Verrucal-Papillary Lesions

Condyloma Acuminatum

Etiology

• A sexually transmitted disease

• Associated with human papillomavirus (HPV) types 6, 11, 16, and 18 most often

• Can result in autoinoculation of other sites via trauma

• Lesions located at the site of contact/traumatic event

Clinical Presentation

• Usually on nonkeratinized tissues in immunocompetent patients (soft palate, lingual frenum)

• Pink to whitish pink, exophytic papillary growths with pedunculated outline

• May be solitary or multiple and variably sized, up to 2 to 3 cm

• Can present as papillomatosis of upper respiratory tract

Diagnosis

• Location and appearance

• Demonstration of koilocytotic cellular changes on biopsy

• In situ hybridization or polymerase chain reaction reveals specific HPV subtype

• Electron microscopy demonstrates intranuclear virions

Differential Diagnosis

• Focal epithelial hyperplasia

• Multiple intraoral verruca vulgaris

• Squamous papilloma

Treatment

• Conservative removal

• Conventional surgery

• Laser ablation

• Topical podophyllin

Prognosis

• Recurrences common

• Contagiousness and autoinoculation are considerations.

Condyloma Acuminatum

Focal Epithelial Hyperplasia

Etiology

• A viral infection (HPV 13 or 32), usually found in childhood

• Familial/ethnic clustering often noted, probably secondary through horizontal viral transmission

• Often occurs in native Americans

Clinical Presentation

• Numerous, slightly raised whitish pink asymptomatic papules and irregular plaques that may become confluent

• Size of lesions ranges from a few millimeters to coalescent papules several centimeters in dimension

Microscopic Findings

• Well-defined acanthotic features

• Broadened, anastomosing epithelial ridges with occasional superficial koilocytotic changes

Diagnosis

• Multiple, characteristic lesions

• Biopsy findings

• In situ deoxyribonucleic acid hybridization to demonstrate HPV subtype

• Ultrastructural localization of intranuclear virions

Differential Diagnosis

• Condyloma acuminatum

• Multiple verruca vulgaris

Treatment

• None; lesions usually regress spontaneously

• Excision if esthetic needs demand

• Intralesional interferon therapy

Prognosis

• Excellent

• No reported malignant transformation

Focal Epithelial Hyperplasia

Keratoacanthoma

Etiology

• Unknown, may be related to several factors, as follows:

• Viral—HPV subtypes 11, 13, 24, 33, 57

• Altered expression of cell cycle proteins including cyclin E, p53, PCNA

• Keratinocyte dedifferentiation reflected in deficient desmoglein production

• Immunosuppression

• Sun damage

• May represent a highly differentiated form of squamous cell carcinoma

• May indicate underlying alimentary neoplasia (Muir-Torre syndrome)

Clinical Presentation

• Usually solitary on sun-exposed areas, including lip

• Initially erythematous papule

• Rapid growth over 4 to 8 weeks

• Nodular, hemispheric, firm nodule

• Central keratin core

• Occasionally regresses spontaneously

• Extremely rare intraorally

Diagnosis

• Clinical evaluation, follow-up

• Histopathology shows keratin plus normal, peripheral epidermis and mature, premature keratinization; no invasion below adnexa; marked pseudoepitheliomatous hyperplasia

Differential Diagnosis

• Squamous cell carcinoma

• Molluscum contagiosum

• Warty dyskeratoma

• Verruca vulgaris

• Pilomatricoma

• Condyloma acuminatum

• Squamous papilloma

Treatment

• Observation and careful follow-up

• Local excision

• Cryotherapy

• Intralesional chemotherapy (methotrexate, 5-fluorouracil, or

bleomycin)

Prognosis

• Excellent

Keratoacanthoma

Lymphangioma

Etiology

• A benign proliferation of lymphatic vasculature

• Usually congenital in nature

Clinical Presentation

• Superficial or deep in location

• Typically waxes and wanes in size

• Most commonly involves the tongue followed by lips, buccal mucosa, palate

• Facial asymmetry may be a presenting sign.

• Superficial mucosal lymphangiomas resemble caviar or frog’s eggs.

• Deeper lesions present as painless fluctuant masses such as macroglossia.

• Often combined with blood vessels

• Rare variant may occur bilaterally on mandibular alveolar ridge of neonates

Diagnosis

• Biopsy

• Lymphangiography

Differential Diagnosis

• Neurofibroma (deep)

• Hemihypertrophy syndromes

Treatment

• Excision

• If large lesions are stable, observation

• Sclerotherapy

Prognosis

• Variable, depending upon depth and extent of lesion

• Cavernous variant has guarded prognosis

Lymphangioma

 

Papillary Hyperplasia (Palatal Papillomatosis)

Etiology

• Generally attributed to ill-fitting maxillary denture

• Often associated with 24 h/d denture wearing

• Candida albicans overgrowth common

• May be noted in habitual mouth breathers (nondenture wearers)

Clinical Presentation

• Erythematous palatal vault beneath denture

• Nodular papillary excrescences

• Generally asymptomatic

Diagnosis

• Clinical appearance

• Biopsy results show fibrous and epithelial papillary hyperplasia; may note pseudoepitheliomatous hyperplasia

Differential Diagnosis

• Contact stomatitis

• Chronic candidiasis

• Denture stomatitis

Treatment

• Establishment of good oral hygiene

• Possible antifungal therapy

• Surgical removal of affected mucosa, if excessive tissue hyperplasia

• Relining/remaking of denture

Prognosis

• Excellent

Papillary Hyperplasia (Palatal Papillomatosis)

Pyostomatitis Vegetans

Etiology

• A pustular eruption usually associated with inflammatory bowel disease and skin disease

• Liver dysfunction (sclerosing cholangitis) may be associated in some cases.

Clinical Presentation

• Mucosal pustules, erythema, edema

• Erosions and ulcers may form with serpiginous outlines (“snail tracks”).

• Folds of nodular to hyperplastic tissue (“cobblestoning”)

Microscopic Findings

• Neutrophilic and eosinophilic infiltrate into epithelium producing microabscesses

• Infiltration between epithelial clefts

• Epithelial hyperplasia

Diagnosis

• Correlation with underlying gastrointestinal disease, such as the following:

• Ulcerative colitis

• Crohn’s disease

• Sclerosing cholangitis

• Malabsorption syndrome

Differential Diagnosis

• Oral Crohn’s disease

• Pseudomembranous (acute) candidiasis

• Melkersson-Rosenthal syndrome

• Orofacial granulomatosis

• Acanthosis nigricans

Treatment

• Successful management of underlying gastrointestinal disease

• Local anti-inflammatory agents

• Dapsone or sulfapyridine systemically

Prognosis

• Correlates with that of systemic disease

Pyostomatitis Vegetans

Squamous Papilloma

Etiology

• A benign epithelial proliferation

• HPV is found in most cases; several subtypes have been identified, especially HPV 6 and 11.

Clinical Presentation

• Exophytic, papillary mass, measuring less than 1 cm

• Usually pedunculated and soft in texture

• White

• Usually solitary; may be multiple

• Favors soft palate; uvula, tongue, gingiva, buccal mucosa may also be involved

Microscopic Findings

• Epithelial hyperplasia with fibrovascular cores

• Papillary projections may be sharp to blunt.

• Epithelium may be dysplastic in some lesions from human immunodeficiency virus–positive patients.

Diagnosis

• Clinical appearance

• Biopsy features

Differential Diagnosis

• Condyloma acuminatum

• Verruca vulgaris

• Focal epithelial hyperplasia

• Verrucous carcinoma

Treatment

• Surgical excision

Prognosis

• Low recurrence rate

Squamous Papilloma

Verruca Vulgaris (Oral Warts)

Etiology

• Infection of mucosal epithelium by members of the human papillomavirus group—usually HPV 2, 4, 6, or 11

Clinical Presentation

• Papular to nodular and exophytic appearance

• Surface texture is cauliflower-like or verruciform in nature

• Perioral skin lesions may be brownish.

• Oral mucosal lesions are usually white to pink.

• May be pedunculated or broad based

• Intraoral sites of predilection include the lips, palate, and attached gingiva.

• Multiple oral lesions may be evident in immunocompromised patients.

Microscopic Findings

• Surface hyperkeratosis

• Granulosis

• Koilocytosis

• Acquired immunodeficiency syndrome–associated oral warts may appear dysplastic microscopically.

Diagnosis

• Clinical appearance

• Microscopic findings

• Immunohistochemical demonstration of HPV common antigen

Differential Diagnosis

• Focal epithelial hyperplasia

• Keratoacanthoma

• Papillary squamous carcinoma

• Squamous papilloma

• Condyloma acuminatum

Treatment

• Excision

• Laser surgery

• Cryosurgery

• Electrosurgery

Prognosis

• Excellent in immunocompetent host

• Recurrence not uncommon

Verruca Vulgaris (Oral Warts)

Verrucous Carcinoma

Etiology

• A well-differentiated, exophytic and endophytic squamous cell carcinoma often associated with tobacco use, especially smokeless tobacco

• A primary or ancillary role for HPV is suspected.

• May be preceded by keratotic patch (see “Verrucous

Hyperplasia” on page 158)

Clinical Presentation

• One-half of cases involve the buccal mucosa.

• Attached gingiva is involved in one-third of cases.

• Early, superficial lesions often are interpreted as verrucous hyperplasia; lesions become exophytic, irregular, and indurated.

• Advancing lesions push into adjacent tissues.

• Late lesions invade the periosteum and destroy bone.

• Metastases are rare.

Microscopic Findings

• Well-differentiated, blunt masses of epithelium extending into submucosa

• Intense lymphocytic infiltrate adjacent to invasive front

Diagnosis

• Microscopic findings

• Full-thickness specimen is necessary to establish diagnosis

Differential Diagnosis

• Verrucous hyperplasia

• Papillary squamous cell carcinoma

• Proliferative verrucous leukoplakia

Treatment

• Wide excision

• Radiation therapy may be effective.

• Dedifferentiation may occur spontaneously or after radiation therapy.

Prognosis

• Excellent

• Local recurrence is a distinct possibility.

Verrucous carcinoma

Verucous carcinoma

Verrucous Hyperplasia

Etiology

• Unknown; tobacco (smokeless) associated most commonly

• Role of HPV is unclear.

• A possible precursor to verrucous carcinoma

Clinical Presentation

• Exophytic, papillary, keratotic fronds of epithelium

• May be part of the proliferative verrucous leukoplakia spectrum

Microscopic Findings

• Papillary to verruciform surface projections

• Keratin varies in thickness

• Broad, bosselated epithelial ridges

• Well-differentiated cellular features

• Some similarity to early verrucous carcinoma

Diagnosis

• Microscopic features

Differential Diagnosis

• Verrucous carcinoma

• Papillary squamous cell carcinoma

• Proliferative verrucous leukoplakia

Treatment

• Excision or ablation (eg, laser, electrocautery)

• Continued observation

Prognosis

• Good with complete excision

• Recurrence is common.

 

Verrucous Hyperplasia