Fibrous, Gingival, Lipocytic, and Miscellaneous Tumors

Fibrous Lesions

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

Clinical Findings

  • Fibroma: This consists of a dome-shaped nodule or papule that may be white/keratotic, mucosa-colored, or ulcerated; it is located in areas readily traumatized by biting (i.e., buccal mucosa, lateral tongue, and lower lip mucosa) or on the gingiva where plaque accumulates ( Fig. 5.1A–D ).

    FIG 5.1
    (A) Fibroma of right buccal mucosa. (B) Cut surfaces of fibroma, dense and white. (C) Fibroma of the lower lip mucosa. (D) Sclerotic fibroma of the palate. (E) Giant cell fibroma on the palatal mucosa.
    (Courtesy Dr. Carl Allen, The Ohio State University, Columbus, Ohio.)
  • Giant cell fibroma: This often has a papillary surface and 90% are located on the gingiva (50% of cases), tongue, and palatal mucosa; a similar histopathologic condition is referred to as the retrocuspid papilla, which occurs on the lingual attached gingiva of the mandibular cuspids, usually bilaterally ( Fig. 5.1E ).

  • Multiple fibromas of the gingiva, buccal mucosa, and tongue are often seen in tuberous sclerosis complex (associated with a mutation in TSC1 or TSC2 ), while sclerotic fibromas are seen in Cowden syndrome (part of PTEN hamartoma tumor syndrome).

Etiopathogenesis and Histopathologic Features

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

  • Fibroma: the nodule consists of a proliferation of fibrocollagenous tissue associated with variable vascularity, neurovascular hyperplasia, parakeratosis or hyperkeratosis, ulceration, inflammation, and epithelial hyperplasia or atrophy ( Figs. 5.2 to 5.4 ); myxoid/mucinous change may be present ( Fig. 5.5 ).

    Fig 5.2
    (A) Fibroma with frictional keratosis. (B) Dense collagenous tissue with dilated capillaries.

    Fig 5.3
    (A) Fibroma with frictional parakeratosis. (B) Fibroma with frictional parakeratotic chevrons.

    Fig 5.4
    (A) Fibroma with frictional hyperkeratosis. (B) Parakeratosis and bacterial colonies typical for frictional/factitial keratosis.

    Fig 5.5
    (A) Fibroma with focal myxoid/mucinous change. (B) Areas of dense collagen interspersed with myxoid/mucinous areas with mild chronic inflammation.
  • Giant cell fibroma: nodules often have a papillary or bosselated surface with acanthosis forming spiky, saw-tooth shaped rete ridges; there are many giant, stellate, bi- and multinucleate fibroblasts that sometimes show cytoplasmic positivity for smooth muscle actin, suggesting differentiation toward myofibroblasts; some of these cells have been shown to be factor XIIIa+; dense collagen and mast cells are often present similar to fibrous papule of the nose ( Figs. 5.6 and 5.7 ).

    Fig 5.6
    Giant cell fibroma. (A) Fibrous nodule with spiky rete ridges and dense collagen. (B) Stellate and multinucleate fibroblasts. (C) Nodule with bosselated surface and tapered interlacing rete ridges. (D) Stellate and multinucleate fibroblasts.

    Fig 5.7
    Giant cell fibroma. (A) Fibrous nodule with papillary surface. (B) Giant and binucleate fibroblast-like cells and dense collagen.
  • Solitary sclerotic fibroma (storiform collagenoma): the nodule contains hyalinized bands of dense collagen with a storiform pattern, usually demarcated from the surrounding soft tissue; there are stellate and fusiform fibroblasts, and clusters of stellate mononuclear cells appearing as multinucleate cells; clefts between collagen fibers are a distinctive feature; a giant cell version is recognized that contains bizarre, true multinucleate giant cells ( Fig. 5.8 ); lesions are positive for CD34, CD99, and occasionally factor XIIIa; multiple sclerotic fibromas are associated with Cowden syndrome.

    Fig 5.8
    Sclerotic fibroma. (A) Well-demarcated nodule of dense, hyalinized collagen. (B) Stellate and fusiform fibroblasts with tissue clefts.
  • Fibromas of the anterior hard palatal mucosa often contain cartilage and branches of the nasopalatine neurovascular bundle ( Fig. 5.9 ).

    Fig 5.9
    Fibroma of anterior palatal mucosa. (A) Nodule containing hyaline cartilage and neurovascular bundles. (B) Mature hyaline cartilage.

Differential Diagnosis

  • Desmoplastic fibroblastoma (collagenous fibroma) contains spindled and stellate fibroblasts but in an edematous to fibromyxoid stroma, and are likely true neoplasms because gene rearrangements have been identified.

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: pp. 182-187.
  • de Sousa SF, Caldeira PC, Grossmann Sde M, de Aguiar MC, Mesquita RA: Desmoplastic fibroblastoma (collagenous fibroma): a case identified in the buccal mucosa. Head Neck Pathol 2011; 5: pp. 175-179.
  • 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: pp. 442-447.
  • Hedin CA, Gerner L, Larsson A: The retrocuspid papilla and factor XIIIa: an epidemiologic and histomorphologic study. Scand J Dent Res 1994; 102: pp. 290-294.
  • Houston GD: The giant cell fibroma: a review of 464 cases. Oral Surg Oral Med Oral Pathol 1982; 53: pp. 582-587.
  • Magnusson BC, Rasmusson LG: The giant cell fibroma. A review of 103 cases with immunohistochemical findings. Acta Odontol Scand 1995; 53: pp. 293-296.
  • Metcalf JS, Maize JC, LeBoit PE: Circumscribed storiform collagenoma (sclerosing fibroma). Am J Dermatopathol 1991; 13: pp. 122-129.
  • Ramos D, Monteagudo C, Carda C, et. al.: Ultrastructural and immunohistochemical characterization of the so-called giant multinucleate cells in cutaneous collagenomas. Histopathology 2002; 41: pp. 134-143.
  • Rapini RP, Golitz LE: Sclerotic fibromas of the skin. J Am Acad Dermatol 1989; 20: pp. 266-271.
  • Santos PP, Nonaka CF, Pinto LP, de Souza LB: Immunohistochemical expression of mast cell tryptase in giant cell fibroma and inflammatory fibrous hyperplasia of the oral mucosa. Arch Oral Biol 2011; 56: pp. 231-237.
  • Fibroma (“Bite” or “Irritation” Fibroma, Fibroepithelial or Fibrovascular Polyp), and Giant Cell Fibroma

    Clinical Findings

    • Fibroma: This consists of a dome-shaped nodule or papule that may be white/keratotic, mucosa-colored, or ulcerated; it is located in areas readily traumatized by biting (i.e., buccal mucosa, lateral tongue, and lower lip mucosa) or on the gingiva where plaque accumulates ( Fig. 5.1A–D ).

      FIG 5.1
      (A) Fibroma of right buccal mucosa. (B) Cut surfaces of fibroma, dense and white. (C) Fibroma of the lower lip mucosa. (D) Sclerotic fibroma of the palate. (E) Giant cell fibroma on the palatal mucosa.
      (Courtesy Dr. Carl Allen, The Ohio State University, Columbus, Ohio.)
    • Giant cell fibroma: This often has a papillary surface and 90% are located on the gingiva (50% of cases), tongue, and palatal mucosa; a similar histopathologic condition is referred to as the retrocuspid papilla, which occurs on the lingual attached gingiva of the mandibular cuspids, usually bilaterally ( Fig. 5.1E ).

    • Multiple fibromas of the gingiva, buccal mucosa, and tongue are often seen in tuberous sclerosis complex (associated with a mutation in TSC1 or TSC2 ), while sclerotic fibromas are seen in Cowden syndrome (part of PTEN hamartoma tumor syndrome).

    Etiopathogenesis and Histopathologic Features

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

    • Fibroma: the nodule consists of a proliferation of fibrocollagenous tissue associated with variable vascularity, neurovascular hyperplasia, parakeratosis or hyperkeratosis, ulceration, inflammation, and epithelial hyperplasia or atrophy ( Figs. 5.2 to 5.4 ); myxoid/mucinous change may be present ( Fig. 5.5 ).

      Fig 5.2
      (A) Fibroma with frictional keratosis. (B) Dense collagenous tissue with dilated capillaries.

      Fig 5.3
      (A) Fibroma with frictional parakeratosis. (B) Fibroma with frictional parakeratotic chevrons.

      Fig 5.4
      (A) Fibroma with frictional hyperkeratosis. (B) Parakeratosis and bacterial colonies typical for frictional/factitial keratosis.

      Fig 5.5
      (A) Fibroma with focal myxoid/mucinous change. (B) Areas of dense collagen interspersed with myxoid/mucinous areas with mild chronic inflammation.
    • Giant cell fibroma: nodules often have a papillary or bosselated surface with acanthosis forming spiky, saw-tooth shaped rete ridges; there are many giant, stellate, bi- and multinucleate fibroblasts that sometimes show cytoplasmic positivity for smooth muscle actin, suggesting differentiation toward myofibroblasts; some of these cells have been shown to be factor XIIIa+; dense collagen and mast cells are often present similar to fibrous papule of the nose ( Figs. 5.6 and 5.7 ).

      Fig 5.6
      Giant cell fibroma. (A) Fibrous nodule with spiky rete ridges and dense collagen. (B) Stellate and multinucleate fibroblasts. (C) Nodule with bosselated surface and tapered interlacing rete ridges. (D) Stellate and multinucleate fibroblasts.

      Fig 5.7
      Giant cell fibroma. (A) Fibrous nodule with papillary surface. (B) Giant and binucleate fibroblast-like cells and dense collagen.
    • Solitary sclerotic fibroma (storiform collagenoma): the nodule contains hyalinized bands of dense collagen with a storiform pattern, usually demarcated from the surrounding soft tissue; there are stellate and fusiform fibroblasts, and clusters of stellate mononuclear cells appearing as multinucleate cells; clefts between collagen fibers are a distinctive feature; a giant cell version is recognized that contains bizarre, true multinucleate giant cells ( Fig. 5.8 ); lesions are positive for CD34, CD99, and occasionally factor XIIIa; multiple sclerotic fibromas are associated with Cowden syndrome.

      Fig 5.8
      Sclerotic fibroma. (A) Well-demarcated nodule of dense, hyalinized collagen. (B) Stellate and fusiform fibroblasts with tissue clefts.
    • Fibromas of the anterior hard palatal mucosa often contain cartilage and branches of the nasopalatine neurovascular bundle ( Fig. 5.9 ).

      Fig 5.9
      Fibroma of anterior palatal mucosa. (A) Nodule containing hyaline cartilage and neurovascular bundles. (B) Mature hyaline cartilage.

    Differential Diagnosis

    • Desmoplastic fibroblastoma (collagenous fibroma) contains spindled and stellate fibroblasts but in an edematous to fibromyxoid stroma, and are likely true neoplasms because gene rearrangements have been identified.

    Management and Prognosis

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

    Clinical Findings

    • Fibroma: This consists of a dome-shaped nodule or papule that may be white/keratotic, mucosa-colored, or ulcerated; it is located in areas readily traumatized by biting (i.e., buccal mucosa, lateral tongue, and lower lip mucosa) or on the gingiva where plaque accumulates ( Fig. 5.1A–D ).

      FIG 5.1
      (A) Fibroma of right buccal mucosa. (B) Cut surfaces of fibroma, dense and white. (C) Fibroma of the lower lip mucosa. (D) Sclerotic fibroma of the palate. (E) Giant cell fibroma on the palatal mucosa.
      (Courtesy Dr. Carl Allen, The Ohio State University, Columbus, Ohio.)
    • Giant cell fibroma: This often has a papillary surface and 90% are located on the gingiva (50% of cases), tongue, and palatal mucosa; a similar histopathologic condition is referred to as the retrocuspid papilla, which occurs on the lingual attached gingiva of the mandibular cuspids, usually bilaterally ( Fig. 5.1E ).

    • Multiple fibromas of the gingiva, buccal mucosa, and tongue are often seen in tuberous sclerosis complex (associated with a mutation in TSC1 or TSC2 ), while sclerotic fibromas are seen in Cowden syndrome (part of PTEN hamartoma tumor syndrome).

    Etiopathogenesis and Histopathologic Features

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

    • Fibroma: the nodule consists of a proliferation of fibrocollagenous tissue associated with variable vascularity, neurovascular hyperplasia, parakeratosis or hyperkeratosis, ulceration, inflammation, and epithelial hyperplasia or atrophy ( Figs. 5.2 to 5.4 ); myxoid/mucinous change may be present ( Fig. 5.5 ).

      Fig 5.2
      (A) Fibroma with frictional keratosis. (B) Dense collagenous tissue with dilated capillaries.

      Fig 5.3
      (A) Fibroma with frictional parakeratosis. (B) Fibroma with frictional parakeratotic chevrons.

      Fig 5.4
      (A) Fibroma with frictional hyperkeratosis. (B) Parakeratosis and bacterial colonies typical for frictional/factitial keratosis.

      Fig 5.5
      (A) Fibroma with focal myxoid/mucinous change. (B) Areas of dense collagen interspersed with myxoid/mucinous areas with mild chronic inflammation.
    • Giant cell fibroma: nodules often have a papillary or bosselated surface with acanthosis forming spiky, saw-tooth shaped rete ridges; there are many giant, stellate, bi- and multinucleate fibroblasts that sometimes show cytoplasmic positivity for smooth muscle actin, suggesting differentiation toward myofibroblasts; some of these cells have been shown to be factor XIIIa+; dense collagen and mast cells are often present similar to fibrous papule of the nose ( Figs. 5.6 and 5.7 ).

      Fig 5.6
      Giant cell fibroma. (A) Fibrous nodule with spiky rete ridges and dense collagen. (B) Stellate and multinucleate fibroblasts. (C) Nodule with bosselated surface and tapered interlacing rete ridges. (D) Stellate and multinucleate fibroblasts.

      Fig 5.7
      Giant cell fibroma. (A) Fibrous nodule with papillary surface. (B) Giant and binucleate fibroblast-like cells and dense collagen.
    • Solitary sclerotic fibroma (storiform collagenoma): the nodule contains hyalinized bands of dense collagen with a storiform pattern, usually demarcated from the surrounding soft tissue; there are stellate and fusiform fibroblasts, and clusters of stellate mononuclear cells appearing as multinucleate cells; clefts between collagen fibers are a distinctive feature; a giant cell version is recognized that contains bizarre, true multinucleate giant cells ( Fig. 5.8 ); lesions are positive for CD34, CD99, and occasionally factor XIIIa; multiple sclerotic fibromas are associated with Cowden syndrome.

      Fig 5.8
      Sclerotic fibroma. (A) Well-demarcated nodule of dense, hyalinized collagen. (B) Stellate and fusiform fibroblasts with tissue clefts.
    • Fibromas of the anterior hard palatal mucosa often contain cartilage and branches of the nasopalatine neurovascular bundle ( Fig. 5.9 ).

      Fig 5.9
      Fibroma of anterior palatal mucosa. (A) Nodule containing hyaline cartilage and neurovascular bundles. (B) Mature hyaline cartilage.

    Differential Diagnosis

    • Desmoplastic fibroblastoma (collagenous fibroma) contains spindled and stellate fibroblasts but in an edematous to fibromyxoid stroma, and are likely true neoplasms because gene rearrangements have been identified.

    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: pp. 182-187.
  • de Sousa SF, Caldeira PC, Grossmann Sde M, de Aguiar MC, Mesquita RA: Desmoplastic fibroblastoma (collagenous fibroma): a case identified in the buccal mucosa.Head Neck Pathol 2011; 5: pp. 175-179.
  • 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: pp. 442-447.
  • Hedin CA, Gerner L, Larsson A: The retrocuspid papilla and factor XIIIa: an epidemiologic and histomorphologic study.Scand J Dent Res 1994; 102: pp. 290-294.
  • Houston GD: The giant cell fibroma: a review of 464 cases.Oral Surg Oral Med Oral Pathol 1982; 53: pp. 582-587.
  • Magnusson BC, Rasmusson LG: The giant cell fibroma. A review of 103 cases with immunohistochemical findings.Acta Odontol Scand 1995; 53: pp. 293-296.
  • Metcalf JS, Maize JC, LeBoit PE: Circumscribed storiform collagenoma (sclerosing fibroma).Am J Dermatopathol 1991; 13: pp. 122-129.
  • Ramos D, Monteagudo C, Carda C, et. al.: Ultrastructural and immunohistochemical characterization of the so-called giant multinucleate cells in cutaneous collagenomas.Histopathology 2002; 41: pp. 134-143.
  • Rapini RP, Golitz LE: Sclerotic fibromas of the skin.J Am Acad Dermatol 1989; 20: pp. 266-271.
  • Santos PP, Nonaka CF, Pinto LP, de Souza LB: Immunohistochemical expression of mast cell tryptase in giant cell fibroma and inflammatory fibrous hyperplasia of the oral mucosa.Arch Oral Biol 2011; 56: pp. 231-237.
  • Gingival Masses

    Gingival nodules may represent one of the following:

    • Reactive/inflammatory gingival nodules, solitary or diffuse; these are by far the most common

    • Peripheral (extraosseous) odontogenic cysts and tumors (see Chapters 14 and 15 )

    • 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

    • Peripheral ossifying fibromas and pyogenic granulomas tend to occur in young patients in the second to fourth decades, but all occur as nodular masses on the marginal gingiva adjacent to teeth or dental implants, often in the maxillary anterior region; fibromas are pink, while pyogenic granulomas and peripheral giant cell granulomas are dusky purple; they may be painful if ulcerated, and if vascular will bleed; the underlying bone may show “saucerization” (especially with peripheral giant cell granuloma) ( Fig. 5.10 ).

      Fig 5.10
      (A) Gingival fibroma. (B) Peripheral ossifying fibroma. (C) Pyogenic granuloma with ulceration. (D) Pyogenic granuloma of the mandibular ridge at an extraction site. (E) Peripheral giant cell granuloma. (F) Peripheral giant cell granuloma causing saucerization of bone ( arrow ).
      ( A , Courtesy Dr. Greg Sarka, private practice, Waterville, Me; B , Courtesy Dr. David Feinerman, private practice, Boynton Beach, Fla; C , Courtesy Dr. Jeffrey Freedman, private practice, Lexington, Mass; E , Courtesy Dr. Shelly Abramawitz, Children’s Hospital Boston, Boston, Mass.)
    • Peripheral giant cell granuloma is the least common and tends to occur in older adults > 50 years.

    • Parulis (“gum boil” or sinus tract) occurs on the attached gingiva and has a punctum and an underlying tract that leads to the infected tooth.

    • Up to 5% of pregnant women develop gingival pyogenic granulomas (granuloma gravidarum or oral pregnancy tumor).

    • Multiple gingival fibromas may be seen in tuberous sclerosis complex and Cowden syndrome (usually sclerotic fibromas).

    Etiopathogenesis and Histopathologic Features

    Multipotent cells in the gingival tissues when traumatized or irritated (usually by accumulation of dental calculus or bacterial plaque, rough edges of restorations, or the 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 Figs. 5.11–5.19 for histopathologic features.

    • A parulis (sinus tract) consists of a mass of edematous granulation tissue with many acute and chronic inflammatory cells and tracts lined by neutrophils ( Figs. 5.20 and 5.21 ).

      Fig 5.20
      Parulis (sinus tract) of the gingiva with gutta-percha tracer.

      Fig 5.21
      Parulis. (A) Edematous granulation tissue with linear tract communicating with the surface. (B) Edematous granulation tissue with linear spaces/tracts. (C) Edematous granulation tissue with foamy macrophages and acute and chronic inflammation, often misdiagnosed as a mucocele. (D) Tract filled with and lined by neutrophils ( arrows ).

    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 are often seen (see Fig. 5.11 )

    • Densely collagenous fibrous tissue and overlying epithelium forms spiky rete ridges; stellate and multinucleate fibroblast–like cells are present (see Fibroma section)

    Pyogenic granuloma (see also Chapter 6 )
    • Lobular or nonlobular proliferation of endothelial cells and small, dilated capillaries; often ulcerated and inflamed (see Figs. 5.12A , 5.13 )

    • Endothelial cells show reactive atypia sometimes with focal “hobnail” pattern, enlarged nuclei with prominent nucleoli and some mitotic activity (see Fig. 5.12B–C )

    • May see fibrosis depending on stage of organization

    Peripheral ossifying fibroma (fibroma with osseous metaplasia)
    • Cellular proliferation of spindled fibroblast-like cells with deposition of osteoid, woven bone with variable osteoblastic rimming, cementum droplets or cementicles (psammoma body–like) (see Figs. 5.14A–C and 5.15 ); sometimes lamellar bone is present

    • Spindle cells have ovoid nuclei, dispersed chromatin and inconspicuous nucleoli (see Fig. 5.14D ); sometimes only subtle or minimal osteoid deposition is present ( Fig. 5.16 )

    • There may be clusters of multinucleate giant cells similar to peripheral giant cell granuloma (see Fig. 5.17 )

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

    Peripheral giant cell granuloma
    • Proliferation of mononuclear and multinucleate giant cells (osteoclast-like or foreign body type) usually in sheets; giant cells contain 10–20 evenly-distributed nuclei; mitoses may be seen in mononuclear cells; fresh hemorrhage and hemosiderin deposits are usually present especially beneath the grenz zone (see Figs. 5.18 and 5.19 )

    • May see concomitant osseous metaplasia similar to peripheral ossifying fibroma

    • Giant cells are positive for TRAP, RANK and osteoprotegrin

    Fig 5.11
    Gingival fibroma/inflammatory fibrous hyperplasia. (A) Fibrous nodule with chronic inflammation. (B) Acanthosis, spongiosis, and chronic inflammation. (C) Dense plasma cell infiltrate is a common feature.

    Fig 5.12
    Granuloma gravidarum. (A) Vaguely lobular proliferation of capillaries, ulcerated. (B) Proliferation of endothelial cells and dilated capillaries with slight hobnailing of nuclei. (C) More cellular areas focally.

    Fig 5.13
    Pyogenic granuloma with early sclerosis. (A) Nonlobular proliferation of endothelial cells and capillaries with intervening fibrous tissue. (B) Fibrous tissue insinuates between and replaces endothelial cells and vessels.

    Fig 5.14
    Peripheral ossifying fibroma. (A) Mass of cellular fibrous tissue with superficial cementum droplet (cementicle) deposition and woven 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 (cementicles). (D) Cementum droplets with lamellar (psammomatoid) appearance.

    Fig 5.15
    Peripheral ossifying fibroma. (A) Nodule of cellular fibrous tissue with abundant woven bone. (B) Cellular proliferation of spindle cells forming osteoid and woven bone. (C) Osteoid rimmed by layers of osteoblasts with plump osteocytes.

    Fig 5.16
    Peripheral ossifying fibroma. (A) Cellular proliferation of plump spindle cells with one focus of calcification. (B) Spindle cells have a storiform pattern with one focus of calcification.

    Fig 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 and mononuclear cells in a hemorrhagic stroma.

    Fig 5.18
    Peripheral giant cell granuloma. (A) Cellular tumor abuts the epithelium focally. (B) Sheets of multinucleate giant cells and mononuclear cells in vascular stroma. (C) Multinucleate giant cells and occasional mitoses in stromal cells.

    Fig 5.19
    Peripheral giant cell granuloma. (A) Cellular tumor with grenz zone. (B) Hemosiderin and siderophages are prominent at the periphery of the lesion. (C) Many spindled mononuclear cells with hemorrhage. (D) Multinucleate giant cells and spindled mononuclear cells.

    Differential Diagnosis

    • A parulis may be mistaken for a mucocele (which does not occur on the attached gingiva) if the edematous tissue is mistaken for extravasated mucin.

    • Infantile hemangioma may look similar to pyogenic granuloma but it is a developmental malformation and is almost always positive for glucose transporter-1 (GLUT-1) ( Fig. 5.22 ).

      Fig 5.22
      Infantile hemangioma of buccal mucosa. (A) Proliferation of endothelial cells that surround minor salivary glands. (B) Cellular proliferation of endothelial cells and capillaries. (C) Occasional mitoses noted. (D) Cytoplasmic positivity for glucose transporter-1 (GLUT-1).
      ( A , Courtesy Dr. Harry Kozakewich, Harvard Medical School, Boston, Mass.)
    • Peripheral odontogenic fibroma produces dentinoid rather than cementum, and epithelial islands are always present distinguishing this from peripheral ossifying fibroma (see later).

    • Aggressive central (intraosseous) giant cell granuloma may erode through bone and radiographs differentiates it from a peripheral (extraosseous) lesions (see Chapter 17 ).

    Management and Prognosis

    • Excision is the treatment of choice, although if underlying irritating factors such as dental plaque are not removed the recurrence rate is 15% to 20%; anecdotal data suggests that pyogenic granulomas in teenagers may exhibit multiple recurrences.

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

    References

  • Andrikopoulou M, Chatzistamou I, Gkilas H, et. al.: Assessment of angiogenic markers and female sex hormone receptors in pregnancy tumor of the gingiva.J Oral Maxillofac Surg 2013; 71: pp. 1376-1381.
  • Buchner A, Hansen LS: The histomorphologic spectrum of peripheral ossifying fibroma.Oral Surg Oral Med Oral Pathol 1987; 63: pp. 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: pp. 631-638.
  • de Oliveira DH, da Silveira EJ, de Medeiros AM, et. al.: Study of the etiopathogenesis and differential diagnosis of oral vascular lesions by immunoexpression of GLUT-1 and HIF-1alpha.J Oral Pathol Med 2014; 43: pp. 76-80.
  • 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: pp. 391-397.
  • Fanourakis G, Lazaris AC, Krithinakis S, et. al.: Expression of receptor activator of NF-kappaB ligand and osteoprotegerin in peripheral giant cell granulomas of the jaws.J Oral Pathol Med 2010; 39: pp. 687-689.
  • Giunta JL: Gingival fibrous nodule.Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999; 88: pp. 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: pp. 2185-2188.
  • Johann AC, Salla JT, Gomez RS, et. al.: GLUT-1 in oral benign vascular lesions.Oral Dis 2007; 13: pp. 51-55.
  • Lester SR, Cordell KG, Rosebush MS, et. al.: Peripheral giant cell granulomas: a series of 279 cases.Oral Surg Oral Med Oral Pathol Oral Radiol 2014; 118: pp. 475-482.
  • 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: pp. 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: pp. 701-708.
  • Reactive/Inflammatory Gingival Nodules

    Clinical Findings

    • Peripheral ossifying fibromas and pyogenic granulomas tend to occur in young patients in the second to fourth decades, but all occur as nodular masses on the marginal gingiva adjacent to teeth or dental implants, often in the maxillary anterior region; fibromas are pink, while pyogenic granulomas and peripheral giant cell granulomas are dusky purple; they may be painful if ulcerated, and if vascular will bleed; the underlying bone may show “saucerization” (especially with peripheral giant cell granuloma) ( Fig. 5.10 ).

      Fig 5.10
      (A) Gingival fibroma. (B) Peripheral ossifying fibroma. (C) Pyogenic granuloma with ulceration. (D) Pyogenic granuloma of the mandibular ridge at an extraction site. (E) Peripheral giant cell granuloma. (F) Peripheral giant cell granuloma causing saucerization of bone ( arrow ).
      ( A , Courtesy Dr. Greg Sarka, private practice, Waterville, Me; B , Courtesy Dr. David Feinerman, private practice, Boynton Beach, Fla; C , Courtesy Dr. Jeffrey Freedman, private practice, Lexington, Mass; E , Courtesy Dr. Shelly Abramawitz, Children’s Hospital Boston, Boston, Mass.)
    • Peripheral giant cell granuloma is the least common and tends to occur in older adults > 50 years.

    • Parulis (“gum boil” or sinus tract) occurs on the attached gingiva and has a punctum and an underlying tract that leads to the infected tooth.

    • Up to 5% of pregnant women develop gingival pyogenic granulomas (granuloma gravidarum or oral pregnancy tumor).

    • Multiple gingival fibromas may be seen in tuberous sclerosis complex and Cowden syndrome (usually sclerotic fibromas).

    Etiopathogenesis and Histopathologic Features

    Multipotent cells in the gingival tissues when traumatized or irritated (usually by accumulation of dental calculus or bacterial plaque, rough edges of restorations, or the 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 Figs. 5.11–5.19 for histopathologic features.

    • A parulis (sinus tract) consists of a mass of edematous granulation tissue with many acute and chronic inflammatory cells and tracts lined by neutrophils ( Figs. 5.20 and 5.21 ).

      Fig 5.20
      Parulis (sinus tract) of the gingiva with gutta-percha tracer.

      Fig 5.21
      Parulis. (A) Edematous granulation tissue with linear tract communicating with the surface. (B) Edematous granulation tissue with linear spaces/tracts. (C) Edematous granulation tissue with foamy macrophages and acute and chronic inflammation, often misdiagnosed as a mucocele. (D) Tract filled with and lined by neutrophils ( arrows ).

    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 are often seen (see Fig. 5.11 )

    • Densely collagenous fibrous tissue and overlying epithelium forms spiky rete ridges; stellate and multinucleate fibroblast–like cells are present (see Fibroma section)

    Pyogenic granuloma (see also Chapter 6 )
    • Lobular or nonlobular proliferation of endothelial cells and small, dilated capillaries; often ulcerated and inflamed (see Figs. 5.12A , 5.13 )

    • Endothelial cells show reactive atypia sometimes with focal “hobnail” pattern, enlarged nuclei with prominent nucleoli and some mitotic activity (see Fig. 5.12B–C )

    • May see fibrosis depending on stage of organization

    Peripheral ossifying fibroma (fibroma with osseous metaplasia)
    • Cellular proliferation of spindled fibroblast-like cells with deposition of osteoid, woven bone with variable osteoblastic rimming, cementum droplets or cementicles (psammoma body–like) (see Figs. 5.14A–C and 5.15 ); sometimes lamellar bone is present

    • Spindle cells have ovoid nuclei, dispersed chromatin and inconspicuous nucleoli (see Fig. 5.14D ); sometimes only subtle or minimal osteoid deposition is present ( Fig. 5.16 )

    • There may be clusters of multinucleate giant cells similar to peripheral giant cell granuloma (see Fig. 5.17 )

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

    Peripheral giant cell granuloma
    • Proliferation of mononuclear and multinucleate giant cells (osteoclast-like or foreign body type) usually in sheets; giant cells contain 10–20 evenly-distributed nuclei; mitoses may be seen in mononuclear cells; fresh hemorrhage and hemosiderin deposits are usually present especially beneath the grenz zone (see Figs. 5.18 and 5.19 )

    • May see concomitant osseous metaplasia similar to peripheral ossifying fibroma

    • Giant cells are positive for TRAP, RANK and osteoprotegrin

    Fig 5.11
    Gingival fibroma/inflammatory fibrous hyperplasia. (A) Fibrous nodule with chronic inflammation. (B) Acanthosis, spongiosis, and chronic inflammation. (C) Dense plasma cell infiltrate is a common feature.

    Fig 5.12
    Granuloma gravidarum. (A) Vaguely lobular proliferation of capillaries, ulcerated. (B) Proliferation of endothelial cells and dilated capillaries with slight hobnailing of nuclei. (C) More cellular areas focally.

    Fig 5.13
    Pyogenic granuloma with early sclerosis. (A) Nonlobular proliferation of endothelial cells and capillaries with intervening fibrous tissue. (B) Fibrous tissue insinuates between and replaces endothelial cells and vessels.

    Fig 5.14
    Peripheral ossifying fibroma. (A) Mass of cellular fibrous tissue with superficial cementum droplet (cementicle) deposition and woven 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 (cementicles). (D) Cementum droplets with lamellar (psammomatoid) appearance.

    Fig 5.15
    Peripheral ossifying fibroma. (A) Nodule of cellular fibrous tissue with abundant woven bone. (B) Cellular proliferation of spindle cells forming osteoid and woven bone. (C) Osteoid rimmed by layers of osteoblasts with plump osteocytes.

    Fig 5.16
    Peripheral ossifying fibroma. (A) Cellular proliferation of plump spindle cells with one focus of calcification. (B) Spindle cells have a storiform pattern with one focus of calcification.

    Fig 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 and mononuclear cells in a hemorrhagic stroma.

    Fig 5.18
    Peripheral giant cell granuloma. (A) Cellular tumor abuts the epithelium focally. (B) Sheets of multinucleate giant cells and mononuclear cells in vascular stroma. (C) Multinucleate giant cells and occasional mitoses in stromal cells.

    Fig 5.19
    Peripheral giant cell granuloma. (A) Cellular tumor with grenz zone. (B) Hemosiderin and siderophages are prominent at the periphery of the lesion. (C) Many spindled mononuclear cells with hemorrhage. (D) Multinucleate giant cells and spindled mononuclear cells.

    Differential Diagnosis

    • A parulis may be mistaken for a mucocele (which does not occur on the attached gingiva) if the edematous tissue is mistaken for extravasated mucin.

    • Infantile hemangioma may look similar to pyogenic granuloma but it is a developmental malformation and is almost always positive for glucose transporter-1 (GLUT-1) ( Fig. 5.22 ).

      Fig 5.22
      Infantile hemangioma of buccal mucosa. (A) Proliferation of endothelial cells that surround minor salivary glands. (B) Cellular proliferation of endothelial cells and capillaries. (C) Occasional mitoses noted. (D) Cytoplasmic positivity for glucose transporter-1 (GLUT-1).
      ( A , Courtesy Dr. Harry Kozakewich, Harvard Medical School, Boston, Mass.)
    • Peripheral odontogenic fibroma produces dentinoid rather than cementum, and epithelial islands are always present distinguishing this from peripheral ossifying fibroma (see later).

    • Aggressive central (intraosseous) giant cell granuloma may erode through bone and radiographs differentiates it from a peripheral (extraosseous) lesions (see Chapter 17 ).

    Management and Prognosis

    • Excision is the treatment of choice, although if underlying irritating factors such as dental plaque are not removed the recurrence rate is 15% to 20%; anecdotal data suggests that pyogenic granulomas in teenagers may exhibit multiple recurrences.

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

    Clinical Findings

    • Peripheral ossifying fibromas and pyogenic granulomas tend to occur in young patients in the second to fourth decades, but all occur as nodular masses on the marginal gingiva adjacent to teeth or dental implants, often in the maxillary anterior region; fibromas are pink, while pyogenic granulomas and peripheral giant cell granulomas are dusky purple; they may be painful if ulcerated, and if vascular will bleed; the underlying bone may show “saucerization” (especially with peripheral giant cell granuloma) ( Fig. 5.10 ).

      Fig 5.10
      (A) Gingival fibroma. (B) Peripheral ossifying fibroma. (C) Pyogenic granuloma with ulceration. (D) Pyogenic granuloma of the mandibular ridge at an extraction site. (E) Peripheral giant cell granuloma. (F) Peripheral giant cell granuloma causing saucerization of bone ( arrow ).
      ( A , Courtesy Dr. Greg Sarka, private practice, Waterville, Me; B , Courtesy Dr. David Feinerman, private practice, Boynton Beach, Fla; C , Courtesy Dr. Jeffrey Freedman, private practice, Lexington, Mass; E , Courtesy Dr. Shelly Abramawitz, Children’s Hospital Boston, Boston, Mass.)
    • Peripheral giant cell granuloma is the least common and tends to occur in older adults > 50 years.

    • Parulis (“gum boil” or sinus tract) occurs on the attached gingiva and has a punctum and an underlying tract that leads to the infected tooth.

    • Up to 5% of pregnant women develop gingival pyogenic granulomas (granuloma gravidarum or oral pregnancy tumor).

    • Multiple gingival fibromas may be seen in tuberous sclerosis complex and Cowden syndrome (usually sclerotic fibromas).

    Etiopathogenesis and Histopathologic Features

    Multipotent cells in the gingival tissues when traumatized or irritated (usually by accumulation of dental calculus or bacterial plaque, rough edges of restorations, or the 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 Figs. 5.11–5.19 for histopathologic features.

    • A parulis (sinus tract) consists of a mass of edematous granulation tissue with many acute and chronic inflammatory cells and tracts lined by neutrophils ( Figs. 5.20 and 5.21 ).

      Fig 5.20
      Parulis (sinus tract) of the gingiva with gutta-percha tracer.

      Fig 5.21
      Parulis. (A) Edematous granulation tissue with linear tract communicating with the surface. (B) Edematous granulation tissue with linear spaces/tracts. (C) Edematous granulation tissue with foamy macrophages and acute and chronic inflammation, often misdiagnosed as a mucocele. (D) Tract filled with and lined by neutrophils ( arrows ).

    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 are often seen (see Fig. 5.11 )

    • Densely collagenous fibrous tissue and overlying epithelium forms spiky rete ridges; stellate and multinucleate fibroblast–like cells are present (see Fibroma section)

    Pyogenic granuloma (see also Chapter 6 )
    • Lobular or nonlobular proliferation of endothelial cells and small, dilated capillaries; often ulcerated and inflamed (see Figs. 5.12A , 5.13 )

    • Endothelial cells show reactive atypia sometimes with focal “hobnail” pattern, enlarged nuclei with prominent nucleoli and some mitotic activity (see Fig. 5.12B–C )

    • May see fibrosis depending on stage of organization

    Peripheral ossifying fibroma (fibroma with osseous metaplasia)
    • Cellular proliferation of spindled fibroblast-like cells with deposition of osteoid, woven bone with variable osteoblastic rimming, cementum droplets or cementicles (psammoma body–like) (see Figs. 5.14A–C and 5.15 ); sometimes lamellar bone is present

    • Spindle cells have ovoid nuclei, dispersed chromatin and inconspicuous nucleoli (see Fig. 5.14D ); sometimes only subtle or minimal osteoid deposition is present ( Fig. 5.16 )

    • There may be clusters of multinucleate giant cells similar to peripheral giant cell granuloma (see Fig. 5.17 )

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

    Peripheral giant cell granuloma
    • Proliferation of mononuclear and multinucleate giant cells (osteoclast-like or foreign body type) usually in sheets; giant cells contain 10–20 evenly-distributed nuclei; mitoses may be seen in mononuclear cells; fresh hemorrhage and hemosiderin deposits are usually present especially beneath the grenz zone (see Figs. 5.18 and 5.19 )

    • May see concomitant osseous metaplasia similar to peripheral ossifying fibroma

    • Giant cells are positive for TRAP, RANK and osteoprotegrin

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    Oct 3, 2019 | Posted by in Oral and Maxillofacial Pathology | Comments Off on Fibrous, Gingival, Lipocytic, and Miscellaneous Tumors

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