Neoplasia: Benign vs. Malignant Tumors * 1

• Neoplasia means 'new growth'

Neoplasm Defined

• An abnormal growth exceeding normal tissue, uncoordinated, and persists after the stimulus stops

Types of Neoplasms

• Benign
• Malignant

Differentiation

• Differentiation refers to the similarity to the source tissue

Benign Differentiation

• Well-differentiated, resembling the tissue of origin with organized structure

Malignant Differentiation

• Undifferentiated, looking different from the tissue of origin, with disorganized structure

Growth Rate

• Benign tumors usually grow slowly
• Malignant tumors tend to grow rapidly

Local Invasion

• Local invasion describes how growth affects surrounding tissue

Benign Local Invasion

• Normally well-circumscribed with no invasion due to its capsule

Malignant Local Invasion

• Invasive with poorly defined margins, infiltrating surrounding tissues because it lacks a capsule

Metastasis

• Metastasis is the spread from the site of origin to distant sites

Benign Metastasis

• Absent

Malignant Metastasis

• Common, spreading via lymphocytes and the bloodstream

Benign Tumor Features

• Capsule
• Relatively normal cells
• Slowly expanding mass

Malignant Tumor Features

• Irregular shape and surface
• Abnormal cells of irregular size
• Tissue invasion
• Invasion of blood vessels
• No capsule
• Necrosis may occur due to rapid growth

Suffix for Benign Oral Neoplasias

• -oma

Benign Oral Neoplasias

• Haemangioma
• Lipoma
• Fibroepithelial polyp
• Papilloma
• Naevus
• Pyogenic Granuloma
• Ameloblastoma
• Pleomorphic Adenoma
• Bony exostosis

Haemangioma Cause

• Benign vasoformative neoplasm (formed from capillaries or blood vessels)

Haemangioma Features

• Capillary or cavernous (large blood-filled spaces)
• Blanches on pressure (paler looking as blood is pushed away)
• May cause troublesome bleeding or cosmetic defect

Haemangioma Treatment

• Cryotherapy (freezing to cause scarring)
• Sclerotherapy (injecting irritant to cause scarring)
• Excision

Haemangioma Appearance

• Red, raised lesion that blanches under pressure

Lipoma Cause

• Benign neoplasm of adipose tissue

Lipoma Features

• Occurs where there is subcutaneous/dermal fat
• Soft, yellow or pink with normal overlying mucosa/skin

Lipoma Treatment

• Surgical excision

Lipoma Appearance

• Soft yellow or pink, with normal overlying mucosa/skin

Fibroepithelial Polyp (FEP) Cause

• Inflammatory hyperplasia due to chronic irritation (e.g., cheek biting, dentures, orthodontic appliances)

Fibroepithelial Polyp (FEP) Features

• Most common benign epithelial tumor in the oral cavity
• Painless, flat or pedunculate lesion
• Uncommon before age 30

Fibroepithelial Polyp (FEP) Treatment

• Local surgical excision only if troublesome

Fibroepithelial Polyp (FEP) Appearance

• Painless, flat or pedunculate lesion in oral cavity

Papilloma Cause

• Benign proliferating lesion caused by human papilloma virus (HPV)
• HPV 6 and 11 (NOT cancer-inducing types 16 and 18)

Papilloma Features

• Most common between ages 30-50
• HPV 6 and 11
• Soft palate and tongue most common locations

Papilloma Treatment

• Local surgical excision / cryotherapy only if troublesome

Papilloma Appearance

• A cecile lesion with a pedunculate, red surface

Melanocytic Naevi Cause

• Genetic tendency; sunburn or excessive sun exposure, fair skin increases risk

Melanocytic Naevi Features

• Pigmented mole
• Develops in childhood and early adult life (30-40)
• Family history

Melanocytic Naevi Treatment

• Local surgical excision if troublesome or concerning

Melanocytic Naevi Appearance

• Pigmented moles that appear brown, tan, or pink

Pyogenic Granuloma Cause

• Reactive hyperplasia of connective tissue
• Caused by low-grade irritation, trauma, poor oral hygiene, hormonal changes (pregnancy)

Pyogenic Granuloma Features

• Reactive hyperplasia of connective tissue
• Not a true granuloma
• Affects gingiva, buccal mucosa, tongue, and lips
• More common in females, especially in the second decade (pregnancy)

Pyogenic Granuloma Treatment

• Local surgical excision with nitrate sticks (including the base) + improved OH

Pyogenic Granuloma Appearance

• Build-up of small blood vessels due to hyperplasia of connective tissue, presenting on gingiva, buccal mucosa, tongue, and lips

Ameloblastoma Cause

• Benign tumor of odontogenic epithelium

Ameloblastoma Features

• 80% in mandible, most commonly in the posterior region
• Expansion, resorption of adjacent tooth roots
• Locally invasive, rarely metastatic spread to lung

Ameloblastoma Treatment

• Surgical excision with margin
• Enucleation (more conservative)

Ameloblastoma Appearance on Radiograph

• A radiolucent area affecting surrounding tissues like the cortical bone

Pleomorphic Adenoma Cause

• Salivary gland tumor

Pleomorphic Adenoma Features

• Most common salivary gland tumor (80%)
• Parotid gland commonly affected
• More common in females (F>M 2:1)
• Any age, but most frequent in 30-60 year olds

Pleomorphic Adenoma Treatment

• Careful surgical excision required Where superficial lobe of parotid is removed because the capsule is thin and can rupture and spread

Pleomorphic Adenoma Appearance

• A smooth surface that grows slowly underneath the ear/around the jaw

Bony Exostosis/Torus Cause

• Benign localized peripheral overgrowth of bone

Bony Exostosis/Torus Features

• Most common in palate and lingual aspect of the mandible.
• Frequently traumatized due to location and thin mucosa.

Bony Exostosis/Torus Treatment

• Surgical reduction if functionally/cosmetically problematic

Bony Exostosis/Torus Appearance

• Enlargement of bone at the palate or lingual surface

Steps if in Doubt About Malignancy

• Regular reviews, photos, or x-rays
• Refer if concern for potential malignancy

Possible Causes for Soft Tissue Swellings in Submandibular Region Due to Parotid Gland

• Sebaceous cyst
• Lipoma
• Cervical lymphadenopathy
• Pleomorphic adenoma
• Warthin’s tumour
• Haemangioma
• Lymphangioma
• Mumps
• HIV
• Parotid TB
• Bacterial Ascending Parotiitis
• Obstructive Sialadenitis
• Branchial cyst

Sebaceous Cyst

• Closed sac filled with sebum
• Smooth, 1mm-5cm, attached to skin, well defined, non-tender
• If infected: larger, reddened, tender
• Cause: blocked sebaceous glands, swollen hair follicles, excessive testosterone
• Treatment: surgical excision

Cervical Lymphadenopathy

• Abnormal enlargement of lymph nodes (LNs) in the head and neck (usually >1 cm)

Infective Causes of Cervical Lymphadenopathy

• Bacterial: teeth, skin, tonsils
• Local viral: URTI, primary HSV
• General bacterial: TB, Cat scratch, secondary syphilis
• General viral: HIV, CMV, EBV, Rubella (occipital: HIV, lice)

Neoplastic Causes of Cervical Lymphadenopathy

• Local metastatic: aero-digestive, skin, salivary, thyroid, sinuses, breast, stomach
• General: Lymphoma, leukemia

Non-Infectious, Non-Neoplastic Causes of Cervical Lymphadenopathy

• Drugs (e.g., phenytoin)
• Tumours

Facial Nerve and Parotid Gland

• Facial nerve runs through parotid gland; tumour removal may lead to paralysis

Sialadenitis

• Salivary gland inflammation

Possible Causes for Soft Tissue Swellings in Submandibular Region Due to Submandibular Gland

• Sjogren’s Syndrome
• Sialosis (hypersalivation)
• Calculi (mealtime syndrome) in Wharton’s ducts
• Neoplasms are more likely than in the parotid gland

Hard Tissue Swellings in the Mandible

• Osteoarthritis, RA
• Ameloblastoma, cementoblastoma
• Ossifying fibroma
• Osteosarcoma
• Multiple myeloma (if in bone, very serious)

Possible Causes for Right Side Paralysis

• Dental (exposed dentine, fracture, periodontitis, osteomyelitis)
• Trigeminal neuralgia
• Trigeminal neuropathy
• Glossopharyngeal neuralgia
• Herpetic & Postherpetic neuralgia
• Diabetic neuropathy
• Migraine
• Cluster headache
• TMJ disorders
• Atypical facial pain
• Burning Mouth Syndrome

Trigeminal Neuralgia

• Compression of the trigeminal nerve by vessels may cause the condition
• Sudden, severe, brief stabbing, recurrent pain in V2/3 (rarely V1)
• Elderly patients usually
• Lightening bolt! 10/10 pain!
• Triggers: shaving, eating, touch, wind, speech (may occur after treatment)
• No facial weakness/sensory changes
• Misread as dental pain
• Treatment: carbamazepine, (phenytoin, valproate), temp LA, surgery

Trigeminal Neuropathy

• Compression of trigeminal roots by tumors may cause condition
• Painful, sudden, sustained, tic-like?

Glossopharyngeal Neuralgia

• Compression by tumors, infections, vessels may cause condition
• Sudden, sustained pain at ear, base of tongue, angle of mandible, tonsillar fossa (IX sensory areas)
• Triggers: eating, swallowing, talking, yawning, coughing
• May be seen in MS

Herpetic & Postherpetic Neuralgia

• Steady sustained pain lasts months (may be shooting)
• Elderly & immunocompromised
• Erythema & typical herpetiform rash.

Migraine

• Blinding, throbbing pain for hours behind 1 eye
• Warnings: nausea, vomit, photo/phonophobia
• Classical (with visual aura) and Common (without)
• Triggers: stress, food (cheese, chocolate, red wine)
• Often starts in teens.
• Family history
• Treatment: migralieve, anti-emetics, tryptans

Cluster Headache

• Severe, dull pain over 1 eye, lasts 20mins-1hr
• Reoccurs at same time, each day, for up to 6 weeks
• Triggers: alcohol, nitrates
• Treatment: high flow O2, triptans, lidocaine nasal spray, carbamazepine, ergotamine

TMJ Disorders

• Preauricular tenderness, ‘clicks/crunches, deviations
• Bruxism – look for attrition, scalloped lateral tongue

Atypical Facial Pain

• History of Depression, Anxiety, Adverse life event
• Often no signs
• Often bizarre symptoms
• Often crosses anatomic boundaries
• Tx – TCA(amitriptyline,dry mouth), SSRI(citalopram/fluoxetine,nausea/agitation), CognBehavTherapy.

Burning Mouth Syndrome

• History of Depression, Anxiety, Adverse life event
• “tongue on fire!”
• Exclude Candidosis, Fe deficiency, Anemia
• Treatment: same as atyp.facial pain.