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Enlarging Lobulated Nodule on Cheek

Case Challenge Number: 61

Diagnostic Information

History of Present Illness Raul is 55-year-old Hispanic male who reports with a chief complaint of, “I have a bump in my mouth that is getting bigger.” He first noticed it about 2 months prior, but is unable to recall any antecedent trauma. He does not relate any pain, but is annoyed by its presence and is starting to worry because it is enlarging. Medical History - Adverse drug effects: penicillin (upset stomach); Lisinopril (angioedema)

- Medications: desvenlafaxine, glyburide, simvastatin, Dyazide, Tylenol

- Pertinent medical history: depression; diabetes mellitus type 2; hypercholesterolemia; hypertension; osteoarthritis

- Pertinent family history: paternal: diabetes type 2, myocardial infarction age 58 (fatal); maternal: healthy; sisters have diabetes mellitus type 2

- Social history: denies tobacco; 2-3 beers / week; denies recreational drug exposure Clinical Findings - BP: 126/ 76 - Pulse: 76 - Extraoral examination reveals a normal TMJ, no muscle tenderness, and no lymphadenopathy - Intraoral examination reveals a well-defined (~ 2.5 cm x 1.5 cm) lobulated, pedunculated, smooth surfaced, soft tissue mass arising from the posterior right buccal mucosa. There is evidence of apparent surface irritation but there is no induration. An excisional biopsy is performed and the tissue submitted for histopathologic examination.

Figure 1. Lobulated tissue mass in the posterior right buccal mucosa.

Figure 2. Manipulation of the buccal mucosa mass to demonstrate a pedunculated attachment.

Histopathologic Findings The biopsy shows an ulcerated inflamed exophytic nodular lobulated proliferation of granulation tissue. The inflammatory infiltrate consists of neutrophils, eosinophils, lymphocytes, plasma cells and histiocytes. The stroma is edematous and contains numerous ectatic congested thin-walled vascular channels lined by plump reactive endothelial cells. The adjacent surface epithelium is hyperplasia and hyperparakeratotic.

Figure 3. Low-power histologic image showing a nodular ulcerated mass of inflamed granulation tissue with adjacent hyperplastic surface epithelium.

Figure 4. High-power histologic image showing acute and chronic inflammation with stromal edema and numerous interspersed ectatic vascular channels lined by plump reactive endothelial cells.