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.
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.
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.
Several rare subtypes of pyogenic granuloma are known. These include:
- the subcutaneous intravascular variant
- the eruptive pyogenic granuloma and
- the pyogenic granuloma with satellitosis.
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% .
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 .
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.
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 .
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- Reference books
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- Original publications
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