5: Fibrous, Gingival, Lipocytic, and Miscellaneous Tumors

5 Fibrous, Gingival, Lipocytic, and Miscellaneous Tumors

Chapter Contents

FIBROUS LESIONS

Fibroma (“Bite” or “Irritation” Fibroma, Fibroepithelial or Fibrovascular Polyp) and Giant Cell Fibroma

GINGIVAL MASSES

Reactive/Inflammatory Gingival Nodules
Diffuse/Multifocal Gingival Hyperplasia

GINGIVAL CYST OF THE ADULT

PERIPHERAL (EXTRAOSSEOUS) ODONTOGENIC NEOPLASMS

Peripheral Odontogenic Fibroma
Peripheral Ameloblastoma
Peripheral Calcifying Cystic Odontogenic Tumor

METASTASES TO THE GINGIVA

DENTURE-ASSOCIATED INFLAMMATORY FIBROUS HYPERPLASIA (EPULIS FISSURATUM)

LIPOCYTIC LESIONS

Lipoma

OTHER UNCOMMON TUMORS

Myofibroma

TUMORS OF UNCERTAIN HISTOGENESIS

Ectomesenchymal Chondromyxoid Tumor of the Tongue
Solitary Fibrous Tumor
Oral Focal Mucinosis

Fibrous Lesions

Fibroma (“Bite” or “Irritation” Fibroma, Fibroepithelial or Fibrovascular Polyp) and Giant Cell Fibroma

Clinical Findings

• Dome-shaped nodule or papule; may be white/keratotic, mucosa-colored or ulcerated and is seen in areas readily traumatized by biting (i.e., buccal mucosa, lateral tongue, and lower labial mucosa) or on gingiva(where plaque accumulates) (Fig. 5-1, A-D).

• Variant giant cell fibroma has a papillary surface and is usually located on gingiva or tongue (see Fig. 5-1, E).

• Sclerotic fibromas may be seen as focal sporadic lesions or in patients with tuberous sclerosis, associated with loss of heterozygosity of the PTEN gene.

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FIGURE 5-1 A, Fibroma of right buccal mucosa. B, Cut surfaces of fibroma, dense and white. C, Fibroma of the lower labial mucosa. D, Sclerotic fibroma of the palate. E, Giant cell fibroma on the gingiva.

(Courtesy of Dr. Shelly Abramawitz, Children’s Hospital Boston, Boston, Mass.)

Etiopathogenesis and Histopathologic Features

Fibroma is a reactive fibrosis and scarring (similar to a hypertrophic scar on the skin) from bite trauma and is not a true neoplasm.

• Nodular proliferation of fibrous tissue is associated with variable vascularity, hyperparakeratosis or orthokeratosis, ulceration, inflammation, epithelial hyperplasia, or atrophy (Figs. 5-2 and 5-3); variable myxoid/mucinous change (Fig. 5-4); or entrapment of muscle (Fig. 5-5).

• Sclerotic fibroma (also called storiform collagenoma) has dense, hyalinized bands of keloidal collagen with a slight storiform pattern and stellate and fusiform fibroblasts with clefts between collagen fibers; lesions are occasionally positive for factor XIIIa and CD34 (Fig. 5-6).

• Giant cell fibroma exhibits papillary surface, epithelial hyperplasia forming spiky rete ridges; giant, stellate, multinucleated fibroblast-like cells that sometimes show cytoplasmic positivity for smooth muscle actin suggesting differentiation toward myofibroblasts; and keloid-like dense collagen. Mast cells are often present (Figs. 5-7 and 5-8) similar to fibrous papule of the nose.

• Fibromas of the anterior hard palate often contain cartilage and branches of the nasopalatine neurovascular bundle (Fig. 5-9).

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FIGURE 5-2 A, Fibroma with frictional keratosis. B, Hyperorthokeratosis with wedge-shaped granulosis typical for lichen simplex chronicus. C, Dense collagen with scattered blood vessels.

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FIGURE 5-3 A, Fibroma with frictional keratosis. B, Hyperparakeratosis and bacterial colonies typical for frictional/factitial keratosis.

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FIGURE 5-4 A, Fibroma with focal myxoid/mucinous change. B, Areas of dense collagen interspersed with myxoid/mucinous areas and mild chronic inflammation.

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FIGURE 5-5 Tongue fibroma/scar with entrapment of muscle.

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FIGURE 5-6 Sclerotic fibroma. A, Dense, hyalinized collagen and epithelial collarette. B, Stellate and fusiform fibroblasts in keloid-like collagen.

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FIGURE 5-7 Giant cell fibroma. A, Fibrous nodules with undulating, bossellated surface. B, Epithelial hyperplasia forming spiky rete ridges. C, Stellate and multinucleated fibroblast-like cells.

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FIGURE 5-8 Giant cell fibroma. A, Fibrous nodule with papillary surface. B, Giant and binucleate fibroblast-like cells and dense collagen.

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FIGURE 5-9 Fibroma of anterior palate. A, Nodule containing hyaline cartilage and neurovascular bundles. B, Mature hyaline cartilage.

Differential Diagnosis

• These may be indistinguishable from end-stage mucocele on lower lip or end-stage pyogenic granuloma.

• Sclerotic solitary fibrous tumors are positive for CD34 and may be difficult to differentiate from sclerotic fibroma if areas of more classic vascular proliferation are not present.

Management and Prognosis

• Excision is curative, although continued irritation and trauma may lead to recurrence.

References

Alawi F, Freedman PD. Sporadic sclerotic fibroma of the oral soft tissues. Am J Dermatopathol. 2004;26:182-187.

Fernandez-Flores A. Solitary oral fibromas of the tongue show similar morphologic features to fibrous papule of the face: a study of 31 cases. Am J Dermatopathol. 2010;32:442-447.

Houston GD. The giant cell fibroma: a review of 464 cases. Oral Surg Oral Med Oral Pathol. 1982;53:582-587.

Magnusson BC, Rasmusson LG. The giant cell fibroma. A review of 103 cases with immunohistochemical findings. Acta Odontol Scand. 1995;53:293-296.

Metcalf JS, Maize JC, LeBoit PE. Circumscribed storiform collagenoma (sclerosing fibroma). Am J Dermatopathol. 1991;13:122-129.

Rapini RP, Golitz LE. Sclerotic fibromas of the skin. J Am Acad Dermatol. 1989;20:266-271.

Gingival Masses

Classification is as follows:

• Reactive/inflammatory gingival nodules, solitary or diffuse

• Peripheral (extraosseous) odontogenic cysts and tumors

• Soft tissue tumors (such as nerve sheath or smooth muscle tumors, discussed in Chapter 6)

• Extension of intrabony lesions into the gingiva

• Metastatic tumors to the gingiva

Reactive/Inflammatory Gingival Nodules

Clinical Findings

• Young patients in second to fourth decades; nodular masses on the marginal gingiva, often maxillary anterior region; pink, erythematous, dusky purple, or ulcerated; may be painful and, if vascular, will bleed; underlying bone may show “saucerization” of bone (especially with giant cell granuloma) (Fig. 5-10)

• Peripheral giant cell granulomas least common; tend to occur in older adults

• Parulis (“gum-boil”) occurs on the attached gingiva; has a punctum and underlying tract that leads to the infected tooth (see later)

• Up to 5% of pregnancies associated with gingival pyogenic granulomas (granuloma gravidarum)

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FIGURE 5-10 A, Gingival fibroma with ulceration. B, Peripheral ossifying fibroma. C, Pyogenic granuloma with ulceration. D, Pyogenic granuloma of the mandibular ridge at extraction sites. E, Peripheral giant cell granuloma.

(B, Courtesy of Dr. Ian Cole, private practice, North Andover, Mass.; C, Courtesy of Dr. Jeffrey Freedman, private practice, Lexington, Mass.; E, Courtesy of Dr. Shelly Abramawitz, Children’s Hospital Boston, Boston, Mass.)

Etiopathogenesis and Histopathologic Features

Pluripotent cells in the gingival tissues when traumatized or irritated (usually by accumulation of dental calculus or bacterial plaque, rough edges of restorations, or presence of implants) differentiate toward endothelial cells, fibroblasts, osteoblasts, or osteoclast-like cells, giving rise to four distinct histologic entities or combinations thereof. Estrogen and progesterone causes overexpression of vascular endothelial growth factor in granuloma gravidarum. See Table 5-1 and Figures 5-11 to 5-19 for histopathologic features.

• Parulis consists of a mass of edematous granulation tissue with many acute and chronic inflammatory cells and tracts lined by neutrophils (Figs. 5-20 to 5-22); they are often mistaken for mucoceles (which do not occur on the attached gingiva).

TABLE 5-1 Reactive Gingival Nodules

Diagnosis Histopathology
Fibroma
(fibrovascular hyperplasia/polyp)
Giant cell fibroma

• Nodule of fibrous tissue with scattered vessels and variable edema and inflammation; crevicular epithelium with underlying plasma cells often seen (see Figs. 5-11 and 5-12)

• In giant cell fibroma, stellate and multinucleated fibroblast–like cells are present (see Fibroma section)

Pyogenic granuloma

• Lobular or nonlobular proliferation of endothelial cells and small, dilated capillaries; often ulcerated and inflamed (see Fig. 5-13, A)

• Endothelial cells show reactive atypia—focal “hobnail” pattern, enlarged nuclei with prominent nucleoli, some mitotic activity (see Fig. 5-13, B and C)

• May see fibrosis depending on stage of organization (see Fig. 5-14)

Peripheral ossifying fibroma (fibroma with osseous prosoplasia)

• Cellular proliferation of spindled fibroblast–like cells with ovoid nuclei that have dispersed chromatin, inconspicuous nucleoli; sometimes only subtle osteoid deposits or focal calcifications are present (see Fig. 5-15, A and B)

• Osteoid, woven bone, or cementum droplets laid down by spindle cells although osteoblastic rimming sometimes seen (see Figs. 5-15, C and D, and 5-16)

• May see clusters of multinucleated giant cells similar to peripheral giant cell granuloma (see Fig. 5-17)

• Bone morphogenetic protein identified in the spindled fibroblast-like cells

Peripheral giant cell granuloma

• Proliferation of mononuclear and multinucleated giant cells (osteoclast-like or foreign body type) usually in sheets; giant cells contain 10-20 nuclei in a central location; mitoses may be seen in mononuclear cells; fresh hemorrhage and hemosiderin deposits, especially beneath the grenz zone (see Figs. 5-18, 5-19)

• May see concomitant osseous prosoplasia similar to peripheral ossifying fibroma

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FIGURE 5-11 Gingival fibroma with minimal inflammation.

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FIGURE 5-12 Gingival fibroma. A, Fibrous nodule with chronic inflammation. B, Epithelial hyperplasia, spongiosis, and chronic inflammation. C, Dense plasma cell infiltrate is a common feature.

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FIGURE 5-13 Granuloma gravidarum. A, Lobular proliferation of capillaries, ulcerated. B, Proliferation of endothelial cells and dilated capillaries with slight hobnailing of nuclei. C, More cellular areas focally.

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FIGURE 5-14 Pyogenic granuloma, sclerosing. A, Vague lobular pattern with intervening fibrous tissue. B, Fibrous tissue insinuates between and replaces endothelial cells and vessels.

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FIGURE 5-15 Peripheral ossifying fibroma. A, Mass of cellular fibrous tissue with superficial cementum deposition and bone deeper in the tissue. B, Cellular proliferation of fibroblast-like spindle cells with deposition of woven bone with osteoid rim. C, Deposition of cementum droplets. D, Cementum droplets with eosinophilic rim.

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FIGURE 5-16 Peripheral ossifying fibroma. A, Nodule of fibrous tissue with abundant bone. B, Cellular proliferation of spindle cells forming osteoid and woven bone. C, Osteoid rimmed by layers of osteoblasts.

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FIGURE 5-17 Peripheral ossifying fibroma and peripheral giant cell granuloma. A, Sheets of giant cells and woven bone. B, Woven bone formation and clusters of osteoclast-like giant cells.

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FIGURE 5-18 Peripheral giant cell granuloma. A, Lesion abuts the epithelium focally. B, Sheets of multinucleated giant cells and mononuclear cells in vascular stroma. C, Multinucleated giant cells and occasional mitoses in stromal cells.

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FIGURE 5-19 Peripheral giant cell granuloma. A, Grenz zone present. B, Hemosiderin just beneath the grenz zone. C, Mixture of multinucleated giant cells and spindled mononuclear cells with hemorrhage. D, Multinucleated giant cells and spindled mononuclear cells.

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FIGURE 5-20 Parulis of the gingiva with gutta percha tracer.

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FIGURE 5-21 Parulis. A, Edematous granulation tissue with linear spaces/tracts. B, Edematous granulation tissue with foamy macrophages and acute and chronic inflammation, often misdiagnosed as mucocele. C, Tract filled with neutrophils (arrows).

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FIGURE 5-22 Parulis with linear tracts that communicate with the mucosal surface.

Differential Diagnosis

• True infantile hemangiomas show a lobular proliferation of endothelial cells and capillaries that are positive for glucose transporter-1 (GLUT-1) (Fig. 5-23)

• Peripheral odontogenic fibroma produces dentinoid rather than cementum or osteoid and epithelial islands are always present, distinguishing this from peripheral ossifying fibroma (see later).

• Aggressive central (intraosseous) giant cell granulomas may erode through bone; radiographs differentiate them from peripheral (extraosseous) lesions.

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FIGURE 5-23 Infantile hemangioma of buccal mucosa. A, Proliferation of endothelial cells that surround minor salivary glands. B, Cellular proliferation of endothelial cells and capillaries with occasional mitoses (inset). C, Cytoplasmic positivity for glucose transporter-1 (GLUT-1).

(A, Courtesy of Dr. Harry Kozakewich, Harvard Medical School, Boston, Mass.)

Management and Prognosis

• Excision is treatment of choice, although if underlying irritating factors such as dental plaque are not removed, the recurrence rate is up to 15%.

• Granuloma gravidarum may resolve postpartum but may also sclerose and become a gingival fibroma.

References

Buchner A, Hansen LS. The histomorphologic spectrum of peripheral ossifying fibroma. Oral Surg Oral Med Oral Pathol. 1987;63:452-461.

Buchner A, Shnaiderman-Shapiro A, Vered M. Relative frequency of localized reactive hyperplastic lesions of the gingiva: a retrospective study of 1675 cases from Israel. J Oral Pathol Med. 2010;39:631-638.

Carvalho YR, Loyola AM, Gomez RS, Araujo VC. Peripheral giant cell granuloma. An immunohistochemical and ultrastructural study. Oral Dis. 1995;1:20-25.

Epivatianos A, Antoniades D, Zaraboukas T, et al. Pyogenic granuloma of the oral cavity: comparative study of its clinicopathological and immunohistochemical features. Pathol Int. 2005;55:391-397.

Giunta JL. Gingival fibrous nodule. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999;88:451-454.

Gordon-Nunez MA, de Vasconcelos Carvalho M, Benevenuto TG, et al. Oral pyogenic granuloma: a retrospective analysis of 293 cases in a Brazilian population. J Oral Maxillofac Surg. 2010;68:2185-2188.

Hirshberg A, Kozlovsky A, Schwartz-Arad D, et al. Peripheral giant cell granuloma associated with dental implants. J Periodontol. 2003;74:1381-1384.

Katsikeris N, Kakarantza-Angelopoulou E, Angelopoulos AP. Peripheral giant cell granuloma. Clinicopathologic study of 224 new cases and review of 956 reported cases. Int. J Oral Maxillofac Surg. 1988;17:94-99.

Ono A, Tsukamoto G, Nagatsuka H, et al. An immunohistochemical evaluation of BMP-2, -4, osteopontin, osteocalcin and PCNA between ossifying fibromas of the jaws and peripheral cemento-ossifying fibromas on the gingiva. Oral Oncol. 2007;43:339-344.

Yuan K, Wing LY, Lin MT. Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones. J Periodontol. 2002;73:701-708.

Diffuse/Multifocal Gingival Hyperplasia

Clinical Findings

• Seen in patients with poor oral hygiene and hormonal changes (e.g., puberty and pregnancy), and in patients on medications such as phenytoin, valproic acid, calcium channel blockers, and cyclosporine

• Diffuse, often slightly nodular enlargement of the gingiva of varying severity (Fig. 5-24, A and B); leukemic infiltrates may have a similar clinical appearance (see Fig. 5-24, C)

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FIGURE 5-24 A, Diffuse gingival hyperplasia secondary to phenytoin use. B, Diffuse gingival hyperplasia secondary to nifedipine and cyclosporine use (postrenal transplantation). C, Diffuse gingival enlargement from leukemic infiltrate.

Etiopathogenesis and Histopathologic Features

Bacterial plaque induces the proliferation of fibroblasts, and hormones such as progesterone exacerbate this; medications cause a reduction in metalloproteinases, leading to accumulation of matrix.

• Fibrovascular and epithelial proliferation with variable chronic inflammation usually plasmacytic; cytoid bodies sometimes are present if there is prominent spongiosis (Figs. 5-25 and 5-26).

• “Test-tube” rete ridges have been reported in patients on phenytoin and also are seen in patients with conventional non–medication-associated gingival hyperplasia.

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FIGURE 5-25 Gingival fibrous hyperplasia. A, Fibrous tissue with marked chronic inflammation. B, Benign epithelial hyperplasia with spongiosis. C, Cytoid bodies present with many plasma cells.

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FIGURE 5-26 Gingival fibrous hyperplasia: epithelial atrophy and chronic inflammation.

Differential Diagnosis

• Presence of an atypical infiltrate should raise suspicion for acute myeloid or monocytic leukemia.

• Presence of pools of eosinophilic material (fibrin that is positive with phosphotungstic acid-hematoxylin) that fills the lamina propria should raise suspicion for ligneous gingivitis/periodontitis, a disorder of plasminogen activator deficiency (Figs. 5-27 and 5-28).

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FIGURE 5-27 Ligneous gingivitis manifesting as one of several ulcerated gingival nodules.

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Related posts:

  1. Pharmacologic Therapy for Common Mucosal Conditions
  2. Antifungal Therapy
  3. 2: Developmental and Congenital Conditions
  4. 4: Bacterial, Viral, Fungal, and Other Infectious Conditions
  5. 7: Ulcerative and Inflammatory Conditions
  6. 9: Pigmented Lesions

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Jan 12, 2015 | Posted by in Oral and Maxillofacial Pathology | Comments Off on 5: Fibrous, Gingival, Lipocytic, and Miscellaneous Tumors

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