Benign Oral Tumors of Mesenchymal Tissue Origin

Benign Tumors of Benign Tumors of Mesenchymal OriginMesenchymal Origin

Fibroma/Irritation FibromaFibroma/Irritation Fibroma:: Description: a reactive tumor; Description: a reactive tumor; reactive proliferationreactive proliferation of of

cellular fibrous connective tissue cellular fibrous connective tissue Clinical Features:Clinical Features: Risk Factors:local irritation (such as calculus or mal-Risk Factors:local irritation (such as calculus or mal-

alignment of teeth)alignment of teeth) Rarely recursRarely recurs Differential Diagnosis: Pyogenic GranulomaDifferential Diagnosis: Pyogenic Granuloma Histopathology:Histopathology: Covered by stratified squamous epithelium with short Covered by stratified squamous epithelium with short

and flat rete pegsand flat rete pegs TreatmentTreatment: :

– excisional biopsy- deep to the underlying bone in excisional biopsy- deep to the underlying bone in order to eliminate the entire lesion. order to eliminate the entire lesion.

– Elimination of irritating stimuliElimination of irritating stimuli

FibromaFibroma

Pyogenic GranulomaPyogenic Granuloma: The pyogenic granuloma is : The pyogenic granuloma is a relatively common, tumorlike, exuberant tissue a relatively common, tumorlike, exuberant tissue response to localized irritation or trauma. “pyogenic response to localized irritation or trauma. “pyogenic granuloma” is a misnomer since the condition is not granuloma” is a misnomer since the condition is not associated with pus and does not represent a associated with pus and does not represent a granuloma histologically. granuloma histologically.

Clinical AppearanceClinical Appearance: soft red nodule , ulcerated, : soft red nodule , ulcerated, and the lesion exhibits a lobular architecture. lesion and the lesion exhibits a lobular architecture. lesion that may develop on the gingival margin or in other that may develop on the gingival margin or in other sitessites

Histopathology: large, thin walled blood vessels; Histopathology: large, thin walled blood vessels; with neutrophils; core of cellular fibrous connective with neutrophils; core of cellular fibrous connective tissue mixed with proliferating vascular channels tissue mixed with proliferating vascular channels and inflammatory infiltrate w/ neutrophils. This and inflammatory infiltrate w/ neutrophils. This lesion is a reactive/inflammatory process. lesion is a reactive/inflammatory process.

Treatment:conservative surgical Treatment:conservative surgical excision.For gingival lesions, excising the excision.For gingival lesions, excising the lesion down to the periosteum and lesion down to the periosteum and scaling adjacent teeth to remove any scaling adjacent teeth to remove any calculus and plaque that may be a source calculus and plaque that may be a source of continuing irritation is recommended.of continuing irritation is recommended.

Pyogenic granuloma occasionally recurs, Pyogenic granuloma occasionally recurs, and a reexcision is necessary.and a reexcision is necessary.

The recurrence rate is higher for pyogenic The recurrence rate is higher for pyogenic granulomas removed during pregnancy.granulomas removed during pregnancy.

Pyogenic GranulomaPyogenic Granuloma

Giant Cell FibromaGiant Cell Fibroma DescriptionDescription:a localized :a localized reactive reactive

proliferationproliferation of fibrous (scar) tissue, much of fibrous (scar) tissue, much like the irritation fibroma. like the irritation fibroma.

Clinical FeaturesClinical Features: small,may have broad : small,may have broad base or thick stalk. It is painless and often base or thick stalk. It is painless and often has lobules or nodules on its surface.; may has lobules or nodules on its surface.; may occur at any age; most commonly seen on occur at any age; most commonly seen on gingiva gingiva

Differs from irritation fibroma in 2 ways: Differs from irritation fibroma in 2 ways: – it contains giant cells (fibroblasts) with it contains giant cells (fibroblasts) with

large, angular nuclei, beneath the large, angular nuclei, beneath the overlying epithelium; overlying epithelium;

– it has a greater tendency to recur. it has a greater tendency to recur.

Giant Cell FibromaGiant Cell Fibroma Histopathologic FindingsHistopathologic Findings::

– Diffuse, immature, avascular collagenic Diffuse, immature, avascular collagenic stroma with scattered fibroblastsstroma with scattered fibroblasts

– Fibroblasts: very large and angular, may Fibroblasts: very large and angular, may have more than one nucleus--most have more than one nucleus--most numerous immediately beneath the numerous immediately beneath the covering epithelium. covering epithelium.

– The epithelium is usually normal but may The epithelium is usually normal but may have elongated and narrow rete ridges. have elongated and narrow rete ridges.

– no capsule or pseudocapsule. Occasional no capsule or pseudocapsule. Occasional lymphocytes may be seen beneath the lymphocytes may be seen beneath the epithelium or around capillaries.epithelium or around capillaries.

TreatmentTreatment is conservative surgical removal. is conservative surgical removal. There is no risk of transformation to cancer. There is no risk of transformation to cancer.

Giant Cell FibromaGiant Cell Fibroma

Peripheral Ossifying Peripheral Ossifying FibromaFibroma

Description:A well-demarcated, encapsulated lesion ; Description:A well-demarcated, encapsulated lesion ; also known as cementifying fibroma, cemento-also known as cementifying fibroma, cemento-ossifiying fibroma, fibrous osteoma and osteofibromaossifiying fibroma, fibrous osteoma and osteofibroma

Clinical Features: no bone involvementClinical Features: no bone involvement Histopathologic findingsHistopathologic findings: composed of highly cellular : composed of highly cellular

fibrous tissue with presence of spherical calcifications fibrous tissue with presence of spherical calcifications (osteoid) and irregular, randomly oriented bony (osteoid) and irregular, randomly oriented bony structures. a well demarcated or less likely, structures. a well demarcated or less likely, encapsulated neoplasm composed of fibrous tissue encapsulated neoplasm composed of fibrous tissue with randomly distributed areas of calcified material. with randomly distributed areas of calcified material.

Treatment: complete enucleation though larger Treatment: complete enucleation though larger lesions may necessitate surgical resection and bone lesions may necessitate surgical resection and bone grafting. Recurrence is raregrafting. Recurrence is rare

Peripheral Ossifying Peripheral Ossifying FibromaFibroma

Central Ossifying Central Ossifying FibromaFibroma

Description: a true neoplasm of the medullary Description: a true neoplasm of the medullary portion of the jaws. Benign, slow-growingportion of the jaws. Benign, slow-growing

arises from elements of the periodontal ligamentarises from elements of the periodontal ligament Clinical Features: tend to occur in younger patients, Clinical Features: tend to occur in younger patients,

most often in the premolar-molar region of the most often in the premolar-molar region of the mandible. Small: asymptomatic but frequently grow mandible. Small: asymptomatic but frequently grow to expand the jaw boneto expand the jaw bone

Histopathologic FindingsHistopathologic Findings: uniform fibroblasts and : uniform fibroblasts and small irregularly mineralized masses resembling small irregularly mineralized masses resembling cementum Similar to fibrous dysplasiacementum Similar to fibrous dysplasia

Radiographic FindingsRadiographic Findings: well-defined unilocular : well-defined unilocular radiolucent lesion which becomes increasingly radiolucent lesion which becomes increasingly calcified with maturation. The progression from the calcified with maturation. The progression from the radiolucent to the radiopaque stage takes at least 6 radiolucent to the radiopaque stage takes at least 6 years. years.

TreatmentTreatment: surgical excision ; recurrence is : surgical excision ; recurrence is uncommon. uncommon.

Central Ossifying Central Ossifying FibromaFibroma

Peripheral Giant Cell Peripheral Giant Cell GranulomaGranuloma

Description: also called giant cell epulisDescription: also called giant cell epulis Clinical Features: hemorrhagic appearance; with Clinical Features: hemorrhagic appearance; with

superficial erosion of bonesuperficial erosion of bone Histologic Findings: multinucleated foreign body-type Histologic Findings: multinucleated foreign body-type

giant cells embedded in cellular stroma containing giant cells embedded in cellular stroma containing both fibroblasts and endothelial cells. cellularity and both fibroblasts and endothelial cells. cellularity and plumpness of the cells contributes to aggressiveness plumpness of the cells contributes to aggressiveness and tendency for recurrence. 50-100 nuclei per cell and tendency for recurrence. 50-100 nuclei per cell may be seenmay be seen

Treatment:Conservative excision is typically curative, Treatment:Conservative excision is typically curative, although the lesion must be completely removed to although the lesion must be completely removed to prevent recurrence. In areas such as the maxillary prevent recurrence. In areas such as the maxillary gingivae where surgical removal may have a gingivae where surgical removal may have a negative esthetic impact, the clinician may want to negative esthetic impact, the clinician may want to consider a gingival graft in conjunction with the consider a gingival graft in conjunction with the excision of the lesion. excision of the lesion.

Peripheral Giant Cell Peripheral Giant Cell GranulomaGranuloma

Central Giant Cell Central Giant Cell GranulomaGranuloma DescriptionDescription:a neoplastic-like reactive :a neoplastic-like reactive

proliferation of the jaws that accounts; rare: proliferation of the jaws that accounts; rare: less than 7% of all benign lesions of the less than 7% of all benign lesions of the jaws in tooth-bearing areas. jaws in tooth-bearing areas.

Clinical FeaturesClinical Features: commonly occurs in : commonly occurs in children and young adults with a slight children and young adults with a slight female predilection. The lesion is more female predilection. The lesion is more common in the mandible than maxilla common in the mandible than maxilla underlying anterior or premolar teeth. underlying anterior or premolar teeth.

Expansile lesions can cause root divergence Expansile lesions can cause root divergence or resorption. Lesions may be slow-growing or resorption. Lesions may be slow-growing and asymptomatic, or rapidly expanding and asymptomatic, or rapidly expanding with pain, facial swelling and root with pain, facial swelling and root resorption. The fast growing variants have resorption. The fast growing variants have a high rate of recurrence. a high rate of recurrence.

Central Giant Cell Central Giant Cell GranulomaGranulomaRadiographic appearanceRadiographic appearance: ranges from : ranges from

unilocular to multilocular unilocular to multilocular radiolucencies with either well-radiolucencies with either well-defined or irregular borders. With defined or irregular borders. With root resorptionroot resorption

HistopathologyHistopathology:Multinucleated giant :Multinucleated giant cells, dispersed throughout a cells, dispersed throughout a hypercellular fibrovascular stroma hypercellular fibrovascular stroma often with bony trabeculae are often with bony trabeculae are present on histology. present on histology.

Central Giant Cell Central Giant Cell GranulomaGranuloma TREATMENTTREATMENT:: Treatment regimens for CGCG have historically included Treatment regimens for CGCG have historically included

– curettagecurettage Small, nonaggressive lesions will usually respond to Small, nonaggressive lesions will usually respond to

through through excision with careful curettageexcision with careful curettage with a with a recurrence rate of less than 15%.recurrence rate of less than 15%.

– segmental resectionsegmental resection Larger, more aggressive lesions, which have higher Larger, more aggressive lesions, which have higher

recurrence rates, require more extensive surgery, recurrence rates, require more extensive surgery, which may include en bloc resectionwhich may include en bloc resection

– Intralesional steroids have also been advocated for Intralesional steroids have also been advocated for managing CGCG in younger patients as a nonsurgical managing CGCG in younger patients as a nonsurgical alternative. alternative.

Individualized treatment depending on the aggressiveness Individualized treatment depending on the aggressiveness of the lesion is the rule. of the lesion is the rule.

Central Giant Cell Central Giant Cell GranulomaGranuloma

LipomaLipoma Description:The lipoma is a benign tumor Description:The lipoma is a benign tumor

(neoplasm) of fatty tissue/neoplasms of adipocytes (neoplasm) of fatty tissue/neoplasms of adipocytes Clinical Features: Clinical Features: usually arises from buccal fat pad usually arises from buccal fat pad

area; lesion is soft and fluctuant to palpation; rare area; lesion is soft and fluctuant to palpation; rare intraoral tumor; slow-growing, soft, smooth-intraoral tumor; slow-growing, soft, smooth-surfaced mass of the submucosal tissues When surfaced mass of the submucosal tissues When superficial, there is a yellow surface discoloration superficial, there is a yellow surface discoloration

benign neoplasm of brown fat= hibernoma benign neoplasm of brown fat= hibernoma Histologic FindingsHistologic Findings: well demarcated, encapsulated : well demarcated, encapsulated

mass of mature fat cells enclosed within fine mass of mature fat cells enclosed within fine alveolar tissue:”signet ring appearance”. Cells are alveolar tissue:”signet ring appearance”. Cells are well-differentiated and contain abundant fatty well-differentiated and contain abundant fatty material. Fat in the fat cells are different from material. Fat in the fat cells are different from normal fatnormal fat

Treatment:Conservative surgical removal is the Treatment:Conservative surgical removal is the treatment of choice for oral lipoma, with occasional treatment of choice for oral lipoma, with occasional recurrences expected recurrences expected

LipomaLipoma

HemangiomaHemangioma DescriptionDescription: a hamartoma or a proliferation of : a hamartoma or a proliferation of

tissues indigenous to the tumor sitetissues indigenous to the tumor site Central Hemangiomas -occur within bone . Central Hemangiomas -occur within bone .

Serious consequences result if teeth are Serious consequences result if teeth are extracted from involved areas. Possible loose extracted from involved areas. Possible loose teeth or oozing of blood around teeth are clues to teeth or oozing of blood around teeth are clues to the nature of the osseous lesion. the nature of the osseous lesion.

The tongue is a common intraoral location of soft-The tongue is a common intraoral location of soft-tissue hemangiomastissue hemangiomas

Histopathologic Findings:an ill-defined Histopathologic Findings:an ill-defined proliferation of blood vessels with blood cells proliferation of blood vessels with blood cells inside. These may be capillary (capillary inside. These may be capillary (capillary hemangioma) or they may be large thin-walled hemangioma) or they may be large thin-walled blood-filled vascular spaces(cavernous blood-filled vascular spaces(cavernous hemangioma). Solid endothelial cell proliferation hemangioma). Solid endothelial cell proliferation (rosettes of endothelium) may be seen in the (rosettes of endothelium) may be seen in the capillary type. capillary type.

Capillary HemangiomaCapillary Hemangioma

HemangiomaHemangioma Radiographic FindingsRadiographic Findings: Central : Central

hemangiomas often feature a finely hemangiomas often feature a finely trabeculated radiolucent pattern; bone trabeculated radiolucent pattern; bone destruction seendestruction seen

TreatmentTreatment: Therapy consists of surgery, : Therapy consists of surgery, cryotherapy or the use of sclerosing cryotherapy or the use of sclerosing solutions. Large hemangiomas ones are solutions. Large hemangiomas ones are difficult therapeutic problems and when difficult therapeutic problems and when they attain this size, therapy is not usually they attain this size, therapy is not usually indicated unless the lesion affords the indicated unless the lesion affords the patient much difficulty or hemorrhage. patient much difficulty or hemorrhage.

Syndromes assoc. w/ Syndromes assoc. w/ hemangiomashemangiomas

Sturge-Weber AngiomatosisSturge-Weber Angiomatosis Description: encephalotrigeminal angiomatosis; Description: encephalotrigeminal angiomatosis;

variant of hemangiomavariant of hemangioma Congenital, not hereditaryCongenital, not hereditary Clinical Features:Clinical Features: Hemangioma in brain leads to mental retardation due Hemangioma in brain leads to mental retardation due

to lack of blood flowto lack of blood flow Calcifications in meninges: “tram-line” or “train Calcifications in meninges: “tram-line” or “train

tracks” calcifications seen on xraytracks” calcifications seen on xray Hemangioma on face (portwine nevus or nevi) found Hemangioma on face (portwine nevus or nevi) found

in ophthalmic and maxillary division of the trigeminal in ophthalmic and maxillary division of the trigeminal nerve (C.N. V)nerve (C.N. V)

Nevus flammeus: hemangioma in the mouth Nevus flammeus: hemangioma in the mouth (unilateral) stops at midline(unilateral) stops at midline

Treatment: neurosurgery of brain hemangiomasTreatment: neurosurgery of brain hemangiomas

Syndromes assoc. w/ Syndromes assoc. w/ hemangiomashemangiomas Rendu-Osler-Weber diseaseRendu-Osler-Weber disease

Hereditary Hemorrhagic Telangiectasia (HHT) A person Hereditary Hemorrhagic Telangiectasia (HHT) A person with HHT has a tendency to form blood vessels that with HHT has a tendency to form blood vessels that lack the capillaries between an artery and vein. This lack the capillaries between an artery and vein. This means that arterial blood under high pressure flows means that arterial blood under high pressure flows directly into a vein without first having to squeeze directly into a vein without first having to squeeze through the very small capillaries. This place where an through the very small capillaries. This place where an artery is connected directly to a vein, tends to be a artery is connected directly to a vein, tends to be a fragile site that can rupture and result in bleeding. We fragile site that can rupture and result in bleeding. We usually call a blood vessel that is abnormal in this way usually call a blood vessel that is abnormal in this way a telangiectasia. if it involves small blood vessels, it’s a telangiectasia. if it involves small blood vessels, it’s called an arterioveneous malformation (AVM) if involves called an arterioveneous malformation (AVM) if involves larger blood vessels. AVM= a big telangiectasis. larger blood vessels. AVM= a big telangiectasis.

Congenital and hereditaryCongenital and hereditary Clinical Features:a telangiectasia or AVM has greater Clinical Features:a telangiectasia or AVM has greater

tendency to rupture and bleed than a normal blood tendency to rupture and bleed than a normal blood vessel. In the nose, skin, GI tract (stomach and vessel. In the nose, skin, GI tract (stomach and intestines), and brain the primary problem they can intestines), and brain the primary problem they can cause is bleeding. cause is bleeding.

Aneurysmal Bone CystAneurysmal Bone Cyst Description: not a true cyst, an aggressive reactive Description: not a true cyst, an aggressive reactive

process. process. Clinical Features: a lesion of large vascular sinusoids, Clinical Features: a lesion of large vascular sinusoids,

so blood can be aspirated with a syringe. No bruit so blood can be aspirated with a syringe. No bruit (pulsing sound) due to the low pressures. It has a (pulsing sound) due to the low pressures. It has a great potential for growth and can result in marked great potential for growth and can result in marked expansion and deformity. The mandible body is the expansion and deformity. The mandible body is the most frequent site. most frequent site.

Histologically,Histologically, large blood-filled sinusoids lined by an large blood-filled sinusoids lined by an endothelial layer with surrounding fibroblastic, endothelial layer with surrounding fibroblastic, hypercellular tissue is present. hypercellular tissue is present.

Radiographic Features:A multilocular radiolucency Radiographic Features:A multilocular radiolucency traversed by thin septae with cortical expansion traversed by thin septae with cortical expansion

Treatment: Simple enucleation is the preferred Treatment: Simple enucleation is the preferred treatment. Recurrence is rare.treatment. Recurrence is rare.

LymphangiomaLymphangioma Description:occurs as an extensive developmental Description:occurs as an extensive developmental

abnormality involving the face and neck; also abnormality involving the face and neck; also known as "cystic hygroma." known as "cystic hygroma."

Clinical Features: The close association of the Clinical Features: The close association of the lesion with surface epithelium imparts the nodular lesion with surface epithelium imparts the nodular configuration to the surface. configuration to the surface.

Histopathologic FindingsHistopathologic Findings: there are numerous thin : there are numerous thin walled lymph channels extending in a diffuse walled lymph channels extending in a diffuse pattern between skeletal muscle bundles. The pink pattern between skeletal muscle bundles. The pink material in the vessels is lymph. The material in the vessels is lymph. The lymphangiomatous proliferation generally extends lymphangiomatous proliferation generally extends to immediately beneath the epithelium and to immediately beneath the epithelium and consists of many thin walled channels containing consists of many thin walled channels containing lymph fluid. lymph fluid.

TreatmentTreatment: These are difficult to treat and often : These are difficult to treat and often impair or compromise the patient's air space. impair or compromise the patient's air space.

LymphangiomaLymphangioma

Odontogenic MyxomaOdontogenic Myxoma DescriptionDescription: from the dental papilla or follicular mesenchyme. : from the dental papilla or follicular mesenchyme.

one of the most rare odontogenic tumors one of the most rare odontogenic tumors Clinical FeaturesClinical Features: sometimes associated with impacted teeth. : sometimes associated with impacted teeth. more common in the maxilla than the mandible and appears more common in the maxilla than the mandible and appears

commonly in the second decade of life. commonly in the second decade of life. It develops slowly and asymptomatically, provoking an It develops slowly and asymptomatically, provoking an

expansion of the alveolar ridges and displacement of expansion of the alveolar ridges and displacement of neighboring teeth. Bneighboring teeth. But it is aggressively invasive and may ut it is aggressively invasive and may become quite large. become quite large.

Histopathologic FindingsHistopathologic Findings: spindle and stellate fibroblasts are : spindle and stellate fibroblasts are associated with basophilic ground substance and associated with basophilic ground substance and myxomatous tissue. myxomatous tissue.

Radiographic Findings: Radiographic Findings: radiolucent;radiolucent; multilocular and multilocular and expansile, with coursing septae which look like a finely expansile, with coursing septae which look like a finely reticulated spider web or reticulated spider web or a honeycomb or mottled a honeycomb or mottled appearanceappearance

Treatment Treatment en bloc resection to prevent recurrence, although en bloc resection to prevent recurrence, although curettage may be attempted for more fibrotic lesions. curettage may be attempted for more fibrotic lesions.

MyxomaMyxoma

ExostosesExostoses Description: exostosis = outgrowth of bone Description: exostosis = outgrowth of bone Torus palatinusTorus palatinus Torus palatinus is found at the midline of the palate. It is an Torus palatinus is found at the midline of the palate. It is an

extension of the bony process and not a well-defined extension of the bony process and not a well-defined neoplasm.neoplasm.

Torus mandibularisTorus mandibularis Buccal exostosesBuccal exostoses Clinical Features: hard swellings covered by somewhat thin Clinical Features: hard swellings covered by somewhat thin

but essentially normal mucosa. but essentially normal mucosa. If the overlying mucosa becomes irritated, ulceration is often If the overlying mucosa becomes irritated, ulceration is often

slow to heal because of poor underlying vascularity. slow to heal because of poor underlying vascularity. Radiographic Features: marked opacity and lack of bone Radiographic Features: marked opacity and lack of bone

resorption so it indicates an innocuous(harmless) condition. resorption so it indicates an innocuous(harmless) condition. zones of radiopacity with some superimposition over the roots zones of radiopacity with some superimposition over the roots of the adjacent teeth;no disruption of the normal bony of the adjacent teeth;no disruption of the normal bony architecture in the area or in the lamina duraarchitecture in the area or in the lamina dura

Treatment: none; a lobular lesion would require removal prior Treatment: none; a lobular lesion would require removal prior to construction of dentures. to construction of dentures.

OsteomaOsteoma Description: Osteomas are considered to be Description: Osteomas are considered to be

benign neoplasms of bone forming tissue. An benign neoplasms of bone forming tissue. An exophytic nodular growth of dense cortical bone exophytic nodular growth of dense cortical bone on or within the jaws in locations other than those on or within the jaws in locations other than those occupied by tori or exostoses.occupied by tori or exostoses.

Clinical Features:Osteomas are less common than Clinical Features:Osteomas are less common than exostoses. exostoses.

Histopathologic findingsHistopathologic findings: cellular and active lesion : cellular and active lesion with areas of loose vascular connective tissue with areas of loose vascular connective tissue containing irregular bone trabeculae. with containing irregular bone trabeculae. with considerable osteoblastic activity. considerable osteoblastic activity.

Radiographic findingsRadiographic findings: round opacity with central : round opacity with central areas of radiolucency. This lesion is much less areas of radiolucency. This lesion is much less radiopaque than the typical exostosisradiopaque than the typical exostosis

Treatment: Treatment of osteomas is only Treatment: Treatment of osteomas is only necessary if they are symptomatic. necessary if they are symptomatic.

Osteoid OsteomaOsteoid Osteoma Description:Osteoid osteoma is a benign Description:Osteoid osteoma is a benign

skeletal neoplasm of unknown etiology that skeletal neoplasm of unknown etiology that is composed of osteoid and woven bone. is composed of osteoid and woven bone. Clinical Features:Pain on palpation well-Clinical Features:Pain on palpation well-demarcated, encapsulated, expansile demarcated, encapsulated, expansile intraosseous lesion of the jawsintraosseous lesion of the jaws

Histopathology: Active central cellular nidus Histopathology: Active central cellular nidus surrounded by zone of osteoid fomationsurrounded by zone of osteoid fomation

Radiographic Features:A circular or ovoid Radiographic Features:A circular or ovoid lucent defect is seen in 75% of patients. lucent defect is seen in 75% of patients. This defect is usually smaller than 1.5 cm in This defect is usually smaller than 1.5 cm in diameter and is associated with sclerosis. diameter and is associated with sclerosis.

Treatment:surgical excisionTreatment:surgical excision

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