BENIGN TUMORS OF EPITHELIAL ORIGIN
DR. ABHAY KUMAR
INTRODUCTION Characteristics: 1) Slow Slow rat rate e of gr growth owth and and long longer er dur durat atio ion n 2) Well ell defin defined ed mas masss of regu regula larr smoot smooth h outl outlin ine e (possesses a fibrous capsule ) 3) Swelling and pressure effect on surrounding surroundin g structures 4) Smaller compared to malignant tumors 5) Displacement of adjacent normal tissues 6) Usually painless
Benign Epithelial Tissue Lesions: 1) Papilloma 2) Keratoacanthoma 3) Squamous Acanthoma
SQUAMOUS PAPILLOMA
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A benign exophytic papillary growth of stratified squamous epithelium
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4th most common oral mucosal mass
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3-4% of all biopsied oral soft tissue lesions
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Associated with papilloma virus (HPV type 6 and 11)
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Low virulence and infectivity rate
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Clinically and microscopically indistinguishable from Verruca Vulgaris (virus-induced focal focal papillary hyperplasia of the epidermis)
Clinical Features: - Exop Exoph hytic ytic grow growth th made made up of of numer numerous ous fing fingrr like like projections (roughened , verrucous or cauliflower surface) - <1cm <1cm in grea greattest est diame iametter - Sessil Sessile e or pedun peduncu cula lated ted and and white white(k (ker erat atini inizzed) or or pink pink (nonkeratinized) , mostly solitary - Occu Occurs rs on on the the soft soft palat palate, e, uvul uvula a , and ven ventr tral al and and dors dorsal al surfaces of the tongue , gingiva and buccal mucosa
- Painl ainles esss , whit white e or or pin pink k in in col colou ourr - Occurs at any age - Papillo apilloma ma lik like e or papill papilloma omato tous us lesi lesions ons as well well as ‘pebbly’ lesions and fibromas of various sites in the oral cavity are recognized as manifestation of multiple hamartoma and neoplasia syndrome (Cowden’s syndrome)
HISTOLOGICAL FEATURES: - Long Long , thin thin , finge finger-l r-lik ike e proje projecti ction onss extend extendin ing g above above the the surface of the mucosa Each made up of continous layer of stratified squamous epithelium Contains a thin , central connective tissue core (supports nutrient blood vessels) - Proli Prolifferat eration ion of of the the spino spinous us cells cells in in papi papilla llary ry patt pattern ern - Ma May y show show basi basilar lar hyp hyper er plasi plasia a and and mild mild mit mitoti oticc activ activity ity (SHAFER’S)
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A thick papillary layer of keratinized or non-keratinized squamous epithelium A central core of fibrovascular connective tissue (characteristic) Long and finger –like or short , rounded and blunt(papillary projections)
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Normal maturation pattern shown by epithelium
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Mild degree of basilar hyperplasia (SAPP)
Differential diagnosis:
Verruca vulgaris Oral condyloma acuminatum
Focal epithelial hyperplasia (Heck disease)
Treatment : - Surgic Surgical al ex excision cision of the the base base of of lesion lesion and small small area area of surrounding normal tissue - Recur ecurrrence ence is unc uncommo ommon n
Squamous Acanthoma Description :- Uncommon Lesion - Represents Represents reactive phenomenon of epithelium - Not true neoplasm - Tomich and Shafer described lesion
Clinical features:Age :- Older Adults Site of Occurance:- Any site on oral mucosa - Appears small flat or elevated - White , sessile or pedunclated pedunclated lesion on mucosa
Causes : - Trauma
H/P features: - Elevated or Umblicated epithelial epithelial proliferation - Thickened layer of orthokeratin and underlying underlying spinous layer of cells
T/P: - Excision - No case of recurrence after excision
KERATOACANTHOMA
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–healing carcinoma ,molluscum pseudoSelf – carcinomatosum , molluscum sebaceum , verrucoma
A benign endophytic epithelial growth appearing as a wellcircumscribed keratin-filled crater on sun-exposed skin
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Low grade malignancy , originates in pilosebaceous glands
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Variant of invasive SCC (considered)
- Occurs on: Hair-bearing skin (cheeks , nose , eyelids , ears ) Lower lip - Arises Arises from from hair hair foll follicl icle e epith epitheli elium um abov above e sebac sebaceou eouss glands - Lower lip – arises from superficial epithelium of sebaceous ducts or from the hair follicle epithelium of adjacent skin
Etiological factors: - Trauma rauma , chemi chemical cal carcino carcinogen genss , human human papillo papilloma ma virus virus , genetic factors and immunocompromised status
Clinical Features: - Seen een abo above >50 >50y yrs of of age age - Male:female – 2:1 - Less Less comm common on in dark dark ski skinn nned ed ind indiv ivid idua uals ls - Occu Occurrs in in sun sun exp expos osed ed area areass - Face,ne ace,neck, ck,and and dors dorsum um of of the the upper upper extr extremi emities ties are are common sites - 8.1% 8.1% case casess occu occurr rred ed on on lips lips(( vermi vermilio lion n bor border der of both both upper and lower lips are equally affected)
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Develops rapidly over a period of 1to2months Soliatry and benign as firm, round ,skin coloured or reddish papules Rapidly progress to dome-shaped nodules with a smooth shiny surface and a central crateriform ulceration or keratin plug (projects like horn) Appears elevated umblicated or crateriform(with depressed central core or plug) 1 to 1.5cm in diameter
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Painful often and regional lymphaedopathy present
Differential diagnosis: Actinic keratosis Molluscum contagiosum
Muir-Torre syndrome SCC Verrucous carcinoma
Histological features: - Hyper Hyperpl plast astic ic squam squamous ous epithe epitheliu lium m growi growing ng in underl underlyin ying g connective tissue - Parak araker eratin atin or orthok orthoker eratin atin cover coverss the surf surface ace with with centr central al plugging - Dysp Dyspla lasstic tic featu eaturres seen seen – occasionally (peripheral zone formed by squamous cells with atypical mitotic figures , hyperchromatic nuclei and loss of polarity ) - Pseud Pseudoc ocar arcin cinom omat atous ous infil infilta tatio tion n typic typicall ally y presen presents ts a smooth , regular , well-demarcated front that does not extend beyond the level of the sweat glands
- Connective ti tissue – shows chronic inflammatory cell infiltration - Char Charac acte teri risstic tic featu eaturres – seen at margins , normal adjacent epithelium elevated towards the central portion of crater (abrupt change in epithelium occurs as hyperplastic acanthotic epithelium is reached)
(SHAFER’S)
Features : - Centr Central al plug plug of of ker keratin atin surroun surrounded ded by by a sharply sharply demarc demarcat ated ed - CupCup-sh shap aped ed but buttres tresss of nor norma mall epid epider ermi miss - Epith Epitheli elium um pattern
repr represen esents ts
pseud pseudoc ocar arcin cinoma omato tous us
grow growth th
- Epith Epitheli elium um compo composed sed of well well-di -diff ffer eren entia tiated ted spin spinous ous cells cells with abundant cytoplasm, minimal pleomorphism , infrequent mitotic figures , absence of abnormal mitotic figures
TREATMENT: - Surgic gical ex excision - Recurr ecurren entt tumor tumorss may may requi require re more more aggre aggressi ssive ve therapy
Benign pigmented lesion - Depe Dependi nding ng on amo amoun untt and dis distr trib ibut utio ion n of melan melanin in in skin or mucosa, different color ranges seen
- Brown - Basal cells - Blac Black k - kerat eratin in and Spino Spinous us cell cellss - Dark blue – Deeper Connective Tissue
ORAL NEVI •
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Oral melanocytic nevus , nevocellular nevus , mole , mucosal melanocytic nevi Ackermann Ackermann and field reported 1st case in 1943 Benign proliferation proliferation of nevus cells either in epithelium or connective tissue
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Benign , Pigmented ,acquired lesion* of skin or mucosa Focal collection (nests) of rounded melanocytes (nevus cells)
Histologic location ,acquired ,acquired nevi classified in 3 types : 1) Junctional Nevi: - Nevus cells limited to to basal cell layer of epithelium 2) Compound Ne Nevus: - Epidermis and dermis 3) Intradermal Nevus: - Nests of nevus cells in connective connective tissue •
*Nevi can be classified as congenital congenital or acquired (Buchner and hansen)
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Blue nevus :
- A true true meso mesode derm rmal al struc tructu turre - Comp Compos osed ed of derm dermal al mela melano nocy cyttes - Spitz nevus (spindle cell or epitheloid cell nevus) :
- know known n as as juv juven enil ile e mel melan anom oma a - Commo Common n muco mucosa sall type type : Int Intrramuco amucosa sall Nevu Nevuss - 2nd common mucosal type : Blue Nevus
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Junctional and compound nevus : 3-6% of all oral nevi Oral acquired melanocytic nevi evolve through stages Junctional Nevi (infants , children & young adults) matures Compound Nevi
Intramucosal Nevi
Congenital Nevi •
Ainsworth and her colleagues divided congenital nevi of skin :
1) Small Small Nevi: Nevi: >1cm >1cm diame diamete terr (3-5 (3-5 cm) cm) 2) Ga Garm rmen entt Nevi Nevi : >10 >10cm cm in in diam diamet eter er
- covers large areas of skin -
1 to 2.5% of neonates
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Flat Flat , pal pale e tan tan macu macule less to ele elev vat ated ed , ver verru ruccous, ous, hairy lesions
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Approx 15% - skin of head and ne neck Intraoral oc occurrence is rare
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Acquired nevi are common
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Eight month of life and
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Number of nevi
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in number with age
as one ages
Clark stated stated “number of nevi a person has is genetically determined”
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85% - young patients (<40 years) 55% - white patients 23% - black patients
Mean age for:
1) Junc Juncti tion onal al /Com /Compo poun und d Nevi Nevi – 22 – 24 yrs 2) Intr Intram amuc ucos osal al / Blue Blue Nev Nevii – 35-38yrs Predominant in women than in man
Site of occurrence:hard palate -40% buccal mucosa – 20%
Vermillion border of lip & labial mucosa gingiva – 10% Tongue and floor of mouth – 1 case reported
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Asymptomatic Asymptomatic , incidental finding on routine dental check up Melanotic macules,amalgam tat tatoos oos , physiologic physiologic ethnic pigmentation , smoke’s melanosis or pigmented lesion Differences :-
- melanotic macules and amalgam tatoos are flat while nevi are elevated from mucosal surface
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85% of oral nevi - pigmented - brown to black or blue Nevi - well circumsribed circumsribed ,round or oval oval , raised (65-80%)
Anatomic distribution distribution closely follows histologic type - 2/3rd of blue nevi – palate - Intramucosal : hard palate -25% buccal mucosa – 25% gingiva – 17% vermilion border of lip – 17% labial mucosa – 9%
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H/P features:-
- Lar Large ovoi ovoid, d, rou round nded ed or or spi spind ndle le –shaped cells with pale cytoplasm - Vesicular nuc nucleus - Granu Granule less of of mel melani anin n pigme pigment nt in cyt cytop opla lasm sm
- Group Group in sheets sheets or cord cordss (nest (nestss or theque theques) s)
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Intramucosal (Intradermal) Nevus:
- common mole - common lesion of oral mucosa
Clinical features:-
Young patients Asym Asymp ptoma omatic, tic, pigm pigmen entted – brown to black Smoot Smooth h flat flat lesion lesion or eleva elevate ted d abo above ve surf surface ace Hard ard pala alate or gingi ingiv va Grows slowly Meas easures <1cm 1cm in in dia diam meter eter
H/P features:-
- Nests Nests , cor cords ds or shee sheets ts of nevus nevus cells cells within within connective tisssue - Mult Multin inuc ucle lessted gian giantt cell cellss see seen n - Spin Spindl dles es cell cellss ma may be be pr presen esentt - Seperated from epithelium by well – defined band of connective tissue - Free of nevus cells
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Junctional Nevus:-
- Benign , brown –black - Skin Skin , oral oral muc mucosa osa (oc (occa casi sion onal al)) - Har Hard Pal Pala ate or or Gin Gingi giv va
H/P features:- No zo zone of dema demarrcation tion
- Nevus Nevus cell cell in cont contac actt and and blen blend d with with surf surfac ace e epithelium - Overly Overlying ing epithel epithelium ium is thin thin ,irr ,irregul egular ar and shows shows cells crossing junction & growing down into connective tissue - Known nown abt abtrropfun opfung g or drop droppi ping ng off off eff effect ect - Featu Feature re showing showing malignan malignantt trans transfformati ormation on ( junctional activity)
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Compond Nevus:-
- Lesi Lesion on Comp Compos osed ed of two two elem elemen ents ts - Comm Common on in ski skin n tha than n in in or oral muc mucosa osa - Pigme Pigment nted ed papul papulae ae or macul macule e on har hard d palat palate e or gingiva
H/P features:-
- Combin Combined ed char charac actteristic eristic seen seen ( intr intramu amuco cosal sal + junctional nevus) (nevus cells in basal region of epithelium and adjacent connective tissue) - Nests of nevus cells dropping dropping off from epidermis
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Blue Nevus:-
- True rue mes mesod oder erma mall str struc uctu turre - Cons Consis isti ting ng of derm dermal al mela melanoc nocyt ytes es - Rarely Rarely under undergo maligna malignant nt trans transfformatio ormation n
- Pres Presen entt at at bir birth th and and ear early ly chil childh dhoo ood d - Remai emains ns uncha unchang nged ed thr througho oughout ut lif life
- Appe Appear arss as as big big pig pigme ment nted ed lesio lesion n - Dark Dark blue blue , dom dome e sha shape ped d pap papul ule e or flat macule on skin or mucosa - Smooth Smooth and exhibi exhibitt hair hair growi growing ng from from surf surface
- Color : – – - Due to melano melanocyt cytes es resid resides es deep deep in connec connectiv tive e tissue overlying vessels dampen brown coloration of melanin BLUE tint seen
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H/P features:-
- Two type typess : 1) Com Commo mon n Blue Blue Nevu Nevuss 2) Cellular Blue nevus 1) Comm Common on Blu Blue Nevus evus::
- Elongated melanocytes with long branching dendritic process lie in bundles -
Parallel to epidermis
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Middle and lo lower third of of dermis
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No junctional activity seen
2) Cellular Blue Nevus:-
- Lar Large , rou round nd or spi spind ndle le cell cell with with pale pale vacuolated vacuolated cytoplasm - Alve Alveol olar ar pat pattern tern arran arrange gemen mentt see seen n
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Spitz Nevus:-
- Chil Childr dren en : on face ace or ext xtre remi miti ties es - 15% 15% repo eported rted in adul adults ts
- Solit Solitar ary y , dome dome-s -sha hape ped d , pink pink to to red reddi dish sh brown papulae - Size < 6mm
H/P features :- Compo Compose sed d of Ple Pleom omor orphi phicc cell cellss of thr three ee typ types es
1) spindle cells 2) oval 3) epitheloid cells - Mono Mononuc nucle lear ar and and mul multi tinu nucl clea eate ted d giant giant cel celll - Arr Arrange anged d in cic cicum umsc scri ribe bed d shee sheets ts - Junc Juncti tion onal al acti activi vitty see seen n
Treatment and Prognosis:1) Acqu Acquir ired ed Pig Pigme men nted Nev Nevus us : - common occurrence - removal adviced – occur in area irritated by clothing (belt or collar line) or increase in size, deepen in colour or ulcerated Trauma to intradermal nevus doesnot induce malignancy
2) Congenital pigmented Nevus:- Great risk for transformation to malignant melanoma - Clark and Coworkers described
B-K mole Syndrome (autosomal dominant condition) - large pigmented nevi - higher risk for development of melanoma - not intraoral
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Conclusion:-
Surgical excision excision of all intraoral pigmented nevi adviced
Due to chronic irritation of mucosa in all intraoral intraoral sites sites ( eating , toothbrushing) toothbrushing)
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