Hyperplastic disorders of oral mucosa; melanocytic lesions and malignant melanoma. Markéta Hermanová Hyperplasia of oral mucosa nGeneralized gingival enlargement nLocalized hyperplastic lesions of oral mucosa (epulides) n - usually responses to chronic inflammation (trauma, irritation, subgingival plaque and calculus) n - granulation tissue production n - chronically inflamed cellular granulation tissue→avascular masses of n dense collagen n n Congenital epulis of the newborns – congenital gingival granular cell tumor: -Incisor region of the maxilla, F>M -Closely packed granular cells covered by flattened squamous epithelium -Benign lesion, unknown etiology n (reactive?,….neoplastic???, but unrelated to granular cell tumor of the tongue ) n Congenital epulis of the newborns – congenital gingival granular cell tumor congenital_epulis_10_030601 1048885-1079023-2232 Gingival enlargement nFibrous overgrowths -Gingival fibromatosis (hereditary, AD) -Chronic hyperplastic gingivitis -Drug associated hyperplasia (epanutin (anti-epilepticum), verapamil, nifedipin (cardiovascular diseases), cyclosporin (immunosuppressive drug)) n nOedematous enlargement -Oedematous gingivitis in puberty, pregnancy, oral contraceptives, scurvy (avitaminosis C) n nSystemic disease -Acute leukaemias -Wegener´s granulomatosis Localized hyperplastic lesions of the oral mucosa nEpulides -Fibrous epulis -Pyogenic granuloma -Pregnancy epulis -Peripheral giant cell granuloma (giant cell epulis) - nPyogenic granuloma nFibroepithelial polyp nDenture irritation hyperplasia nPapillary hyperplasia of the palate Vascular epulides types Epulis_on_the_lower_left_gum2-522x460 preganancy_epulis2-529x361 Fibrous epulis Vascular epulis Epulides/summary nLocalized gingival hyperplasia n nReactive to local irritation/trauma n nMay recur unless predisposing factors removed n nFibrous/vascular types result from exuberant production of granulation/fibrous tissue n nChronic inflammation cell infiltrate – source of growth factors n nVascular type may mature to most commonest fibrous type n nGiant cell type clinically and histologically distinct nFibrous epulis -Pedunculated or sessile mass -Consistency and colour similar to adjacent gingiva -May be superficially ulcerated -Most between 11-40 years of age -Fibroblast granulation tissue and mature collagen fibers, inflammatory infiltration n nVascular epulides (pyogenic granuloma and pregnancy epulis) -Soft, deep reddish-purple swelling, often ulcerated -Haemorrhages -Vascular proliferation+oedematous cellular fibrous stroma n nGiant cell epulis (peripheral giant cell granuloma) -Peak incidence: males in 2nd decade, females in 5th decade -Pedunculated or sessile swelling, dark red, often ulcerated; interdentally localized -Osteoclast-like giant cell in a richly vascular and cellular stroma -Unknown pathogenesis….reactive hyperplasia?....multiple lesions ass. with hyperparathyreoidism or rarely with NF type I - - - Vascular epulis – pyogenic granuloma Pyogenic_granuloma_upper_gum-532x393 Pyogenic_granuloma_lip-533x371 nPyogenic granuloma -Extragingivally localized -Morhology the same as in vascular type epulis of the gingiva n nFibroepithelial polyp -Cheeks – along occlusal line, lips, and tongue -Firm, pink, painless pedunculated or sessile polypoid swelling -Relatively avascular and acellular fibrous tissue covered by squamous epithelium n nDenture irritation hyperplasia -Hyperplastic mucosae related to the periphery of an ill-fitting denture n nPapillary hyperplasia of the palate -Minor trauma (due to rocking and rotation ill-fitting denture) -Poor denture hygiene -Often Candida-ass. denture stomatitis -Numerous small tightly packed papillary projections over part or all of the denture-bearing area, red, oedematous mucosa Fibroepithelial polyp Oral_Fibroma_or_Fibro-Epithelial_Polyp_of_the_right_lower_cheek-533x394-524x387 Oral_Fibroma_or_Fibro-Epithelial_Polyp_of_the_right_side_of_the_tongue-532x396-528x392 Denture irritation hyperplasia dent_trauma_hyperplasia1 Denture related stomatitis afp20081001p845-f7 Papillary hyperplasia of the palate Papillary_Hyperplasia_of_the_Roof_of_the_Mouth-533x356 - Traumatically (denture stomatitis) + poor oral hygiene + Candida albicans infection + stomatitis nicotinica Melanocytic lesions n Benign: n freckles (ephelides) n benign lentigo n pigmented nevus n spindle and epitheloid cell nevus (Spitz nevus) n atypical (dysplastic) nevus n Malignant melanoma: n lentigo maligna n superficial spreading melanoma n nodular melanoma n acral lentiginous melanoma n n Pigmented nevus n benign tumor, congenital or acquired n congenital nevus usually larger (esthetic surgery) n micro: njunctional nevi n groups of pigmented cells (= nests) grow in dermoepidermal junction ncompound nevi n nests grow in junction zone and into the underlying dermis (in dermis arranged also in cords) nintradermal nevi n nests/cords only in the dermis n 01 Melanocytic lesions copy Pigmented nevus nevi-pigmentosi-detail Intradermal pigmented nevus nevus-id-7463-00-he-2,5x 1.Melanocytes 2.Papillary dermis separating nests of melanocytes and epidermis 1 1 2 Intradermal pigmented nevus nevus-id-7463-00-he-10x Compound pigmented nevus smíšený névus2, 200x.jpg smíšený névus, 400x.jpg Malignant melanoma n origin: nmalignization of preexisting nevi nde novo n n localization: nskin nmucous membranes nmeninges neye Malignant melanoma n gross: n similarity to congenital nevus at early stage n irregular borders n variegation of color within a pigmented lesion n ulceration, darkening, bleeding at late stages n nclinic ABCD rule n Assymetry n irregular Border n uneven Colour n Diameter > 6mm Malignant melanoma n micro: n assymetry n atypical pleomorphic epitheloid or spindle cells n large hyperchromatic nuclei with prominent nucleoli n mitoses (atypically localized) n irregular rough granular pigmentation n forms with complete absence of pigment possible n immunoprofile: n melan A, HMB-45, S-100 n n n Malignant melanoma n gross: n similarity to congenital nevus at early stage n irregular borders n variegation of color within a pigmented lesion n ulceration, darkening, bleeding at late stages n nclinic ABCD rule n Assymetry n irregular Border n uneven Colour n Diameter > 6mm Malignant melanoma n 3 growth phases: n melanoma in situ (intraepidermal phase) n n radial growth phase - superficial MM n superficial growth within epidermal layers associated with invasion into the papillary dermis n n vertical growth phase – nodular MM n downward invasion into the reticular dermis n clone of cells with metastatic potential melanom-nodularni-detail Malignant melanoma vertical growth phase with nodularity mm-nodul-799-93-he-1,25x Large tumor infiltrating fat tissue, without horizontal growth component; local enormous melanin production Malignant melanoma – nodular MM Melanocytic naevi in oral sites nSlightly elevated, pigmented lesions on the hard palate or buccal mucosa nHamartomatous lesions nMost common intramucosal type (equivalent to the intradermal naevus of skin) n Melanocytic naevi in oral sites n n Oral nevi BlueNevusClTitle Malignant melanoma (MM) in oral sites nMM of oral mucosae rare nM>F nPosterior maxillary alveolar ridge and hard palate nMostly advanced and extensively invasive lesion at presentation nIn 1/3 of MM cases there is a history of previous pigmentation in the area nMost dark-brown or bluish black lesions with uneven nodular or papillary surface nHistologically highly pleiomorphic, variable melanin pigment amount nPrognosis poor in most patients n Malignant melanoma malignant-melanoma-4 Thanks for your attention……..