Pyogenic granuloma

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Classification according to ICD-10
L98.0 Granuloma pediculatum [Granuloma pyogenicum]
ICD-10 online (WHO version 2019)

The pyogenic granuloma ( lat. Granuloma pyogenicum ) is an acquired benign vascular skin tumor from the group of hemangiomas . It is an exophytic vascular proliferation .

An early stage pyogenic granuloma on a finger.
Multiple pyogenic granuloma on the penis of a four-year-old (anterior view).
Same patient (dorsal view).
A large pyogenic granuloma on the left thigh of a 28-year-old woman with HIV .
The same thigh five months after treatment.
A pyogenic granuloma on the palate of a 16-year-old patient.

This strongly proliferating tumor ( hyperplasia ) is often misinterpreted as a malignant tumor ( cancer ). The pyogenic granuloma does not have a specific histological appearance. Therefore, it has received a variety of names in the past, including Granuloma pediculatum , Pediculatum , Epulis granulomatosa , Granuloma teleangiectaticum , Epulis angiomatosa , wound granuloma , peduncles , telangiectaticum , pseudobotryomycom , telangiectatic wound granuloma , eruptive angioma, and proliferative angioma .

The widespread name pyogenic granuloma is a mistake in the name ( misnomer ), since it is not a bacterial infection ( pyogenic = 'pus-forming'), but inflammatory hyperplasia. Strictly speaking, the term granuloma is also incorrect.

Therefore, some authors prefer the term lobular capillary hemangioma ( . English lobular capillary hemangioma , LCH), while other authors distinguish two subspecies in pyogenic granuloma: said lobular capillary hemangioma and a non-LCH-type ( non-LCH ). Both subtypes differ in their histology.

Distribution and Incidence

Pyogenic granuloma can occur in both men and women of any age group. It occurs more frequently in the second and third decades of age. In fair-skinned people, the prevalence of 86.4 percent is significantly higher than that of dark-skinned people (6.2 percent) and Asian (0.8 percent).

Since the pyogenic granuloma often occurs during pregnancy, it is also called pregnancy tumor ( granuloma gravidarum or epulis gravidarum ) in these cases . The changed hormone levels in women during pregnancy increase the likelihood of developing a lobular capillary hemangioma. Depending on the study, very different values ​​of 0.2 to 14% are given for the prevalence of a pregnancy tumor.

Pyogenic granuloma is a skin tumor. It is very rarely found in the gastrointestinal tract - with the exception of the oral cavity . The incidence of oral pyogenic granulomas is very high.

etiology

The exact pathomechanism that leads to a pyogenic granuloma is still largely unclear. Wounds , local irritations, certain drugs or hormonal changes are in principle able to initiate tumor formation.

Many patients report that they have previously had an injury or irritation where they developed pyogenic granuloma . For example, pyogenic granulomas can form after circumcision. Also, second-degree burns can later promote the local development of pyogenic granulomas same year. Fire stains ( nevus flammeus ) are an often observed starting point for a pyogenic granuloma. Obviously, the malformed blood vessels in the nevus flammeus favor their development.

For a long time it was assumed that human papilloma viruses would play a role in the genesis of pyogenic granuloma. However, no viruses of HPV types 6, 11, 16, 31, 33, 35, 42 or 58 could be detected using the polymerase chain reaction .

The inducible NO synthase (iNOS), the vascular endothelial growth factor (VEGF), the fibroblast growth factor (FGF) and the connective tissue growth factor (CTGF) play an essential role in angiogenesis and the growth of pyogenic granuloma.

During pregnancy, complex changes in blood vessels that are not yet fully understood take place. In addition to a pyogenic granuloma, nevi aranei (spider nevi ), glomus tumors or edema (especially in the face and legs) are increasingly formed. Most of these symptoms regress after the end of pregnancy - including granuloma gravidarum (pregnancy tumor). Poor oral hygiene during pregnancy significantly increases the likelihood of pyogenic granuloma. In many cases - for various reasons - oral hygiene deteriorates during pregnancy, so that, among other things, more tartar can form. A gingivitis get about 35 to 50% of all pregnant women during their pregnancy.

Certain drugs, such as first-generation retinoids ( isotretinoin ) used to treat acne , are suspected of causing pyogenic granulomas in certain cases.

description

Main types

Typical of the pyogenic granuloma is the rapid growth of the tumor with the formation of a red knot, which is pinched off towards the base in the further course of growth (mushroom-shaped structure). In most cases, the diameter is between 10 and 30 mm. The tumor is rarely larger and usually only occurs singly. A satellitesosis is very rarely observed. There is a sharp demarcation from healthy tissue. In many cases, the surface of the mostly soft, spherical tumor is fissured and encrusted as it tends to ooze or bleed easily. In the late stage, the tumor is prone to secondary ulceration . The tumor itself usually does not cause pain.

A pyogenic granuloma preferably forms on the extremities, in the head and neck area and on the oro-nasal mucous membranes . Accordingly, it can often be found on the lips , scalp , face , fingertips , tongue , palm, and toes . Occasionally the penis can also be affected. A pregnancy tumor, on the other hand, occurs almost exclusively in the oral cavity.

Granuloma pyogenicum is very rarely found in other organs such as the liver , the small intestine , the stomach, the sigmoid colon (the last section of the large intestine) or in the gastrointestinal tract at all .

With the exception of pregnancy tumors ( granuloma gravidarum ), spontaneous regressions are very rare. If the removal is incomplete, the recurrence rate is very high.

Subtypes

Several rare subtypes of pyogenic granuloma are known. These include:

  • the subcutaneous intravascular variant
  • the eruptive pyogenic granuloma and
  • the pyogenic granuloma with satellitosis.

Differential diagnosis

The pyogenic granuloma can only be differentiated from amelanotic malignant melanoma (a special form of black skin cancer) histologically. A heme angiosarcoma , and - especially in the oral cavity - a squamous cell carcinoma are also to be considered. Squamous cell carcinomas are the most common malignant tumors in the oral cavity with a share of around 80% .

therapy

Since a pyogenic granuloma - with the exception of the pregnancy tumor - does not resolve in most cases, removal of the tumor is indicated in many cases. This can be done either surgically by excision or by laser ablation . In both cases it is important that the central blood vessel that supplies the tumor is completely removed, otherwise recurrences will very often occur. Some authors advise against laser ablation because of the high rate of recurrence. The recurrence rate for excision is in the range of up to 15 percent. Recurrences can return to the original tumor size a few days after therapy . In adults, the excision can be performed under local anesthesia . General anesthesia is usually used in children .

In addition to these two established procedures, cryosurgery , intralesional injection of corticosteroids , ethanol and other sclerosing substances have been used or discussed in the past .

forecast

Pyogenic granuloma is usually not a serious condition because of its benignity . After complete removal of the tumor, there is a very high probability of complete cure .

There are known cases of pregnancy tumors that have formed on the nasal mucosa, filled the entire nasal cavity, and then grew out of the nose. The patients then lost up to 500 ml of blood when they bleed. Due to the extreme tumor growth, parts of the nasal skeleton and the paranasal sinuses can degenerate.

Initial description

The pyogenic granuloma was first described in 1897 by the French Antonin Poncet and Louis Dor in a patient who had this tumor in the oral cavity. They named the disease Botryomycosis hominis because they thought it was botryomycosis (grape fungus disease) transmitted from horses to humans ; a chronic infectious wound disease. Seven years later, MB Hartzell found that this assumption was wrong. He gave the disease the name Granuloma pyogenicum, which is still the most widely used - factually incorrect - name .

Individual evidence

  1. ↑ a b c d e A. Vilmann et al .: Pyogenic granuloma: evaluation of oral conditions. In: Br J Oral Maxillofac Surg 24, 1986, pp. 376-382. PMID 2945586
  2. ^ A b C. Spinelli: Multiple pyogenic granuloma of the penis in a four-year-old child: a case report. In: Cases J 2, 2009, 7831. PMID 19918487
  3. ↑ a b c d e f g h i M. Grosskopf: The "pregnancy tumor" of the gingiva. Dissertation, Johann Wolfgang Goethe University Frankfurt am Main, 2005
  4. ↑ a b c H. Jafarzadeh et al: Oral pyogenic granuloma: a review. ( Memento of the original from May 28, 2007 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. In: J Oral Sci 48, 2006, pp. 167-175. PMID 17220613 (Review) @1@ 2Template: Webachiv / IABot / www.jstage.jst.go.jp
  5. ↑ a b P. M. Nthumba: Giant pyogenic granuloma of the thigh: a case report. In: Journal of Medical Case Reports 2008, 2:95. doi : 10.1186 / 1752-1947-2-95 PMID 18377654 ( Open Access )
  6. ↑ SN Bhaskar and JR Jacoway: Pyogenic granuloma - clinical features, incidence, histology, and result of treatment: report of 242 cases. In: J Oral Surg 24, 1966, pp. 391-398. PMID 5220911
  7. ↑ RA Miller et al .: Multiple granulation tissue lesions occurring in isotretinoin treatment of acne vulgaris - successful response to topical corticosteroid therapy. In: Journal of the American Academy of Dermatology 12, 1985, pp. 888-889. PMID 3159762
  8. ^ A b M. Mooney and C. Janniger: Pyogenic granuloma. In: Cutis 55, 1995, pp. 133-136. PMID 7634842 (Review)
  9. ↑ C. EVANS: Pyogenic granuloma; multiple local recurrence following excision. In: Proceedings of the Royal Society of Medicine. Volume 47, Number 12, December 1954, pp. 1063-1065, PMID 13237197 , PMC 1919179 (free full text).
  10. ↑ M. Ceyhan et al .: Pyogenic granuloma with multiple dissemination in a burn lesion. In: Pediatric Dermatology 14, 1997, pp. 213-215. PMID 9192415
  11. ↑ DJ Sheehan and JL Lesher: Pyogenic granuloma arising within a port-wine stain. In: Cutis 73, 2004, pp. 175-180. PMID 15074345 (Review)
  12. ↑ A. Miller et al .: The role of human papillomavirus in the development of pyogenic granulomas. In: International Journal of Dermatology 36, 1998, pp. 673-676. PMID 9352408
  13. ↑ K. Shimizu et al .: Inducible nitric oxide synthase is expressed in granuloma pyogenicum. In: British Journal of Dermatology 138, 1998, pp. 769-773. PMID 9666820
  14. ^ R. Bragado et al .: Increased expression of vascular endothelial growth factor in pyogenic granulomas. In: Acta Dermato-Venereologica 79, 1999, pp. 422-425. PMID 10598753
  15. ↑ K. Hagiwara et al.: Mast cell "densities" in vascular proliferations: a preliminary study of pyogenic granuloma, portwine stain, cavernous hemangioma, cherry angioma, Kaposi's sarcoma, and malignant hemangioendothelioma. In: The Journal of Dermatology 26, 1999, pp. 577v586. PMID 10535252
  16. ↑ C. Bachmeyer et al .: Pyogenic granuloma of the tongue in chronic graft versus host disease. In: Annales de Dermatologie et de Vénéréologie 123, 1996, pp. 552-554. PMID 9615106 (article in French)
  17. ^ F. Henry et al .: Blood vessel changes during pregnancy: a review. In: American Journal of Clinical Dermatology 7, 2006, pp. 65-69. PMID 16489843 (Review)
  18. ↑ GT Terezhalmy et al: Pyogenic granuloma (pregnancy tumor). In: Quintessence Int 31, 2000, pp 440-441. PMID 11203964
  19. ↑ RP Levin: Pregnancy gingivitis. In: J Md State Dent Assoc 30, 1987, p. 27. PMID 3473151
  20. ↑ MA Dawkins et al: Pyogenic granuloma-like lesion associated with topical tazarotene therapy. In: Journal of the American Academy of Dermatology 43, 2000, pp. 154-155. PMID 10863244
  21. ↑ A. Türel et al .: A rare side-effect of systemic isotretinoin treatment: pyogenic granuloma. In: Journal of the European Academy of Dermatology and Venereology 17, 2003, pp. 609-611. PMID 12941114
  22. ↑ a b c d H. Kutzner: Vascular tumors. In: Dermatology and Venereology. O. Braun-Falco and HH Wolff (editors), Verlag Springer, 2005, ISBN 3-540-40525-9 , p. 1352. Restricted preview in the Google book search
  23. ↑ a b c P. Altmeyer: Encyclopedia of Dermatology, Venereology, Allergology, Environmental Medicine. ( Memento of the original from May 29, 2011 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. Verlag Springer, 2009, ISBN 3-540-89542-6 @1@ 2Template: Webachiv / IABot / 132.187.10.79
  24. ↑ KM Eickhorst et al .: Pediatric pyogenic granuloma of the glans penis. In: Urology 61, 2003, p. 644. PMID 12639669 (Review)
  25. ↑ JC Smulian et al: Non-oral pyogenic granuloma in pregnancy: a report of two cases. In: Obstetrics & Gynecology 84, 1994, pp. 672-674. PMID 9205444
  26. ↑ F. Abaalkhail et al.: Lobular capillary hemangioma of the liver. In: Hepatobiliary Pancreat Dis Int 8, 2009, pp. 323-325. PMID 19502177 (Review)
  27. ↑ DC Moffatt, P. Warwryko, H. Singh: Pyogenic granuloma: an unusual cause of massive gastrointestinal bleeding from the small bowel. In: Canadian journal of gastroenterology = Journal canadien de gastroenterologie. Volume 23, Number 4, April 2009, pp. 261-264, PMID 19373418 , PMC 2711675 (free full text) (review).
  28. ↑ A. Kusakabe et al .: Pyogenic granuloma of the stomach successfully treated by endoscopic resection after transarterial embolization of the feeding artery. In: J Gastroenterol 40, 2005, pp. 530-535. PMID 15942720 (Review)
  29. ↑ MC González-Vela et al .: Pyogenic granuloma of the sigmoid colon. In: Ann Diagn Pathol 9, 2005, pp. 106-109. PMID 15806519 (Review)
  30. ^ A. Malhotra et al .: Clinical challenges and images in GI. Diagnosis: Gastric pyogenic granuloma. In: Gastroenterology 136, 2009, p. 1463. PMID 19250652 (Review)
  31. ↑ RR Fortna and JM Junkins-Hopkins: A case of lobular capillary hemangioma (pyogenic granuloma), localized to the subcutaneous tissue, and a review of the literature. In: The American Journal of Dermatopathology 29, 2007, pp. 408-411. PMID 17667179 (Review)
  32. ↑ W. Bengel: Differential diagnosis of oral mucosal diseases. Free Association of German Dentists (publisher), Bonn, 1996, ISBN 3-921-84504-1
  33. ↑ SB Kapadia and DK Heffner: Pitfalls in the histopathologic diagnosis of pyogenic granuloma. In: Eur Arch Otorhinolaryngol 249, 1992, pp. 195-200. PMID 1642875
  34. ↑ W. Tantinikorn include: nasal granuloma gravidarum presenting with recurrent massive epistaxis. In: J Med Assoc Thai 86, 2003, pp. 473-476. PMID 12859106
  35. ↑ E. Lance et al .: Pyogenic granuloma gravidarum of the nasal fossa: CT features. In: J Comput Assist Tomogr 16, 1992, pp. 663-664. PMID 1629433
  36. ↑ A. Poncet and L. Dor: Botryomycose humaine. In: Rev Chir Orthop 18, 1897, p. 996.
  37. ↑ MB Hartzell: Granuloma pyogenicum (botryomycosis of French authors). In: Journal of Cutaneous Disease 22, 1904, pp. 520-523.

further reading

Reference books
Review article
Original publications

Web links

Commons : Pyogenic Granuloma  - Collection of pictures, videos, and audio files