epulis Fissuratum
AKA
Cause
Location
Clinical presentation
Composed of
Treatment
A
• AKA: denture-induced fibrous hyperplasia, fibrous inflammatory hyperplasia
• Cause: ill-fitting denture
• Location: vestibule (maxilla or mandible), along the
denture border
•Clinical presentation: Arranged in elongated folds of tissue into which the
denture flange fits; • Surface ulceration within the folds is common
• Composed of dense fibrous connective tissue
• Treatment: surgical excision (scalpel vs CO2 laser -laser is better)
and reline then remake of denture
13
Q
What is this clinical finding?
A
Epulis Fissuratum
14
Q
Inflammatory Papillary Hyperplasia of the Palate
Majority occur with what disease?
Associated with what?
Clinical appearance
Treatment
A
- Majority occur with denture stomatitis
- Associated with a removable full or partial denture or orthodontic
- appliance (Something you see in patients who wear denture all the time, don’t take it out, chronic denture wear)
-
Clinical Appearance: Palatal vault is covered by multiple erythematous papillary projections (fibrous connective tissue surfaced by epithelium) –(papillary but no papilla, instead it’s bumpy and bosselated)
- Granular or cobblestone appearance
- Erythema is usually due to superinfection with candida
- Treatment:Treat underlying candidiasis, fix denture. These bumps can be removed, take electrosurgery loop, and scrape off the bumps – heals well
15
Q
What is this clinical finding?
A
Inflammatory Papillary Hyperplasia of the Palate
16
Q
What are the 3P
or 4P?
A
• Pyogenic granuloma/pregnancy tumor
• Peripheral ossifying**_or_**cementifying fibroma
• Peripheral giant cell granuloma
• Peripheral fibroma (4P)
Memorize these well!
All benign soft tissue lesions
17
Q
Pyogenic Granuloma
What is it?
Etiology
Assossiated with which demographics?
Location?
Treatment?
A
- What is it? Reactive connective tissue hyperplasia - exuberant granulation tissue; Misnomer – not pyogenic and not a true granuloma
- Etiology: Response to injury - calculus or overhang restoration
- Assosiated with? Often occurs in pregnant women (“pregnancy tumor”), also associated with puberty
- Treatment: Excision and removal of irritant (eg calculus, overhanging restorations)
18
Q
Pyogenic Granuloma
What a differential diagonsis to consider if we see it
A
- if it’s on the gingival tissues, take a radiograph
- always consider SCC as a differential diagnosis
19
Q
How to differentiate Pyogenic Granuloma from the other 2Ps ?
(Peripheral ossifying or cementifying fibroma & Peripheral giant cell granuloma)
A
- They often occur in the gingival, but can occur in multiple areas
- that’s the one thing that distinguishes this from the other 2 P’s: pyogenic granuloma can occur on ANY oral site, most commonly on the gingival tissues
20
Q
What is the clinical finding?
A
Pyogenic Granuloma
We can see the corresponding radiograph;
-although the radiograph suggests generalized bone loss, there is a lot of calculus on
the distal of #16 > it makes sense that this is a pyogenic granuloma
21
Q
Pyogenic Granuloma
Clinical appearance
Location
Size
Developing rate
Age:
A
- Clinical appearance
- Usually ulcerated
- Soft exophytic lesion, either sessile or pedunculated
- Deep red to purple in color, bleeds easily
-
Location:
- Most common – gingiva
- Also occurs in other areas of the oral mucosa ( can happen anywhere)
- Size: small to large (millimeters to centimeters)
- Develop rapidly and then remain static
- Age: Any age
22
Q
What is this clinical finding?
A
Pyogenic Granuloma:
23
Q
Pyogenic Granuloma
Histology
A
They are filled with blood vessels so they’re very very rich
in vascularization > they tend to bleed easily
24
Q
What is this clinical finding?
A
A parulis
It is not a pyogenic granuloma
A parulis is a proliferation of granulation tissue at the opening of a sinus tract
When the infection breaks through the alveolar bone and presents itself,
it will sometimes cause this proliferation of granulation tissue
25
**Peripheral Ossifying or Cementifying Fibroma**
_What is it?_
_Clinical appearance_
_Derived from_
_Age_
_Sex_
_Reccurance rate_
_Treatment_
* a reactive benign soft tissue lesion
* **Clinical appearance:** Well-demarcated, sessile or pedunculated lesion that appears to originate from _the gingival interdental papilla_
* **Derived from:** cells of the periodontal ligament
* **Age**: children and young adults
* **Sex**: females more than males
* **Recurrence rate** – about 16%
* **Treatment**: Surgical excision
26
What is this clinical finding?
**Peripheral Ossifying or Cementifying Fibroma**
## Footnote
Lesion in the image is pedunculated – put a periodontal probe on normal gingiva and glide along underneath it, there’s a stalk
27
**Peripheral Ossifying Fibroma**
Histology
* When sessile, when removing it, take scalpel blade and just cut into it
* If has a little bone or cementum formation inside it, you can feel the bone with the scalpel
28
**Peripheral Giant Cell Granuloma**
_What is it?_
_Location?_
_Age?_
_Clinical appearance:_
_Radiographic finding?_
* **What is it?** Probably a reactive lesion due to local irritating factors (giant cells develop inside the lesion which is a benign soft tissue lesion)
* **Location**: _Gingiva_, usually anterior to the molars
* **Age:** Most frequently seen between 40-60 years old
* **Clinical appearance:** dusky purple, sessile or pedunculated, smooth-surfaced, dome-shaped papule or nodule. Most lesions are less than 1.5 cm in diameter, though infrequently, may grow as large as 5 cm in greatest dimension
* **Radiographic Features:** Usually none, but superficial destruction of the alveolar bone may occur
29
What is this clinical finding?
**Peripheral Giant Cell Granuloma**
30
Peripheral Giant Cell Granuloma
Histology
Giant cells inside the lesion
31
_Diagnosis_ and _Treatment_
of the 3Ps
•**Diagnosis**: All 3 “P” lesions usually occur on gingival interdental papillae ( however pyogenic granuloma can occur anywhere)
• Since they can look similar clinically, **excisional biopsy necessary to
determine diagnosis**
• **Treatment**: complete excision and removal of local irritant (scaling
and root planing)
32
**Gingival Enlargement**
Etiology
- Response to chronic inflammation
- Hormonal changes (pregnancy/puberty)
- Immune-mediated/plasma cell gingivitis
- Drug induced
- Genetic/ Inherited
NOTE: Gingival enlargement is not always ***hyperplastic tissue***
33
**What is this clinical finding?**
Inflammatory Gingival Enlargement
Example of someone with true hyperplastic gingivitis
Maybe related to very poor plaque control
In this case, either porcelain or porcelain fused to metal full coverage restorations that have very
bulky margins, and that may play a role for food to pick up
34
**Drug Induced Gingival
Enlargement**
**What are the famous drugs that are known to cause it?**
* **Phenytoin**: (or Dilantin) – the drug that used to be given to every single
* person that had seizures
* Calcium-channel blockers
* Nifedipine *not as prescribed anymore*
* Dilitiazem still prescribe
* Amlodipine: is prescribed as one of the first line therapy for hypertension (very commonly prescribed); it doesn’t typically cause gingival overgrowth except in some selected patients, usually
those with pretty poor oral hygiene
* Cyclosporine A (used for for bone marrow transplant, graft vs
host disease, solid organ transplant)
* **Cyclosporine is universally recognized as causing gingival hyperplasia**
* **Cyclosporine** is largely replaced with **Tacrolimus**, which typically doesn’t cause gingival overgrowth
* Cyclosporine A is largely replaced with Tacrolimus, which typically doesn’t cause gingival overgrowth
Some drugs have more connective tissue component, others have more epithelial component
Not all identical under the microscope
* Cyclosporine provides more epithelial change, Dilantin causes more of a connective tissue change
35
What is the Differential diagnosis of gingival enlargement
Acute Myelogenous Leukemia (AML)
Wegener’s Granulomatosis
Kaposi Sarcoma
Plasma Cell Gingivitis
**Generalized gingival enlargement – all different cases and diseases**
36
**Hereditary Gingivofibromatosis**
_What causes it?_
_How common?_
_what effects on oral cavity?_
_Treatment?_
**What causes it?**
* Various genes that are implicate (Putative inherited mutations are in the SOS1 or CAMK4 genes.) Linked to both autosomal dominant and recessive patterns of inheritance
**How common?**
* Very rare
**what effects on oral cavity?**
* Sometimes gingival overgrowth will completely obliterate the teeth, grow around entire tooth
* Enlargement may be present at birth or may become apparent only with
the eruption of the deciduous or permanent dentitions.
* Tooth migration, prolonged retention of the primary dentition, and
diastemata are common, and enlargement may completely cover the
crowns of the teeth, resulting in compromised oral function.
**Treatment**
* Need surgical (usually laser) treatment – just grows back, so have to get it done periodically
37
What is this clinical finding?
Hereditary Gingivofibromatosis
38
Infantile
Hemangioma
_When do they appear?_
_Rate of Development_
_Clinical presentation_
_Treatment_
* **_When do they appear?_** They are rarely present at birth, infants are Born with this in place.
* **Rate of development:** the tumor will demonstrate rapid development that occurs at a faster pace than the infant’s overall growth in the first few weeks of life,
* **Clinical presentation:** Either superficial or deeper tumors
* Superficial tumors of the skin appear raised and bosselated with a bright-red color (“strawberry” hemangioma); They are firm and rubbery to palpation, and the blood, cannot be evacuated by applying pressure.
* Deeper tumors may appear only slightly raised with a bluish hue.
* May be left with a _pink or magenta macule_ in site where hemangioma occurred after its involute
* **Treatment:** Typically will involute with time, Some cases don’t involute, so need to be removed
* *It is a vascular Anomaly*
39
**Infantile
Hemangioma**
**(“strawberry” hemangioma).**
Infant with two red, nodular masses on
the posterior scalp and neck
*Neville Cr*
40
**Capillary
Malformation** (Low
flow)
* a type of vascular anomaly
* CMs are commonly known as port wine stains.
* They look like a pink, red or purple patch of skin
* occur in 1 in 300 newborns.
41
How to recogonize a **capillary Malformation?**
When you apply pressure to it, it evacuates the lesion (disappears!), when you pull away, it refills and you see it again – that tells you it’s a vascular lesion
42
What is this clinical finding?
**Capillary
Malformation (Low
flow)**
43
How to differentiate between
**Venous
malformation (low
flow)**
from
**Arteriovenous or
arteriolar malformations
(High flow)**
Venous malformation
(Low flow)
**No bruit, non-pulsatile**
vs
Arteriovenous or
arteriolar malformations
(High flow)
**Bruit and pulsatile**
**In other word, Venous lesion = Does not have pulse**
**Histopathologically they look different too**
**Treatment:**
**-**Don't biopsy this unless it's rapidly growing, if it is rapidly growing then suspect ► *angiosarcoma*? ( unlikely)
-can be surgically treated by oral surgeons -clamping off the blood vessel and dissecting it out, or putting a sclerosis agent
44
What is this clinical finding?
Venous
malformation (low
flow)
*Many pts can live with this without treatment*
45
**Osler-Weber-Rendu
Syndrome**
_AKA_
_What is it and its clinical appearance_
_Type of Herditary and Etiology_
_What can it cause?_
_Location?_
**AKA**
• _Hereditary Hemorrhagic Telangiectasia_
**What is it and its clinical appearance**
• _disorder of development of the vasculature_ characterized by **telangiectases** and
**arteriovenous malformations** in specific locations. These are essentially endothelial cell issue – get tafted area of abnormal blood vessels multiple different organ systems – causes complications
**Type of Herditary and Etiology**
•Autosomal dominant with mutations i_n at least five gene_s but mutations in two **genes (ENG and ACVRL1/ALK1)** cause approximately 85% of cases.
**What can it cause?**
• Can cause hemorrhage
**Location?**
often on fingers, lips,tongue, but always look at the fingers!
46
**What are these clinical findings ( which syndrome or complex is this)?**
Osler-Weber-Rendu
Syndrome
47
**Sturge-Weber
Angiomatosis**
**Sturge-Weber syndrome**
* Rare, non-hereditary developmental condition
* **Vascular proliferation** involving tissues of the brain and face
* Face: **Unilateral** distribution along one or more segments of the trigeminal nerve ( unilateral means don't cross the midline) known as **port wine stain/ nevus flammeus --** they are deep-purple color.
* **Intracranial calcifications**; **neurological disorders**
* **Intraoral involvement** _is common_
48
What are these clinical findings? (What is the syndrome or complex)?
Sturge-Weber
Angiomatosis
Sturge-Weber syndrome
49
What are these clinical findings (What is the syndrome or complex)?
**Sturge-Weber
Angiomatosis**
**Sturge-Weber syndrome**
Notice how the vascular malformation is only one side..
Remember: Vascular changes follow trigeminal nerve, so it doesn’t cross midline
50
**Lymphangioma**
_What is it?_
_Types_
_Locations:_
_Treatment_
**What is it?**
• Benign tumor of lymphatic vessels
**Types**
* Microcystic
* Mixed
* Cystic hygroma (macrocystic)
**Location**
* Most frequent extra-oral location: **posterior triangle of the nec**k;
* intraoral location: **tongue**
**Treatment**:
monitor, surgery if needed, _recurrence common_
51
What is this clinical finding?
**Lymphangioma**
52
What is this clinical finding?
**Cystic Hygroma**
a type of Lymphangioma
53
**Neuroma**
_AKA_
_What is it?_
_Clinical presentation_
_Location_
**AKA**
* _traumatic neuroma_
**What is it?**
* Reactive (ie not a true neoplasm) proliferation of nerve tissue after injury, usually extraction or other surgical procedure
**Clinical presentation**
* They are smooth-surfaced, nonulcerated nodules.
* May be painful (30% of cases) and sometimes associated with altered nerve sensations that can range from anesthesia to dysesthesia to overt pain
**Location**
* mental foramen area, tongue, lower lip
54
What is this clinical finding?
**Neuroma**
**(Traumatic Neuroma)**
Not a benign true neoplasm, it’s reactive lesion
This is an edentulous patient, so resorbed bone, so flange of denture is impinging in the area of mental foramen – develop from repeated trauma
Sometimes have to cut into nerve, peel the neuroma from nerve, careful not to sever nerve
55
Multiple Endocrine Neoplasia (MEN) Syndrome
_What is it?_
_Inhertiance type?_
_Which type is associated with multiple mucosal neruoma?_
_What other presentations?_
_Increase risk of which cancer?_
***_What is it?_***
Group of rare conditions
***_Inhertiance type?_***
Autosomal dominant
***_Which type is associated with multiple mucosal neruoma?_***
**Type 2B associated with multiple mucosal neuromas (one of the first
visual signs)**
***_What other presentations?_***
• Marfanoid features
• Multiple tumors and hyperplasias of endocrine organs (ie
pheochromocytoma)
*_Increase risk of which cancer?_*
**•** Increased risk for **medullary thyroid cancer (prophylactic thyroidectomy)**
*_Common board questions_*
56
What are these clinical findings (Which syndrome or complex)?
Multiple Endocrine
Neoplasia (MEN)
Syndrome
57
**Neurofibroma**
_What is it?_
_Clinical presentation?_
_Location?_
_Treatment?_
_Mailgnancy?_
**What is it?**
* A benign tumor arising from peripheral nerve tissue
**Clinical presentation:**
* Slow growing, painless lesion
* Smooth-surfaced, nodular mass that varies in size
* Skin more commonly involved than oral mucosa
Location:
* **Common oral mucosal sites:** tongue and buccal mucosa
* May develop _centrally in bone_
**Treatment**: surgical excision
**Malignant transformation** _reported, but rare_
58
What is this clinical finding?
neurofibroma
-it looks like **lymphoepithelial cyst,** but this is further anterior and not where you would get
lymphoid tissue – so it’s not lymphoepithelial cyst, it’s neurofibroma
Yellow – nerves typically yellow
59
What is this clinical finding?
neurofibroma
60
**Neurofibromatosis syndrome**
_Most common form?_
_intheritance type?_
_Clinical presntation?_
_Malignant transformation?_
_Most common form?_
Several forms, **type I** is **most common (von Recklinghausen’s Disease)**
_intheritance type?_
• 85-97% of cases inherited as _autosomal dominant trait,_ c**hromosome 17 (NF1 gene)**
**Clinical presentations:**
* **Skin nodules** **(neurofibromas)**
* **Café au lait** pigmentation on skin
* **Lisch nodules** very diagnostic (a pigmented hamartomatou in the iris of the eyes)
**Malignant transformation**
* reported in 5% of cases (**neurofibrosarcoma**)
61
What are these clinical findings (which syndrome or complex)?
**Neurofibromatosis syndrome**
**von Recklinghausen’s Disease**
* Lisch nodules on iris, pigmented (eye picture)
* Neurofibromatosis in mouth (bottom left picture)
* Café au lait (bottom right picture)
62
**Schwannoma/ Neurilemoma**
_What is it?_
_Age?_
_Location?_
_Clinical presentation?_
_Treatment?_
malignant
transformation ?
**What is it?**
• Benign neoplasm of Schwann cell origin
• Uncommon lesion: 28-48% occur in the
head and neck
**Age?**
• Most common in young and middleaged
adults
**Location?**
• Most common intraoral location:
tongue
**Clinical presentation?**
• The **solitary** schwannoma is a slow-growing, encapsulated
tumor that typically arises in association with a nerve trunk.
• May present with pain
**• Treatment**
• surgical excision
**malignant
transformation**
reported, but rare
63
What is the clinical finding?
Schwannoma/ Neurilemoma
64
What is this clinical finding?
Schwannoma/ Neurilemoma
65
Schwannoma/ Neurilemoma
_Histology_
**Antoni A and Antoni B.**
Streaming fascicles of spindle-shaped Schwann cells characterize Antoni A tissue.
These cells
often form a palisaded arrangement around central acellular, eosinophilic areas known as **Verocay bodies.** Antoni B
tissue is less cellular and less organized; the spindle cells are randomly arranged within a loose, myxomatous stroma.
66
**Granular Cell Tumor**
**What is it?**
**Location?**
**Age?**
**Treatment?**
**What is it?**
Benign tumor derived from
Schwann cells
**Location?**
• Oral cavity is the most common
location
• Vast majority of cases seen on
dorsal tongue
**Clinical presentation?**
* Typically an **asymptomatic sessile nodule that is usually 2 cm or less in size (firm)**
* The mass is typically **pink,** but some granular cell tumors appear **yellow**.
* The granular cell tumor is usually solitary, although multiple, separate tumors sometimes occur, especially in black patients.
* The lesion often has been noted for many months or years, although sometimes the patient is unaware of its presence.
**Age**:
40-60, rare in children
**Treatment**
• Treated by surgical excision (Be careful with excision! no need
to get all of it out, just most of it)
rarely recurs
67
What is this clinical finding?
Granular Cell Tumor
68
What is this clinical finding?
Granular Cell Tumor
69
Granular Cell Tumor
Histology
Has pseudoepitheliomatus hyperplasia of epithelium (seen on left picture)
Characteristic feature are the granular cells on the right picture
Infiltrate down into the muscle layers, that’s when pathologist confirms granular cell tumor
70
Congenital Epulis
## Footnote
**AKA**
**Cell resemble?**
**Cell origin?**
**Clinical features & location**
**Treatment?**
• **AKA**: Congenital epulis of the newborn
• **Cells resemble** cells of the granular cell tumor
**• Cell of origin** is unknown, not derived from nerve
**• Clinical features:**
* Sessile or pedunculated mass, usually found on
* *the anterior** **gingiva/ alveolar mucosa**
* Almost always occurs in baby girls
* Present at birth
**• Treatment:**Surgical excision, does not recur
71
What is this clinical finding?
**Congenital Epulis**
72
**Neuroectodermal tumor of infancy**
_Location?_
_Rate of development?_
_Treatment?_
_Origin?_
_Clinical presentation?_
**Location?**
Often occur as soft tissue mass largely in _anterior maxilla_
**Rate of development?**
So fast developing that it envelops and moves the teeth
**Treatment?**
Needs to be surgically excised
**Origin?**
Thought to be of **neuroectodermal source**
**Clinical presentation?**
Pigmented change in tissue
73
What is this clinical finding?
Neuroectodermal tumor of infancy
look how they removed it here surgically
*is rare, rapidly growing, pigmented neoplasm of neural crest origin. It is generally accepted as a benign tumour despite of its rapid and locally destructive growth.*
74
**Lipoma**
_What is it?_
_Location?_
_Cliniclly?_
_Histologically?_
_Treatment?_
* **What is it:** Benign tumor of mature fat cells; Relatively rare
* **Location:**Won’t see on gingival tissue, will see _on buccal mucosa, on the tongue, and floor of the mouth_
* **Clinically** appears as _a yellowish mass_ surfaced by thin overlying epithelium, When you feel it, it’s soft
* **Histologically**: a well-delineated tumor composed of mature fat cells with a thin capsule
* **Treatment**: surgical excision,does not recur
75
What is this clinical finding?
**Lipoma**
Usually very orange looking lesion in site where there’s adipose tissue
Very obvious, nothing as orange as lipoma
76
Lipoma vs Lipofibroma
* Sometimes lipomas can be mixed with fibrous tissue, can be **lipofibromous**
* Two lesions that look almost identical but one is **lipoma**, one is **lipofibroma**
* Only difference is that **one has fibrous tissue in it, no other difference**
77
Benign Tumors of Muscle
• **Leiomyoma**
• Benign tumor of smooth muscle
**• Vascular Leiomyoma**
• Benign tumor of smooth muscle walls of
blood vessels
**• Rhabdomyoma**
• Benign tumor of skeletal muscle
They are SUPERRR rare
If become malignant, they become leiomyosarcoma or rhabdomyosarcoma – malignant even
more rare
78
What is this clinical finding?
**Vascular leiomyoma**
**High-power view showing spindle-shaped cells with bluntended
nuclei. Immunohistochemical analysis shows
strong positivity for smooth muscle actin (inset).**
79
**What is this clinical finding?**
**Rhabdomyoma**
## Footnote
Will see the striated muscle
Differential diagnosis… looks like granular cell tumor – don’t know til you remove it
If patient presents with relatively slow growing tumor like this, will I get incisional biopsy or
excisional biopsy? Hard to say
If confident benign tumor and it’s this size and I don’t think it’s vascular (no pulse, can do
aspiration), feels firm – try to excise it
If it looks different, like you think it’s malignant minor salivary gland neoplasm (won’t find it in this
site, but if it’s on hard palate) – incision?
80
What is Sarcoma ?
Sarcoma is cancer of soft tissue (such as muscle), connective tissue (such as tendon or cartilage), or bone.
81
**Leiomyosarcoma**
* a type of rare cancer that grows in the smooth muscles.
* So, so rare
* Diseases that move rapidly, because they’re malignancies
* You might see surface ulcerations, they’re moving so fast, they break through the epithelium
82
What is this clinical finding?
**Leiomyosarcoma**
83
**Rhabdomyosarcoma**
* is a type of sarcoma.
* **Rhabdomyosarcoma** usually begins in muscles that are attached to bones and that help the body move, but it may begin in many places in the body
84
What are these clinical findings?
Rhabdomyosarcoma
In this case, hasn’t broken through epithelium
They don’t all break through
85
Fibrosarcoma
_what is it?_
_Age?_
_Rate of growth?_
_Treatment?_
_Survival rates?_
**•What is it?** Malignant tumor of fibroblasts
• **Age?** Most common in young adults and
children
• **Rate of growth?** Slow growing lesion that is usually not
painful (Can be slow growing, can be rapidly growing – different criteria determining high or low grade)
• **Treatment**: surgical excision, recurrence is common(Aren’t always easy to surgically remove, because already metastasized into other reservoirs, spread into contiguous areas) Aren’t always radiosensitive, don’t always respond to radiation treatment
• 5-year **survival rates** range from 40-70%
86
What is this clinical finding?
**Fibrosarcoma**
87
**Vascular Malignant Neoplasms**
**• Angiosarcoma**
• Malignant tumor of blood vessels
**• Lymphangiosarcoma**
• Malignant tumor of lymphatic vessels
**• Kaposi’s sarcoma**
* Malignant neoplasm associated with endothelial cells
* Seen predominantly in poorly controlled HIV infected patient population (not exclusively)
* Elderly people can develop Kaposi
88
**Kaposi Sarcoma**
_Etiology_
_Types_
_Treatment_
**Etiology**:Caused by **HHV-8 (human herpesvirus 8) /***part of herpes family*
**Types:**
* **Classic:** late adult life, Italian and Jewish men, skin of lower extremities
* **Endemic:** African form
* **Iatrogenic immunosuppression-associated:** most often occurs in recipients of organ transplants
* **AIDS-related**
**Treatment**
* Surgical excision, radiation therapy or systemic chemotherapy for multiple nonoral lesions, if it gets large, dose-radiation therapy!
89
What is this clinical finding?
**Kaposi Sarcoma**
Solitary vascular lesion on hard palate – it was so small so he decided to just excise it in this case^
90
What are these clinical findings?
**Kaposi Sarcoma**
* Widespread Kaposi, can see cutaneous lesions
* Oral images of this patient: on palate, starts with macule on patient’s left posterior palate –macular stage
* Then in becomes proliferative – exophytic nodular stage (seen on patient’s right anterior palate,surrounding canine and some incisors)
* Can see engorged blood vessels in area on histology slide
91
**Plasmacytoma in Multiple Myeloma**
Presents as soft tissue lesion
It is possible that a patient can present with plasmacytoma that would be the first sign of multiple
myeloma (it would be a rare sign, but it can happen)
92
What is this clinical finding?
**Plasmacytoma in Multiple Myeloma**
* They already had **multiple myeloma** then developed plasmacytoma
* When you biopsy this, **it’s filled with plasma cells** bc they’re producing the abnormal immunoglobulins, which are the cause of the devastating issues of multiple myeloma
93
**Acute myelogenous
leukemia***with*
**granulocytic
sarcoma**
## Footnote
* *Complaining of lump inside of her cheek**
* *Notsomuch worried about her gingiva**, despite her overgrowth – leukemic infiltrates that got into gingival tissues
* *Left buccal mucosa**, kept biting on it, feeling incredibly fatigued though she was always working out
* *Oral surgeon biopsied** her buccal mucosa and read by pathologist as pyogenic granuloma
* *Physician** sent her for bloodwork, dental school sent her for bloodwork too
94
**Lymphoma**
* **Lymphoma** is a general term for a complex group of heterogeneous lymphoreticular malignancies.
* **Lymphoma** is the _sixth most common malignancy_ and the **second most common neoplasm of the head and neck after squamous cell carcinoma** and **accounts for 50-59% of head and neck neoplasms in children.**
* They constitute approximately 3-5% of all known malignancies and are generally divided into two morphologically distinct types: **Hodgkin’s lymphoma (HL)** and **non-Hodgkin’s lymphoma (NHL).**
* These malignancies typically **arise within the lymphatic tissues and can progress to extranodal disease as in NHL.**
* **Cervical lymph node involvement can be present in any type of lymphoma**.
* HL extends by means of contiguous nodal spread whereas NHL tends to disseminate hematogenously and is typically a systemic diagnosis.
* Within the head and neck, **Waldeyer’s ring** is the most common site of involvement, accounting for more than half of all extranodal head and neck lymphomas.
* **Oral involvement by lymphoma** may represent _a localized disease process_ but is _more often part of a systemic process that secondarily involves the cervical lymph nodes._
* **Lymphoma** arising within the oral cavity accounts for less than 5% of all oral malignancies, and **approximately 85% of these lesions involve the pharyngeal tonsil** and the **palate**
* Extralymphatic sites include the **salivary glands, paranasal sinuses, oral cavity, and larynx.**
95
What is this clinical finding?
Lymphoma
* Well circumscribed ulceration in area
* Associated swelling in periphery
* White change in the patient’s left area
* Been there for 3 weeks
* It’s lymphoma
96
What is this clinical finding?
Looks like it could be a salivary gland neoplasm, but it’s not
It was another **lymphoma**
Manifest in a number of different ways
97
**Case**
**40 year old male
Completely healthy otherwise
Not taking any medications
Presents with bump on the tongue**
First question: did you do anything that might have led to this? Bite your tongue?
“possible I bit my tongue, or it could be when I had a dental procedure, maybe they accidentally
cut into the side of my tongue” – then it developed
This tells us, is this a reactive lesion?
Is it pedunculated or sessile? It’s pedunculated, larger at the top than the base
Let’s look at the surface: it’s ulcerated
When palpating, it’s only on the surface - don’t feel any submucosal presentation
Tongue underneath feels relatively normal
This bump is kind of firm and it bleeds like crazy when you touch it
When you look at teeth, no area where they’re too sharp
**Do you think it’s a fibroma? No. Why?**
Fibroma is covered with normal coloring epithelium – sometimes see a little white change on surface or see tiny traumatic ulcer on surface This is not like that, this is completely ulcerated
Not fibroma; fibroma is a chronic bump that patient is aware of
**Is it squamous cell carcinoma? Interesting, it is indeed very friable; but no**
Sometimes SCC can develop and can be exophytic and don’t have deep invasion, But this is pedunculated, SCC would not be pedunculated
History says there could be some kind of trauma, biting, or nick with bur – not squamous cell
**Mucocele? No**
Would you typically develop mucocele on lateral border of tongue? No
Not going to be as many mucoceles in this area, but there are the glands of Blandin and Nuhn, so it’s possible to develop on ventral surface of tongue
This bump doesn’t look like a fluid filled bump though, it has surface ulceration, redness ;Mucoceles have intact surface, would not bleed, or be red
**Granular cell tumor? No**
Granular cell tumor would have normal overlying epithelium (it’s pushing up from underneath)
This does not have normal overlying epithelium
**Hemangioma reserved for congenita**l; not a vascular malformation either
**Neurofibroma? No, not the same surface**
**Salivary gland neoplasms? Possible**, there are salivary glands in that area; keep this in differential
The one that this is is **pyogenic granuloma**: usually red, ulcerated, and bleeds easily
