Hyperplasia, Neoplasia and related .

(disorders of oral mucosa (II

Before we start I would like to overview this chapter to make it easier this is chapter 8 in text book : the chapter divide in to two main topic hyperplasia of oral mucosa connective tissue neoplasm and allied condition each one of these topic has a number of lesion : classified under it as in this list hyperplasia of oral mucosa Epulides Pyogenic granuloma Fibroepithelial polyp Denture irritation hyperplasia Papillary hyperplasia of the palate

connective tissue neoplasms and allied condition

Tumors of fibrous tissue Tumors of adipose tissue Tumors of vascular tissue Tumors of peripheral nerves The granular cell tumor Tumors of muscle Malignant lymphomas

And we will talk about each lesion in more details So let us start our lecture

 Last time we talk about epulis , and we say that Epulis : its a reactive lesion that occur in the gingiva and depending on it histopathologic picture : we can divide them in to a) Fibrous epulis : firm , pale and depending on the predominant : fibroblast we can divided it in to
Peripheral ossifying fibroma The fibroblast are predominant forming a . bundle and bone Chronic hyperplastic gingivitis The number of fibroblast is limited and the lesion form by . collagen

B) Vascular epulis : has numerous capillaries , giving the lesion . vascular appearance also called : " lobular capillary hemangioma " : c) Peripheral giant cell granuloma . it's not neoplasm in histopathology its similar to " central giant cell granuloma " , but The central true tumor The Peripheral not true tumor , its a reactive lesion

 Now we will go to next lesion

Fibroepithelial polyp : ((irritation fibroma the most commonest lesion . occur in oral cavity
so when we see a mass in the oral cavity , first of all it should come . to your mind its irritation fibroma

its a reactive fibrous lesion , not benign tumor , so we add the word " irritation " to not confused with . benign tumor chronic mild trauma , so .( with time the tissue will build a fibrous ( collagen

The sever trauma will cause ulceration caused by continuous

In this picture we suggest the buccally (erupted 3rd molar(more inclined buccaly

Although , this name " Fibroepithelial polyp " didn't use in USA because its a little confused, so when we say Fibroepithelial we will think that the epithelium are hyperplastic, but actually its not include in hyperplastic .
the epithelium, we (1) .don't see hyperplasia

((( the hyperplastic of epithelium is not a feature of Fibroepithelial ((( polyp

this lesion my occur many area of oral cavity , like buccal fibrous (2) , lateral border of tongue , and labial mass of mucosa

tissue & the cellular component is : not predominant collagen

. mucosa buccal mucosa lower labial

mucosa the most common location is : buccal mucosa due . to biting , mastication , sharp cusps little pale or . same color , no redness and no ulceration actually it may produce ulcer as continuous of causative agent and we call it secondary .ulceration, but typically it doesnt ulceration
this a sessile lesion , on buccal surface the color similar to surrounding tissue the fibrous Treatment :reduce the translucency of Surgical excision lesion and show less blood . vessels , so look a little paler

ear old woman

.

this ate. tine ture

If it located under the denture , it will be squeezed and become flat " known as " LEAF FIBROMA

From Fibroepithelial polyp there is : distinctive lesion called " Giant cell fibroma "

Giant cell fibroma

not true tumor , called "Giant" because we have . multinucleated fibroblast So , the origin of giant cell here is fibroblast not . microphage

You can see the fibroblast at the arrows , with star shape . cell

occur higher in keratinized area ( gingival , dorsum .( of tongue , hard palate behavior like Fibroepithelial polyp , no deference . except slight changes in histopathology . Treatment : Surgical excision -

Retrocuspid papilla
. same histopathology as Giant cell fibroma its a small nodules occur lingual to mandibular . canine . Not reactive to trauma , they are development they think this lesion (papilla) cover neurovascular canal in lingual aspect of . the mandible

. more prevalence in children & young adult -

Denture irritation hyperplasia (Epulis : (Fissuratum occur more labially & buccally to denture, and may have folds as in figure , ulceration may occur in . depth between these folds Due to fissures (folds) Because its occur on gingiva ." also called " Epulis Fissuratum -

: Histopathology . fibrous tissue hypocellular (1) hyperplastic epithelium with rete (2) ridges

: Papillary Hyperplasia of the Palate

wearing the complete denture all time (day & night) with poor hygiene and Candida colonization , the palate will have what we call " Papillary ." Hyperplasia of the Palate
the Candida colonized on the denture surface (so if we take a biopsy from patient we may not found it, its on .(denture the Candida products cause inflammation of palate & also hyperplasia of surface epithelium as will as fibrous . hyperplasia

remember that all the lesion we take are not neoplastic Now we will go to the 2nd main topic of this chapter : which is connective tissue neoplasm " , as you know C.T "
contain ( fat cell , blood v. , nerve ) so we will discuss lesions affect these parts

: Tumors of fibrous tissue

True fibrous tumors are rare , in your text book they but : osis~ contain a list of few fibrous tumors "just know a table
aggressive lesion between the benign & malignant

"them , we will not explain it

Peripheral odontogenic fibroma (Fibrous histiocytoma (two type of cell ( Nodular fasciitis (neoplastic like lesion , not tumor Fibromatosis .all fibrous lesion "Fibroblast" its origin *

: Gingival fibromatosis
Fibromatosis may be heredity as this case : heredity
Not tumor

- the gingiva thick, prevent eruption of teeth , so the surgeon cut gingival allowing the teeth to erupt . - in some case as long as the teeth erupt the gingiva are growing up and cover the teeth, so they extract all teeth. when I say Fibromatosis as tumor : its the mass border line tumor, over growth of fibroblast which aggressive , may loss teeth , perforate the bone and when take a biopsy we will see hyper cellular .

Aggressive fibromatosis :
- localized fibromatosis , may be ulcerated. . when take a biopsy we will see hyper cellular -

:ibrosarcoma

.Rare in the oral cavity .Malignant lesion , has better prognosis -

how can I can differentiate between fibromatosis and ?fibrosarcoma

they have same clinical appearances but fibrosarcoma will have Pleiomorphisim (variation in size of nuclei) of fibroblast & hyperchromatism of nuclei & abnormal mitotic figure over . nucleus & cellular change in shape and size
Fibrosarcoma
(Malignant lesion)

fibromatosis
between

Fibroma (Benign lesion)

: Tumors of adipose tissue

. fat cell is the origin found in Buccal mucosa , Tongue , Flour of the mouth and any where the adipose tissue exist ( we see them
. ( under the surface epithelium

: may be Malignant Liposarcoma Benign tumor Lipoma type : We call it

: Lipoma
Yellowish in color , show a little vascularity .on surface . most common location Buccal mucosa .(histology is : mature adiposities (can't see nuclei when take a biopsy and I placed it in formalin it will . float on the surface in the Buccal mucosa due to trauma , the fat cell may go in between the muscle layers called traumatic .(herniation (common in children

Circumscribed : almost encapsulated , so its easy to remove surgically and easy to differentiate if . from other benign lesion encapsulated benign lesion are limited in number : like lipoma , Schwannoma , Leiomyoma according to the component histologically we can call : it
contains a fibrous tissue with mature fat cell

fibrolipoma

contains a vascular tissue with mature fat angio-lipoma cell

: liposarcoma
. Malignant lesion immature adiposities , Lipoblasts with pleomorphic nuclei and some .time the cell is multinucleated

One of malignant tumor features is . invasion

: Tumors of vascular tissues : Hemangioma

:Hamartoma excessive amount of . benign normal tissue in . normal location

.arise from endothelial cell tumor & may considered as hamartoma . we see endothelial lined blood spaces -

occur in : Mucosa, muscles, bone, major salivary gland and one of major reason for children swallowing . salivary gland is hamartoma . may be apparent or not Clinically : ark red-purple , D mooth surface , s ts lobulated but i ts soft , its i compressible because its contain fluids (blood) , and its Blanching under pressure ( the color will disappear .( under pressure : May increase in size hemorrhage thrombosis inflammation :Histopathology Cavernous (1) Capillary (2) may be very cellular we see only endothelial cell with very limited canalization , we call it Cellular

(2)

(1)

.(hemangioma (common in children

: Other Malformations :(AVM (Arteriovenous malformation

there is ateries with thick musclar wall while the vein . has thin wall

:Other vascular anomalies (sublingual varicosities (Dilatation of the vein : Angiomatous syndromes If hemangioma multiple . We will start think about : syndrome which is Strurge-Weber Syndrome Hemangiomatous lesions of one or more of the branches of the trigeminal nerve extra-orally & . intraorally Ipsilateral hemangiomas of meninges ( like this children will have hemangiomas ( over meninges in his left side

contralateral Convulsions affecting the limbs

so the Convulsions <spasm of muscle> will be in his right ) ( side

: In this pic we see intraorally the plate is red the size of tongue and gingival is big

So , the dr assume this hemangiomas is deep in T.N

:other Angiomatous syndromes Hereditary hemorrhagic telangiectasia

:Hereditary hemorrhagic telangiectasia Multiple dilated capillaries , and we see some time people with dilated capillaries on their face ( specially
.( surrounding the nose or the mouth

side effect is : nose bleeding (Malignant vascular lesions: (just know the name -

Kaposi sarcoma

and

angiosarcoma (vascular
spaces lined by pleomophic .(endothelial cells

: And we still in Tumors of vascular tissues

Lymphangioma
. benign tumor & may considered as hamartoma . found in children and especially in tongue Increase in size due to: inflammation, and . calcification lead to sudden increase in size the color almost normal unless there is secondary . bleeding :deferent from hemangioma .Not red in color (1 .Not soft (2 .Not lobulated, its bubbled surface (3 cause of this Bubbled surface is that the lymphatic spaces are very close to the .surface epithelium

:Microscopically look at homogenous pinkish material this is protein , not blood, not RBC, and they are endothelial lined ( the endothelium of lymphatic channel is not
( exactly the endothelium of blood vessels its different

Cystic hygroma : the name of Lymphangioma that occur early and present extra-orally (ascending to . neck) and its large in size

:Tumors of peripheral nerves

non neoplastic lesion Traumatic neuroma Nerve sheath tumors .Neurofibroma (1 Neurilemmoma (2 ((Schwannoma

Neurofibroma
. solitary (single) and multiple . fibroblast and Schwann cell the multiple one , we will think about syndrome which is : (Neurofibromatosis syndrome 1 ) .OR : von Recklinghaisens disease of nerves (affecting Cutaneous nerves (not central nerve Mutation in Neurofibromatosis gene (NF1) , . which is tumor suppressor gene Ne ur

ofibroma could be diffused, could be very large, could . be small in size Neurofibroma can be confused clinically with irritation fibroma but histologically it term to be neurofibroma , the Schwann cell are have a wavy and thin nucleus ( dolphin like nucleus ) mixed with fibroblast

the stroma among these cell is collagen and . mucoid tissue may be loose in consistency , it may be firm in . consistency . may be well defined , and may be diffused : return to : (Neurofibromatosis syndrome 1 ) as we say its NF1 gene Mutation , and it multiple Neurofibroma in skin and oral . cavity as you see in pic . again affecting Cutaneous nerves this lesion increase probability of having malgnant transformation with surgical

.(removal (so they cant remove it

. No treatment they have axillary freckling (freckling usually occur in sun exposed area) but they have it in non sun . exposed areas . they have " Caf-au lait spots " on the skin Intraoraly there is mucosal swellings that look like Neurofibroma, the mental & ID nerve may be involved . Malignant transformation , and increase 5-15% . with surgical removal : There is subtype of Neurofibroma you must know Plexiform neurofibromas are characterstic ( more indicated ) with Neurofibromatosis . syndrom so the multi Neurofibroma is enough to know that its Neurofibromatosis syndrom , but if you see two Plexiform neurofibromas you will be more sure that . is Neurofibromatosis syndrom

(Schwannoma (Neurilemmoma

. tumor of Schwann cell alone the Schwann cell do a proliferation , making a mass encapsulated , some times it attach to the nerve trunk , the nerve may . pass over the capsule this lesion have a characteristic feature which is : the nuclei are palisaded and parallel to ch ea ot r he as u yo n ca e se in .c pi

. this feature only for Schwannoma -

Traumatic neuroma . remember : non neoplastic lesion reactive to trauma ( sharp cutting to the nerve ) , -

may be during operation or extracting of teeth or other trauma , the nerve try to regenerate bundles of axons with some Schwann cell and some fibroblast so give us haphazard collection of . nerves

. This arrow indicated to axons with myelin sheath : this pic if there is a cause then its Traumatic neuroma but if have more than one in patient mouth I will think about syndrome : which is (MEN (multiple endocrine neoplasia (MEN II b (multiple endocrine neoplasia . MEN Type two B . its endocrine related syndrome there are multiple mucosal neuromas that -

histology to Traumatic neuroma and there is cromocytoma (tumors of adrenal gland cortex ) and there is medullary thyroid carcinoma , now the most important actually is medullary thyroid carcinoma ... because it aggressive and may be fatal so , if we see this lesion in patient mouth we can survive hem if we know that this is . MEN II b syndrome Some times we remove patient thyroid gland to save . him from medullary thyroid carcinoma :

look similar in

The granular cell tumor

. its origin is Schwann cell Previously called : granular cell myoblastoma because they thought that its origin is myoblast . cell later on , they found the new stain (s100) with this lesion is positive , and (s100) is marker of .(most neural origin cell (Schwann cell its benign tumor , but ill defined with surrounding . tissue like skeletal muscle . not encapsulated . most occurs on tongue Feeling of invasion when you . see the pic but it is benign the granular cells contain . lysosomes within the cytoplasm its cell have granular cytoplasm , its not . homogeneous the cell are rounded big

interesting feature : these cell induce Psuedo- epitheliomatous hyperplasia ( its appear to invading the under lining tissue ) , but there is no . abnormal mitosis END Forgive me for any mistake :Done by mohannad al-rawwash