tumors of connective tissue

7/28/2019 tumors of connective tissue

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Reactive Hyperplasia



1. Fibrous Connective Tissue in Origin1.1 Reactive Hyperplasia

1.1.1 Pyogenic Granuloma

- represents an exuberantconnective tissue proliferation to aknown stimulus or injury

- appears as a red massbecause it is composed

predominantly of hyperplasticgranulation tissue in whichcapillaries are very common



Location: commonly seen at the gingiva

due to calcular deposit or foreign

material

Age: seen at any age

Gender: more common in females



Differential diagnosis:- peripheral giant cell granuloma- peripheral odontogenic- ossifying fibroma

Treatment: surgical excisionremoval of local etiologic factors

Prognosis: recurrence is occasional due to

incomplete excision or failure toremove the cause or reinjury of the area



1.1.2 Peripheral Giant Cell Granuloma- uncommon and unusual hyperplastic

connective tissue response to injury of gingival tissue

Location: seen exclusively in gingiva,

usually between the firstpermanent molars and theincisors

- arises from periodontalligament or periosteum and causeresorption of the alveolar bone



Age: occurs at any age

Gender: female

Clinical features: present as red to blue,

broad-based masses

- secondary ulceration due to

trauma may give the lesions a focalyellow zone as a result of the

formation of fibrin clot over the ulcer



Histopathologic features:

- fibroblast are the basic element of

peripheral giant cell granuloma

Differential diagnosis:

- pyogenic granuloma

- central giant cell granuloma



Treatment: surgical excisionremoval of local factors or

irritants

Prognosis: recurrence is believed to berelated to lack of inclusion of

periosteum or periodontalligament in the excised

specimen



1.1.3 Peripheral Fibroma

- a reactive hyperplastic mass that

occurs on the gingiva and is believe

to be derived from connective tissue

of the submucosa or periodontal

ligament

Location: gingiva anterior to thepermanent molars




have a predilection to young adults

Gender: females

Clinical features: pedunculated or sessile

mass that is similar in color to the

surrounding connective tissue- ulceration may be noted




- highly collagenous and avascular

- contain mild to moderate chronic

inflammatory cell- subtypes:

1. peripheral ossifying fibroma

2. peripheral odontogenic

fibroma3. giant cell fibroma



Differential diagnosis:- pyogenic granuloma

- peripheral giant cell granuloma

Treatment: local excision that shouldinclude periodontal ligament

- removal of calcular depositand foreign material

Prognosis: recurrence is common toperipheral ossifying fibroma



Neoplasm



1.2 Neoplasm

1.2.1 Myxoma



1.2.2 Fibrosarcoma- was once considered to be the

most common soft tissue sarcoma

- defined as a malignant spindle cell

tumor showing a herringbone or interlacingfascicular pattern

Location: head and neck

- when it occurs in bone it mayarise from periosteum,endosteum or periodontalligament



Age: young adults are usually affected

Gender:

Clinical feature: secondary ulceration may

be seen as the lesion enlarges

- an infiltrative neoplasm that is

more of locally destructive problemthan a metastatic problem



Histopathologic features: exhibitsmalignant-appearing fibroblasts,

typically in a herringbone or

interlacing fascicular pattern

Treatment: Wide surgical excision

- because of the difficulty

in controlling local growth



Prognosis: recurrence is common butmetastasis is infrequent

- bone lesions are more like tometastasize via bloodstream

- overall survival rate rangesbetween 30% and 50%

- patient with soft tissue lesion f are better than with primary lesion of the

bone

- well-differentiated lesion havebetter prognosis than poorlydifferentiated lesion



Congenital Lesion



2. Vascular Lesions

2.1 Congenital Lesion

2.1.1 Congenital Hemangioma

- also known asStrawberry Nevus

- used to identify benign

congenital neoplasms of

proliferating endothelial cells



Location: lips, tongue, buccal mucosa

Clinical features:

- later by involution phase mayexhibit rapid growth phase that is

followed several years

- color may range from red to blue

- when compressed, blanchingoccurs

- flat, nodular or bosselated



Extensive hemangioma of the tongue, in a 60 year-old

woman.



Hemangioma of the lateral aspect of the tongue in an 82

year-old man.



Frontal view of 10-month-old patient with an extensive capillary cavernous

mixed-type hemangioma. Frontal view of same patient after 8 months of mask therapy. Frontal view of same patient 5 years after involution of

hemangioma after pressure-mask therapy. Frontal view of same patient at

age 15 years after orthognathic surgery and excision of the involuted

tumor.



Classifications: (Shafer)1. capillary hemangioma

2. cavernous hemangioma

3. metastasizing hemangioma

4. nevus vinosus5. angioblastic hemangioma

6. diffuse systemic hemangioma

7. racemose hemangioma

8. hereditary hemorrhagictelangiectasia



2.1.1.1 Hereditary HemorrhagicTelangiectasia

- also known as Rendu-Osler-Weber

Syndrome

- rare condition that can be

transmitted in an autosomal-

dominant manner

- it features abnormal vascular dilations of terminal vessels in skin,

mucous membranes and viscera



Location: face, chest and oral mucosa

Age: appears early in life, persistthroughout childhood and lesions

increase in number

Clinical features:

- most common presenting sign

- epistaxis due to intranasallesion



- bleeding from oral lesions

- lesions appear as red macules or

papules


- vascular spaces are lined by

endothelium without muscular

support



Photograph showing several characteristic telangiectases on

the tongue (upper part of photograph) and lower lip (lower part

of photograph) of an asymptomatic 42-yr-old man



Differential diagnosis:- CREST Syndrome

- C alcinosis cutis- R aynaud’s phenomenon - E sophageal dysfunction- S clerodactyly- T elangiectasia

Diagnosis of hereditary hemorrhagic telangiectasia

is based on clinical findings, hemorrhagic history andfamily history.



Treatment:- Surgical approach

- Laser therapy



2.1.2 LymphangiomaLocation:

- tongue – the most common

intraoral site – causing

macroglossia

- lip – may cause macrochelia

Age: usually appears within first twodecades of life



Clinical features: present as painless,nodular, vesicle-like swelling whensuperficial or as a submucosal masswhen located deeper

- color ranges from lighter than thesurrounding tissue or red-blue whencapillaries are part of the congenitalmalformation

- on palpation – may produce acrepitant sound as lymphatic fluid ispushed from one area to another



Lymphangioma of the posterior aspect of the

tongue in an adult. This tumor was partially excised

in childhood.



Lymphangioma of the neck- is known as cystic hygroma

hygroma colli

cavernous lymphangioma- a diffuse soft tissue swelling that may be

life threatening because it involves vital

structures of the neck



Histopathologic features: The lymphaticvessels contain eosinophilic lymph that

includes red blood cells.

Treatment: Surgical excision

Prognosis: Recurrence is common

because of lack of encapsulation



Neoplasm



2.2 Neoplasm2.2.1 Kaposi’s Sarcoma

- also known as Angioreticuloendothelioma (Shafer)

- a proliferation of endothelial cellorigin, although dermal, submucosaldendrocytes, macrophages,

lymphocytes and mast cells may

have a role in the genesis of these

lesions

- described by Kaposi in 1872



- a recently discovered herpesvirus known ashuman herpesvirus 8 (HHV8) or Kaposi’s

sarcoma herpesvirus (KSHV) has been

identified in all forms kaposi’s sarcoma

lesions as well as in AIDS- 3 different clinical patterns

- 1st – rare skin lesion in older men

living in Mediterranean basin

- appears as multifocal reddishbrown nodules primarily in the skin of

the lower extremities



- rare in the oral cavity- fair prognosis

- 2nd - identified in Africa where it is

considered endemic

- typically seen in the extremities of

blacks

- skin - most commonly affected organ

- clinical course is prolonged- overall prognosis is fair



- 3rd - seen in patients withimmunodeficiency states including

organ transplants and especially

AIDS

- skin lesions are not limited to the

extremities and may be multifocal

- oral and lymph node lesions are

common

- visceral organs are involved

- youngster age-group is affected



- clinical course is rapid andaggressive

- prognosis is poor

- Kaposi’s sarcoma seen in oral regions –

palate, gingiva and tongue – most

commonly affected

- appears as flat lesion to late nodular exophytic lesion



Kaposi's Sarcoma on the Back



- lesion may be single or multifocal- color is usually red to blue


- lesion is subtle, composed of

hypercellular foci containing bland-

appearing spindle cells, ill-defined

vascular channels and red blood cells



This HIV-positive patient presented with an intraoral

Kaposi’s sarcoma lesion with an overlying candidiasis

infection.



This HIV patient presented with intraoral Kaposi’s sarcoma

of the hard palate secondary to his AIDS infection.



Differential diagnosis:- hemangioma

- erythroplakia

- melanoma

- pyogenic granuloma

- bacillary angiomatosis

Treatment: Surgery, low-dose radiationand chemotherapy



2.2.2 Malignant LymphomaLymphomas are malignant

neoplasms of component cells of lymphoidtissue

2.2.2.1 Non-Hodgkin’s Lymphoma - common group of neoplasms that oftenoccur in extranodal head

and neck sites, especiallyin HIV-infected (AIDS)patients



- comprise a heterogenous group of lymphoid neoplasms with a spectrum of

behavior

- some are indolent (quiet) but fatal

others are aggressive and if leftuntreated kill the patient rapidly

- very common in the GIT

- West – common in the stomach- Middle East – common in the

intestine



- head and neck is the second most commonlocation, with majority found at the

Waldeyer’s ring

- Classification (microscopically) is based on

Revised European American Lymphoma

(REAL)

- T-cell lymphoma

- B-cell lymphoma



- Etiology:1. genetic predisposition

2. immunodeficiency

- defective immune response to

Epstein-Barr virus



- Ann Arbor Staging SystemStage I – involvement of a single lymphnode region

Stage II – involvement of two or morelymph node regions on the sameside of the diaphragm

Stage III – involvement of lymph noderegions on both sides of thediaphragm

Stage IV – diffuse or disseminated involvement of one or more distant extranodal organs

with or without associated lymph nodeinvolvement



Clinical features: 3 groups1. Indolent – slow growth. Wide

dissemination, a long natural history

and relatively incurability

2. Aggressive

3. Highly aggressive

Aggressive and highly aggressivecharacterized by rapid growth, frequent localized

presentation, short natural history



- most aggressive lymphomas are the onesmost likely to be cured and indolent

lymphomas are least likely to be cured

- most lymphomas in adults are diffuse B-cell

lymphoma or follicular lymphoma

- Follicular lymphoma rarely occur in the oral

cavity

- T-cell lymphoma less common at all sitesincluding the oral cavity



- aggressive and highly aggressivelymphomas are most common in children

Treatment: Radiation therapy

Chemotherapy

- goal of chemotherapy is to

maximize tumor toxicity but

minimize damage to normaltissue



Prognosis:Indolent lymphoma – poor prognosis

- survival is long with a mean

time of 8 years; incurable



Three main clinical variants:1. Endemic

- the most common malignancy of children in thisarea

- children affected with the disease often also hadchronic which is believed to have reducedresistance to (EBV) allowing it totake hold

- the disease characteristically involves the jaw or

other facial bone, distal ileum, cecum, ovaries, kidneyor the breast.

http://en.wikipedia.org/wiki/Epstein-Barr_virus



http://en.wikipedia.org/wiki/Malaria



2. Sporadic

- also known as "non-African"

- another form of

found outside of Africa. The tumor cells have asimilar appearance to the cancer cells of classical

African or endemic Burkitt lymphoma.

http://en.wikipedia.org/wiki/Non-Hodgkin_lymphoma





3. Immunodeficiency-associated BurkittLymphoma

- usually associated with infection

http://en.wikipedia.org/wiki/HIV



A patient with

Burkitt's lymphoma

showing disruption

of teeth and partialobstruction of

airway.



The malignant cells are B-lymphocytes, & the white circular cells

scattered throughout the picture are macrophages



Patient, with swelling in jaw.Ebstein-Barr virus usually

found in the malignant B-

lymphocytes. This disease

is often found in malaria

areas of Africa: malaria may

mediate some T-cell

immunosuppression. Note

illogical nomenclature: -oma

suffix, but this is malignant!



2.2.2.3 Hodgkin Lymphoma- rarely involve the oral cavity

Location: maxilla and mandible

Age: between 15 and 35 years of age

beyond 55 years old

Gender: male



Clinical features:- characterized by painless enlargement of

lymph nodes or extranodal lymphoidtissue

- oral cavity – tonsillar enlargement may beseen in the early phase

- extranodal swelling – submucosalswelling may be seen,

submucosal ulceration or erosion of underlying bone



Histopathologic features:- greatest significance – identification of

Reed-Sternberg cell which must be

present in the diagnosis of Hodgkin

lymphoma- 4 entities

1. lymphocyte-rich, classic type

2. nodular sclerosis3. mixed cellularity

4. lymphocyte depletion types



- lymphocyte-rich, classic type has themost favorable prognosis

- lymphocyte depletion has the least

favorable prognosis

- nodular-sclerosing type most commonform of Hodgkin lymphoma

- mixed-cellularity – prognosis is between

nodular-sclerosing type and the

lymphocyte depletion type

- abundant Reed Sternberg cell



Differential diagnosis:1. chronic lymphadenitis

2. infectious disease

3. infectious mononucleosis

Treatment: External radiation therapy and

Chemotherapy

Prognosis: Fair to good



Reactive Lesion



3. Neural Lesions3.1 Reactive Lesion

3.1.1 Traumatic Neuroma

- caused by injury to a

peripheral nerve- trauma from a surgicalprocedure

- as a result of the peripheralnerve to regenerate, it becomes

entangled and trapped in the developingscar, which results to a mass of fibroustissue, schwann cells and axons



Location:- mental foramen - most common

location

- extraction sites – anterior maxilla

and posterior mandible

- lower lip, tongue, buccal mucosa,

palate

Age: wide age range; most seen in adult



Traumatic neuroma, posterior buccal mucosa



Clinical features: pain ranges from occasionaltenderness to constant , severe pain

Histopathologic features: bundles of nerves inhaphazard or, tortuous (twisted)arrangement are found with densecollagenous fibrous connectivetissue


Prognosis: Good



3.2 Neoplasm3.2.1 Schwannoma

- also known as Neurilemmoma

- benign neoplasm that is

derived from a proliferation of

Schwann cells of the

neurilemma, or nerve sheath

Location: tongue – favored site




Clinical features:

- presence of mass which is asymptomatic

- slowly growing tumor but may undergo

sudden increase



Cut surface of aschwannoma shows a

thick stalk and a central

core of pure white neural

tissue, surrounded bymore routine fibrovascular

tissue. Note the traumatic

ulcer of the superior

surface and granulation

tissue from trauma in the

upper right.



Histopathologic features:spindle cells – 2 patterns

1. Antoni A – consist of spindle

cells organized in palisaded

whorls and waves

2. Antoni B – consist of spindle cells

haphazardly distributed in adelicate fibrillar microcystic

matrix



No cytologic atypia or mitotic activity was identified.Antoni A regions of the tumor are more cellular and

compact, while Antoni B areas are more loosely

organized and hypocellular.




Prognosis: Excellent



3.2.2 Neurofibroma- may appear as solitary or multiple

lesions as part of the syndrome

Neurofibromatosis (Von

Recklinghausen’s disease of skin)

- for solitary lesion, the cause is

unknown

- for neurofibromatosis, it is inherited

as autosomal-dominant trait



Location: tongue, buccal mucosa andvestibule – most commonly affected

areas in the oral region

Age: present at any age

Clinical features: present as an

uninflammed asymptomatic,submucosal mass



- oral lesions are typically associated with

neurofibromatosis- condition includes the following:

1. multiple neurofibromas2. cutaneous café-au-lait macules3. bone abnormalities

4. central nervous system changes- neurofibromas range clinically from discrete, superficialnodules to deep,

diffuse masses



- intraoral neurofibromas may be seen in 25%of patients with neurofibromatosis

- malignant degeneration of neurofibroma into

neurogenic sarcoma is seen in 5% to 15%

of patients with neurofibromatosis- the presence of 6 or more café-au-lait macules

greater than 1.5 cm in diameter – suggestive

of neurofibromatosis

- bone changes seen in patients with

neurofibromatosis



A. Numerous cutaneousneurofibromas.

B. Large plexiform

neurofibroma.



Histopathologic features: solitary and multipleneurofibromas have the same microscopic

features

- presence of spindle-shaped cells with

fusiform or wavy nuclei found in the a delicateconnective tissue matrix

- plexi form neurof ibroma – histologic

subtype regarded as highly characteristic of

neurofibromatosis



Histopathologic image of cutanous

neurofibroma obtained by biopsy



Differential diagnosis:- traumatic fibroma- granular cell tumor - lipoma

Treatment: For solitary neurofibroma - surgicalexcisionFor multiple lesions of neurofibromatosis –

surgical excision(impractical – because of numerous

lesions)

Prognosis: little chance of recurrencePoor – with neurosarcomatous change



3.2.3 Multiple Endocrine Neoplasia Syndrome(MEN Syndrome)

Classifications

1. Type 1 (MEN 1)

2. Type 2 (MEN 2)

2.1 Type 2A

2.2 FMTC (Familial Medullary ThyroidCarcinoma)

2.3 Type 2B or (MEN 3)

(source: http://dermnetnz.org/systemic/pdf/multipleendocrineneoplasiatype2b-dermnetnz.pdf)



Multiple Endocrine Neoplasia Syndrome Type III(or MEN Type 2B)

- mucosal neuromas are predominant

- inherited as autosomal-dominant trait

Location: tongue, lips, buccal mucosa

Age: appears early in life



Clinical features:- MEN III consists of the following:

1. medullary carcinoma of the thyroid2. pheochromocytoma (benign neoplasm

that produces catecholamines thatmay cause significant hypertension and

other cardiovascular abnormalities) of the adrenal

3. mucosal neuromas4. café-au-lait macules5. neurofibromas of the skin

- mucosal neuromas appear as small, discretenodules on the conjunctiva, labia, larynx or oral

cavity



Histopathologic features: composed of serpiginous bands of nerve tissue

surrounded by normal connective tissue

Treatment:Mucosal neuromas – surgical excision

Medullary carcinoma of the thyroid has the

ability to metastasize to local lymph

nodes and distant organs



Prognosis:Medullary carcinoma – the 5-year survival

rate of this malignancy is about 50%



3.2.4 Malignant Peripheral Nerve Sheath Tumor - rare malignancy that develops either from

a preexisting neurofibroma

- cell origin is believed to be the Schwann

cell and possibly other nerve sheath cells

Clinical features: appears as an expansile

mass that is asymptomatic



Histopathologic features:- seen arising from a neurofibroma or from a

nerve trunk- composed of abundant spindle cells with

variable numbers of abnormal mitotic

figures

Treatment: Wide surgical excision

Prognosis: Fair to Good

(recurrence is common andmetastasis is frequently seen)



Benign



4. Lesions of Muscle and FatBenign

4.1 Leiomyoma (plural is 'leiomyomata')

- tumor of the smooth muscle

- very common and may arise

anywhere in the body

- most commonly arise in the

muscularis layer of the gut and inthe body of the uterus

- rare in the oral cavity



Location: tongue, hard palate, buccal mucosa

Age: seen at any age (usually discoveredwhen it is 1 to 2 cm I diameter)

Clinical features:

- present as submucosal mass

- slow-growing

- asymptomatic




Leiomyomaenucleated from a

uterus. External

surface on left; cut

surface on right



On directlaryngoscopy, the

tumor fills most of the

tracheal lumen. There

lumen was reduced to

a tiny slit. Frozen

section showed a

spindle cell tumor and

the final diagnosis

came back asleiomyoma of the

trachea.



4.2 Rhabdomyoma- tumor of the striated muscle

Location: floor of the mouth, soft palate,

tongue, buccal mucosa

Age: age range: children to adult

Mean age: 50 years old



Clinical features:- asymptomatic

- well-defined submucosal mass


- 2 variants

1. adult type – the neoplastic

cells closely mimic their normal counterpart



2. fetal type – the neoplastic cells areelongated and less

differentiated and exhibit

fewer cross-striations

Treatment: Excision

Prognosis: Good



Intra operativepicture showing

rhabdomyoma

protruding

through the aorticopening.



4.3 Lipoma- uncommon neoplasm of the oral cavity

that may occur in any region

Location: buccal mucosa, tongue, floor of the mouth

Clinical features: typically asymptomatic,

yellowish submucosal mass



Gladys at left, from

Bayelsa State, who

had been suffering from

lipoma condition

for 6 years withoutmedical attention.



The man with a largelipoma, a fatty tissue that

grows wildly out of

control, is being treated.

The doctor must be

careful to minimize

hemorrhaging, which can

be easily a problem when

operating on a very

vascular head.



5 years history of soft,homogeneous tumor, placed on

the internal side of the left arm.



Lipomectomy andelliptical skin

excision.



Surgical Specimen.




The overlying epithelium is intact andsuperficial blood vessels are usually evident

over the tumor

Differential diagnosis:Granular cell tumor

Neurofibroma

Traumatic fibroma

MucoceleMixed tumor



Treatment: Excision

Prognosis: Good



4.4 Granular Cell Tumor

- formerly known as

Granular Cell Myoblastoma

- uncommon benign tumor of unknowncause

- Theories:- believe to be of neural origin

(Schwann cell)

- believed to be originated from skeletal

muscle, macrophages, undifferentiatedmesenchymal cells and pericytes



Location: head and neck- tongue – most common location

Age: Age range: children to elderly

Mean age: middle adult life

Clinical features: present as an uninflammed

asymptomatic mass less than 2 cm in

diameter - yellowish surface coloration



Painless, elevatedwhitish keratotic

lesion of the

tongue in a 20

year-old woman.



Histopathologic feature: The clinicaltumescence of granular cell tumors

is due to the presence of

unencapsulated sheets of large

polygonal cells with pale granular or grainy cytoplasm.

Differential diagnosis: Neurofibroma,

Schwannoma, Lipoma, Focal fibroushyperplasia



Granular cell tumor. Thecells contain innumerable

fine cytoplasmic granules

as well as scattered larger

eosinophilic globules.




Prognosis: Good



4.5 Congenital Gingival Granular Cell Tumor - also known as

Congenital Epulis of the Newborn

- composed of cells that are

microscopically identical to those of granular cell tumor

- appears on the gingiva (usually

anterior) of the newborn



- presents as uninflammed,pedunculated or broad-based mass

- maxillary gingiva is more often involved

- girls are affected more often than boys

- treatment: surgical excision

- prognosis: no recurrence and

spontaneous regression



The mass is seen protruding from

the girl's mouth (lateral view).

The mass is seen protruding from

the girl's mouth (anterior view).



Malignant



Malignant4.1 Leiomyosarcoma

- rare in the oral cavity- most commonly arise in the

retoperitonium, mesentery, omentum,

subcutaneous and deep tissues of thelimbs- present in all age-groups- diagnosis is considerable challenge

because of similarities to other

spindle cell sarcomas- treatment: wide surgical excision- prognosis: good



Note the presence of

spindle cells in

leiomyosarcoma



4.2 Rhabdomyosarcoma

- subdivided in three principalmicroscopic forms:

1. embryonal

2. alveolar 3. pleomorphic

embryonal and alveolar – occurs in

childrenpleomorphic – occurs in adult



embryonal type – consist of primitive round

cells in which striations arerarely found

- most commonly seen in thehead and neck

- two subtypes:(with excellent prognosis)

1. spindle cell2. botryoid

alveolar type – composed of round cells but ina compartmentalized pattern



Botryoid



pleomorphic type – the most well- differentiated,contains strap or spindle cells that often exhibit

cross striations

rhabdomyosarcoma- when it occurs in the head and neck

– primarily found in children

- when it occurs outside the head and

neck

- seen typically in adult



Orbital Rhabdomyosarcoma



rhabdomyosarcoma

- present as a rapidly growing mass thatmay cause pain or paresthesia if there is jawinvolvement

- most commonly affected oral sites:

- tongue and soft palate

- treatment: combination of surgery,radiation, and chemotherapy

- prognosis: with more aggressivetreatment – survival rates haveincreased from 10% to 70%



4.3 Liposarcoma

- rarely encountered in soft tissue of thehead and neck

- a lesion of the adulthood- may occur in any site- generally a slow growing tumor

- microscopically, it has 4 types:1. well- differentiated2. myxoid3. round cell4. pleomorphic

- treatment: surgery, radiation- prognosis: fair to good



Well-differentiated

Includes atypical lipomaMost common subtype (50% of liposarcomas)Low grade (doesn’t metastasize, but may recur locally)Risk of dedifferentiation

Myxoid Intermediate gradeIncludes round-cell variant as its high-grade

counterpartMost common type in pediatric age groupMetastatic risk especially in round-cell variant

Pleomorphic

Rarest type (5-10% of liposarcomas)High gradeMay mimic MFH or even carcinoma or melanomaHigh risk of local recurrence and metastasis



Large fungating,ulcerated

liposarcoma of the

tongue is lobulated

and has a yellowishcolor. This was a

rapidly enlarging

lesion.

tumors of connective tissue

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