Soft Tissue Tumors

Reactive and Benign lesions of Fibroblastic and Histiocytic Origin

Irritation Fibroma
Giant Cell fibroma
Inflammatory Fibrous Hyperplasia
Inflammatory Papillary Hyperplasia
Fibrous Histiocytoma
Fibromatosis and Myofibromatosis
Oral Focal Mucinosis
Pyogenic Granuloma
Peripheral Giant Cell Granuloma
Peripheral Ossifying Fibroma

Benign Tunors of Fat tissue origin

Lipoma

Benign Tumors of Neural Origin

Traumatic Neuroma
Palisaded Encapsulated Neuroma
Schwannoma
Neurofibroma
Granular Cell Tumor
Congenital Epulis
Melanotic Neuroectodermal Tumor of Infancy
 Benign Tumors of Vascular Origin
Hemangioma
Lymphangioma

Benign Tumors of Muscle Origin

Leiomyoma
Rhabdomyoma

Osseous and Cartilaginous Choristomas

Malignant Tumors of Connective Tissue

Fibrosarcoma
Malignant Fibrous Histiocytoma
Liposarcoma
Neurofibrosarcoma
Angiosarcoma
Kaposi’s Sarcoma
Leiomyosarcoma
Rhabdomyosarcoma

Metastases to Oral Soft Tissues

 Irritation Fibroma (Traumatic Fibroma)

Clinical Features
• Reactive hyperplasia of fibrous connective tissue

• Can occur anywhere in the oral cavity that is susceptible to constant

trauma – like buccal mucosa and tongue due to biting

• Color is similar to surrounding mucosa and is pedunculated or sessile

• Symptoms present only if ulcerated

• 4th to 6th decades of life

Treatment: Conservative surgical excision

 Giant Cell Fibroma

Clinical Features
• Occurs at a much younger age compared to fibroma and
presents as asymptomatic sessile/pedunculated nodule <1cm

• Not associated with trauma

• More than half the cases occurs on the gingiva and has a
papillary surface; Mandible>Maxilla

• Similar to retrocuspid papilla

Treatment: Conservative surgical excision

Recurrence is rare
Histology
• Vascular and loosely arranged
fibrous connective tissue

• Hallmark is the presence of

large, stellate shaped fibroblasts
which are multinucelated

• Rete ridges are narrow and

elongated
 Epulis Fissuratum (Inflammatory Fibrous hyperplasia;
Denture Injury Tumor)
Clinical Features
• Tumor-like hyperplasia of fibrous connective tissue that
develops in association with the flange of an ill-fitting denture

• Presents as single or multiple folds of tissue in the alveolar

mucosa; usually presents as two folds with denture flanges
in between

• The size varies from < 1 cm to large lesions involving the entire
length of the vestibule

• Appears as firm, fibrous tissue with variable ulcerations and

erythema

• Most common location is facial aspect of alveolar ridges;anterior

portions of jaws and older adults with female predilection
 Epulis Fissuratum
Histology:
• Fibrous connective tissue hyperplasia

• Overlying epithelium is
hyperkeratotic and shows
hyperplasia of rete ridges

• Pseudoepitheliomatous
hyperplasia

• Ulceration and chronic inflammation is also seen frequently

Treatment: Surgical removal and denture should be relined

or remade
 Inflammatory Papillary Hyperplasia
• Reactive lesion that most commonly develops under a denture
an ill-fitting denture
poor oral hygiene
wearing the denture 24 hours

• Usually occurs on the hard palate beneath a denture base

• Starts at the palatal vault but advanced lesions can cover

the entire palate

• Candidiasis can also be seen associated with the lesion

• Mucosa is pebbly or papillary and appears erythematous

Treatment: Removal of denture

Surgical removal with altering the denture
 Inflammatory Papillary Hyperplasia

Histology
• Papillary growths surfaced by
hyperplastic startified
squamous epithelium

•Pseudoepitheliomatous
hyperplasia

• Chronic inflammation
 Fibrous Histiocytoma

• Group of tumors which have both fibroblastic and histiocytic

differentiation

• Most common in the skin called dermatofibroma

• Oral cavity – rare; buccal mucosa and vestibule

• Middle aged and older adults

• Painless nodular mass of varying size

Treatment: Local surgical excision

 Fibromatosis and Myofibromatosis
• Group of fibrous proliferations that have intermediate
biologic behavior

• Named based on clinicopathologic features: juvenile

aggressive fibromatoses, extrabdominal desmoids

• Myofibromatosis is similar but less aggressive

• Painless mass occurring in children or young adults

• Most common site: Paramandibular soft tissues

•Tumor can grow to considerable size and can cause significant

facial disfigurement

• Destruction of adjacent bone can be seen in radiographs

 Fibromatosis and Myofibromatosis
Histology:
• Cellular proliferation of spindle-shaped cells arranged in
fascicles

• Poorly circumscribed and infiltrates adjacent tissues

• Cells should be uniform with NO pleomorphism and

hyperchromatism

Treatment: Wide excision

23% recurrence rate
Metastasis does not occur
 Myofibroma (Myofibromatosis)
• Rare spindle cell neoplasm that consists of myofibroblasts

• The multicentric disease affects infants and young children

and this is called myofibromatosis

• Predilection to the head and neck; occurs in the first 4 decades

of life with most lesions occurring in neonates and infants

• Most common oral site is the mandible followed by lips, cheek,

and tongue

• Painless mass in dermis or subcutaneous tissue and

intrabony cases are radiolucent

Treatment: Local excision; can spontaneously regress; lesions

affecting vital or visceral organs are aggressive and can be fatal
 Oral Focal Mucinosis
• Uncommon tumor-like mass of unknown cause.

• Maybe due to overproduction of hyaluronic acid

• Commonly seen in young adults with a 2:1 female-to-male ratio

• Most commonly seen in the gingiva followed by hard palate

• Sessile painless nodule of normal color

• Size varies from a few mm to 2 cm

Histology: Well-demarcated loose myxomatous tissue

surrounded by dense collagenous tissue

Treatment: Surgical excision and recurrence is rare

 Pyogenic Granuloma
• Common tumor-like growth of the oral cavity

• Exuberant response to irritation or trauma; periodontal irritation

could be a major source

• Smooth or lobulated pedunculated mass which appears pink

to red in color and is commonly ulcerated

• Range from a few mm to several cm – hormone dependent

• GINGIVA however other sites also affected

• Most common in children and young adults with females>males

• Develops in pregnant women during first trimester and increases

through 7th months - Pregnancy tumors; Some will resolve
after delivery
 Pyogenic Granuloma
Histology
• In spite of name, not a true granuloma

• Vascular proliferation that resembles granulation tissue

• Surface is usually ulcerated

• Mixed inflammatory infiltrate

• Younger lesions are very vascular, but older lesions mature

and are fibrous

Treatment: Conservative surgical excision.

Recurs if incompletely excised; Irritation also
has to be removed.
 Peripheral Giant Cell Granuloma
• Reactive lesion due to local irritation or trauma

• Resembles central giant cell granuloma

• GINGIVA or edentulous alveolar ridge

• Red or reddish-blue nodular mass which is usually < 2 cm

• Appearance similar to pyogenic granuloma

• 5th to 6th decades; F > M (60% occurs in females)

• Mandible > Maxilla

• Although occurs in soft tissues a “cupping” resorption of bone

 Peripheral Giant Cell Granuloma
Histology:
• Proliferation of multinucleated giant cells in a background of
plump ovoid and spindle-shaped cells

• Abundant hemorrhage is observed

Treatment:
• Local surgical excision down to the underlying bone
• Scaling of the adjacent teeth of any source of irritation
• Rarely, lesions similar to this are seen in hyperparathyroidism
(however these are mostly intraosseous)
Peripheral Giant Cell Granuloma
 Peripheral Ossifying Fibroma
• Reactive growth of the gingiva with uncertain histogenesis

• Believed to be a matured pyogenic granuloma that ultimately

undergoes calcifications

• It does not represent central ossifying fibroma

• Occurs exclusively on the GINGIVA

• Nodular mass that is either pedunculated or sessile usually of

the interdental papillae and appears red to pink and frequently
ulcerated

• Younger adults and teens with F > M

• Maxilla > Mandible; >50% cases occur in the incisor/canine area

 Peripheral Ossifying Fibroma
Histology:
• Fibrous proliferation associated with formation of mineralized
product

• The surface if ulcerated, shows a fibrinopurulent membrane

• The mineralized component varies from bone, cementum-like

material or dystrophic calcifications

Treatment:
• Local surgical excision down to the periosteum

• Scaling of the adjacent teeth to remove irritants

• Recurrence rate of 16%

Peripheral Ossifying Fibroma
 The Four “P”s
• Peripheral Fibroma

• Pyogenic Granuloma

• Peripheral Giant Cell Granuloma

• Peripheral Ossifying Fibroma

 Lipoma
• Benign tumor of fat

• It represents the most mesenchymal tumor, however most

of them occur in the trunk and extremities – Head and Neck
are less common

• Oral lipomas are soft nodular masses that is sessile or

pedunculated with yellow color

• Asymptomatic and present for several years

• Buccal mucosa and vestibule are the most common sites

• >40 years; female = male

Treatment: conservative local excision

 Traumatic Neuroma

• Reactive proliferation of neural tissue after damage to

nerve bundle

• Smooth nodules most common in mental foramen, tongue

and lower lip with a history of trauma; intraosseous lesions
appear as radiolucencies

• Any age but mostly middle-age, with F>M

• Hallmark is PAIN which could be intermittent or constant

and mild or severe; Mental nerve neuromas are painful
especially with denture flange impingement
 Traumatic Neuroma

Histology: Haphazard proliferation of mature, myelinated

nerve bundles within a fibrous connective tissue

• Mild chronic inflammation is also seen sometimes

Treatment: Surgical excision along with a small portion of the

involved nerve; low recurrence rate
 Palisaded Encapsulated Neuroma
• Benign neural tumor common in the head and neck area

• Trauma is considered as a major etiological factor

• Face: 90% of cases with majority occurring on the nose

and cheek
• Oral cavity: hard palate and maxillary labial mucosa

• Smooth, PAINLESS nodules; More common in adults; F=M

Histology: Well-circumscribed and encapsulated with interlacing

fascicles of spindle cells (Schwann cells); wavy nuclei with no
mitotic activity or pleomorphism; parallel oriented cells

Treatment: Conservative surgical excision

Palisaded Encapsulated Neuroma
 Schwannoma (Neurilemoma)
• Benign neural neoplasm of Schwann cell origin

• Relatively uncommon, however 25-48% of all cases occur in

the Head and Neck area

• Usually painless; slow-growing that arises in association with

a nerve trunk; Asymptomatic and pushes the nerve aside

• Younger and middle-aged adults

• Tongue is the most common location

• Intraosseous appears as unilocular or multilocular

radiolucency in posterior mandible

• Pain and paresthesia seen in intrabony tumors

 Schwannoma (Neurilemoma)

Histology: Encapsulated tumor with varying amounts of

Antoni A and Antoni B cells
Antoni A: Streaming fascicles of spindle-shaped Schwann cells;
These cells are often palisaded around acellular eosinophilic
areas called Verocay bodies (which are reduplicated basement
membrane and cytoplasmic processes)
Antoni B: is less cellular and organized
Degenerative changes are seen in older lesions
•Treatment: Surgical excision
 Neurofibroma

• MOST COMMON type of peripheral nerve tumors arising from

a mixture of Schwann cells and perineural fibroblasts

• Can be solitary or associated with Neurofibromatosis

• Solitary are more common and present as slow-growing, soft,

painless nodule, most common in the skin

• Oral cavity lesions are seem mostly in tongue and

buccal mucosa

• Intraosseous lesions also seen as poorly defined unilocular or

multilocular radiolucencies
 Neurofibroma

Histology: Not well-demarcated and consists of interlacing

bundles of spindle-shaped cells that exhibit wavy nuclei
Numerous mast cells are present
Treatment: local surgical excision; If multiple lesions are
present, patients should be evaluated for Neurofibromatosis
 Granular Cell Tumor
• Benign tumor that shows predilection to oral cavity

• Derived from Schwann cells or neuroendocrine cells

• Dorsal surface of TONGUE – most common site; followed by

buccal mucosa

• 4th to 6th decades of life and 2:1 (F:M) ratio

• Asymptomatic sessile nodule that is <2 cm and appears

pink or yellow in color

• Usually solitary but multiple sometimes seen in black patients

Treatment: Conservative local excision

 Granular Cell Tumor
Histology:
• Large polygonal cells with abundant pale eosinophilic,
granular cytoplasm and pale nuclei

• Cells arranged in sheets

• Lesion is not encapsulated and appears to infiltrate into

surrounding tissues

• Overlying epithelium shows acanthosis and

pseudoepitheliomatous hyperplasia

Treatment: Conservative local excision

Granular Cell Tumor
 Congenital Epulis
• Occurs exclusively in the alveolar ridge of the newborn

• Histologically similar to granular cell tumor, but ultrastructurally

and immunohistochemical different

• Pink-red smooth surfaced mass on the alveolar ridge

of newborns

• Size varies from small to over 7.5 cm with multiple tumors

also occurring in 10% of cases

• Maxilla > Mandible in the area of lateral incisor and canine

• STRIKING FEMALE PREDILECTION (90% cases)

Treatment: Surgical excision; spontaneous regression also seen

 Melanotic Neuroectodermal Tumor of Infancy

• Generally considered a benign tumor despite rapid growth

of neural crest origin

• Rare pigmented neoplasm that occurs during the

first year of life

• Striking predilection for the anterior maxilla (almost

2/3 of cases)

• Occurs as a rapidly expanding mass that is black or

blue in color

• Destroys bone and displaces associated developing teeth

• Can also occur in skull, mandible, brain and testis

Melanotic Neuroectodermal Tumor of Infancy
 Melanotic Neuroectodermal Tumor of Infancy

Histology: Biphasic population of cells that form nests, tubules and

alveolar structures within a dense connective tissue

The 2 cell types: cuboidal epithelioid cells and neuroblastic

 Melanotic Neuroectodermal Tumor of Infancy
Lab Tests: ↑ Vanillylmandelic acid (VMA) as in other
neural crest lesions

Treatment: Surgical removal

Rapid growth and destruction despite being

called benign

15% recurrence rate

6% behave like malignancy and metastasize

 Hemangioma and Vascular Malformations

Hemangiomas are considered to be benign tumors of infancy

that are characterized by a rapid growth phase with endothelial
cell proliferation, followed by gradual involution

Vascular malformations are structural anomalies of blood

vessels without endothelial proliferation

Most hemangiomas are not recognized at birth, but arise during

the first 8 weeks later of life

Vascular malformations are present at birth and persist

throughout life
 Hemangioma
Most common tumors of infancy

More common in females (3:1)

Most common in Head and Neck (60% of cases)

Mostly occurs as single lesions

Red/blue lesions that occur in skin, lips, tongue and buccal

mucosa; The lesion blanches when compressed

Intraosseous lesions also occur – Mandible > Maxilla and

occurs as multilocular radiolucency
 Vascular Malformations

Present at birth and persist throughout life

PORT-WINE STAINS are common capillary malformation

occurring most commonly on the face particularly in the area
of the trigeminal nerve

Port-wine stains are pink or purple macules that grows

proportionally with the patient; Older patients have darker
lesions and becomes nodular
 Hemangioma
Histology
Cellular Hemangioma

Capillary Hemangioma

Cavernous Hemangioma

Treatment: Most congenital lesions will involute (“Watchful

Neglect”)
Surgical removal and sclerotherapy with 95% ethanol
 Sturge-Weber Syndrome

Hamartomatous vascular proliferation of the face and brain

Dermal capillary malformation (Port wine stain) in a unilateral

distribution along one or more segments of trigeminal nerve

Leptomeningeal angiomas involving the ipsilateral cortex

revealing “tramline” calcifications on X-rays

Mental retardation and convulsions

Eye involvement: glaucoma and vascular malformations

Intraoral: Vascular involvement of the ipsilateral oral mucosa

 Lymphangioma
Benign hamartomatous tumors of lymphatic vessels

Predilection to the head and neck with 50 – 75% occurring

Three types: capillary; cavernous and cystic lymphangiomas

Cavernous lymphangiomas are most common in oral cavity

Most frequent site in the oral cavity - anterior 2/3 of the tongue
where it causes MACROGLOSSIA

Pebbly surface resembling cluster of translucent vesicles

(similar to frog eggs)
Cystic Hygroma (Cystic Lymphangiomas)

Most commonly occur in the neck and axilla

Cervical lymphangiomas are most common in the

posterior triangle and are soft, fluctuant masses

Occasionally could extend into the mediastinum or

upward into oral cavity ; could also extend into the
anterior triangle resulting in respiratory difficulties
or dysphagia
Histology

Treatment
Intraoral: Excision and prognosis is good; recurrence does occur
Cystic: Well circumscribed and have lower recurrence rate

SCLEROSING AGENTS DO NOT WORK AS IN HEMANGIOMAS

 Leiomyoma

Benign neoplasms of smooth muscle

Most of these have origin in the vascular smooth muscle

3 types: SOLID, VASCULAR AND EPITHELIOID

75% of oral cases are vascular leiomyomas

Can occur at any age; slow-growing mucosal nodule that

occasionally can be PAINFUL

Commonly seen in lips, tongue, palate and cheek

Local surgical excision

 Rhabdomyoma
Benign neoplasm of skeletal muscle

Adult and Fetal types

Adult: Middle-aged and older patients; M>F

Intraoral lesions: FOM, soft palate and base of the tongue
Nodule or mass that grows for many years

Fetal: Young children with a male predilection; face and

periauricular region

Treatment: local surgical excision

 Osseous and Cartilagenous Choristomas
Choristoma is a tumorlike growth of microscopically normal
tissue in an abnormal location

Bone, cartilage or both

TONGUE (85% of cases); especially posterior tongue near the

foramen cecum

Gagging or dysphagia are common symptoms

Histology: well-circumscribed mass of dense lamellar bone

or mature cartilage

Treatment: Surgical excision

DENTAL CHORISTOMA: THE FIRST CASE OF ECTOPIC
DEVELOPING TOOTH IN THE TONGUE
 Soft Tissue Sarcomas
Account for less than 1% of cancers in the oral and
maxillofacial area

Fibrosarcoma
Malignant fibrous histiocytoma
Liposarcoma
Malignant peripheral nerve sheath tumor
Olfactory neuroblastoma
Kaposi’s sarcoma
Leiomyosarcoma
Rhabdomyosarcoma
Synovial sarcoma
Alveolar soft part sarcoma
 Rhabdomyosarcoma
Malignant neoplasm of skeletal muscle origin

MOST COMMON SOFT TISSUE SARCOMA IN CHILDREN

HEAD AND NECK IS THE MOST SITE (40% of cases)

Primarily occurs in the first decade, teenagers and young adults

60% of cases occurs in males

Painless infiltrative mass that grows rapidly

Orbit > nasal cavity and nasopharynx

Intraoral: PALATE
3 Histologic Types
Embryonal, Alveolar and Pleomorphic

The head and neck cases are either embryonal or alveolar

Embryonal: First 10 years of life and 60% of cases

Alveolar: occurs between 10-25 years and accounts for

20% - 30% of cases

Treatment: Local surgical excision followed by multiagent

chemotherapy (vincristine, actinomycin D and
cyclophosphamide)
Radiation therapy

Prognosis: 5 year survival rate is 60% to 70%

 Metastases to Oral Soft Tissues
Uncommon representing 1% of all oral malignancies

Oral metastases can occur in bone and soft tissues

Lymphatic and blood-borne route

Batson’s plexus: a valveless vertebral venous plexus that

might allow retrograde spread of tumor cells, bypassing
filtration through the lungs

GINGIVA followed by the tongue

Nodular masses often resembling hyperplastic or reactive

growths with occasional ulcerations and loosening of
adjacent teeth
 Metastases to Oral Soft Tissues
Oral metastases is more common in males
More common in middle-aged and older adults
Male: Primary tumor is seen in lung cancer
Female: Primary tumor is seen in breast cancer (25% of cases)

In most cases, the primary tumor is known before the

metastases is discovered; HOWEVER IN SOME CASES THE
ORAL LESION IS THE FIRST SIGN OF MALIGNANT DISEASE

Histology is similar to the primary tumor

MOST CASES TO ORAL CAVITY ARE CARCINOMAS AND
NOT SARCOMAS

Treatment: Poor prognosis; palliative management