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HYPERPLASTIC,HYPERPLASTIC,NEOPLASTIC ANDNEOPLASTIC AND
RELATED DISORDERS OFRELATED DISORDERS OF
ORAL MUCOSAORAL MUCOSA
DR. RIMA SAFADIDR. RIMA SAFADI
ORAL AND MAXILLOFACIALORAL AND MAXILLOFACIAL
PATHOLOGYPATHOLOGY
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Hyperplasia of oral mucosaHyperplasia of oral mucosa
Localized hyper plastic lesions of oralLocalized hyper plastic lesions of oral
mucosamucosa
Cause: chronic inflammationCause: chronic inflammation Inflammation and repair togetherInflammation and repair together
Production of granulation tissueProduction of granulation tissue
Range: richly cellular and vascularRange: richly cellular and vascular
Non inflamed,Non inflamed, avascularavascular, dense collagen, dense collagen
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Hyperplasia of oral mucosaHyperplasia of oral mucosa
Localized hyperplastic lesions of oralLocalized hyperplastic lesions of oral
mucosamucosa
Location:Location: Any where in the mouthAny where in the mouth
Gingiva: epulisGingiva: epulis
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Hyperplasias of Oral MucosaHyperplasias of Oral Mucosa
LocalizedLocalized hyperplastichyperplastic lesions of oral mucosalesions of oral mucosa
PyogenicPyogenic granulomagranuloma
Peripheral giant cellPeripheral giant cell granulomagranuloma
*Peripheral ossifying fibroma*Peripheral ossifying fibroma
*Irritation fibroma (focal fibrous hyperplasia)*Irritation fibroma (focal fibrous hyperplasia)
Giant cell fibromaGiant cell fibroma
RetrocuspidRetrocuspid papillapapilla
*In your text book these are considered as*In your text book these are considered as
fibrousfibrous epuliusepulius
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Hyperplasia of Oral MucosaHyperplasia of Oral Mucosa
FibroepithelialFibroepithelial polyppolyp
EpulisEpulis FissuratumFissuratum, inflammatory fibrous, inflammatory fibrous
hyperplasia,hyperplasia, denture irritation hyperplasia
Inflammatory papillary hyperplasia (papillaryInflammatory papillary hyperplasia (papillaryhyperplasia of the palate)hyperplasia of the palate)
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EpulidesEpulides
hyperplastichyperplastic, not neoplastic, not neoplasticMostly fromMostly from interdentalinterdental tissuetissue
Irritation from dental plaque and calculusIrritation from dental plaque and calculus
Types:Types: FibrousFibrous epulisepulis (ossifying fibroma,(ossifying fibroma, hyperplastichyperplastic
gingivitis)gingivitis)
commonestcommonest
PyogenicPyogenic granulomagranuloma Peripheral giant cellPeripheral giant cell
granulomagranuloma
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EpulidesEpulides
More common in femalesMore common in females
More in anterior to molar regionMore in anterior to molar region
Maxilla>mandibleMaxilla>mandible
Recur if causative factor persistsRecur if causative factor persists
Or if incompletely excised as in PGCGOr if incompletely excised as in PGCG
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FibrousFibrous epulisepulis
Clinically:Clinically:
Pedunculated orPedunculated or
sessilesessile
FirmFirm
Similar in color toSimilar in color to
adjacent gingivaadjacent gingiva
Ulceration +Ulceration +--
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Fibrous epulisFibrous epulis
Histopathology:Histopathology:
Cellularity variableCellularity variable
Mature collagenMature collagen
Inflammatory infiltrateInflammatory infiltrate
Mainly plasma cellsMainly plasma cells
Bone formationBone formation
Could be less cellularCould be less cellularand less vascularand less vascular
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Fibrous epulisFibrous epulis
Chronic hyperplastic gingivitisChronic hyperplastic gingivitis
OrOr
Peripheral ossifying fibromaPeripheral ossifying fibroma
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Peripheral ossifying fibromaPeripheral ossifying fibroma
Histopathology:Histopathology:
Fibrous proliferationFibrous proliferation
Formation of mineralized product,Formation of mineralized product,cementumcementum likelike
HighHigh cellularitycellularity
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Vascular epulis: PyogenicVascular epulis: Pyogenic
granulomagranulomaOrigin of the name:Origin of the name:
Clinically:Clinically:
Soft, lobulatedSoft, lobulated
RedRed--purple often ulceratedpurple often ulceratedBleeding is commonBleeding is common
Rapid growthRapid growth
History of traumaHistory of trauma
On gingivaOn gingiva 7575% of the time or any other mucosal site% of the time or any other mucosal site
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Pyogenic granulomaPyogenic granuloma
Pregnancy epulis:Pregnancy epulis:
pyogenic granulomapyogenic granuloma
in a pregnant femalein a pregnant female
Gradually increasing inGradually increasing insizesize
Regress after deliveryRegress after delivery
Recur if excised inRecur if excised in
pregnancy and bleedpregnancy and bleed
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Pyogenic granulomaPyogenic granuloma
Histopathology:Histopathology:
Highly vascularHighly vascular
proliferationproliferation
Lobular organizationLobular organization
(lobular capillary(lobular capillary
hemangiomahemangioma))
_+ Ulcerated surface_+ Ulcerated surface
Older lesions: moreOlder lesions: morefibrousfibrous
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Pyogenic granulomaPyogenic granuloma
Treatment and prognosisTreatment and prognosis
Conservative surgical excision down toConservative surgical excision down to
periosteumperiosteum
Occasionally it may recurOccasionally it may recur
Pregnancy tumor: delay treatment, mayPregnancy tumor: delay treatment, may
resolve spontaneouslyresolve spontaneously
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Peripheral giant cell granulomaPeripheral giant cell granuloma
Exclusively on theExclusively on the gingivagingiva
or alveolar ridgeor alveolar ridge
Anterior to molar teethAnterior to molar teeth
Slightly More inSlightly More inmandiblemandible
Dark red in colorDark red in color
Commonly ulceratedCommonly ulcerated
Present interdentallyPresent interdentally
BuccalBuccal and palatal parts:and palatal parts:hourhour-- glass appearanceglass appearance
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Peripheral giant cellPeripheral giant cell
granulomagranulomaNeed a radiograph to rule out central giantNeed a radiograph to rule out central giantcell granulomacell granuloma
May reveal superficial bone erosionsMay reveal superficial bone erosions
Pathogenesis:Pathogenesis:
Most likely arise from periosteumMost likely arise from periosteum
Giant cells origin:Giant cells origin:
Macrophages or osteoclastsMacrophages or osteoclasts
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Peripheral giant cell granulomaPeripheral giant cell granuloma
Histopathology:Histopathology:
Giant cellsGiant cells variation invariation in
size and number ofsize and number of
nucleinuclei
RichlyRichly vascularvascularandand
cellular stromacellular stroma
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Peripheral giant cell granulomaPeripheral giant cell granuloma
Histopathology:Histopathology:
Extravasated RBCs andExtravasated RBCs and
haemosiderinhaemosiderin
Stromal cells:Stromal cells:Spindled or ovoidSpindled or ovoid
Macrophage orMacrophage or
fibroblasts or endothelialfibroblasts or endothelial
cellscellsOccasional bone formationOccasional bone formation
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Peripheral giant cell granulomaPeripheral giant cell granuloma
If multiple:If multiple:
HyperparathyroidismHyperparathyroidism
OR RARELYOR RARELY
Neurofibromatosis INeurofibromatosis I
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Peripheral giant cell granulomaPeripheral giant cell granuloma
Treatment:Treatment:
Local surgical excison to underlying boneLocal surgical excison to underlying bone
Scaling and polishingScaling and polishing
PrognosisPrognosis
Recurrence rateRecurrence rate 1010%%
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HYPERPARATHYROIDISMHYPERPARATHYROIDISM
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Fibroepithelial polypFibroepithelial polyp
(irritation fibroma)(irritation fibroma)The commonest lesion of the oral cavityThe commonest lesion of the oral cavity
A true tumor?A true tumor?
Doesnt increase significantly in size with timeDoesnt increase significantly in size with time
Most common site is theMost common site is the buccalbuccal mucosamucosa
Labial mucosa tongue andLabial mucosa tongue and gingivagingiva
ChronicChronic minor traumaminor trauma appears to be theappears to be the
causecause
Under denture: Leaf fibromaUnder denture: Leaf fibroma
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Irritation fibromaIrritation fibroma
HistopathologyHistopathology
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Giant cell fibroma and retrocuspidGiant cell fibroma and retrocuspid
papillapapilla
DistinctiveDistinctive
histopathologichistopathologic
findingfinding
MultinucleatedMultinucleatedfibroblastsfibroblasts
On keratinizedOn keratinized
mucosa:mucosa: gingivagingiva,,
tongue and hardtongue and hard
palatepalate
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Giant cell fibromaGiant cell fibroma
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Retrocuspid papillaRetrocuspid papilla
Same histopathology as giant cellSame histopathology as giant cellfibromafibroma
Developmental lesion, lingual toDevelopmental lesion, lingual to
mandibular canine on the interdentalmandibular canine on the interdentalpapillapapilla
2525--9999% of young adults and children% of young adults and children
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Denture irritation hyperplasiaDenture irritation hyperplasia
Epulis FissuratumEpulis Fissuratum
Related to theRelated to the
flange of ill fittingflange of ill fitting
denturedenture
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Denture irritation hyperplasiaDenture irritation hyperplasia
Clinically:Clinically:
Multiple folds of tissue in the vestibuleMultiple folds of tissue in the vestibuleFirm and fibrousFirm and fibrous
Commonly on the facial aspect of theCommonly on the facial aspect of the
flangeflange Leaf fibroma on the hard palateLeaf fibroma on the hard palate
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Denture irritation hyperplasiaDenture irritation hyperplasia
HistopathologyHistopathology
y
ear o womanear o woman
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LEAF FIBROMALEAF FIBROMA
year o womanear o woman
nts thisnts thisalate.alate.
routineroutine
entureenture..
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Papillary Hyperplasia of the PalatePapillary Hyperplasia of the Palate
Ill fitting dentureIll fitting denture
Continuous dentureContinuous denture
wearingwearing
Candida associatedCandida associated
denture mucositisdenture mucositis
HistopathologyHistopathology
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Connective tissue neoplasmsConnective tissue neoplasms
SwellingsSwellings
Resemble their counterparts in other sitesResemble their counterparts in other sites
in the bodyin the bodyTissue of originTissue of origin
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Tumors of fibrous tissueTumors of fibrous tissue
Benign tumorsBenign tumors (true fibroma)(true fibroma) are rareare rare
Peripheral odontogenic fibromaPeripheral odontogenic fibroma
Fibrous histiocytomaFibrous histiocytomaNodular fasciitis (neoplastic like lesion)Nodular fasciitis (neoplastic like lesion)
FibromatosisFibromatosis
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GingivalGingival fibromatosisfibromatosisThis is not neoplasticThis is not neoplastic
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Aggressive fibromatosisAggressive fibromatosis
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Tumors of fibrous tissueTumors of fibrous tissue
FibrosarcomaFibrosarcoma
Rare in the oral cavityRare in the oral cavity
Relatively good prognosisRelatively good prognosis 55 year survivalyear survivalrate israte is 7070%%
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FibrosarcomaFibrosarcoma
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FibrosarcomaFibrosarcoma
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Tumors of adipose tissueTumors of adipose tissue
LIPOMALIPOMA
YellowishYellowish colored swelling most commonlycolored swelling most commonlyinin buccalbuccal mucosa and tonguemucosa and tongue
CircumscribedCircumscribed mass of mature tissue:mass of mature tissue: Variable proportions of stroma and mature fatVariable proportions of stroma and mature fat
tissue:tissue:
fibrofibrolipomalipoma,, angioangiolipomalipoma,, myxomyxolipomalipoma
Floats in formalinFloats in formalin
** traumatic** traumatic herniationherniation of theof the buccalbuccal pad ofpad offat in infants and young childrenfat in infants and young children
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lipomalipoma
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LipomaLipoma
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liposarcomaliposarcoma
Lipoblasts with pleomorphic nuclei
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Tumors of vascular tissuesTumors of vascular tissues
Hemangioma:Hemangioma:
May be hamartomaMay be hamartoma
Common especially in oral cavityCommon especially in oral cavity
Mucosa, muscles, bone, major salivary glandMucosa, muscles, bone, major salivary gland
Infants and childrenjuvenile hemangioma inInfants and childrenjuvenile hemangioma in
parotid glandparotid gland
If multipleIf multiple . think of syndromes???. think of syndromes???
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HemangiomaHemangiomaClinicallyClinically
DarkDark redred--purplepurpleElevation: smooth,Elevation: smooth,
lobulatedlobulated, soft or, soft or
hardhard
BlanchingBlanching onon
pressurepressure
May increase in size:May increase in size:
hemorrhagehemorrhage
thrombosisthrombosis
inflammationinflammation
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HemangiomaHemangioma
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HemangiomaHemangioma
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HemangiomaHemangioma
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HemangiomaHemangioma
HistopathologyHistopathology:: Capillary, cavernous and mixedCapillary, cavernous and mixed
Other Malformations:Other Malformations:
ArteriovenousArteriovenous malformation (AVM)malformation (AVM)
Other vascular anomalies: sublingualOther vascular anomalies: sublingual
varicositiesvaricosities
Malignant vascular lesionsMalignant vascular lesions: Kaposi: Kaposi
sarcoma andsarcoma and angiosarcomaangiosarcoma
AngiomatousAngiomatous syndromessyndromes::
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Capillary and cavernousCapillary and cavernous
hemangiomahemangioma
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Cellular hemangiomaCellular hemangioma
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AVMAVM
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Kaposi sarcomaKaposi sarcoma
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AngiosarcomaAngiosarcoma
Sinosoidal vascular spaces lined by pleomophic endothelial cells
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Angiomatous syndromesAngiomatous syndromes
StrurgeStrurge--Weber SyndromeWeber Syndrome
1.1. Hemangiomatous lesions of one or more ofHemangiomatous lesions of one or more of
the branches of thethe branches of the trigeminal nervetrigeminal nerve
2.2. Ipsilateral hemangiomas and calcifications inIpsilateral hemangiomas and calcifications inthethe meningesmeninges over cerebral cortexover cerebral cortex
3.3. ConvulsionsConvulsions affecting the limbs on theaffecting the limbs on the
opposite sideopposite side
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..Angiomatous syndromes:..Angiomatous syndromes:
Hereditary hemorrhagic telangiectasiaHereditary hemorrhagic telangiectasia
Multiple dilated capillariesMultiple dilated capillaries
Nose bleedingNose bleeding
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Tumors of vascular tissuesTumors of vascular tissues
LymphangiomaLymphangioma
HamartomatousHamartomatous
Predilection for the children and especiallyPredilection for the children and especially
tonguetongue
Increase in size due to: inflammation,Increase in size due to: inflammation,
calcification, or sudden increase in sizecalcification, or sudden increase in size
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Lymphangioma
L h i
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Lymphangioma
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Cystic hygromaCystic hygroma
Early in developmentEarly in development
of lymphatic changesof lymphatic changes
Detected at birthDetected at birth
Up toUp to 1010 cm incm indiameterdiameter
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Tumors of peripheral nervesTumors of peripheral nerves
Nerve sheath tumors:Nerve sheath tumors:
1.1. Neurofibroma, solitary and multipleNeurofibroma, solitary and multiple
2.2. Neurilemmoma (Schwannoma)Neurilemmoma (Schwannoma)
Traumatic neuroma: non neoplasticTraumatic neuroma: non neoplastic
Multiple mucosal nueromaMultiple mucosal nueroma
N fibN fib
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NeurofibromaNeurofibroma
Soliotary orSoliotary or
Multiple/ associated with:Multiple/ associated with:
Neurofibromatosis, vonNeurofibromatosis, vonRecklinghaisens disease of nervesRecklinghaisens disease of nerves
Cutaneous nervesCutaneous nerves
Mutation in tumor suppressor gene: NFMutation in tumor suppressor gene: NF11
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NeurofibromaNeurofibroma
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NeurofibromaNeurofibroma
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NeurofibromaNeurofibroma
Histologically:Histologically:
Considerable variationConsiderable variation
Schwann cells and fibroblastsSchwann cells and fibroblastsVarying amount of collagen and mucoidVarying amount of collagen and mucoid
tissuetissue
A few nerve fibers run through the lesionA few nerve fibers run through the lesionMay be circumscribed or diffuseMay be circumscribed or diffuse
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NeurofibromaNeurofibroma
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NeurofibromaNeurofibroma
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Neurofibromatosis INeurofibromatosis I
NFNF11 mutation (tumor suppressor gene)mutation (tumor suppressor gene)
Familial, AD or sporadic mutationFamilial, AD or sporadic mutation
Multiple neurofibromas ofMultiple neurofibromas ofcutanouscutanousnervesnerves
Intraoraly: mucosal swellings and boneIntraoraly: mucosal swellings and bone
involvement (mental and ID nerve)involvement (mental and ID nerve)
CafCaf--au lait spotsau lait spots
Other findings: axillary freckelingOther findings: axillary freckeling
Malignant transformationinMalignant transformationin 55--1515% of all% of all
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NeurofibromatosisNeurofibromatosis
Types I (skin) and II (central nervousTypes I (skin) and II (central nervous
system)system)
Plexiform neurofibromas arePlexiform neurofibromas arecharacterstic of Neurofibromatosischaracterstic of Neurofibromatosis
Arise within or around nerve trunksArise within or around nerve trunks
A mass of nerves surrounded by SchwannA mass of nerves surrounded by Schwann
cells and fibroblastscells and fibroblasts
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Schwannoma (Neurilemmoma)Schwannoma (Neurilemmoma)
EncapsulatedEncapsulated
Nerve fibersNerve fibers dont passdont pass through thethrough the
lesionlesion May be over the capsuleMay be over the capsule
Spindled cells with parallel nucleiSpindled cells with parallel nuclei
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Traumatic neuromaTraumatic neuroma
Non neoplastic disorganized overgrowth ofNon neoplastic disorganized overgrowth ofnerve fibers, Schwann cells and scar tissuenerve fibers, Schwann cells and scar tissue
severed end of nervessevered end of nerves
Exaggerated regeneration of nerve tissueExaggerated regeneration of nerve tissue
Clinical featuresClinical features
Slowly growingSlowly growing
Firm, fixed to surrounding structuresFirm, fixed to surrounding structures
Painfulto palpationPainfulto palpation
large nerves, such as mentallarge nerves, such as mental
foramenforamen
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MEN (multiple endocrineMEN (multiple endocrine
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MEN (multiple endocrineMEN (multiple endocrine
neoplasia)neoplasia)
TypeType IIbIIb
Multiple mucosal neuromasMultiple mucosal neuromas
PhaecromocytomaPhaecromocytoma Medullary thyroid carcinomaMedullary thyroid carcinoma
RETRET oncogeneoncogene mutationmutation
Can be used for screeningCan be used for screening
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Granular cell tumorGranular cell tumor
Previously called : granular cellPreviously called : granular cell
myoblastomamyoblastoma
Arise from Schwann cellsArise from Schwann cells
Etiology: benign neoplasm, probably ofEtiology: benign neoplasm, probably of
Schwann cellsSchwann cells
Clinical featuresClinical features
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Clinical featuresClinical features
Slowly growing.Slowly growing.
Most common inMost common in
tongue.tongue.
Firm, fixed toFirm, fixed to
overlying mucosaoverlying mucosa
and deep structuresand deep structures
Multiple tumors mayMultiple tumors mayoccuroccur
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Non encapsulatedNon encapsulated
Feeling of invasion/but it is benignFeeling of invasion/but it is benign
Granular cells: contain lysosomesGranular cells: contain lysosomes
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PsuedoPsuedo--epitheliomatousepitheliomatous
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pp
hyperplasiahyperplasia
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Tunmors of musclesTunmors of muscles
Leiomyoma, leiomyomatous hamartoma,Leiomyoma, leiomyomatous hamartoma,
leiomyosarcomaleiomyosarcoma
Rhabdomyoma, rhabdomyosarcomaRhabdomyoma, rhabdomyosarcoma
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LeiomyomaLeiomyoma
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RhabdomyomaRhabdomyoma
L hL h
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LymphomaLymphoma
Hodgkins lymphomaHodgkins lymphoma
NonNon--Hodgkins lymphomaHodgkins lymphoma
H d ki l hH d ki l h
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Hodgkins lymphomaHodgkins lymphoma
3030% of all lymphomas% of all lymphomas
Young age groupYoung age group
Cervical lymph nodes inCervical lymph nodes in 7575%%
ReedReed-- Sternberg cell is the diagnostic cell: largeSternberg cell is the diagnostic cell: largecell withcell with 22 nuclei or bilobed nucleus (mirrornuclei or bilobed nucleus (mirror
image)image)
Genetic factors and viral infection (EBV)Genetic factors and viral infection (EBV)
Prognosis: clinicalPrognosis: clinical stagingstaging and histologicand histologic gradinggrading
Distribution: mainly nodalDistribution: mainly nodal
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H d ki l hH d ki l h
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Hodgkins lymphomaHodgkins lymphoma
Histopathologic types:Histopathologic types:
Lymphocyte predominantLymphocyte predominant
Mixed cellularityMixed cellularity
Nodular sclerosisNodular sclerosis
Lymphocyte depletionLymphocyte depletion
NN H d ki l hH d ki l h
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NonNon--Hodgkins lymphomaHodgkins lymphoma
B cell: majorityB cell: majority
T cell/ NKT cell/ NK
extra nodalextra nodal MALT lymphomaMALT lymphoma better prognosis than better prognosis than
nodal, remian localized for long periodsnodal, remian localized for long periods
Salivary glandSalivary gland.Sjogren Syndrome and.Sjogren Syndrome and
myoepithelial sialadentitismyoepithelial sialadentitis BoneBone
AIDSAIDS
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B kit L hB kit L h
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Burkits LymphomaBurkits Lymphoma
Endemic and sporadicEndemic and sporadic
Endemic: Africa:Endemic: Africa: EBV and MalariaEBV and Malaria
ChildrenChildren 22--1414 yrsyrs
Starts in the jaws, maxillary and posteriorStarts in the jaws, maxillary and posterior
Rapidly growing, multifocalRapidly growing, multifocal
Sporadic: no viral associationSporadic: no viral association
Starts in the abdomenStarts in the abdomenChromosomal translocationChromosomal translocation 88,,1414. c. c--mycmycactivationactivation
Starr Sk patternStarr Sk pattern
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Starry Sky patternStarry Sky pattern
B cell typeB cell type
Dark small malignant lymphoid cellsDark small malignant lymphoid cells
Pale stained macrophagesPale stained macrophages
Macrophages are not neoplasticMacrophages are not neoplastic
NK/T cell lymphomaNK/T cell lymphoma
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NK/T cell lymphomaNK/T cell lymphoma
Angiocentric T cell lymphoma, lethalAngiocentric T cell lymphoma, lethal
midline granulomamidline granuloma
Extensive destruction of midline structuresExtensive destruction of midline structures
EBV in neoplastic cellsEBV in neoplastic cells
Lethal midline granulomaLethal midline granuloma
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gg
Tcell lymphomaTcell lymphoma
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