6. Pathology of Connective and Submucosal Tissues Flashcards
(35 cards)
1
Q
Two types of connective tissue
• Connective tissue proper
– ____ connective tissue
– ____ connective tissue
Specialized connective tissue – \_\_\_\_ connective tissue supporting lymphoid organs – Bone – \_\_\_\_ – Ligaments – \_\_\_\_ – Blood
• Proper ○ Oral mucosa ○ Skin • Specialized ○ Blood ○ Bone ○ Cartilage ○ Fat
A
loose dense reticular cartilage adipose
2
Q
Cellular components • Fixed cells develop and remain in place – \_\_\_\_ – Adipocytes – \_\_\_\_ – Mast cells – \_\_\_\_
• Resident within the CT • Fibroblasts ○ Give rise to collagen and reticular fibers • Adipocytes ○ Give rise to fat • Pericytes ○ Like smooth muscle cells > contractile ○ Found wrapped around \_\_\_\_ • Mast cells ○ Immune • Macrophages ○ Resident and transient cells ○ Live in \_\_\_\_ worlds • Pathology from mast/macro's > pathology is \_\_\_\_ in nature
A
fibroblasts
pericytes
macrophages
capillaries
both
hematologic
3
Q
• Reactive lesions ○ \_\_\_\_ ○ Peripheral ossifying ○ \_\_\_\_ ○ Most common occurring on the gingival tissues § Of the 3, only one on gingiva or elsewhere > \_\_\_\_ □ Reddish blue looking □ Not tumors ○ Reacting to chronic irritation
A
pyogenic granuloma
peripheral giant cell
pyogenic granuloma
4
Q
Choristoma • Normal tissue found in an \_\_\_\_ location • Most found in \_\_\_\_ – Posterior third near \_\_\_\_ • Usually \_\_\_\_ and/or osseous
• Other reactive lesions that may look like tumors but not \_\_\_\_ • Most commonly presenting lesion on posterior dorsum tongue close to the foramen cecum (embryonic structure through tongue arises during embryogenesis) • Not a reactive lesion, it's not a tumor > \_\_\_\_ lesion • Composed of bone and/or cartilage ○ The bone/cartilage looks normal except it's not occurring in the \_\_\_\_ place
A
abnormal tongue foramen cecum cartilaginous developmental normal
5
Q
Mr. Potato Head sitting on a dining room table = ____
Scrambled Mr. Potato Head in a child’s bedroom = ____
• Hamartoma is also developmental, looks like tumor/mass except it's a lesion that’s composed of histologically normal tissue arranged \_\_\_\_ but where it's supposed to be actually located ○ Mixed up, but sitting in kid's bedroom where it should be found
A
choristoma
hamartoma
abnormally
6
Q
Inflammatory papillary hyperplasia of the palate
• Etiologic factors – Ill–fitting \_\_\_\_ – Denture hygiene – Dentures \_\_\_\_ hours / day – \_\_\_\_?? • Also known as palatal papillomatosis
• Choristoma is not reactive it's developmental • These following lesions are all caused by dentures ○ Poorly fitting dentures ○ Or poorly maintained dentures ○ Patients who keep the dentures in the oral cavity for long periods of time • IPHP and PP are synonomyous • They're not papillomas ○ A papilloma is a true benign epithelial \_\_\_\_ ○ Which may be caused by \_\_\_\_ ○ Lesions look \_\_\_\_ and wart-like ○ Only occur on the \_\_\_\_ underneath the denture base • Associated with candida ○ Question whether it's predisposing or it's an opportunistic infection ○ Seen superinfecting the papillary growths
A
denture 24 candida albicans tumor HPV papillomatous hard palate
7
Q
Inflammatory papillary hyperplasia of the palate
• Microscopically:
○ ____ appearance
§ They look like fingers, up-and-down lumpy-bumpy > reflects it clinically
• Therapy:
○ If robust (in the picture) > surgeon will reline the denture, apply an ____ to the denture base to reduce the candidiasis with the hope that these two steps will resolve the lesion
○ If it doesn’t > surgeon will take a diamond acrylic ____ and drill the palate and then will reline the denture and allow to resolve
○ Cannot ____ this surgically because the palate is so thin
A
papilloma
antifungal
bur
excise
8
Q
Palatal papillomatosis
• Treatment
– Denture reline / ____
– Topical anti-____ medication – Surgical ____
A
refrabication
fungal
excision
9
Q
Epulis fissuratum
- Due to irritation from denture ____
- Develops within ____(s)
- Epithelial and fibrous ____• Reactive pathology
• The vestibules are affected where the denture flange is sitting
○ The edge of the denture will chronically irriate the surrounding mucosa > overgrowth of tissue on ____ sides of the flange (lingual and facial) > a fissure is formed
• The tissue is reactive > epitehlial and ____ hyperplasia
○ But looks like a tumor clinically
A
flange vestibules hyperplasia both fibrous
10
Q
Epulis fissuratum
Squamous cell carcinoma mimicking epulis fissuratum
• Similar lesion • \_\_\_\_ in the center and flap of tissue on both sides of the fissure • Both patients had ill-fitting \_\_\_\_ ○ One has EF and one had SCC
A
fissure
denture
11
Q
Denture-associated pathologies
- Inflammatory papillary ____ of the palate
- Epulis ____
- ____ fibroma
- Osseous and ____ (Cutright lesion)• All denture pathologies become more commonly in ____, older patients
○ Assume that estrogen and progest play a role in pathogenesis
§ Like in ____pathogenesis
• Leaf fibroma
○ ____ mass
○ ____ lesion that flattened due to pressure of denture over time
○ Clip the fibroma off and one stitch to close up the wound
○ Microscopically: expression of epithelial and fibrous ____
• Small mass on gum > thought one of the three P’s > was in fact a osseous and chondromatous metaplasia
○ Not hyperplastic > ____: one normal cell type replaced with another normal cell type
§ Seeing CT becoming metaplastic bone and ____
§ Specifically on the ____
• Mass-forming in appearance but not tumors
A
hyperplasia
fissuratum
leaf
chondromatous metaplasia
female
pyogenic granuloma
pedunculated
reactive
hyperplasia
cartilage
alveolar ridge
12
Q
Origin of soft tissue neoplasms
• Any \_\_\_\_ type can give rise to a tumor – Epithelium – Fibrous – Vascular – Nerve – Smooth muscle – Skeletal muscle – Fat – Salivary gland – Bone – Cartilage
Assess which tissue types are most ____ in the area in question – include those diagnoses in the differential diagnosis
A
tissue
abundant
13
Q
Lipoma • \_\_\_\_ decades • Soft, \_\_\_\_ consistency – Yellowish color • Usually arise in areas of \_\_\_\_ – Buccal mucosa, vestibules
• Vascular pathologies ○ May appear clinically pigmented, and may be confused with \_\_\_\_ or \_\_\_\_ • These tumors will not be red or blue, and will not have coloration • May all look somewhat alike clinically but derived from different cell types
Lipoma
• Benign tumor of fat
○ ____, floor of mouth, vestibules, buccal mucosa
○ Won’t occur on the ____ (no fat here); not the dorsum tongue
○ Does not correlate with ____; if you gain weight > will increase in size, but once you lose the weight it won’t ____ in size
• Occurs in older age group
• Has a doughy feel when palpated
○ Yellowish color - fat is yellow
• Indication you’re dealing with lipoma > rising of fat tissue to surface in ____, all other tissues not fat based will drop to the bottom of the bottle
• ____ completely in order to treat
A
5th-7th
doughy
fat
nevi melanoma ventral tongue hard palate weight reduce formadelhyde excise
14
Q
Neural origin
• Neurofibroma
– ____
• Schwannoma
– ____
• Granular cell tumor
– ____
• Mucosal neuroma
– ____
Schwann cells
– Form ____ and unmyelinated axon sheaths
– Located only in ____ nervous system
• Nerve cells can give rise to various tumors • Periphery: schwann cells ○ Myelinating cells that myelinate axons in PNS and not the CNS (\_\_\_\_) • NF, schwannoma and GCT are thought to be derived from \_\_\_\_ cells
A
neurofibromatosis type I
neurofibromatosis type II
congenital epulis
multiple endocrine neoplasia type 3
myelinated
peripheral
oligodendrocytes
schwann
15
Q
Neurofibroma
Small, ____-surfaced
Usually ____
____ excision
• Most commonly occurring benign tumor of \_\_\_\_ tissue • Nothing distinctive clinically ○ Could be a \_\_\_\_ cyst, maybe a fibroma (reactive lesion) • \_\_\_\_ excision is more than adequate for treatment ○ Only upon biopsy you'll know what you're dealing with \_\_\_\_
A
smooth asymptomatic simple nerve lymphoepi simple microscopically
16
Q
Schwannoma / Neurilemmoma
- Derived from ____ cells
- ____ gene mutation• Has a characteristically occurring gene mutation > sporadic
○ Merlin
§ Chromosome ____
§ When mutated > gives rise to a schwannoma
§ Mutated in germ line > multiple schwannomas occurring ____ the body and other complications as well
§ Non-germline > formation of ____ lesion
• Not descriptive ____
○ Only upon microscopy will it be revealed
• Slow growing, and will grow if left untreated
A
schwann merlin 22 throughout one clinically
17
Q
Histopathology
• \_\_\_\_ • Antoni A – Cellular areas composed of \_\_\_\_ cells – \_\_\_\_ nuclei around central, acellular eosinophilic material (\_\_\_\_ body) • Antoni B – Less \_\_\_\_ areas
• Histology is \_\_\_\_ for this tumor • Encapsulated ○ Surrounded by fibrous capsule ○ Well defined mass • Microscopically: ○ Well defined ○ Antoni A tissue (pathognomonic for this tumor) § Have tumor cells (schwann cells) where the nuclei are arranged in a \_\_\_\_ pattern > palisading § Another packet of cells that are arranged in a parallel pattern § In between the two packets > microscopically looks \_\_\_\_ □ \_\_\_\_ processes of the cells intermingling with one another § Collectively the whole structure is called a verocay body ○ Antoni B tissue § \_\_\_\_ arranged tissue • Remove tumor in entirety: \_\_\_\_ and curative
A
encapsulated schwann palisading verocay cellular
pathognomonic palisading pink cytoplasmic randomly diagnostic
18
Q
Granular cell tumor
• F : M -> ____ : 1
• >80% in ____ cavity
– Usually ____ tongue
• Benign nerve tumor > granular cell tumor ○ Female predilection • Can occur anywhere in the body ○ Of all possible anatomic site, the most common is the \_\_\_\_ tongue > don't take on distinctive appearance ○ Mass on the dorsum tongue > should think of \_\_\_\_ • Distinctive histology: ○ Granular cell tumor > tumor cells have a very \_\_\_\_ cytoplasm § Like salt and pepper ○ How to know nerve in origin > cytokeratin are expressed in epithelial cells, but nerve cells express \_\_\_\_ § Stain the tumor with S100 > will light up with this ab > implying it's derived from a nerve cell origin ○ Overlying epithelium over these tumors > peculiar pattern > almost looks like a SCC overlying the tumors macroscopically § Not cancer! § \_\_\_\_ □ \_\_\_\_ change to overlying epithelium that makes think invading SCC ® Patients are commonly \_\_\_\_ and tongues are removed • Excise the tumor in its entirety
A
2
oral
dorsum
dorsum GCT grainy S100 pseudoepitheliomatous hyperplasia reactive misdiagnosed
19
Q
Histopathology • Cells with \_\_\_\_ cytoplasm • Tumor cells express \_\_\_\_ protein • May show pseudoepitheliomatous hyperplasia – May be mistaken for \_\_\_\_
A
granular
S100
squamous cell carcinoma
20
Q
Congenital epulis • Unknown \_\_\_\_ • F:M -> \_\_\_\_:1 • Appears at \_\_\_\_ or in utero (not after) • Exclusively on \_\_\_\_ • S100 \_\_\_\_
• Similarly appearing tumor microscopically that only occurs in newborn infants ○ Not \_\_\_\_ in origin, but it's a soft tissue tumor • Not a nerve tumor, but looks identical to the GCT ○ Context is in newborn ○ Tumor that occurs only on alveolar ○ Always occurs anteriorly ○ And sometimes occurs on both the top and the bottom • More striking female predilection • These tumors do not stain with S100 • Unknown which \_\_\_\_ give rise to these tumors • On high power has a \_\_\_\_ granular appearance • Never evidence of \_\_\_\_ ○ Only difference bt GCT • Not thinking \_\_\_\_ nodules, but they are both newborns
A
pathogenesis 9 birth alveolar ridge negative
neural cells grainy psuedoepi hyperplasia bohn's
21
Q
Muscle tissue
Striated muscle
Skeletal muscle
– ____
– Attached to bone and other tissues
Non-striated muscle • Smooth muscle – \_\_\_\_ – Walls of hollow structures • Blood vessels • Gastrointestinal tract • Urinary bladder • Airways
A
voluntary
involuntary
22
Q
Leiomyoma
• ____ muscle tumor
• Vascular leiomyoma mimics ____
• Benign smooth muscle tumor ○ Nomenclature is not intuitive • Take one two appearances: ○ (1) Not \_\_\_\_ ○ (2) Vascular leiomyoma > mimic \_\_\_\_ clinically (or a hematoma, or a pyogenic granuloma) § Not a vascular tumor (the caps aren't becoming neoplastic and are proliferating), the smooth muscle around the BV is proliferating § Within the center of the tumor is a \_\_\_\_ > gives rise to reddish color of tumor □ Surrounding is the \_\_\_\_ tissue □ Staining with a muscle protein ab > \_\_\_\_ (expressed by muscle cells) ® Center isn't staining (the BV itself) • Benign skeletal muscle pathology is very \_\_\_\_ • Of all tissue types that give rise to tumors of the body, the only tissue where the \_\_\_\_ is more common than benign tissue is the skeletal muscle ○ Will find a malignant version more commonly than a benign neoplastic version; the only case ○ Benign skeletal muscle > \_\_\_\_
A
smooth hemangioma descriptive hemangioma BV muscle desmin rare malignancy rhabdomyoma
23
Q
Cowden syndrome
Autosomal ____
– High ____, variable expressivity
____ mutation
Cutaneous lesions
– ____
– Palmoplantar keratosis
– ____ fibromas
• Caused by mutation on chromosome \_\_\_\_ in germline of gene called PTEN • Characterized by primarily a skin as well as tumors of skin and oral lesions • In the \_\_\_\_ > the lesions are hamartomas and tumors ○ True tumors of skin > \_\_\_\_ fibromas § Very densely collagenized fibromas in a distinctive histologic pattern • Palmoplantar keratosis ○ \_\_\_\_ (not pathognomonic) ○ Differentiates it from \_\_\_\_ (hands and feet are involved) ○ Wouldn not differentiate cowden from pachnic because they're both characterized by this manifestation • Prone to developing fibromas ○ Not neoplastic; numerous fibromas ○ This is \_\_\_\_ for cowden syndrome § \_\_\_\_, multifocal fibromas in the oral cavity • Biopsy more than \_\_\_\_ lesion to get the diagnosis • Patients may have breast cancer in families, ovarian, thyroid and GI cancer ○ Give rise to genetic \_\_\_\_ • Nothing you can do - will live like this unless it gets so bad they cannot live (rare) ○ Thing to worry about is the development of significant \_\_\_\_ they may develop (either benign or malignant)
A
dominant
penetrance
PTEN
hamartomas
sclerotic
10
skin sclerotic pachynictic congenita white sponge nevus pathognomonic diffuse one cancers tumors
24
Q
Cowden syndrome
Oral lesions
– ____
Benign and malignant tumors – \_\_\_\_ – Thyroid – \_\_\_\_ – Female genitourinary tract
A
fibromas
breast
GI
25
Neurofibromatosis Type 1
von Recklinghausen’s disease
Autosomal ____
– High penetrance, variable expressivity
Mutation in ____ gene
Increased risk for ____
• Charcaterized by a germline mutation in ____ called neurofibromin
○ Formation of multiple ____
§ Each papule, nodule and mass represents a distinct neurofibroma
§ Lots of tumors - the risk is ____ > more likely tumors become malignant
□ At risk for cancer derived from nerve tissue > ____ (not carcinoma - epithelail cancer); sarcoma implies cancer of ____ elements
• ____ neurofibromas - pathognomonic for NFT1
○ Plexiform NF > sack hanging off of skin
dominant
neurofibromin
neurofibrosarcoma
```
chr21
neurofibromas
additive
neurofibrosarcoma
CT
two
```
26
Neurofibromatosis Type 1
```
Diagnostic criteria
• ____ or more café-au-lait macules
• ≥ ____ neurofibromas or ____ neurofibroma
• Freckling in ____ region
– Crowe’s sign
• ≥ 2 ____ nodule
```
• Café-au-lait spots
○ Pigmented lesions on the skin
○ 6+ = pathognomonic
○ These are ____
• Tumors feels like a bag of marbles
• Smaller freckling in armpits and in groin (axillary) > crowe's sign = pathognomonic
• ____ spots in eyes > Lisch nodules = pathognomonic
• Treatment:
○ Don't treat them
○ If ____ you treat them
○ Functional deficit you treat, or treat the cancer if they develop
○ Cannot excise all the tumors
§ Risk of treatment is ____ than leaving these untreated
```
6
2
plexiform
axillary
lisch
```
macular
brown
symptomatic
worse
27
Neurofibromatosis Type 2
• Autosomal ____
• ____ gene mutation
• ____ NOT neurofibromas
• Characterized by Merlin mutations in the germline
○ Same gene that gives rise to schwannoma
• Prone to developing multiple schwannoma, not neurofibromas!
• When occurs single lesion, when occur in brain in area of ____ nerve
○ Pathognomonic - a single acoustic neuroma, as long has another element on list of diagnosis
○ Acoustic neuroma (not a neurofibroma - it's a schwannoma)
dominant
merlin
schwannomas
acoustic
28
Neurofibromatosis Type 2
• Diagnostic criteria
– Bilateral ____ schwannomas OR
– Family history AND either ____ vestibular schwannoma OR two of the following
• ____, meningioma, ____, cataract
– OR ____ vestibular schwannoma AND one of the above
• Bilateral acoustic neuromas > pathogonomic on it's own
• One single acoustic neruoma and one on the skin
• Acoustic neuroma and father has known sydnrome
• Prone to other tumors > meningioma and glioma
○ Other types of brain tumors
• Will not treat patients unless producing ____ impingement and deafness
○ Cannot chase bc the whole body contains this mutation
```
vestibular
unilateral
schwannoma
glioma
unilateral
```
nerve
29
Multiple endocrine neoplasia Type 3 (= Type 2B)
• Autosomal ____
• Mutation in proto-oncogene ____
```
• Multiple findings
– ____ carcinoma
– Pheochromocytoma
– ____ neuromas
– Marfanoid habitus
```
• Not caused by mutation in TSG
○ Cowden - PTEN, and merlin for NF are ____
○ This disorder > proto-oncogene RET > chr ____
• Includes an array of tumors
○ Tumor in adrenal gland > ____
○ Tumors in thyroid (malignant) > medullary thyroid carcinoma
○ Nodular lesions involving oral tissues
§ Look like cowdens, but are not fibromas
§ These nodules are ____ (can be seen microscopically)
□ Diagnosed as mucosal neuromas
® Pathognomic for this syndrome (MEN type 3)
◊ MICROSCOPICALLY
dominant
RET
medullary thyroid
multiple mucosal
TSGs
10
pheochromocytoma
fibromas
30
Mucosal neuromas (MEN type 3)
• ____, tongue, commissures
• Neuromas of ____, GI tract, bronchi
• ____ histology
• Occur in mucosal sites including the oral cavity
○ GI tract, eyes
○ First sign of disease may be rectal ____
• In photo > nodules on the commisures
○ Pathognomic for this disorder (MEN type 3)
• Don't need to know microscopically
• Composed of aberrant ____ tissue
○ This is pathognomonic for this tissue
```
lips
eyes
pathognomonic
bleeding
nerve
```
31
```
Malignant neoplasms
Most common cancers in oral cavity
– ____
– ____d neoplasms
– ____a / Leukemia
Soft tissue ____ are rare
```
• Many tumors are characterized by distinctive molecular changes > usually ____
• Can get malignant soft tissue tumor occuring in oral cavity > rhabdomyosarcoma (malignant skeletal muscle cancer)
○ Very ____!
```
squamous cell carcinoma
salivary gland
lymphoma
malignancies
translocations
rare
```
32
Malignant soft tissue tumors
• Any ____ type can give rise to cancer
• Don’t let appearance of lesion fool you
• Distinct molecular changes or etiologic agents characterize certain cancers
• Do not let appearance of lesion sway you to benign vs malignant consideration
• When cancers occur in oral cavity > ____ in origin (smooth, skeletal, fat) > characterized by distinctive molecular changes > chromosomal ____
• Sequenced Rhabdomyosarcoma > identified unique translocation that has a treatment specifically designed for that translocation > the translocation resulted in new fusion protein which triggers growth of the tumors
○ Specific treatment via ____ therapies!
• Don't recognize clinically
• Treated with a massive resection
○ Liposarcoma is ____
○ Lipoma is ____
• Still see the same hallmarks of malignancy (pleo, hyperchrom, inc N:C, anaplasia, etc.)
```
tissue
soft tissue
translocation
targeted
benign
malignant
```
33
Metastatic cancer
• ≈ ____% of all oral cancers
• May develop within ____ or soft tissue
• Tumor cells travel through ____ or lymph
• May represent first sign of ____ disease
• Most common soft tissue site is ____
• Metastasize thorugh BV or lymphatic channels > go ____ sites
• Tumors from other sites can go oral cavity
○ Most common site to go to oral cavity > ____ bone; and when go to the soft tissue most commonly they go to the ____
§ Which is why you biopsy things that you think are pyogenic granulomas, peripheral ossifying or peripheral giant cell
```
1
bone
blood
malignant
gingiva
```
distant
jaw
gingiva
34
Breast adenocarcinoma
* Lesions that mimiced the ____
* Both patients have metastatic breast cancer
three P's
35
Colon carcinoma
Hepatocellular carcinoma
Renal cell carcinoma
• Abscess on RCT > colon cancer metastasis
• Patient spending a year in prosthodontic therapy > during the procedure developed lesion > the dentist kept excising > recurred > a month later > dentist sent for biopsy as ____ cancer (metastatic)
○ Must analyze the tissue
• Was ____ cancer metastasis to the oral cavity
liver
| kidney
