Oral & Maxillofacial Pathology IIOral & Maxillofacial Pathology IIDB 3702DB 3702

Thursdays, 10:00 – 11:50 amRoom DB 132

Course Director: Dr. J. E. BouquotCourse Director: Dr. J. E. BouquotRoom 3.094b; 713Room 3.094b; 713--500500--44204420Jerry.Bouquot@uth.tmc.eduJerry.Bouquot@uth.tmc.edu

Topic: Soft Tissue TumorsTopic: Soft Tissue Tumors

This presentation is intended for students of Dr. Jerry Bouquot. Designated owners of the photographic images in this lecture retain the copyrights for those images but have agreed to allow their photos to be used for teaching. You are welcome to use this presentation for your learning, alone or with other dental students, but permission is not given for the publication of these photos in electronic or any other format.

This presentation created by This presentation created by Dr. J. E. BouquotDr. J. E. Bouquot

Disclaimer: Dr. Bouquot is Professor & Chair,Department of Diagnostic Sciences,

University of Texas Dental Branch at Houston.The information and opinions provided herein are,

however, his own and do not represent official opinion or policy of the University of Texas.

FibrosarcomaFibrosarcoma

FibrosarcomaFibrosarcoma

Malignant neoplasm of fibroblastsEtiology = unknown

GALP:– None– Children, teenagers, young adults– Palate > tongue > buccal– 10% of all are in H&N

Painless, firm massOften lobulatedMay have surface ulcerationSlow-growing in beginningModerate growth speed-- May be rapid

FibrosarcomaFibrosarcomaHistopathologyHistopathology

Spindle cells in collagenSpindle cells may be dysplasticGrade is important for prognosis-- Grades I - IVNot encapsulatedMitotic figuresHerring bone pattern

Grade IGrade I

Grade IIIGrade III

FibrosarcomaFibrosarcomaPathophysiology, TreatmentPathophysiology, Treatment

Can grow rapidly toward end--Especially high grade lesionsDestroys underlying boneFibrosarcoma of bone-- Perforates through cortex

Treatment:-- Radical surgical removal-- Including affected bone5-year survival = 50%

Malignant Fibrous Malignant Fibrous HistiocytomaHistiocytoma

Malignant Fibrous HistiocytomaMalignant Fibrous HistiocytomaFibroxanthoma; DermatofibromaFibroxanthoma; Dermatofibroma

Malignant neoplasm of histiocytes-- With fibrous differentiation

GALP:– None– Middle-age and older (but skin lesions: young adults)– Buccal< vestibule-- Rare in mouth

Painless, firm massMay be lobulatedMay be ulcerated

Malignant Fibrous HistiocytomaMalignant Fibrous HistiocytomaHistopathologyHistopathology

Numerous spindle cellsOpen nuclei (like histiocytes)Storiform patternMaybe rounded histiocytic cellsMay look benign!

Pyogenic Pyogenic GranulomaGranuloma

Pyogenic GranulomaPyogenic GranulomaPyogenic Granuloma Type HemangiomaPyogenic Granuloma Type Hemangioma

Lack of reduction of granulation tissueduring normal healing process-- Not an infection, no pus

but “pyogenic” = pus producing-- Not a granulomatous infection

GALP:– None (although strong female predilection in biopsied cases)– Children & young adults– Gingiva (75%), lips, tongue, buccal– 50th most common mucosal lesion-- Prevalence = 1/10,000 adults

“Proud flesh”

Pyogenic GranulomaPyogenic Granuloma

Edematous granulation tissueNeovascularityChronic inflammatory cellsAcute inflammatory cellsSurface ulceration, oftenLobular (locular) capillary hemangioma

Lobular hemangiomaLobular hemangioma

Pyogenic GranulomaPyogenic Granuloma

Painless erythematous massOften hemorrhagicOften lobulated surfaceOften ulceratedOften pedunculated

Pyogenic GranulomaPyogenic GranulomaSpecial VariantsSpecial Variants

Pregnancy tumor:-- PG of gingiva-- In pregnant woman-- Papilla involved-- May be multiple-- Poor oral hygiene

Epulis granulomatosum:-- PG within poorly healed

extraction socket-- Curette thoroughly

Parulis (gum boil):-- PG at opening of dental fistula -- Check for abscess in bone-- Treat the tooth

Parulis

Epulis granulomatosum

Pregnancy tumor

Pyogenic GranulomaPyogenic Granuloma

May shrink over timeMay become irritation fibroma-- Fibrotic pyogenic granuloma

Pregnancy tumor:-- Often disappears after

birth of babyTreat: Surgical excision-- Remove cause

For pregnancy tumor:-- Wait until after birth

May recur -- If original cause

is not removed-- More infection, trauma

LookLook--Alike: Traumatic Eosinophilic UlcerAlike: Traumatic Eosinophilic UlcerTraumatic Ulcer with Stomal EosinophiliaTraumatic Ulcer with Stomal Eosinophilia

May mimic pyogenic

granuloma

Peripheral Peripheral Ossifying FibromaOssifying Fibroma

Peripheral Ossifying FibromaPeripheral Ossifying FibromaPeripheral Cementifying/Ossifying FibromaPeripheral Cementifying/Ossifying Fibroma

Inflammatory proliferation of fibrous tissue

From periodontal fibersPrimitive stromaBone or cementum

GAL:– 2/3 females– Teenagers and young adults– Gingival papilla

(must be in this location)-- Edentulous alveolus also

Peripheral Ossifying Peripheral Ossifying FibromaFibroma

HistopathologyHistopathology

Primitive spindle cellsin fibrous stromaImmature bone formation-- Often with active osteoblastsMaybe cementoid globules-- Few cementoblasts-- Almost no cementocytes

Peripheral Ossifying Peripheral Ossifying FibromaFibroma

Painless mass of papillaFirm, red/pink May be lobulatedMay be ulceratedMay show radiopacitiesCan separate teethMay develop in socket

Peripheral Ossifying FibromaPeripheral Ossifying FibromaCan Spread Teeth ApartCan Spread Teeth Apart

Peripheral Ossifying FibromaPeripheral Ossifying Fibroma

Usually < 2 cm.-- Occasionally up to 3 cm.Treat:

-- Conservative surgical excision-- With curettage of base– Cleaning/scaling adjacent teeth15% recur

Peripheral Ossifying Fibroma (In Socket)Peripheral Ossifying Fibroma (In Socket)Epulis GranulomatosumEpulis Granulomatosum

Peripheral Ossifying FibromaPeripheral Ossifying FibromaCan (Rarely) Produce Massive Sclerosis Above the CrestCan (Rarely) Produce Massive Sclerosis Above the Crest

Peripheral Ossifying FibromaPeripheral Ossifying FibromaCan Occur on Edentulous Ridge (From Residual Periodontal Fibers)Can Occur on Edentulous Ridge (From Residual Periodontal Fibers)

Peripheral Giant Peripheral Giant Cell GranulomaCell Granuloma

Peripheral Giant Cell GranulomaPeripheral Giant Cell GranulomaPeripheral Giant Cell Lesion; Giant Cell EpulisPeripheral Giant Cell Lesion; Giant Cell Epulis

Inflammatory proliferation of phagocyticcells from:– Irritation-- Trauma-- Infection

GAL:– 60% in females– Fifth-sixth decades– Gingiva-- Alveolar mucosa

Peripheral Giant Cell GranulomaPeripheral Giant Cell GranulomaHistopathologyHistopathology

Immature fibrous stroma Multinucleated giant cellsExtravasated erythrocytesSpindled, oval mesenchymal cells

Peripheral Giant Cell GranulomaPeripheral Giant Cell GranulomaClinical FeaturesClinical Features

Painless massPerhaps hemorrhagicOften red/bluish/brownSomewhat soft to palpationMay cup out underlying bony cortex-- Saucerization (from pressure)Maybe calcifications on radiograph-- Near lower borderOften ulcerated In socket = epulis granulomatosum

Peripheral Giant Cell GranulomaPeripheral Giant Cell GranulomaPathophysiology; TreatmentPathophysiology; Treatment

Generally remain less than 2 cm.May become more than 4 cm.No malignant transformationTreat: Conservative surgical excision--With curettage of base– And cleaning/scaling of adjacent teeth10% recurCaution: large or multiple or recurring lesionsmight be brown tumor of hyperparathyroidism

HyperparathyroidismHyperparathyroidism

↑ PTH >> ↑ calcium taken from bonePrimary: ↑PTH from tumor-- 90%: from parathyroid adenoma-- 10% from parathyroid hyperplasia-- Rare: from parathyroid carcinomaSecondary: chronic ↓ calcium >> ↑PTH-- Usually: chronic renal disease-- ↓ vitamin D made by kidney >>-- ↓ calcium GI absorption >>-- ↓ serum calcium (hypocalcaemia)-- Severe: renal osteodystrophy

GALP: -- 1:4 male:female ratio-- >60 y/o -- Kidneys, bone

Ground glass skullGround glass skull

Osteitis Osteitis fibrosa fibrosa cysticacystica

HyperparathyroidismHyperparathyroidism

“Bones, moans and abdominal groans”Renal calculi (kidney stones, nephrolithiasis)-- From ↑ serum calciumMetastatic calcification-- Dystrophic calcification of soft tissues-- From ↑ serum calciumSubperiosteal resorption of phalanges-- Index & middle fingersGround glass bone-- ↓ trabeculae-- Blurred radiographLoss of lamina dura (early sign)Brown tumorOsteitis fibrosa cystica-- Severe variant of bone change-- Marrow degeneration-- Fibrosis of brown tumors

HyperparathyroidismHyperparathyroidism

Duodenal ulcers (painful)WeaknessLethargyConfusionDementia

Brown tumor-- Multinucleated giant cells-- Extravasated RBCs-- Hemosiderin deposits-- Radiolucency

(often multilocular)-- Bony expansion-- May be multiple-- Like central giant cell

granuloma of jaws

HyperparathyroidismHyperparathyroidismGround Glass Bone; Loss of Lamina DuraGround Glass Bone; Loss of Lamina Dura

HemangiomaHemangioma

HemangiomaHemangiomaCavernous Hemangioma; Capillary HemangiomaCavernous Hemangioma; Capillary Hemangioma

Benign developmental growth of vesselsBenign neoplasm of blood vessels

GALP:– 3x females– Children and teenagers– Seldom congenital, but develop shortly after birth– Tongue > buccal > lips– 6th most common mucosal lesion– Prevalence = 6/1,000 adults– Head and neck:

most common location

HemangiomaHemangiomaHistopathologyHistopathology

Dilated vessels: cavernous hemangiomaSmall vessels:capillary hemangiomaEndothelium-lined channelsEndothelial nuclei are enlarged-- Plump; bulge into lumen-- If flat: inactive lesionBlood-filled luminaWithout blood:lymphangiomaNo encapsulationPort wine stain = capillary hemangioma

Capillary & Cavernous Capillary & Cavernous HemangiomaHemangioma

HemangiomaHemangiomaClinical CharacteristicsClinical Characteristics

Sessile, lobulated Soft red mass

Often lobulatedPainlessSmooth-surfaceFluctuates and blanchesBlue color if venous bloodRed if arterialDeep lesions: no surface colorOn skin: port wine stain, -- Berry angioma-- Sturge-Weber syndrome

Deep HemangiomaDeep HemangiomaDeep lesions may only discolor surfaceDeep lesions may only discolor surface

HemangiomaHemangiomaPathophysiologyPathophysiology

Infancy lesions:-- Often spontaneously regress-- Later lesions do notSome lesions continue to enlarge-- Until adulthood-- Perhaps even after– No cancer developmentProblems:-- Hemorrhage-- Clots (from stagnant blood)

Intramedullary HemangiomaIntramedullary HemangiomaEndosteal HemangiomaEndosteal Hemangioma

Central sunburst pattern

HemangiomaHemangiomaTreatmentTreatment

Often left aloneChildhood lesions:-- Corticosteroids-- Interferon-α-2aLaser therapy can be effectiveInjection of sclerosing solutions-- Sodium morulate-- 95% ethanol

Mucoepidermoid Carcinoma Mucoepidermoid Carcinoma (Blue Color from Mucus)(Blue Color from Mucus)

Hemangioma LookHemangioma Look--Alike LesionsAlike Lesions

KaposiKaposi’’s Sarcomas Sarcoma(AIDS)(AIDS)

Lingual VaricositiesLingual Varicosities HematomaHematoma(Does not Blanch)(Does not Blanch)

Traumatic Traumatic Angiomatous LesionAngiomatous Lesion

Traumatic Angiomatous LesionTraumatic Angiomatous LesionVenous Pool; Venous Lake; Venous Pool; Venous Lake;

Venous AneurysmVenous Aneurysm

Acute trauma to subepithelial vein-- With focal dilation or “aneurysm”GAL: – None-- Middle-aged and older-- Lips, buccalSmall, painless red bleb– BlanchesMicro: single dilated venous structurePerhaps with thrombus (may calcify)Remains indefinitely– Usually remains less than 4 mm– No malignant developmentTreat: conservative surgical removalOK to leave alone, except for esthetics

SturgeSturge--WeberWeberAngiomatosisAngiomatosis

Sturge-Weber AngiomatosisSturge-Weber Syndrome,

Encephalotrigeminal Angiomatosis

Vascular plexus forms around cephalicpart of neural tube at six weeks-- Regresses after the ninth week-- Doesn’t regress with S-W syndrome– Not inheritedGALP:– None– Congenital– Face, buccal, maxilla-- Rare

Sturge-Weber AngiomatosisSturge-Weber Syndrome,

Encephalotrigeminal Angiomatosis

Purple/red macule(s) of face-- Port wine stain-- Nevus flammeus-- Trigeminal nerve distribution, usually

Often with involvement of oral mucosaAngiomas of ipsilateral leptomeninges-- May cause seizures--May cause mental retardationCalcifications of gyri

AngiosarcomaAngiosarcoma

AngiosarcomaMalignant

Hemangioendothelioma

Vascular neoplasm of endotheliumLooks like hemangioma-- More rapid growthNo painDestroys adjacent structuresMets via blood (to lungs)Poor prognosis-- 10-year survival = 21%Hemangioendothelioma

-- Histology may look OK-- Can’t predict from micro.

Kaposi SarcomaKaposi Sarcoma

Kaposi SarcomaKaposi SarcomaIn AIDSIn AIDS

Vascular proliferation (neoplasm?)-- Usually in AIDS-- Non-AIDS cases usually in old meStimulated by herpesvirus 8-- Kaposi’s sarcoma-associated herpesvirusGAL:– Strong male predilection– Young adults and middle-aged– Tongue, lips, gingivaSoft-to-firm red or purple nodule-- May be macular– Painless– Nonhemorrhagic-- May be multiple-- May be lobulated or granular

Kaposi SarcomaKaposi SarcomaHistopathology, Pathophysiology, Histopathology, Pathophysiology,

TreatmentTreatment

Combination of proliferating spindled &endothelial cells– Extravasated erythrocytes– Staghorn clefts (veins)Slowly enlargeNew lesions developing over timeTreat: lesions disappear withsuccessful AIDS treatment-- Protease inhibitors, antivirals, etc.

Kaposi SarcomaKaposi Sarcoma

LymphangiomaLymphangioma

LymphangiomaLymphangioma

Benign neoplasm of lymph vesselsHamartoma of lymph vesselsGAL:– None– Children and teenagers– Tongue (produces macroglossia)Soft painless cluster of clear blebsOften with outlying or satellite blebs-- Several mm from main massMay be scattered clear blebs

LymphangiomaLymphangiomaHistopathologyHistopathology

Same appearance as hemangioma,but without blood in the luminaCavernous type, usuallyPlump endothelial nuclei-- If flat: inactive lesionMay be admixed with blood vesselsNo encapsulation

LymphangiomaLymphangiomaPathophysiology, TreatmentPathophysiology, Treatment

Slowly enlarges with body growthNo spontaneous regression-- As with hemangiomaNo cancer developmentTreat: conservative surgical removal– Usually deliberately leave tumor behind(debulking)

Repeat surgery is not uncommon-- Congenital cases: average = 4

Cystic HygromaCystic HygromaDevelopmental Cavernous LymphangiomaDevelopmental Cavernous Lymphangioma

Developmental LymphangiomaDevelopmental Lymphangioma

LymphangiomaLymphangiomaLookLook--Alike LesionsAlike Lesions

Inflammatory Papillary HyperplasiaInflammatory Papillary Hyperplasia(Early, Edematous Lesions)(Early, Edematous Lesions)

Benign Lymphoid AggregatesBenign Lymphoid Aggregates

LymphangiosarcomaLymphangiosarcoma

LymphangiosarcomaLymphangiosarcoma

Malignant neoplasm of lymph vesselsVery rareDysplastic endothelial cellsNo blood in vesselsTreat: radical surgeryPoor prognosis

LipomaLipoma

LipomaLipoma

Benign neoplasm of fat cellsSome are developmental GALP:–None– Middle-aged– Buccal, vestibule– Most common soft tissue tumor in the body,

but not so common in the mouth– 38th most common mucosal lesion in adults– Prevalence = 3/10,000

LipomaLipomaClinical FeaturesClinical Features

Sessile, yellowish massVery softPainlessEncapsulated: freely movable

LipomaLipomaHistopathologyHistopathology

Micro: mature adipocytes-- With collagen trabeculaeMay or may not be encapsulatedMay “infiltrate” great distancesinto surrounding stromaSometimes admixed with fibrous tissue (fibrolipoma) Problem: herniated buccal fat pad

LipomaLipomaPathophysiology, TreatmentPathophysiology, Treatment

Slowly enlargeUsually remain < 3 cm.No malignant transformationTreat: conservative surgical excision– Usually do not recur, except the infiltrating types

Familial LipomatosisFamilial Lipomatosis

Photo: Dr. J. Bouquot, University of Texas, Houston, Texas

Traumatic NeuromaTraumatic Neuroma

Traumatic NeuromaTraumatic Neuroma

Reactive proliferation of neural tissue-- After nerve injury

GAL:-- None-- Middle-aged-- Mental foramen

Smooth-surfaced noduleSoft, nonulceratedLess than half are tender or painful, may be burningMicro: Intertwining, tortuous nerve fibers in a fibrous stromaUsually remain less than 1 cm.; no malignant transformationTreat: conservative surgical excision-- With small part of affected nerveMay lead to paresthesia and painMay recur

NeurofibromaNeurofibroma

NeurofibromaNeurofibroma

Benign neoplasm of Schwann cells-- And perineural fibroblastsGALP:– None– Young adults– Tongue, buccal– The most common peripheral nerve tumor-- 1/1,000 adultsSmooth-surfaced soft, nonulcerated nodulePainlessMay be huge and pendulous

NeurofibromaNeurofibromaIn Inferior Alveolar CanalIn Inferior Alveolar Canal

Photo: Dr. J. Bouquot, University of Texas, Houston, Texas

NeurofibromaNeurofibroma

Well circumscribed interlacing bundlesof spindle-shaped cells with wavy nuclei-- In a fibrous stromaUsually < 2 cm.-- May become hugeOral lesions seldom become malignant-- Less likely than skin lesionsTreat: conservative surgical excision– Recurrence is rare

SchwannomaSchwannoma

SchwannomaSchwannomaNeurilemmomaNeurilemmoma

Benign neoplasm of Schwann cellsGALP:– None– Young adults and middle-aged– Tongue, hard palate– Up to half occur in head and neck areaSmooth, soft noduleNonulceratedPainlessMoveableNormal color or yellowish white

SchwannomaSchwannomaHistopathologyHistopathology

EncapsulatedTwo tissue types: – Antoni A: streaming fascicles of spindle

Schwann cells forming Verocay bodies– Antoni B: disorganized neurites in

loose fibrous stroma

SchwannomaSchwannomaPathophysiology, TreatmentPathophysiology, Treatment

Usually remain less than 2 cmOral lesions seldom become malignantSkin lesions can but it is uncommonTreat: conservative surgical excision– Recurrence is rare

NeurofibrosarcomaNeurofibrosarcoma

NeurofibrosarcomaNeurofibrosarcomaMalignant Peripheral Nerve Sheath TumorMalignant Peripheral Nerve Sheath Tumor

Dysplastic spindle cellsFew recognizable nervesTreat: radical surgery5-year survival = 40-50%

NeurofibromatosisNeurofibromatosis

von Recklinghausen Neurofibromatosisvon Recklinghausen NeurofibromatosisMultiple Endocrine Neoplasia I (MEN I)Multiple Endocrine Neoplasia I (MEN I)

Multiple neurofibromas-- Some schwannomas-- Throughout body-- Maybe hundreds-- Oral lesions in 1/4 of casesAutosomal dominant inheritance-- Gene is on chromosome 17

von Recklinghausen Neurofibromatosisvon Recklinghausen NeurofibromatosisMultiple Endocrine Neoplasia I (MEN I)Multiple Endocrine Neoplasia I (MEN I)

Café au lait spots (brown skin patches)Abnormal bone developmentLisch nodules (brown spots on iris)5-10% chance of malignant development-- Usually neurofibrosarcoma

(malignant peripheral nerve sheath tumor)

Multiple Mucosal Multiple Mucosal Neuroma SyndromeNeuroma Syndrome

Multiple Endocrine Neoplasia IIBMultiple Endocrine Neoplasia IIBMultiple Mucosal Neuroma Syndrome; MEN IIIMultiple Mucosal Neuroma Syndrome; MEN III

Autosomal dominant inherited disease-- Multiple tumors or hyperplasias of

neuroendocrine tissues

Mutation of RET protooncogene-- On chromosome 10

GALP:– None– Teenagers and young adults– Tongue, lips-- Rare

Multiple Endocrine Neoplasia IIBMultiple Endocrine Neoplasia IIBClinical FeaturesClinical Features

Sessile, soft nodules-- Smooth-surfaced-- Painless-- Yellowish white-- MoveableOral signs: often first evidence of diseaseNarrow face

Multiple Endocrine Neoplasia IIBMultiple Endocrine Neoplasia IIBClinical FeaturesClinical Features

Long extremitiesAbraham Lincoln appearanceWeak musclesPheochromocytomas (50%)Medullary thyroid carcinomas (90%)Elevated serum and urinary calcitonin-- From thyroid tumorElevated urinary vanillylmandelic acid (VMA)Increased epinephrine-to-norepinephrine ratio-- From adrenal tumor

Multiple Endocrine Neoplasia IIBMultiple Endocrine Neoplasia IIBHistopathology, Pathophysiology, TreatmentHistopathology, Pathophysiology, Treatment

Micro: intertwining, tortuous nerve fibers-- Thick perineurium-- Spaces (artifactual) around nervesOral neuromas remain small-- Less than 5 mmOral neuromas do not become malignantTreat: no treatment needed for oral lesions-- Except for estheticsTreat systemic problems and tumors prn

Neuroectodermal Neuroectodermal Tumor of InfancyTumor of Infancy

Neuroectodermal Tumor of InfancyNeuroectodermal Tumor of InfancyProgonoma; Retinal Anlage TumorProgonoma; Retinal Anlage Tumor

Neoplasm of neural crest cells

GALP:– None– Infancy; newborns– Anterior maxillary alveolus– Very rare

Rapidly expanding blue/black painless mass

Usually destroys underlying bone

Elevated urinary vanillylmandelic acid (VMA)-- From oral tumor

Neuroectodermal Tumor of InfancyNeuroectodermal Tumor of InfancyHistopathologyHistopathology

Micro: two cell types: – Small dark round neuroblastic cells– Large epithelioid cells with melanin

Neuroectodermal Tumor of InfancyNeuroectodermal Tumor of InfancyPathophysiology, TreatmentPathophysiology, Treatment

May reach alarming sizeMay destroy anterior alveolar boneMalignant variants (very rare)Treat: Moderately severe surgical excision– 15% recurrence

Granular Cell Granular Cell TumorTumor

Granular Cell TumorGranular Cell TumorGranular Cell MyoblastomaGranular Cell Myoblastoma

Benign neoplasm of Schwann cellsOriginally thought to be from striated muscle cells

GALP:– 2x females– Fourth-sixth decades– Tongue-- 50% of all body cases

are oral

Sessile mass-- Painless-- Firm-- Pale

Granular Cell TumorGranular Cell TumorGranular Cell Myoblastoma (Schwann Cell Origin)Granular Cell Myoblastoma (Schwann Cell Origin)

Granular Cell TumorGranular Cell TumorHistopathologyHistopathology

Large, polygonal cells-- Like histiocytes-- Granular cytoplasm-- Small nucleiIn sheets and globulesMay be spindled cellsNot encapsulated

Granular Cell TumorGranular Cell TumorHistopathologyHistopathology

May infiltrate between muscle fibersProblem: -- Pseudoepitheliomatous hyperplasia-- Mimics squamous cell carcinoma

Granular Cell TumorGranular Cell TumorPathophysiology, TreatmentPathophysiology, Treatment

Usually remain 1-2 cm.Seldom enlarge after initial noticeNo malignant transformation riskTreat: conservative surgical excision-- Recurrence is very rare

Granular Cell EpulisGranular Cell Epulis

Granular Cell EpulisGranular Cell EpulisCongenital EpulisCongenital Epulis

Developmental tumor of unknown histogenesisGAL:

– 90% females– Newborn– Anterior maxillary alveolus

Pedunculated, soft, noduleSmooth-surfacedPink or pale

Granular Cell EpulisGranular Cell EpulisHistopathologyHistopathology

Large, polygonal cells-- Granular cytoplasmLike cells in granular cell tumor-- But different immunohistochemistryAtrophic epithelium-- No pseudoepitheliomatous hyperplasia

Granular Cell EpulisGranular Cell EpulisPathophysiology, TreatmentPathophysiology, Treatment

Usually remains less than 2 cm-- May become up to 9 cmTreat: conservative surgical excision-- As soon as baby can tolerate surgery– Does not recurIf left untreated: small lesions shrink-- Often disappear-- Does not interfere with tooth eruption

LeiomyomaLeiomyoma

LeiomyomaLeiomyoma

Benign neoplasms of smooth muscleGALP: – None– Infancy or childhood– Tongue, lips– Very rareUsually sessile, firm, painless massNormal surface color and smooth surfaceMicro: cellular proliferations of smooth muscle cellsUsually encapsulatedUsually remain less than 2 cm.No cancer transformationTreat: conservative surgical removal– Few recurrences

LeiomyosarcomaLeiomyosarcoma

LeiomyosarcomaLeiomyosarcoma

Malignant neoplasm of smooth muscleEtiology: unknownGALP:-- None-- Young adults & middle age-- No location predilection-- Rare

Lobulated massRelatively firmMay be ulcerated

LeiomyosarcomaLeiomyosarcomaHistopathology, TreatmentHistopathology, Treatment

Dysplastic spindle cells-- blunt, cigar-shaped nuclei

Treat: radical surgeryOverall: poor prognosisHigh grade = worse prognosis

RhabdomyomaRhabdomyoma

RhabdomyomaRhabdomyoma

Benign neoplasmof striated muscleEtiology: unknownGAL:– None– Infancy or childhood– Tongue, lips– Very rareUsually sessile, firm, painless massNormal surface color and smooth surface

RhabdomyomaRhabdomyoma

Micro: cellular proliferationsof striated muscle cells-- Usually encapsulatedUsually remain less than 2 cm.No cancer transformationTreat: conservative surgical removal– Few recurrences

RhabdomyosarcomaRhabdomyosarcoma

RhabdomyosarcomaRhabdomyosarcoma

Malignant neoplasm of striated muscle

GALP:-- None-- Childhood/young adults-- Tongue-- Rare

Firm massOften lobulatedSometimes ulcerated

RhabdomyosarcomaRhabdomyosarcomaHistopathologyHistopathology

Dysplastic striate muscle cellsEmbryonal typeAlveolar typeTreat: radical surgery70% 5-year survival

ChoristomaChoristoma

Cartilaginous ChoristomaCartilaginous ChoristomaSoft Tissue ChondromaSoft Tissue Chondroma

Tumor-like proliferation of normal cartilage-- But in wrong place GAL: – None– Teens and young adults (probably started much earlier)– TongueSessile, firm, painless mass with normal surface color or pallorMicro: Normal cartilage (hyaline or fibrous) in a fibrous stroma

Cartilaginous ChoristomaCartilaginous ChoristomaSoft Tissue ChondromaSoft Tissue Chondroma

Usually remain 1-2 cmNo cancer transformationTreat: conservative surgical removal– No recurrenceSpecial variant: Cutright tumor:– Presumably secondary to continuing, low-level trauma– Older persons– Anterior maxillary alveolar midline– Firm, sessile nodule under denture– Treat: conservative surgical removal and fix denture

(seldom recurs)

Osseous ChoristomaOsseous ChoristomaSoft Tissue OsteomaSoft Tissue Osteoma

Tumor-like proliferation of normal bone-- But in wrong place GALP:– None– Teens and young adults (probably started much earlier)– Tongue-- RareSessile, firm massNormal surface color or pallorPainlessMicro: Normal but immature bone-- Perhaps with marrow-- In fibrous stromaUsually remain 1-2 cmNo cancer transformationTreat: conservative surgical removal– No recurrence

MetastasisMetastasisto the Mouthto the Mouth

Metastasis to the MouthMetastasis to the Mouth

Metastatic spread from extraoral source-- Almost always carcinomaUsually from lung, breast and GIGALP:– Moderate male predilection– Middle-aged and older– Gingiva, tongue-- 1-2% of all oral cancersFirm, smooth-surface nodule-- Often with normal colorOften ulceratedMay be painfulMay destroy bone

Metastasis to the MouthMetastasis to the Mouth

Micro: same appearance as primary cancerEnlarge rapidlyEventually with surface ulceration, painTreat: -- Radical surgical excision-- Radiotherapy-- Chemotherapy– Depends on condition of the primary tumor-- Depends on other metastases