Shiva PC2: Benign Soft Tissue Pathology

Soft tissue tumors

• Derived from mesenchymal tissues

• Majority of benign soft tissue tumors are reactive

• Due to low-grade chronic irritation

• Some are neoplastic

• Fibrous

• Adipose

• Vascular

• Lymphatic

• Neural

• Muscle

• Uncertain Origin

Soft tissue pathology categories

Fibroma

• Most common benign soft

tissue mass

• Results from irritation or trauma

• Reactive lesion

Fibroma

• Well-localized

• Dome-shaped

• Asymptomatic (unless secondary

ulceration)

• Smooth surface

• Often pink but may be ulcerated

if traumatized

• Sessile or pedunculated

Fibroma (histology)

Nodular mass of fibrous connective tissue covered by stratified

squamous epithelium

• Surface may exhibit hyperkeratosis from secondary trauma

Frenal tag (type of fibroma)

• Fibrous hyperplasia

• Most common on the maxillary

labial frenum

• Small, asymptomatic, exophytic

growths

• Can be diagnosed clinically so no

treatment is necessary

Surgical excision, biopsy, Malignancies can mimic

benign entities!

Fibroma - treatment

Epulis fissuratum

Reactive hyperplasia due to an

ill-fitting denture or alveolar

resorption

Epulis fissuratum

• Found in the vestibules

• Redundant folds

• Rubbery

• May be ulcerated

• Overgrowth of tissue along the

border of a denture

Epulis fissuratum

Excision, remake denture

Epulis fissuratum - treatment

Inflammatory papillary hyperplasia

• Reactive tissue growth related to

• An ill-fitting denture

• Poor denture hygiene

• 24-hour denture wearing

mouth-breathers

Inflammatory papillary hyperplasia may also

be seen in patients who are ...

Inflammatory papillary hyperplasia

• Usually occurs on the hard

palate beneath a denture base

• Usually asymptomatic

• Mucosa is erythematous and has

a pebbly or papillary surface

removal of dentures at night, Excise excessive tissue if necessary, Antifungal therapy

Inflammatory papillary hyperplasia - treatment

Gingival hyperplasia

• May be hereditary

• May be medication related

• Dilantin (Phenytoin)

• Cyclosporine

• Nifedipine

Dilantin (Phenytoin), Cyclosporine, Nifedipine

3 medications that are linked to medication induced Gingival hyperplasia

Gingival hyperplasia

• Begins in the interdental

papillae

• Gingiva may cover the crowns

• Firm

Discontinuation of the offending medication, Gingivectomy

Gingival hyperplasia - treatment

• Pyogenic Granuloma

• Peripheral Giant Cell Granuloma

• Peripheral Ossifying Fibroma

• Peripheral Fibroma

The 4 P’s (Dr. Cohen emphasized these!)

Pyogenic granuloma (AKA Lobular capillary hemangioma)

• Common

• Cause: local irritation or trauma

Pyogenic granuloma

• 75% on the gingiva

• Sometimes called the

“pregnancy tumor”

• Smooth or lobulated vascular

mass

• Pink-red-purple

• Usually ulcerated

Pyogenic granuloma (histopathology)

• Ulcerated stratified squamous epithelium

• Vascularized fibrous connective tissue

• Mixed inflammatory infiltrate

Surgical excision, biopsy, In pregnant patients defer treatment

Pyogenic granuloma - treatment

Peripheral Giant Cell Granuloma

• Common

• Reactive lesion caused by local

irritation or trauma

Peripheral Giant Cell Granuloma

• Occurs exclusively on the gingiva

or edentulous alveolar ridge

• Red or red-blue nodular mass

• Frequently ulcerated

• "Cupping" resorption of the

underlying alveolar bone may be

noted

surgical excision down to the underlying bone, biopsy, Adjacent teeth should be carefully scaled

Peripheral Giant Cell Granuloma - Treatment

Peripheral Ossifying Fibroma

• Common

• Reactive lesion caused by local

irritation or trauma

Peripheral Ossifying Fibroma

• Occurs exclusively on the gingiva

• Nodular mass

• Frequently ulcerated

• Red to pink

• Seen most commonly in teens

and young adults

Local surgical excision down to periosteum, biopsy, Adjacent teeth should be thoroughly scaled

Peripheral Ossifying Fibroma - Treatment

Giant cell fibroma

• Fibrous tumor

• Unlike the traumatic fibroma, it

does not appear to be

associated with chronic irritation

Giant cell fibroma

• Asymptomatic

• The surface of the mass often

appears papillary

• More common in young patients

• Approximately 50% of all cases

occur on the gingiva

• Tongue and palate also are

common sites

Retrocuspid papilla

• Papillary-like growth

• Mandibular gingiva lingual to

canine

• Frequently bilateral

• 25-99% of children/YA

• Involutes with age

• Should be recognized clinically

as a normal anatomic variation

surgical excision, biopsy, recurrence is rare

Giant cell fibroma - Treatment

Granular cell tumor

• Uncommon

• Derived for Schwann cells

• Cytoplasm is granular because of

lysosomes

Granular cell tumor

• Most commonly found on the

dorsal tongue

• Asymptomatic sessile nodule

• Pink to yellowish in color

Conservative local excision, biopsy, recurrence is rare

Granular cell tumor - treatment

Congenital epulis (Congenital granular cell lesion)

• Uncommon

• Occurs almost exclusively on the

alveolar ridges of newborns

• Bears a microscopic

resemblance to the granular cell

tumor

Congenital epulis

• Pink-to-red, smooth-surfaced,

polypoid mass on the alveolar

ridge of a newborn

• More common on the maxilla

than the mandible

• 90% occur in females

Surgical excision, biopsy, no reports of recurrence

Congenital epulis - treatment

Lipoma

• Benign tumor of fat

• 4% of mesenchymal tumors of

oral cavity

Lipoma

• Soft, doughy, smooth-surfaced

nodular

• Asymptomatic

• Pink to yellow in color

Conservative local excision, biopsy, Recurrence is rare

Lipoma - treatment

Hemangioma

• Congenital lesion

• Most common tumor of infancy

• Vascular proliferation

• Often red/blue

• Early rapid growth, followed by

slow involution

Vascular malformation

◦ Most common sites in the head

and neck:

◦ Lips, tongue, buccal mucosa, or

palate

◦ Deep red or blue compressible

lesion

◦ Lesions can in the soft tissue or

central (intraosseous) in location

spontaneous remission, surgery, embolization, sclerosing agents, cryotherapy, laser , DO NOT BIOPSY (refer it)

Vascular malformation - treatment

Lymphangioma

• Benign, hamartomatous

tumorlike growths of lymphatic

vessels

• Likely represent developmental

anomalies that arise from

sequestrations of lymphatic

tissue that do not communicate

normally with the rest of the

lymphatic system

Lymphangioma

• Predilection for the head and

neck

• Oral lymphatic malformations

are most frequent on the

anterior two thirds of the

tongue, where they often result

in macroglossia

• Demonstrates a pebbly surface

that resembles a cluster of

translucent vesicles

Surgical excision, Sclerotherapy, May recur

Lymphangioma - treatment

Neurofibroma

• Most common peripheral nerve

neoplasm

• Can be a solitary tumor or be a

component of

neurofibromatosis*

Neurofibroma

• Slow-growing, soft, painless

lesions that vary in size from

small nodules to larger masses

• Can be in the soft tissue or

central (in bone)

Neurofibroma

inferior alveolar nerve canal looks extremely expanded

Surgical excision

Neurofibroma - treatment

Schwannoma

• Benign neural neoplasm of

Schwann cell origin

• Uncommon

Schwannoma

• Slow-growing, encapsulated

tumor that typically arises in

association with a nerve trunk

• Asymptomatic

• The tongue is the most common

location for oral _____

• Can arise centrally

Surgical excision

Schwannoma - treatment

Traumatic neuroma

• Reactive proliferation of neural

tissue after transection or other

damage of a nerve bundle

Traumatic neuroma

• Smooth-surfaced, nonulcerated

nodules

• Most common in the mental

foramen area, tongue, and lower

lip

• A history of trauma often can be

elicited

• May be intraosseous

• About 1/3 are painful

Squamous papilloma

Verruca vulgaris

Condyloma acuminatum

What is your differential for the lesion pictured?

1. Squamous papilloma

2. Verruca vulgaris

3. Giant cell

What is you differential for the lesion pictured?

1. oral melanotic macul

2. Acquired melanocytic nevus

3. Blue nevus

What is you differential?

seborrheic keratosis

Diagnosis:

-74-year-old female

-Admits to a long history of sun exposure

-CC: "This thing on my face is so ugly"

Epulis Fissuratum

-64-year-old male

-Non-contributory medical and social history

-Are there any questions you'd like to ask before you answer the question above?

Gingival hyperplasia, ask questions about medications (Dylantin), frequent hygiene and gingivectomy

Diagnosis and treatments

1. Giant Cell Granulomas

2. Pyogenic granuloma

3. Peripheral Ossifying Fibroma

peripheral giant cell granuloma, peripheral Ossifying Fibroma

Which of the 4 P's occur exclusively on the gingiva?

Lipoma

Fibroma

Schwanomma