Recurrent pyogenic granuloma: an update
DOI:
https://doi.org/10.18203/issn.2454-2156.IntJSciRep20150196Abstract
Background: Given the fierce controversy about the nature of pyogenic granulomas, starting with its unfitting name and ending up with its ideal treatment modality, this paper tries to numerically identify some predisposing factors of recurrence.
Methods: The literature was initially reviewed and a total of twenty recurrent cases of pyogenic granuloma were contrasted, on one hand, to their initial appearance. On the other hand, all are contrasted to a similar number of normal mucosa using three histochemical stains: Alcian blue, periodic acid-Schiff and Masson’s trichrome.
Results: For all recurrent lesions, all specimens showed myxoid structure histologically even if their initial appearance had possessed a sparse myxoid structure. The age of recurrence has been correlated to the histochemical findings. For the Alcian Blue stain (AB), the value of t-test was 3.808840. The pertaining value of P was 0.000593. The result was significant at P ≤0.05. For the PAS stain, the value of t-test was 3.640327. The value of P was 0.000871. The result was significant at P ≤0.05. In Masson’s trichrome staining, the value of t-test was 3.100816. The value of P was 0.002942. The result was significant at P ≤0.05. Accordingly, all stains showed significant difference in fibrous content in the initial and recurrent lesions. Conversely, the count of both endothelial vessels and inflammatory infiltrates in the recurrent lesions were significantly lower than the primary precursors.
Conclusions: Given that collagen fibers are continually degraded and resynthesized while proteolytic degradation occur outside the cells through the activity of enzymes called matrix metalloproteinases (MMPs), it is suggested that MMPs -positively expressed by PAS reactions- account for the spacing of the fibrous stroma, allowing for reshaping the three dimensional structure of the connective tissue. Myxoid structures are certainly promoting recurrence either via excessive secretion of hyaluronic acids or unknown mechanisms. The undisputed fact is the presence of myxoid structures in all our reported recurrent cases. Both inflammatory cascade and endothelial proliferation have no vital role in the recurrence according to our morphometric results. Finally, PAS stain should give more details in examining PGs than the other recruited counterparts.
Keywords: Recurrent pyogenic granuloma, PAS stain, Myxoid structures, Etiopathogensis
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References
Ross M, Pawlina W. Inflammation. In: Ross M, Pawlina W, eds. Histology: A Text and Atlas: with Correlated Cell and Molecular Biology. 4th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health; 2001: 158-178.
Neville BW, Damm DD, Allen CM, Bouquot JE. Pyogenic granuloma. In: Neville BW, Damm DD, Allen CM, Bouquot JE, eds. Oral and Maxillofacial Pathology. 3rd ed. Philadelphia Elsevier; 2009: 447-449.
Kamal R, Dahiya P, Puri A. Oral pyogenic granuloma: various concepts of etiopathogenesis. J Oral Maxillofac Pathol. 2012;16(1):79-82.
Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: a review. J Oral Sci. 2006;48(4):167-75.
Gomes S, Shakir Q, Thaker P, Tavadia J. Pyogenic granuloma of the gingiva: a misnomer? - A case report and review of literature. J Indian Soc Periodontol. 2013;17(4):514-9.
Hartzell M. Granuloma pyogenicum. J Cutan Dis Syph. 1904;22:520-5.
Bhaskar S, Jacoway J. Pyogenic granuloma - clinical features, incidence, histology, and result of treatment: report of 242 cases. J Oral Surg. 1966;24:391-8.
Regezi JA, Sciubba J, Jordan R. Pyogenic granuloma. In: Regezi JA, Sciubba J, Jordan R, eds. Oral Pathology: Clinical Pathological Considerations. 4th ed. Philadelphia: WB Saunders; 2003: 115-116.
Mussalli NG, Hopps R, Johnson NW. Oral pyogenic granuloma as a complication of pregnancy and the use of hormonal contraceptives. Int J Gynaecol Obstet. 1976;14:187-91.
Kuo Yuan, Lih-Yuh C. Wing, Ming T. Lin, Pathogenetic roles of angiogenic factors in pyogenic granulornas in pregnancy are modulated by female sex hormones. J Periodontol. 2002;73(7):701-8.
Bachmeyer C, Devergie A, Mansouri S, Dubertret L, Aractingi S. Pyogenic granuloma of the tongue in chronic graft versus host disease. Ann Dermatol Venereol. 1996;123:552-4.
Eversole L. Pyogenic granulomas. In: Eversole L, eds. Clinical Outline of Oral Pathology: Diagnosis and Treatment. 3rd ed. Hamilton: BC Decker; 2002: 113-114.
Kang Y, Byun J, Choi MJ, Lee JS, Jang JH, Kim YI, et al. Co-development of pyogenic granuloma and capillary hemangioma on the alveolar ridge associated with a dental implant: a case report. J Med Case Rep. 2014;8:192.
Pilch B. Pyogenic granuloma. In: Pilch B, eds. Head and Neck Surgical Pathology. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2001: 389-390.
Macleod R, Soames J. Epulides: a clinicopathological study of a series of 200 consecutive lesions. Br Dent J. 1987;163:51-3.
Patussi C, Sassi LM, Da Silva WP, Zavarez LB Schussel JL. Oral pyogenic granuloma after tongue piercing use: case report. Dentistry. 2014;4:5.
Aguilo L. Pyogenic granuloma subsequent to injury of a primary tooth. A case report. Int J Paediatr Dent. 2002;12(6):438-41.
Esmeili T, Lozada-Nur F. Epstein Common benign oral soft tissue masses. J Dent Clin North Am. 2005 Jan;49(1):223-40.
Kneafsey L, Hughes C. Quadhelix appliance therapy resulting in pyogenic granuloma of the tongue. Dent Update. 2002 Nov;29(9):462-3.
Asnaashari M, Bigom-Taheri J, Mehdipoor M, Bakhshi M, Azari-Marhabi S. Posthaste outgrow of lip pyogenic granuloma after diode laser removal. J Lasers Med Sci. 2014;5(2):112-6.
Philip S, Lewis E, Wysocki G. Pyogenic granuloma. Contemp Oral Maxillofac Pathol. 1997;9:306.
Correa Y, Pinto C, Guilherme L, Senna M, Leipner M. Clinical and histological evaluation of granuloma gravidarum: case report. Braz Dent J. 2000;11(2):135-9.
Saikhedkar R, Shrivastava S, Melkundi M, Viswanathan V. Pyogenic granuloma - a case report. Int J Dent Clin. 2011;(3):87-8.
Lee L, Miller P, Maxymiw W, Messner H, Rotstein L. Intraoral pyogenic granuloma after allogeneic bone marrow transplant. Report of three cases. Oral Surg Oral Med Oral Pathol. 1994;78:607-10.
Higgins E, Hughes J, Snowden S, Pembroke A. Cyclosporin-induced periungual granulation tissue. Br J Dermatol. 1995;132(5):829-30.
Suarez-Amor O, Cabanillas M, Monteagudo B, de Las Heras C, Cacharron J. Disseminated pyogenic granuloma induced by erythropoietin? Actas Dermosifiliogr. 2009;100(5):439-40.
Vergara A, Isarria M, Rodriguez-Peralto J, Guerra A. Disseminated lobular capillary hemangiomas. Actas Dermosifiliogr. 2008;99(6):494-6.
Wollina U. Multiple eruptive periungual pyogenic granulomas during anti-CD20 monoclonal antibody therapy for rheumatoid arthritis. J Dermatol Case Rep. 2010;4(3):44-6.
Campbell J, Grekin R, Ellis C, Matsuda-John S, Swanson N, Voorhees J. Retinoid therapy is associated with excess granulation tissue responses. J Am Acad Dermatol. 1983;9(5):708-13.
Badri T, Hawilo AM, Benmously R, Fenniche S, Mokhtar I. Acitretin-induced pyogenic granuloma. Acta Dermatovenerol Alp Panonica Adriat. 2011;20(4):217-8.
Teknetzis A, Ioannides D, Vakali G, Lefaki I, Minas A. Pyogenic granulomas following topical application of tretinoin. J Eur Acad Dermatol Venereol. 2004;18(3):337-9.
Bouscarat F, Bouchard C, Bouhour D. Paronychia and pyogenic granuloma of the great toes in patients treated with indinavir. N Engl J Med. 1998;338(24):1776-7.
Wu PA, Balagula Y, Lacouture ME, Anadkat MJ. Prophylaxis and treatment of dermatologic adverse events from epidermal growth factor receptor inhibitors. Curr Opin Oncol. 2011;23(4):343-51.
Curr N, Saunders H, Murugasu A, Cooray P, Schwarz M, Gin D. Multiple periungual pyogenic granulomas following systemic 5-fluorouracil. Australas J Dermatol. 2006;47(2):130-3.
35. Piguet V, Borradori L:. Pyogenic granuloma-like lesions during capecitabine therapy. Br J Dermatol. 2002;147(6):1270-2.
36. Freiman A, Bouganim N, O'Brien E: Case reports: mitozantrone-induced onycholysis associated with subungual abscesses, paronychia, and pyogenic granuloma. J Drugs Dermatol. 2005;4(4):490-2
Devillers C, Vanhooteghem O, Henrijean A, Ramaut M, de la Brassinne M. Subungueal pyogenic granuloma secondary to docetaxel therapy. Clin Exp Dermatol. 2009;34(2):251-2.
Paul L, Cohen P. Paclitaxel-associated subungual pyogenic granuloma: report in a patient with breast cancer receiving paclitaxel and review of drug-induced pyogenic granulomas adjacent to and beneath the nail. J Drugs Dermatol. 2012;11(2):262-8.
Sibaud V, Dalenc F, Mourey L, Chevreau C. Paronychia and pyogenic granuloma induced by new anticancer mTOR inhibitors. Acta Derm Venereol. 2011;91(5):584-5.
Epivatianos A, Antoniades D, Zaraboukas T, Zairi E, Poulopoulos A, Kiziridou A, et al. Pyogenic granuloma of the oral cavity: comparative study of its clinicopathological and immunohistochemical features. Pathol Int 2005; 55, 391-7
Piraccini BM, Bellavista S, Misciali C, Tosti A, de Berker D, Richert B. Periungual and subungual pyogenic granuloma. Br J Dermatol. 2010;163(5):941-53.
Greenberg MS, Glick M. The pyogenic granuloma. In: Greenberg MS, Glick M, eds. Burket’s Oral Medicine: Diagnosis and Treatment. 10th ed. Hamilton: BC Decker; 2003: 141-142.
Mubeen K, Vijayalakshmi K, Abhishek R. Oral pyogenic granuloma with mandible involvement: An unusual presentation. J Dent Oral Hyg. 2011;3(1):6-9.
Patrice S, Wiss K, Mulliken J. Pyogenic granuloma (lobular capillary hemangioma): a clinicopathologic study of 178 cases. Pediatr Dermatol. 1991 Dec;8(4):267-76.
Bouquot J, Nikai H. Lesions of the oral cavity. In: Bouquot J, Nikai H, eds. Diagnostic Surgical Pathology of the Head and Neck. 5th ed. Philadelphia: Saunders; 2001: 141-233.
Parisi E, Glick PH, Glick M. Recurrent intraoral pyogenic granuloma with satellitosis treated with corticosteroids. Oral Dis. 2006;12:70-2.
Gonçales E, Damante J, Rubira C, Taveira L. Pyogenic granuloma on the upper lip: an unusual location. J Applied Oral Sci. 2010;18(5):538-41.
Saravana G. Oral pyogenic granuloma: a review of 137 cases. Br J Oral Maxillofac Surg. 2009;47:18-9.
Harris MN, Desai R, Chuang TY, Hood AF, Mirowski GW. Lobular capillary hemangiomas: An epidemiologic report, with emphasis on cutaneous lesions. J Am Acad Dermatol. 2000 Jun;42(6):1012-6.
Santosh H, Bose A. Oral pyogenic granuloma of upper labial mucosa: an unusual case presentation. J Appl Oral Sci. 2010;18(5):538-41.
Amirchaghmaghi M, Falaki F, Mohtasham N, Mozafari P. Extragingival pyogenic granuloma: a case report. Cases J. 2008;1:371.
Angelopoulos A. Pyogenic granuloma of the oral cavity: Statistical analysis of its clinical features. J Oral Surg. 1971;29:840-7.
Goodman-Topper ED, Bimstein E. Pyogenic granuloma as a cause of bone loss in a twelve-year-old child: report of case. ASDC J Dent Child. 1994;61:65-7.
Kamal R, Dahiya P, Palaskar S, Shetty V. Comparative analysis of mast cell count in normal oral mucosa and oral pyogenic granuloma. J Section: Oral Med Pathol. 2010;1:232-8.
The McGraw-Hill Companies. McGraw-Hill concise dictionary of modern medicine. In: McGraw-Hill, eds. A Dictionary. New York: The McGraw-Hill Companies, Inc.; 2002.
Graadt van Roggen JF, Hogendoorn PCW, Fletcher CDM. Myxoid tumours of soft tissue. Histopathology. 1999;35:291-312.
Brian J. Sutton, Jennifer Laudadio. Aggressive angiomyxoma. Arch Pathol Lab Med. 2012 Feb;136(2):217-21.
Ralph LL. Chondromyxoid fibroma of bone. J Bone Joint Surg. 1962;44-B:7.
Luca Oscar Redaelli de Zinis, Michela Piccioni, Antonino Roberto Antonelli, Piero Nicolai. Management and prognostic factors of recurrent pleomorphic adenoma of the parotid gland: personal experience and review of the literature. Eur Arch Otorhinolaryngol. 2008;265(4):447-52.
Francois Loubignac, Christophe Bourtoul, Francoise Chapel. Myxoid liposarcoma: a rare soft-tissue tumor with a misleading benign appearance. World J Surg Oncol. 2009;7:42.
Burch DM, Tavassoli FA. Myxoid leiomyosarcoma of the uterus. Histopathology. 2011;59(6):1144-55.
Asha V, Dhanya M, Patil BA, Revanna G. An unusual presentation of pyogenic granuloma of the lower lip. Contemp Clin Dent. 2014;5(4):524-6.
Robyn F. Gmyrek, Robert Beer, David N. Silvers, Robert Reiffel, Marc E. Grossman. Periungual myxoid neurofibroma. Cutis. 2002 Jan;69(1):54-6.
Hornick JL, Fletcher CD. Cellular neurothekeoma: detailed characterization in a series of 133 cases. Am J Surg Pathol. 2007 Mar;31(3):329-40.
Krishnan J, Hastak VH, Rajeev G. Redkar. Myxoid lipoblastoma. Indian Pediatr. 2013;50:603-5.
Dewan V, Darbyshire A, Sumathi V, Jeys L, Grimer R. Prognostic and survival factors in myxofibrosarcomas. Hendawi. 2012;2012:830879.
Mohammed S. Saeed, Thukaa T. Yahya, Osama E. Hudder, Issraa A. Hussein. Undifferentiated (Embryonal) sarcoma of the liver. Case report and review of literature. Embryonalsarc Liver. 2011;10(4):234-7.
Altaf Taher, Chitra Pushpanathan. Plexiform fibrohistiocytic tumor: a brief review. Arch Pathol Lab Med. 2007;131(7):1135-8.
Vicente Estrems Díaz, Francesc Xavier Bertó Martí, Víctor Zarzuela Sánchez, Maria Isabel Cabanes Ferrer, Antonio Bru Pomer. Parachordoma of soft tissues of the arm: a very rare tumour. Hindawi. 2013;2013:252376.
Meis-Kindblom Jeanne M, Kindblom Lars-Gunnar. Acral myxoinflammatory fibroblastic sarcoma: a low-grade tumor of the hands and feet. Am J Surg Pathol. 1998; 22(8):911-24.
Lone RA, Ahanger A, Singh S, Mehmood W, Shah S, Lone G, et al. Atrial myxoma: trends in management. Int J Health Sci (Qassim). 2008 Jul;2(2):141-51.
James William, Berger Timothy, Elston Dirk. Pyogenic granulomas. James William, Berger Timothy, Elston Dirk, eds. Andrews’ Diseases of the Skin: Clinical Dermatology. 10th ed. Philadelphia: Saunders; 2005: 614.
Miettinen M, Finnell V, Fetsch JF. Ossifying fibromyxoid tumor of soft parts--a clinicopathologic and immunohistochemical study of 104 cases with long-term follow-up and a critical review of the literature. Ame J Surgl Pathol. 2008;32:996-1005.
Meis JM, Enzinger FM. Juxta-articular myxoma: a clinical and pathologic study of 65 cases. Hum Pathol. 1992;23:639-46.
Boström A, von Lehe M, Hartmann W, Pietsch T, Feuss M, Boström JP, et al. Surgery for spinal cord ependymomas: outcome and prognostic factors. Neurosurgery. 2011;68(2):302-9.
Reimann JD, Fletcher CD. Myxoid dermatofibrosarcoma protuberans: a rare variant analyzed in a series of 23 cases. Am J Surg Pathol. 2007 Sep;31(9):1371-7.
Hruban RH, Senie RT, Woodruff JM. Malignant peripheral nerve sheath tumors of the buttock and lower extremity. A study of 43 cases. Cancer. 1990;66(6):1253-65.
Kourea HP, Leung DH, Lewis JJ, Woodruff JM. Subdiaphragmatic and intrathoracic paraspinal malignant peripheral nerve sheath tumors: a clinicopathologic study of 25 patients and 26 tumors. Cancer. 1998;82(11):2191-203.
Wong WW, Hirose T, Scheithauer BW, Schild SE, Gunderson LL. Malignant peripheral nerve sheath tumor: analysis of treatment outcome. Int J Radiat Oncol Biol Phys. 1998;42(2):351-60.
Aaron P. Mitchell, Michael Poiesz, Allen Leung. A case of highly aggressive extraskeletal myxoid chondrosarcoma. Case Rep Oncol. 2011;4(2):377-84.
Nishida Y, Tsukushi S, Nakashima H, Ishiguro N. Clinicopathologic prognostic factors of pure myxoid liposarcoma of the extremities and trunk wall. Clin Orthop Relat Res. 2010 Nov;468(11):3041-6.
Sato H, Takeda Y, Satoh M. Expression of the endothelial receptor tyrosine kinase Tie in lobular capillary hemangioma of the oral mucosa: an immunohistochemical study. J Oral Pathol Med. 2002;31:432-8.
Powell J, Bailey C, Coopland A, Otis C, Frank J, Meyer I. Nd:YAG laser excision of a giant gingival pyogenic granuloma of pregnancy. Lasers Surg Med. 1994;(14):178-83.
White J, Chaudhry SI, Kudler J, Sekandari N, Schoelch M, Silverman S. Nd:YAG and CO2 laser therapy of oral mucosal lesions. J Clin Laser Med Surg. 1998;(16):299-304.
Meffert J, Cagna D, Meffert R. Treatment of oral granulation tissue with the flashlamp pulsed dye laser. Dermatol Surg. 1998;24:845-8.
Ishida CE, Ramos-e-Silva M. Cryosurgery in oral lesions. Int J Dermatol. 1998;37:283-5.
Mohamad I, Periasamy C, Dawood Y. Tongue pyogenic granuloma excision by using ultrasonic scissors. Arch Orofac Sci. 2011;6(2):3.
Yuen A, Wong B. Ultrasonic glossectomy--simple and bloodless. Head Neck. 2005;27(8):690-5.
Ichimiya M, Yoshikawa Y, Hamamoto Y, Muto M. Successful treatment of pyogenic granuloma with injection of absolute ethanol. J Dermatol. 2004;31:342-4.
Parisi E, Glick PH, Glick M. Recurrent intraoral pyogenic granuloma with satellitosis treated with corticosteroids. Oral Dis. 2006;12:70-2.
Moon S, Hwang E, Cho K. Treatment of pyogenic granuloma by sodium tetradecyl sulfate sclerotherapy. Arch Dermatol. 2005;141:644-6.
Taira J, Hill T, Everett M. Lobular capillary hemangioma (pyogenic granuloma) with satellitosis. J Am Acad Dermatol. 1992;27:297-300.
Vilmann A, Vilmann P, Vilmann H. Pyogenic granuloma: evaluation of oral conditions. Br J Oral Maxillofac Surg. 1986;24:376-82.
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