Soft Tissue Tumors

DR KHAIRY ABU ZANT

FIBROMA
• FIBROMA (IRRITATION FIBROMA; TRAUMATIC FIBROMA; FOCAL
FIBROUS HYPERPLASIA; FIBROUS NODULE)
• Fibroma is the most common “tumor” of the oral cavity.
• Although the irritation fibroma can occur anywhere in the mouth, the
most common location is the buccal mucosa along the bite line.
Presumably, this is a consequence of trauma from biting the cheek
• The labial mucosa, tongue, and gingiva also are common sites
 Clinical features
• The lesion typically appears as a smooth surfaced pink nodule that is
similar in color to the surrounding mucosa. In black patients, the mass
may demonstrate gray-brown pigmentation.
• In some cases the surface may appear white as a result of
hyperkeratosis from continued irritation.
• Most fibromas are sessile, although some are pedunculated.
• They range in size from tiny lesions that are only a couple of
millimeters in diameter to large masses that are several centimeters
across;
Histopathologic Features
• microscopic examination of the irritation fibroma shows a nodular mass of
fibrous connective tissue covered by stratified squamous epithelium
• This connective tissue is usually dense and collagenized
• The lesion is not encapsulated; the fibrous tissue instead blends gradually
into the surrounding connective tissues. The collagen bundles may be
arranged in a radiating, circular, or haphazard fashion.
• The covering epithelium often demonstrates atrophy of the rete ridges
because of the underlying fibrous mass. However, the surface may exhibit
hyperkeratosis from secondary trauma.
• Scattered inflammation may be seen, most often beneath the epithelial
surface. Usually this inflammation is chronic and consists mostly of
lymphocytes and plasma cells.
Treatment and Prognosis
• Remove the etiological factor
• The irritation fibroma is treated by conservative surgical excision.
• recurrence is extremely rare. However, it is important to submit the
excised tissue for microscopic examination because other benign or
malignant tumors may mimic the clinical appearance of a fibroma.
 GIANT CELL FIBROMA
• Is a fibrous tumor with distinctive clinicopathologic features. Unlike
the traumatic fibroma, it does not appear to be associated with
chronic irritation.
• The giant cell fibroma is typically an asymptomatic sessile or
pedunculated nodule
• The surface of the mass often appears papillary; therefore, the lesion
may be clinically mistaken for a papilloma .
• Compared with the common irritation fibroma, the lesion usually
occurs at a younger age
Histopathologic Features
• mass of vascular fibrous connective tissue, which is usually loosely
arranged
• The hallmark is the presence of numerous large, stellate fibroblasts
within the superficial connective tissue. These cells may contain
several nuclei
• sometimes multinucleated fibroblasts (‘giant cells’) near the edge
under the epithelium.
Treatment and Prognosis
• giant cell fibroma is treated by conservative surgical excision.
• Recurrence is rare.
EPULIS FISSURATUM
• (INFLAMMATORY FIBROUS HYPERPLASIA; DENTURE INJURY TUMOR;
DENTURE EPULIS)
• The epulis fissuratum is a tumorlike hyperplasia of fibrous connective
tissue that develops in association with the flange of an ill-fitting
complete or partial denture.
• Although the simple term epulis sometimes is used synonymously for
epulis fissuratum, epulis is actually a generic term that can be applied
to any tumor of the gingiva or alveolar mucosa.
• The redundant tissue is usually firm and fibrous, although some
lesions appear erythematous and ulcerated, similar to the
appearance of a pyogenic granuloma.
• The epulis fissuratum typically appears as a single or multiple fold or
folds of hyperplastic tissue in the alveolar vestibule .
• Most often, there are two folds of tissue, and the flange of the
associated denture fits conveniently into the fissure between the
folds.
Treatment and Prognosis
• The treatment of the epulis fissuratum or fibroepithelial polyp
consists of surgical removal,
• The ill-fitting denture should be remade or relined to prevent a
recurrence of the lesion.
INFLAMMATORY PAPILLARY HYPERPLASIA
(DENTURE PAPILLOMATOSIS)
• Inflammatory papillary hyperplasia is a reactive tissue growth,
develops beneath a denture. Some investigators classify this lesion as
part of the spectrum of denture stomatitis .
• Candida organisms also have been suggested as a cause
• Although the exact pathogenesis is unknown, the condition most
often appears to be related to the following:
1. An ill-fitting denture
2. Poor denture hygiene
3. Wearing the denture 24 hours a day
• Inflammatory papillary hyperplasia usually occurs on the hard palate
beneath a denture base
• Early lesions may involve only the palatal vault, although advanced cases
cover most of the palate.
• Less frequently, this hyperplasia develops on the edentulous mandibular
alveolar ridge .
• On rare occasions, the condition occurs on the palate of a patient without
a denture, especially in people who habitually breathe through their mouth
or have a high palatal vault.
• Candida-associated palatal papillary hyperplasia also has been reported in
dentate patients with human immunodeficiency virus (HIV) infection
• Inflammatory papillary hyperplasia is usually asymptomatic.
• The mucosa is erythematous and has a papillary surface
Treatment and Prognosis
• For very early lesions of inflammatory papillary hyperplasia, removal of the denture may allow
the erythema and edema to subside, and the tissues may resume a more normal appearance.
• The condition also may show improvement after topical or systemic antifungal therapy.
• For more advanced and collagenized lesions, many clinicians prefer to excise the hyperplastic
tissue before fabricating a new denture. Various surgical methods have been used, including the
following:
1. Partial-thickness or full-thickness surgical blade excision
2. Curettage
3. Electrosurgery
4. Cryosurgery
5. Laser surgery
• After surgery, the existing denture can be lined with a temporary tissue conditioner that acts as a
palatal dressing and promotes greater comfort. After healing, the patient should be encouraged
to leave the new denture out at night and to keep it clean
FIBROUS HISTIOCYTOMA
• Fibrous histiocytomas are a diverse group of tumors that exhibit
fibroblastic and histiocytic differentiation
• The fibrous histiocytoma can develop almost anywhere in the body.
The most common site is the skin of the extremities, where the lesion
is called a dermatofibroma. Tumors of the oral and perioral region
are rare
• The tumor is usually a painless nodular mass and can vary in size from
a few millimeters to several centimeters in diameter
Histopathologic Features
• Microscopically, the fibrous histiocytoma is characterized by a cellular
proliferation of:
1. spindle-shaped fibroblastic cells with vesicular nuclei
2. Rounded histiocyte-like cells
3. multinucleated giant cells can be seen occasionally (touton cells)
Treatment and Prognosis
• Local surgical excision is the treatment of choice. Recurrence is
uncommon, especially for superficial tumors. Larger lesions of the
deeper soft tissues have a greater potential to recur.
PYOGENIC GRANULOMA (LOBULAR
CAPILLARY HEMANGIOMA)
• The pyogenic granuloma is a common tumorlike growth of the oral
cavity that traditionally has been considered to be nonneoplastic in
nature.
• Although it was originally thought to be caused by pyogenic
organisms, it is now believed to be unrelated to infection. Instead, the
pyogenic granuloma is thought to represent an exuberant tissue
response to local irritation or trauma. In spite of its name, it is not a
true granulom
• The pyogenic granuloma is a smooth or lobulated mass that is usually
pedunculated, although some lesions are sessile .
• The surface is characteristically ulcerated and ranges from pink to red to
purple, depending on the age of the lesion.
• Young pyogenic granulomas are highly vascular in appearance; older
lesions tend to become more collagenized and pink.
• They vary from small growths only a few millimeters in size to larger lesions
that may measure several centimeters in diameter.
• Typically, the mass is painless, although it often bleeds easily because of its
extreme vascularity.
• Pyogenic granulomas may exhibit rapid growth, which may create alarm
for both the patient and the clinician, who may fear that the lesion might
be malignant
• Oral pyogenic granulomas show a striking predilection for the gingiva,
which accounts for approximately 75% to 85 of all cases
• Gingival irritation and inflammation that result from poor oral hygiene may
be a precipitating factor in many patients.
• The lips, tongue, and buccal mucosa are the next most common sites. A
history of trauma before the development of the lesion is not unusual,
especially for extra gingival pyogenic granulomas.
• Lesions are slightly more common on the maxillary gingiva than the
mandibular gingiva; anterior areas are more frequently affected than
posterior areas. These lesions are much more common on the facial aspect
of the gingiva than the lingual aspect; some extend between the teeth and
involve both the facial and the lingual gingiva.
• Although the pyogenic granuloma can develop at any age, it is most common in
children and young adults.
• Most studies also demonstrate a definite female predilection, possibly because
of the vascular effects of female hormones.
• Pyogenic granulomas of the gingiva frequently develop in pregnant women, so
much so that the terms pregnancy tumor or granuloma gravidarum often are
used.
• Such lesions may begin to develop during the first trimester, and their
prevalence increases up through the seventh month of pregnancy. The gradual
rise in development of these lesions throughout pregnancy may be related to the
increasing levels of estrogen and progesterone as the pregnancy progresses.
• After pregnancy and the return of normal hormone levels, some of these
pyogenic granulomas resolve without treatment or undergo fibrous maturation
and resemble a fibroma
• 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