Benign Tumors and Tumor-like Growths of the Oral Soft Tissues

Categories of Tissue Overgrowth

-

Relative Hyperplasia
o Shape and location correspond to a source of irritation
o Limited growth potential
o One of more tissues may be involved (FEP fibrous/epithelial/immune)
Approach to treatment
Eliminate the source of irritation
Monitor/Biopsy
o Confirm suspicion
Remove
o Restore normal tissue contours
Developmental Malformation (Hamartoma)
o Excessive amount of a tissue normally present in the area
o Growth corresponds with skeletal growth
o Tissue is of normal histologic appearance
o Examples
Osseous (Osteochondroma, Odontoma)
Soft tissue (Hemangioma)
Neoplasm
o Clonal proliferation of cells that have a growth advantage over neightbouring
cells
Benign Neoplasm
o Expansile growth
Displace and compress
o Well-differentiated cells
o Generally name the tumors based on the tissue it originates from (i.e.
papilloma = epithelial)
Malignant Neoplasm
o Invasive growth; potential to metastasize
o Effaces normal tissue architecture
o Spectrum of differentiation and cytological atypia

Papilloma
- Exophytic (entire lesion projects above surface)
- Papillary lesion (epithelial origin)
- <1cm diameter
- Well demarcated
- Histologically
o Verify that they ARE exophytic
o Projects can be stubby
o Normal maturation of the epithelium
Verruca Vulgaris (low-risk HPV)
- Sessile, with convergent rete ridges
- More common on skin (but lips and mouth are not uncommon)
- Hyperkeratotic, sessile
- HPV has close relationship with SSE (basal layer) but the upper levels harbor
assembled virus
- Viral cytopathic effect
o Koilocytes (cells containing viral particles)

Nucleous looks like raisin (undulated border)

Clear cytoplasm
Individuals can autoinnoculate see this on the hands THEN lips (sometime vice
versa)

Condyloma Acuminatum (Genital Warts)

- Rounded, not sharp, papillary projections (different from papilloma)
o Cauliflower shaped
- Broad anastomosing rete ridges
- Viral cytopathic effect
o Koilocytes
- More common among the immunosuppressed patients
Focal Epithelial Hyperplasia
- Elevated papulonodular (undulating bumps) lesions
- Acanthosis, parakeratosis and epithelial hyperplasia
- There is a lack of inflammatory response and koilocytic cells
Keratoaconthoma
- Sun-exposed areas
- Indurated, crusted lesion
- Rapid growth
- Well-demarcated with keratin-filled craters
- Well differential epithelium
- Exophytic and endophytic (pushes inwards) components
- Large, glassy epithelial cells
Pigmented Nevus
- Flat dark-brown lesion, most commonly on the palate
- Show up early in life (and may regress as one ages)
- Nest of nevus cells at the epithelial-connective tissue junction
o Immunostains will tell the difference between mealnocytes and nevus cells
o Phenotypically, nevus cells come in nests (melanocytes are dispersed)
o Genetically BRAF is mutated in nevus cells to grow into groups (but they
have limited growth potential)
- Junctional nevus flat @ in the epidermis
- Dermal nevus nests of nevus cells in the connective tissue
o Not ALL may pigment and it is generally confined to the superficial nevus cells
Fibroepithelial Polyp/Irritation Fibroma (and variations on the theme of FEP)
- Reactive Hyperplasia (involving both connective and epithelial tissue)
- Confirm source of irritation (not all have to be biopsied if this is confirmed) must
monitor
o Limited growth potential
- Variations
o Epulis fissuratum or inflammatory papillary hyperplasia (of the palate)
Medication-associated gingival enlargement (NOT HYPERPLASIA there is no increase of
cells)
- Phenytoin (Dilantin)
- Nifedipine (Adalat, Procardia)
- Cyclosporine
o These medications interfere with the normal breakdown of the ECM

Pyogenic Granuloma
- VERY vascular and quite edematous (and erythematous)
o Changes size quickly
- Exuberant proliferation of granulation tissue
- Over-reaction to a small irritation
- Lips/Tongue/Buccal mucosa
Peripheral Ossifiyng Fibroma
- Reactive
- Not a lot of bone/calcification
- ONLY shows up on the gingiva
o Cells need to come from the periostium or periodontal ligaments
Peripheral Giant Cell Granuloma
- Reactive
- Purple in colour (possibly because of the hemosiderin)
- Proliferation of mononuclear cells and multinucleated giant cells in stroma with
extravasated blood and hemosiderin
Fibromatosis
- Painless slowly enlarging mass on the lingual aspect of the mandible associated with
the destruction of the lingual cortex
- Interlacing bundles of fibroblasts and collagen; infiltrates into adjacent tissues
o Aggressive but does not metastasize
o Wide surgical excision +/- XRT
Myxoid Lesions of Soft Tissues Oral Focal Mucinosis
- Tumors of myxoid tissue Fibroblasts are making ground substance as opposed to
collagen
- Conservative excision is the treatment
Lipoma
- Benign tumor of fat cells
- Yellow in colour
Granular Cell Tumor
- Asymptomatic nodule on the dorsum of tongue
- Large cells with eosinophilic granular cytoplasm and a small central nucleus
- Pseudoepitheliomatous hyperplasia of the overlying epithelium (should be limited to
the areas where there are granular cells)
- S100+
- Not encapsulated
- Indistinct borders of the lesion
Congenital Epulis
- Benign lesion of neonates
- Anterior maxilla (generally)
- More common in female infants (9:1)
- Can be QUITE large
- FULL of granular cells
o Does NOT show pseudoepitheliomatous hyperplasia
o S100 ve
Benign Vascular Proliferations
- Red to purple lesions that may be flat or raised, not well circumscribed

Benign vascular proliferations (arteriovenous, capillary, venous or superficial/deep)

and hemangiomas
- Hamartomas
o Hemangioma
++ endothelial cells (capillary type) which may or may not show
obvious lumens
Not uncommon to show phleboliths (vessels are small sometimes with
slower flow)
- Can be left alone if asymptomatic
- +ve diascopy must see purple colour disappear with application of pressue (i.e.
colour is due to circulating tissue)
- Varix NOT vascular proliferations, simply a stretching of the vessel
Lymphatic Malformations
- Nodular, translucent lesion of the tongue
o Dialated lymphatics covered by thin epithelium
o Connective tissue stroma tends to show lymphocyes
- Closely-packed, dilated lymphatic with eosinophilic coagulum in the lumen
- Can be deeply seated
o Causes macroglossia, cystic hygroma, marcochelia
- Typically not removed
o Infection is an issue as bacteria get directly into lymphatics
Traumatic Neuroma
- Non-neoplastic proliferation of axons, schwann cells, perinurial and endoneurial cells
within loose connective tissue
o Background can be loose and myxoid to densely packed collagen
o S-100 (schwann cells) to prove this is neural tissue
- Poor attempt at regeneration after damage
o Proximal end cannot find distal end
- Tongue, lip, mental nerve (areas were trauma is common)
- Presents as small nodule +/- pain
Poormans panel for spindle cells:
Cell type
Fibroblast
Myofibroblas
t
Smooth
muscle
Schwann

Cytokerati
n
-

Vimentin

SMA

Desmin

S100

+
+

(Vimentin shows they are, in fact, spindle cells)

Schwannoma (Neurilemoma)
- Slowly enlarging, discrete nodular lesion of oral soft tissues
- Clinically, they look the same but differ in histology and biology
- May be asymptomatic or painful and can be found almost anywhere
- Schwannoma
o Schwann cells (spindle cells from neuroectoderm support neurons and make
myelin sheath)
o Encapsulated, well demarcated
o Antoni A and Antoni B patterns

Antoni A compact bundles of spindle cells, often with palisaded nuclei and
Verocay bodies
Neurofibromas
o Perineural fibroblasts +/- schwanna cells
o Well circumscribed, unencapsulated
o Bucles of spindle ells with wavy nuclei
o Mucoid stroma
o Nerve axons can be shown by silver stains
o Some of the cells are S-100 positive
Look for caf-au-lait spots
R/O neurofibromatosis
o