Pyogenic granuloma
Pyogenic granuloma is a relatively common skin growth that presents as a shiny red mass. The surface has a raspberry-like or raw minced meat appearance. Although they are benign (non-cancerous), pyogenic granulomas can cause problems of discomfort and profuse bleeding. Pyogenic granuloma is characterized by a rich profusion of anastomosing vascular channels, usually with plump endothelial cell nuclei, i.e. neovascularity (Figures ). The background stroma is typically
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edematous, but fibroplasia is often active and older lesions may have undergone considerable fibrosis (fibrotic pyogenic granuloma). The fibroblasts are typically plumb and mitotic activity may be noted in the stromal cells. Older lesions demonstrate fewer and more mature cells, i.e. fibrocytes.
The blood vessels often show a clustered or medullary pattern separated by less vascular fibrotic septa, leading some authorities to consider the pyogenic granuloma to be a polypoid form of capillary hemangioma or nothing more than an inflamed lobular hemangioma occurring on the skin or mucosal surfaces, others prefer to use the term granulation tissue-type hemangioma (Figure ). A mixed chronic and acute inflammatory cell infiltrate is scattered throughout the stroma, with early lesions containing more neutrophils than older lesions. Occasional lesions demonstrate an extreme predominance of plasma cells, prompting some pathologists to call them plasma cell granuloma (Figure ) a term which is best avoided because of the potential confusion with mucosal solitary plasmacytoma or multiple myeloma. Rare examples of intravenous pyogenic granuloma have been reported.
Lesions usually first appear as a small pinhead-sized red, brownish-red or blue-black spot that grows rapidly over a period of a few weeks to anywhere between 2mm and 2cm in diameter. Occasionally they may reach up to 5cm. They bleed easily and may ulcerate and form crusted sores. Usually a single lesion is present but in rare cases groups of multiple lesions may develop. The cluster of blood vessels making up the pyogenic granuloma forms a dark red spot that becomes ulcerated and crusts over. This process usually takes 1 to 2 weeks. It is considered an abnormal healing response. Normally, blood vessels respond with growth to help heal a traumatic site. In this condition, it's as if the response is excessive and doesn't know when to turn off.
Pyogenic granuloma of the oral and oropharyngeal region is similar to its counterparts in other parts of the body, although it may occur under rather unique circumstances. During pregnancy, for example, hormonal excesses combine with poor oral hygiene to produce a generalized inflammatory enlargement of the gingiva, occasionally with one or more interdental papillae increasing to more than 2.0 cm. in size. This pregnancy tumor (granuloma or epulis gravidarum) usually regresses after the birth of the child, possibly to reappear with the next pregnancy. It was most likely the first pyogenic granuloma reported in the English literature.
Another special pyogenic granuloma is the epulis granulomatosa (epulis haemangiomatosa), a hemorrhagic gingival mass of granulation tissue protruding from the poorly healing bony socket of a recently extracted tooth. A third unique presentation is a draining granulation tissue mass, or parulis, surrounding and often hiding the end of a fistulous tract from an underlying intraosseous dental infection.
Removal of the lesion is indicated to alleviate any bleeding, discomfort, cosmetic distress, and diagnostic uncertainty. A number of malignant tumors may clinically mimic pyogenic granuloma, making histopathologic confirmation important if the presentation is atypical. Aside from cutaneous and oral lesions, pyogenic granuloma has been reported throughout the gastrointestinal tract, the nasal mucosa, the larynx, and the conjunctiva and cornea. This chapter discusses only cutaneous and oral involvement. Pyogenic granuloma is treated by conservative surgical excision with removal of potential traumatic or infective etiologic factors. Recurrence occurs in approximately 15% of lesions thus removed, with gingival cases showing a much higher recurrence rate than lesions from other oral mucosal sites. Therefore, pyogenic granuloma of the gingiva, i.e. epulis granulomatosa, should not only be excised, but the surgical wound bed should be curetted and adjacent teeth should be scaled and root planed. If at all possible, removal in a pregnant woman should be postponed until after the birth. Lesional shrinkage at that time may make surgery unnecessary. |
