Section III of Interesting Cases

Section III:
Case 14: Case 15: Case 16: Case 17: Case 18: Case 19: Case 20: Case 21:

Section IV: Cases from 22 - 28
Section V: Cases from 29 onwards

A pedenculated growth of 3 cm arising from palatal gingiva between upper central incisors. Growth was spherical, reddish in color irregular surface. Bleed profusely on slight provocation. The patient first noticed the lesion 3 months back, small in size when she first noticed and was non painful. It was affecting her esthetics and mastication. When the lesion was excised the surgical site was bleeding profusely for two hours. The bleeding site was pinpointed it was pulsating type seems to be from incisive foramen. The excision was done superficially no deep incision was placed to excise the growth. Radiograph of the site showed bone loss till middle third of the root.

Diagnostic Interpretations of this case by Members:
Elias Romero
Pyogenic Granuloma

Yeshwant B. Rawal
Pyogenic granuloma

Suresh
Kaposi sarcoma

James Cade
Pyogenic granuloma

Mario Nava
Cellular hemangioma vs hemangioendothelioma

Nasser Said-Al-Naief
Cellular hemangioma. More higher power pics may help identify other vascular lesions that may occur in the area

JAMES C ADRIAN
This appears to represent a pyogenic granuloma.

Dr.G.N.Mohanty
Bleeding history, gross appearance with endothelial cell proliferation and varying sizes of capillaries lined by endothelial cells. I feel it is a 'Capillary haemngioma'

Gerardo Meza
Solitary fibrous tumor

Anil Joshi
Angiofibroma

Lynn Solomon
Hemangioma
A/V malformation

Jose M. Aguirre
Myopericitoma?

Carl M. Allen
Pyogenic granuloma. The excess bleeding undoubtedly is related to cutting one of the arteries that normally exit the incisive foramen.

Rafik Abdelsayed
Looks like a pyogenic granuloma.

A Sriv
Cap heamngioma

Jim Burns
Pyogenic granuloma

Ravi Shetty
This is not HEMANGIOMA. The varyiong diameters of vessels. Absence of RBC, presence of inflammatory cells between the vessels rules out both hemangioma and pyogenic granuloma. This is type II epulis which contains chronic granulation like tissue. Bleeding is due to damage to vessles passing through incisive canal.

Dr Susmita Saxena
Age and sex of the patient is not known. High power is suggestive of Haemangioendothelioma.

Dr. Nirima Oza
Capillary haemangioma

Dr Priya N S
Capillary Hemangioma

Dr. Rakesh
Seems like a vasoproliferative lesion - Hemangioendothelioma?

Click here to view photomicrographs
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Case 15:

A 14-year-old female patient residing in Bangalore Rural , India, reported with a complaint of enlarged upper and lower gingivae, which was diffuse type predominant on the right side. It started 1 year back as a small swelling that increased to present size. The growth is non painful. The patient is from low-socioeconomic strata; both the parents are daily wageworkers. No family history of similar condition in the family was evident.
   The patient has not attained menarche. The patient’s oral hygiene regimen is fair. Provisionally the case was diagnosed as inflammatory enlargement and gingivoplasty was performed and the tissue was sent for histopathology examination. Histopathology reveals multiple granuloma with Langerhan's gaint cell. So case was suspected as tuberculosis gingival enlargement .Chest x-ray revealed to be normal. Family history was non contributory. No family members were affected with tuberculosis. No history of weight loss, evening fever or loss of appetite. OPG showed no bone loss.

Diagnostic Interpretations of this case by Members:

Fábio Pires
Wegener granulomatosis?

James Cade
Sarcoid, Crohn's disease. Have special stains been used such as Ziehl-Neelsen’s stain for acid fast bacillus (TB and leprosy)?

Suresh
OFG r/o leprosy

Nasser Said-Al-Naief
Providing that no foreign body material was found, PAS and GMS stains for fungi (and AFB)were negative, and workup for Crohn's disease, sarcoidosis and allergy to certain food stuff and other materials all proven negative, this case would be labeled as " orofacial granulomatosis) and syndromes should be added to the list/investigated

Dr.G N Mohanty
Discrete noncaseating granulomas ,almost of same sizes with langhann type of giant cells: sarcoid comes to my mind.

Dr Alpana
Can you please include a few more higher magnification picture as in the forth Photomicrograph there are some nucleolated cells and one what looks like RS like cell. As Hodgkin's disease can have predominantly granulomatous picture and thus quite often misdiagnosed as granulomas. I have atleast two cases in lymphnodes with the previous diagnosis of tuberculosis although I had IHC to prove that. As far as this case is concerned it looks like simple granulomatous lesion at low power with the differential diagnosis of sarcoidosis/ tuberculosis, but I would look more carefully to see if there are RS like cells and if they are there will do CD15 and CD 30 stains to confirm their presence.

Paul Freedman
Oral manifestations of Crohn's disease-patient should have GI evaluation

Jose M. Aguirre
Sarcoidosis
Crohn

Carl M. Allen
Non-necrotizing granulomatous inflammation. Special stains should be ordered to rule out specific infection. Examination with polarized light would be appropriate to rule out foreign body granulomas. If these studies are negative, conditions such as orofacial granulomatosis and the various diseases associated with that process should be considered.

Rafik Abdelsayed
Dx:Granulomatous gingivitis. There are things need to be done. First, special stains to r/o specific infections including TB, and Fungal organisms. Second, GIT evaluation for Crohn's disease. Third, Blood testing for the serum angiotensin converting enzyme for Sarcoidosis. If all is negative, I will call this Gingivitis Granulomatosa, propably consistent with orofacial granulomatosis or limited Sarcoidosis. One more comment pertaining to your description of the multinucleated giant cells in the histology. You described them as "Langerhans' cells". In TB, they should be referred to as "Langhans' giant cells", not Langerhans. May be nothing big, but to be accurate. Thanks for posting these interesting cases.

Jim Burns
Do special stains: R/O Leprosy, Fungus, Sarcoid, Crohn's, Oral Granulomatous Disease, etc.

Ravi Shetty
This is nothing but tuberculosis

Dr. Susmita Saxena
HP picture is that of tuberculosis gingiva. Tuberculin test and isolation of AFB can be done. Secondly Sarcoidosis may be considered

Dr Priya N S
1. SARCOIDOSIS
2. GRANULOMA ASSOCIATED WITH LEPROSY

            Click here to view photomicrographs
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Case 16:

A 30 year old female patient with Pachyonychia Congenita from birth reported to our department with poor periodontal status . Patient had most of the classical features of the disease which includes hyperkeratosis of nails, hyperhidrosis, leukokeratosis of right half of tongue, buccal mucosa. Patient also had oral candidiasis, hoarseness of voice and Molluscum Contagiosum on her arms and back. Heamogram revealed a raised ESR(87mm/hr) but serum calcium, phosphorous and urea creatinine were all within normal limits. On routine radiological examination revealed an interesting finding of multiple hyperostotic areas between premolars and molars in all quadrants except upper left quadrant. Patient also had talons cusp on all her upper anterior teeth. I would kindly request your opinion regarding the diagnosis of the radiological finding in this case.

Diagnostic Interpretations of this case by Members:

John Giunta
Retained deciduous root tips and hypercementosis

Dr. Carl M. Allen
The radiodensities seen in the mandibular premolar region have the same degree of opacity as dentin. Furthermore, the lesions are sharply demarcated, and in areas, remnants of lamina dura and periodontal ligament space are seen. For these reasons, I feel that these are radicular tooth fragments of the deciduous molars. Often these roots are flared, and the apical portions may be amputated and left behind in the jaw as the succedaneous tooth erupts.

Joseph C Whitt
I believe these lesions represent retained primary tooth roots.

Nasser Said
Looks like idiopathic osteosclerosis. One jaw/teeth abnormality mentioned in Pachyonychia Congenita is the presence of natal teeth (in Jackson Lawler Syndrome) but this subtype usually has no other oral lesions.
I would like to learn from you and others on this case once responses are sent.

Mervyn Shear
The so-called 'hyperostotic areas' look to me like root remnants. Note lamina dura.

Craig Fowler
I believe these are most likely residual root fragments from the primary molar dentition.

Yeshwant B. Rawal
While the objects in question are radiopaque, they are not hyperostotic (bone forming). The radiodensity is homogenously devoid of trabeculation and comparable to that of dentin of adjacent teeth. In addition, the radiopacities are surrounded by a thin radiolucent rim which in turn is surrounded by a sclerotic 'lamina dura' like trabeculation. In summation, the features are indicative of retained root stumps of deciduous predecessors.

Kurt Summersgill
The radiopacities look very much like retained primary molar roots. You can see the periodontal ligament space around them.

Paul Edwards
Retained primary roots

Don Karaki
Hopefully, you have considered the possibility of retained deciduous roots. Perhaps ankylosis and even hypercementotic layering of abnormally splayed roots not resorbed following eruption of succedaneous 2nd premolars.

Paul Freedman
Radio-opaque structures seem to have a periodontal ligament space around them so I suspect that they are supernumerary teeth.

Sybil Niemann
Retained roots from primary teeth. A periodontal ligament space and lamina dura are visible around the ones on the mandibuloar right.

Mario Nava
Supernumerary teeth of aberrant morphology (in an image appear a space around from opacity, supernumerary teeth are associated with multiple syndromes)

Charles L. Halstead
Retained roots from primary molars

James Cade
I am not sure of the connection between pachyonychia congenita and the radiopaque lesions, but they resemble root tips or underdeveloped microdonts. J Cade

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Case 17:
A 42 year old female, HIV seropositive diagnosed to have squamous cell carcinoma lateral border of tongue in the anterior 2/3rd region. Histology shows an area of extreme epithelial atrophy undergone neoplastic transformation. The lady was devoid of any of the offending / nefarious habits. The patient is ambulatory without evidence of overt systemic infections. The tongue coating with oral candida was conspicous.
Difficulties: 1. The reason for extreme epithelial atrophy preparatory to neoplastic transformation?
2. The carcinogenic agent, what it could be, in a situation where all the known potentially carcinogenic habits are absent.
3. The patient was reported to have a low CD 4 cell count but the reactive inflammatory response to invading neoplastic islands was intense. How do you view this finding?

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Case 18:
A 48 year old male patient reported with an ulcer on the lingual aspect of retromolar region on the right side. It was a punched out ulcer of size 0.5 x 0.5 cm with rolled in margins and of short duration.

Click here for photomicrographs

Diagnostic Interpretations of this case by Members:

Necrotizing Sialometaplasia: 17
Mucoepidermoid carcinoma: 12
Basal cell carcinoma: 2
Acinar cell carcinoma: 1
Adenosquamous carcinoma: 1
Kaposi sarcoma: 1

Following is the list of members who have interpreted the case as Necrotizing Sialometaplasia.

James Adrian
Hx of trauma would be supportive but I believe the histopathology is C/W
A stage of Necrotising sialometaplasia.

Sook-Bin Woo
Necrotizing sialometaplasia

James Cade
Necrotizing sialometaplasia

Paul Freedman
Photomics do not show ulcer, but do show something suggestive of sialometaplasia

Raghu AR
Mucous acinar changes, metaplastic changes, focal aggregates of chronic inflammatory cells, Pseudoepitheliomatous hyperplasia, NO FRANK NECROSIS, Inadequate deeper tissue as well as areas of ulcertion
Impression: Sialo metaplasia

Jose M Aguirre
Necrotizing sialometaplasia

Allan Dovigi
Necrtoizing Sialometaplasia

Carl M. Allen
Where is the ulcer? The history is somewhat suggestive of necrotizing sialometaplasia, although the location is peculiar. Focal areas of the photomicrographs also suggest necrotizing sialometaplasia.

Allan
It is a interesting case. Necrotizing Sialometaplasia

Douglas Gnepp
Looks like an early necrotizing sialometaplasia

Susan Zunt
The photomicrographs appear to demonstrate accessory salivary glands with maintenance of the lobular architecture and benign islands of squamous epithelium that looks most like necrotizing sialometaplasia to me.

R Melrose
Mild chronic sialadenitis with focal sialometaplasia: This is not NS or an MET

Fabian Ocampo
Necrotizing sialometaplasia of minor salivary gland

Jesus de santos alba
Necrotizing sialometaplasia

Jerry Bouquot
Looks like necrotizing sialometaplasia, partially healed.

JAMES ADRIAN
Histopathology: Very well differentiated mucoepidermoid Ca Vs Necrotising sialometaplasia. The photomicrographs are not sufficient to make a distinction between the two.

Dr SC Boy
Necrotising sialometaplasia

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Case 19:

A 35 year old male reported with a slowly growing swelling since 2 years in the left palatal region. It was soft, non-tender, sessile growth extending from the first premolar to second molar. There were no causative factors or radiographic changes present.

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Diagnostic Interpretations of this case by Members:

Polymorphous low grade adenocarcinoma - 1
Pleomorphic Adenoma - 7
Mucoepidermoid carcinoma - 2
Epithelial – Myoepithelail Carcinoma - 1
Necrotising sialometaplasia - 1
Adenocarcinoma NOS - 1
Mucocele – 1

Name: Prof. Paolo Boccato, MD, FIAC
Coherent with Polymorphous Low Grade Adenocarcinoma

Case 20:
            A 58 year old male patient reported with a swelling on the hard palate in posterior region on the left side . It was soft and extending from alveolus to midline and of size 4x4 cm. The swelling was noticed by the patient 20 years back. There were no radiographic changes present.

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Diagnostic Interpretations of this case by Members:

Epithelial – Myoepithelail Carcinoma – 10
Pleomorphic Adenoma - 7
Adenoid cystic carcinoma - 4
Acinic cell carcinoma - 1
Scelorosing polycystic adenosis – 1
Mucoepidermoid carcinoma - 1

Paul Freedman
Epithelial-myoepithelial carcinoma

Beatriz Aldape
Epithelial-myoepithelial carcinoma

J Sciubba
Epithelial-myoepithelial carcinoma

Lewei Zhang
Epithelial-myoepithelial carcinoma of intercalated ductal origin

Doug Gnepp
Probably epithelial myoepithelial carcinoma, but need the slides to rule out a mixed tumor

M Shear
Epithelial-myoepithelial carcinoma

Maria Cássia Aguiar
The images suggest an epithelial-mioepithelial carcinoma

Dennis Solt
Epithelial-Myoepithelial Carcinoma

Elias Romero
Epithelial-myoepithelial carcinoma

Susan L Zunt
Several of the images look like an epithelial-myoepithelial carcinoma of salivary gland origin, but they out of focus and I think that this precludes accurate diagnosis. I also cannot see the growth pattern at the margins which is helpful to identify benign vs. malignant salivary gland neoplasia.

Case 21:

A 25 year old male patient reported with a diffuse swelling of 8 years duration, firm in consistency, size of 2x1.5 cm, extending from upper lateral incisor to first molar. The mucosa over the swelling is intact. No complaint of pain, tenderness or altered sensation of the mucosal area.

Click here for photomicrographs

Diagnostic interpretations of this by members

Plexiform neurofibroma : 7
Rhabdomyoma: 2
Traumatic neuroma: 2
Leiomyomatous Hamartoma: 1
Peripheral odontogenic fibroma: 1
Giant cell granuloma: 1

Paul Freedman
Neuroma-r/o MEN2B
Possible plexiform neurofibroma r/o NF-1

Susan Zunt
It is really hard for me to make out the specific cell types. The clinical photo and the pattern of the photomicrographs suggests a non-necrotizing granulomatous response such as seen in sarcoid. Examination with polarized light might be helpful as well as an S100 protein to rule out neural structions in a somewhat plexiform pattern. I am looking forward to hearing the final diagnosis on this case.

Sook-Bin Woo
Hard to tell but they look like neuromas (possibly even plexiform type). Does the pt have neurofibromatosis or MEN II? Was there an S100 and neurofilament protein stain?

Dr T.Elangovan
This looks like a case of Plexiform Neurofibroma. While systemic examination may be done to rule out MEN

K.T.Magesh
Looks like neural tissue proliferation-- neurofibroma.

Dr. Nirmala rao
Neurofibroma (Plexifrom)

Dr. Ravi Shetty:
Neurofibroma

Our Diagnosis:
Plexifrom neurofibroma (ruled out MEN II)

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