Soft Tissue Tumors

DR KHAIRY ABU ZANT

• Epulis granulomatosa is a term used to describe hyperplastic growths
of granulation tissue that sometimes arise in healing extraction
sockets . These lesions resemble pyogenic granulomas and usually
represent a granulation tissue reaction to bony sequestra in socket
Histopathologic Features
• Microscopic examination of pyogenic granulomas shows a highly vascular
proliferation that resembles granulation tissue .
• Numerous small and larger endothelium-lined channels are formed that
are engorged with red blood cells. These vessels sometimes are organized
in lobular aggregates—hence, the term lobular capillary hemangioma.
• The surface is usually ulcerated and replaced by a thick fibrinopurulent
membrane.
• A mixed inflammatory cell infiltrate of neutrophils, plasma cells, and
lymphocytes is evident. Neutrophils are most prevalent near the ulcerated
surface; chronic inflammatory cells are found deeper in the specimen.
• Older lesions may have areas with a more fibrous appearance. In fact,
many gingival fibromas probably represent pyogenic granulomas that have
undergone fibrous maturation.
Treatment and Prognosis
• The treatment of patients with pyogenic granuloma consists of
conservative surgical excision, which is usually curative.
• The specimen should be submitted for microscopic examination to rule
out other more serious diagnoses.
• For gingival lesions, the excision should extend down to periosteum and
the adjacent teeth should be thoroughly scaled to remove any source of
continuing irritation.
• A recurrence rate of 3% to 15% has been reported in most studies. In rare
instances, multiple recurrences have been noted.
• For lesions that develop during pregnancy, usually treatment should be
deferred unless significant functional or aesthetic problems develop. The
recurrence rate is higher for pyogenic granulomas removed during
pregnancy, and some lesions will resolve spontaneously after parturition
PERIPHERAL GIANT CELL GRANULOMA
(GIANT CELL EPULIS)
• The peripheral giant cell granuloma is a relatively common tumorlike
growth of the oral cavity. It probably does not represent a true
neoplasm but rather is a reactive lesion caused by local irritation or
trauma.
• Some investigators believe that the giant cells show
immunohistochemical features of osteoclasts, whereas other authors
have suggested that the lesion is formed by cells from the
mononuclear phagocyte system. The peripheral giant cell granuloma
bears a close microscopic resemblance to the central giant cell
granuloma
Clinical and Radiographic Features
• The peripheral giant cell granuloma occurs exclusively on the gingiva or
edentulous alveolar ridge, presenting as a red or red-blue nodular mass
• Most lesions are smaller than 2 cm in diameter, although larger ones are
seen occasionally. The lesion can be sessile or pedunculated and may or
may not be ulcerated. The clinical appearance is similar to the more
common pyogenic granuloma of the gingiva
• although the peripheral giant cell granuloma often is more blue-purple
compared with the bright red of a typical pyogenic granuloma.
• Peripheral giant cell granulomas can develop at almost any age, especially
during the first through sixth decades of life. The mean age in several large
series ranges from 31 to 46 years. Approximately 52% to 60% of cases
occur in females.
• It may develop in either the anterior or posterior regions of the
gingiva or alveolar mucosa, and the mandible is affected slightly more
often than the maxilla.
• Although the peripheral giant cell granuloma develops within soft
tissue, “cupping” resorption of the underlying alveolar bone
sometimes is seen. On occasion, it may be difficult to determine
whether the mass arose as a peripheral lesion or as a central giant cell
granuloma that eroded through the cortical plate into the gingival soft
tissues.
Histopathologic Features
• Microscopic examination of a peripheral giant cell granuloma shows a
proliferation of multinucleated giant cells
Treatment and Prognosis
• The treatment of the peripheral giant cell granuloma consists of local
surgical excision down to the underlying bone. The adjacent teeth
should be carefully scaled to remove any source of irritation and to
minimize the risk of recurrence.
PERIPHERAL OSSIFYING FIBROMA
• (OSSIFYING FIBROID EPULIS; PERIPHERAL FIBROMA WITH
CALCIFICATION; CALCIFYING FIBROBLASTIC GRANULOMA)
• The peripheral ossifying fibroma is a relatively common gingival
growth that is considered to be reactive rather than neoplastic in
nature.
• The pathogenesis of this lesion is uncertain. Because of their clinical
and histopathologic similarities, researchers believe that some
peripheral ossifying fibromas develop initially as pyogenic granulomas
that undergo fibrous maturation and subsequent calcification.
• The mineralized product probably has its origin from cells of the
periosteum or periodontal ligament.
Clinical Features
• The peripheral ossifying fibroma occurs exclusively on the gingiva.
• It appears as a nodular mass, either pedunculated or sessile, that usually
emanates from the interdental papilla
• The color ranges from red to pink, and the surface is frequently, but not
always, ulcerated.
• The growth probably begins as an ulcerated lesion; older ones are more
likely to demonstrate healing of the ulcer and an intact surface. Red,
ulcerated lesions often are mistaken for pyogenic granulomas; the pink,
nonulcerated ones are clinically similar to irritation fibromas.
• Most lesions are less than 2 cm in size, although larger ones occasionally
occur. The lesion often has been present for many weeks or months before
the diagnosis is made.
• The peripheral ossifying fibroma is predominantly a lesion of
teenagers and young adults, with peak prevalence between the ages
of 10 and 19. Almost two-thirds of all cases occur in females.
• There is a slight predilection for the maxillary arch, and more than
50% of all cases occur in the incisor-cuspid region. Usually, the teeth
are unaffected; rarely, there can be migration and loosening of
adjacent teeth.
histopathologic Features
• The basic microscopic pattern of the peripheral ossifying fibroma is one of
a fibrous proliferation associated with the formation of a mineralized
product .
• The deeper fibroblastic component often is cellular, especially in areas of
mineralization. In some cases, the fibroblastic proliferation and associated
mineralization is only a small component of a larger mass that resembles a
fibroma or pyogenic granuloma.
• The type of mineralized component is variable and may consist of bone,
cementum-like material, or dystrophic calcifications. Frequently, a
combination of products is formed. Usually, the bone is woven and
trabecular in type, although older lesions may demonstrate mature
lamellar bone
Treatment and Prognosis
• The treatment of choice for the peripheral ossifying fibroma is local
surgical excision with submission of the specimen for histopathologic
examination.
• The mass should be excised down to periosteum because recurrence
is more likely if the base of the lesion is allowed to remain.
• In addition, the adjacent teeth should be thoroughly scaled to
eliminate any possible irritants. Periodontal surgical techniques, such
as repositioned flaps or connective tissue grafts, may be necessary to
repair the gingival defect in an aesthetic manner. Although excision is
usually curative, a recurrence rate of 8% to 16% has been reported.
LIPOMA
• The lipoma is a benign tumor of fat.
• Lipomas of the oral and maxillofacial region are much less frequent,
accounting for only 1% to 4% of all such tumors. The pathogenesis of
lipomas is uncertain, but they appear to be more common in obese people.
• Oral lipomas are usually soft, smooth-surfaced nodular masses that can be
sessile or pedunculated .
• Typically, the tumor is asymptomatic and often has been noted for many
months or years before diagnosis. Most are less than 3 cm in size, but
occasional lesions can become much larger. Although yellow hue often is
detected clinically, deeper examples may appear pink.
• The buccal mucosa and buccal vestibule are the most common intraoral
sites and account for nearly 50% of all cases.
Histopathologic Features
• Most oral lipomas are composed of mature fat cells that differ little in
microscopic appearance from the surrounding normal fat. The tumor
is usually well circumscribed and may demonstrate a thin fibrous
capsule
Treatment and Prognosis
• Lipomas are treated by conservative local excision, and recurrence is
rare.
TRAUMATIC NEUROMA (AMPUTATION
NEUROMA)
• The traumatic neuroma is not a true neoplasm but a reactive
proliferation of neural tissue after transection or other damage of a
nerve bundle.
• After a nerve has been damaged or severed, the proximal portion
attempts to regenerate and reestablish innervation of the distal
segment by the growth of axons through tubes of proliferating
Schwann cells. If these regenerating elements encounter scar tissue
or otherwise cannot reestablish innervation, then a tumorlike mass
may develop at the site of injury.
Clinical and Radiographic Features
• Traumatic neuromas of the oral mucosa are typically smooth-surfaced,
nonulcerated nodules. They can develop at any location but are most common in
the mental foramen area, tongue, and lower lip.
• A history of trauma often can be elicited; some lesions arise subsequent to tooth
extraction or other surgical procedures. Intraosseous traumatic neuromas may
demonstrate a radiolucent defect on oral radiographs
• Many traumatic neuromas are associated with altered nerve sensations that can
range from anesthesia to dysesthesia to overt pain.
• This pain can be intermittent or constant and ranges from mild tenderness or
burning to severe radiating pain.
• The treatment of choice for the patient with a traumatic neuroma is surgical
excision, including a small portion of the involved proximal nerve bundle. Most
lesions do not recur; in some cases, however, the pain persists or returns at a
later date.
SCHWANNOMA (NEURILEMOMA)
• Benign neural neoplasm of Schwann cell origin
• although 25% to 48% of all cases occur in the head and neck region.
• Bilateral schwannomas of the auditory-vestibular nerve (CNVIII) are
a characteristic feature of the hereditary condition, neurofibromatosis
type II (NF2).
• Characteristic symptoms include progressive sensorineural deafness,
dizziness, and tinnitus.
• Multiple schwannomas also occur in another genetic disorder
known as schwannomatosis
Clinical and Radiographic Features
• The solitary schwannoma is a slow-growing, encapsulated tumor that
typically arises in association with a nerve trunk.
• As it grows, it pushes the nerve aside.
• Usually, the mass is asymptomatic, although tenderness or pain may
occur in some instances (late stage).
• The lesion is most common in young and middle-aged adults and can
range from a few millimeters to several centimeters in size.
Intra -oral
• The tongue is the most common location for oral schwannomas,
although the tumor can occur almost anywhere in the mouth
• On occasion, the tumor arises centrally within bone and may produce
bony expansion. Intraosseous examples are most common in the
posterior mandible and usually appear as either unilocular or
multilocular radiolucencies on radiographs.
• Pain and paresthesia are not unusual for intrabony tumors.
Treatment and Prognosis
• the solitary schwannoma is treated by surgical excision, and the lesion
should not recur. Malignant transformation does not occur or is
extremely rare.
• Vestibular schwannomas in patients with NF2 are difficult to manage.
Surgical removal is indicated for large symptomatic tumors, but this
often results in deafness and risks facial nerve damage.
NEUROFIBROMA
• The neurofibroma is the most common type of peripheral nerve neoplasm. It
arises from a mixture of cell types, including Schwann cells and perineural
fibroblasts.
• It have tendency to make infiltration of the involved nerve
• Neurofibromas can arise as solitary tumors or be a component of
neurofibromatosis
• Solitary tumors are most common in young adults and present as slow growing,
soft, painless lesions that vary in size from small nodules to larger masses.
• The skin is the most frequent location for neurofibromas, but lesions of the oral
cavity are not uncommon . The tongue and buccal mucosa are the most common
intraoral sites.
• On rare occasions, the tumor can arise centrally within bone, where it may
produce a well-demarcated or poorly defined unilocular or multilocular
radiolucency
Treatment and Prognosis
• The treatment for solitary neurofibromas is local surgical excision, and
recurrence is rare. Any patient with a lesion that is diagnosed as a
neurofibroma should be evaluated clinically for the possibility of
neurofibromatosis .
• Malignant transformation of solitary neurofibromas can occur,
although the risk appears to be remote, especially compared with
that in patients with neurofibromatosis
HEMANGIOMA AND VASCULAR
MALFORMATIONS
• Oral hemangiomas (OHs): are benign tumors that develop due to
endothelial cell proliferation and occur in and around the oral cavity.
• Currently, hemangiomas are considered to be benign tumors of
infancy that display a rapid growth phase with endothelial cell
proliferation, followed by gradual involution.
• Most hemangiomas cannot be recognized at birth, but arise
subsequently during the first 8 weeks of life
• vascular malformations: are structural anomalies of blood vessels
with normal endothelial cell turnover.
• By definition, vascular malformations are present at birth and persist
throughout life. They can be categorized according to the type of
vessel involved (capillary, venous, or arteriovenous) and according to
hemodynamic features (low flow or high flow).
• Infantile hemangiomas are rarely present at birth.
• During the first few weeks of life, the tumor will demonstrate rapid
development . Superficial tumors of the skin appear 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.
• The initial proliferative phase usually lasts for 6 to 12 months, after
which the tumor grows proportionately with the child, followed by
slow involution. By age 5, most of the red color is usually gone.
• After tumor regression is complete, normal skin will be restored in
about 50% of patients; however, up to 40% of affected individuals will
show permanent changes such as atrophy, scarring, wrinkling
• Congenital hemangiomas, which are fully developed at birth, occur in two
varieties.
1.Rapidly involuting congenital hemangioma (RICH): shows early regression,
with full involution by 9 to 14 months of age.
2.Noninvoluting congenital hemangioma (NICH): grows proportionately
with the child and does not undergo involution.
• The most common problem is ulceration, which may occur with or without
secondary infection. Although hemorrhage may be noted, significant blood
loss does not usually occur.
• Hemangiomas that occur in crucial areas can be associated with significant
morbidity.
• Tumors in the neck and laryngeal region can lead to airway obstruction.
Vascular Malformations
• In contrast to hemangiomas, vascular malformations are present at
birth and persist throughout life
• Low-flow venous malformations: They are present at birth. Typically,
venous malformations are blue and are easily compressible . They
often grow proportionately with the patient, but they may swell when
dependent or with increased venous pressure
• Arteriovenous malformations: are high-flow lesions that result from
persistent direct arterial and venous communication.
• Although they are present from birth, they may not become
noticeable until later in childhood or adulthood.
• Because of the fast vascular flow through these lesions, a palpable
thrill or bruit often is noticeable.
• The overlying skin typically feels warmer to touch.
• Presenting symptoms may include pain, bleeding, and skin
ulceration.
• Intrabony Vascular Malformations: Intrabony “hemangiomas” also
may occur and usually represent either venous or arteriovenous
malformations.
• In the jaws, such lesions are detected most often during the first
three decades of life.
• They are slightly more common in females than in males and occur
three times more often in the mandible than the maxilla.
• The lesion may be completely asymptomatic, although some
examples are associated with pain and swelling. Mobility of teeth or
bleeding from the gingival sulcus may occur. A bruit or pulsation may
be apparent on auscultation and palpation.
• The radiographic appearance of intrabony vascular malformations is
variable.
• Most commonly, the lesion shows a multilocular radiolucent defect.
The individual loculations may be small (honeycomb appearance) or
large (soap bubble appearance).
• In other cases the lesion may present as an ill-defined radiolucent
area or a well-defined, cystlike radiolucency
• . Large malformations may cause cortical expansion, and occasionally
a “sunburst” radiographic pattern is produced
Histopathologic Features
• Capillary Hemangioma:
• The tumor consists of anastomosing vascular channels lined by
endothelial cells and pericytes , and there is increased deposition of
fibrous tissue between the vascular channel
• Cavernous hemangioma:
• The tumor consists of large space lined by endothelial cells and
pericytes , and there is increased deposition of fibrous tissue between
the vascular channel
• With few inflammatory cells
Treatment and Prognosis
• Because most hemangiomas of infancy undergo involution, management
often consists of “watchful neglect.” It is important to educate parents that
although rapid growth may be seen, regression will occur
• Systemic corticosteroids also may help to reduce the size of the lesion
• Vascular malformations of the jaws are potentially dangerous lesions
because of the risk of severe bleeding, which may occur spontaneously or
during surgical manipulation. Needle aspiration of any undiagnosed
intrabony lesion before biopsy is a wise precaution to rule out the
possibility of a vascular malformation. Severe and even fatal hemorrhages
have occurred after incisional biopsy or extraction of teeth in the area of
such lesions.