Traumatic ulcerative granuloma with stromal eosinophilia: a reactive lesion of the oral mucosa

Non-Healing Chronic Traumatic Ulcer, an Entity That Can Resemble Other Chronic Ulcers

Introduction

Traumatic ulcer commonly occurs in the oral cavity, resulting in the loss of the entire epithelium. Traumatic ulcers often appear to mimic other lesions of the oral mucosa but the causative factors and other characteristic features rule out the differential diagnosis. It may have a similar appearance to some oral ulcer lesions such as traumatic ulcer granuloma with stromal eosinophilia (TUGSE) and oral squamous cell carcinoma (OSCC).

Objective

To identify traumatic ulcers from other chronic lesions such as TUGSE and OSCC.

Case

First case, a 63-year-old female complained of pain on the right side of the tongue for 4 months. Intraoral examination showed a painful single ulcer, mild keratosis white halo, and induration on the right lateral of the tongue. The second case, a 38-year-old male complained of pain on the left side of the tongue for 2 months. Intraoral examination showed a painful single ulcer, mild keratosis white halo, and induration on the left lateral of the tongue. In both cases, there were some retained roots where the ulcer was located, and due to its contact with lateral of the tongue and the appearance of the lesion, we got a provisional diagnosis of traumatic ulcer.

Case Management

These ulcers had a visual appearance similar to OSCC and TUGSE, so eliminating etiological factors and a comprehensive treatment plan were needed. We planned to extract teeth close to the lesion that was suspected to be the etiology of traumatic ulcer. We also prescribed 0.1% triamcinolone acetonide in orabase to improve healing. One week later, the ulcer in both patients had healed.

Conclusion

Recognition of traumatic ulcer characteristics is crucial in eliminating local factors to get rid of any differential diagnosis.

Follicular helper T-cell lymphomas: disease spectrum, relationship with clonal hematopoiesis, and mimics. A report of the 2022 EA4HP/SH lymphoma workshop

Follicular helper T-cell lymphomas (TFH lymphomas) were discussed in session V of the lymphoma workshop of the European Association for Haematopathology (EA4HP)/Society for Hematopathology (SH) 2022 meeting in Florence, Italy. The session focused on the morphologic spectrum of TFH lymphoma, including its three subtypes: angioimmunoblastic-type (AITL), follicular-type, and not otherwise specified (NOS). The submitted cases encompassed classic examples of TFH lymphoma and unusual cases such as those with early or indolent presentations, associated B-cell proliferations, or Hodgkin/Reed-Sternberg-like cells. The relationship between TFH lymphoma and clonal hematopoiesis was highlighted by several cases documenting divergent evolution of myeloid neoplasm and AITL from shared clonal mutations. The distinction between TFH lymphoma and peripheral T-cell lymphoma, not otherwise specified (PTCL, NOS), was stressed, and many challenging examples were presented. Various cases highlighted the difficulties of differentiating TFH lymphoma from other established types of lymphoma and reactive conditions. Cutaneous T-cell lymphoma expressing TFH markers, particularly when resulting in lymph node involvement, should be distinguished from TFH lymphomas. Additional immunophenotyping and next-generation sequencing studies were performed on various cases in this session, highlighting the importance of these technologies to our current understanding and classification of TFH lymphomas.

Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE): Case report of a 63-year-old male patient with a rare self-healing oral mucosal lesion

Traumatic Ulcerative Granuloma with Stromal Eosinophilia (TUGSE)/Riga Fede disease is a rare mucosal and submucosal benign reactive inflammatory process, usually involving the tongue. Trauma is believed to be a major factor amongst the multiple pathogenic mechanisms that have been hypothesized in TUGSE. The lesion presents as an isolated indurated or even ulcerated mass, which may mimic, clinically a squamous cell carcinoma (SCC). We herein report a case of TUGSE in a 63-year-old male referred by his treating physician for high suspicion of tongue malignancy. Histopathological examination confirmed the diagnosis of TUGSE, without any evidence of a neoplasic, infectious or hematologic process. TUGSE occurs in patients with an age range of 41-60 years. Sufficiently deep biopsies with comprehensive immunohistochemical and molecular analyses are mandatory to confirm the benign nature of the lesion and to, definitely, rule out malignancy. This report highlights the need for adequate histological differential diagnosis to avoid inappropriate heavy treatments in a benign condition.

Top Ten Lymphoproliferative Lesions Not to Miss When Evaluating Oral Ulcer Biopsies

BACKGROUND

Oral ulcers represent a full thickness loss of the mucosal epithelium leading to exposure of the submucosal connective tissue. These are common and usually self-limited lesions, although they may sometimes result from neoplasms, most commonly squamous cell carcinoma. Lymphoproliferative disorders may be difficult to diagnose in apthous ulcers since they mimic reactive inflammation.

METHODS

This review presents ten rare oral lymphoid proliferations which should not be missed when assessing oral ulcer biopsies.

RESULTS

The ten lesions include several with diagnostic cells which look similar to the histiocytes of a reactive inflammatory ulcer, including Rosai-Dorfman disease, reticulohistiocytoma, Langerhans cell histiocytosis, and traumatic ulcerative granuloma. Other lesions, such as EBV-positive mucocutaneous ulcer, extranodal marginal zone lymphoma of mucosal-associated lymphoid tissue, and plasmablastic lymphoma have lymphoid and/or plasma cell differentiation that mimic the reactive lymphocytes and plasma cells found in reactive ulcers. Two dendritic cell lesions, follicular dendritic cell sarcoma and blastic plasmacytoid dendritic cell neoplasm, both have distinct phenotypes which are required to make an accurate diagnosis.

CONCLUSION

Each of these lesions are diagnosed by evaluating their histology, along with their phenotypic profile, which is sometimes enhanced by pertinent molecular findings.

Multifocal Oral Epstein-Barr Virus-Positive Mucocutaneous Ulcers Associated with Dual Methotrexate and Leflunomide Therapy: A Case Report

Epstein-Barr virus (EBV)-positive mucocutaneous ulcer (EBVMCU) is a unique clinicopathologic entity of lymphoproliferative disorder, occurring in immunosuppressed patients. Due to its rarity, EBVMCU may be under-recognized by clinicians as well as pathologists. In addition, its clinical and histopathologic features overlap with other benign and malignant conditions, making a diagnosis challenging. This report presents an unusual case of multifocal oral EBVMCUs in a 52-year-old female patient with rheumatoid arthritis, receiving the combination of methotrexate and leflunomide for 5 years. The patient presented with persistent multiple large painful ulcers involving her palate and gingiva for 6 months. The histopathologic examination revealed extensive ulceration with diffuse polymorphic inflammatory infiltrate admixed with scattered atypical lymphoid cells showing occasional Hodgkin and Reed/Sternberg-like cell features. These atypical cells showed immunoreactivity for CD20, CD30 and MUM1/IRF4. EBV-encoded small RNA in situ hybridization was positive, validating the presence of EBV-infected cells. Two months after discontinuation of both immunosuppressive medications, oral lesions gradually regressed. At 9-month follow-up, no evidence of relapsing oral EBVMCU has been observed. The multifocal presentation of EBVMCU is rare and could be resulted from the overwhelming immune suppression by long-term use of dual immunosuppressants. Its diagnosis requires comprehensive correlation of patient history, clinical findings, histopathologic, and immunophenotypic features. The ability of EBVMCU to regress following removal of immunosuppressive causes is in drastic contrast to a variety of its potential clinical and histopathologic mimics. Therefore, accurate diagnosis is crucial to avoid unnecessary patient management and achieve optimal patient outcomes.

Eosinophilic ulcer of the oral mucosa: An update on clinicopathologic features, pathogenesis, and management

Eosinophilic ulcer of the oral mucosa is a benign, reactive, self-limited lesion. Its pathogenesis is unclear, and it clinically manifests as a punched-out ulcer with surrounding indurated border, raising suspicion for a possible malignancy. On histology, an acute and chronic dense inflammatory infiltrate can be appreciated, which can extend to the deep underlying tissue (including skeletal muscle). Eosinophils are especially conspicuous on hematoxylin and eosin staining and might play an important role in the development of the ulcer. Removal of possible triggers followed by monitoring and possible biopsy are among the initial recommendations. Most lesions heal spontaneously without the need for intervention. This review aims at assisting dermatologists to easily recognize this entity, avoiding unnecessary interventions and apprehension.

EBV-positive B-cell ulcerative proliferation in the oral cavity associated with EBV-negative follicular lymphoma in a patient with common variable immunodeficiency: A case report and review of the literature

Lymphoproliferative disorders (LPDs) are a group of conditions characterized by excessive production of lymphocytes manifested in various patterns including lymphadenopathy, tumor-like lesions, and lymphomas. LPD may be stimulated by Epstein-Barr virus (EBV) infection that most commonly appears in the setting of immunocompromised status such as long-term use of immunosuppressive medications and in individuals with primary immunodeficiency disorders. EBV mucocutaneous ulcer is a benign LPD reaction that mostly regresses spontaneously but sometimes requires medical or surgical intervention. This article presents a case of oral EBV mucocutaneous ulceration that affected an individual with a history of complex primary immunodeficiency disorders consisted of common variable immunodeficiency disease associated with T-cell dysfunction. This case is unique because the oral lesions led to the diagnosis of concurrent widespread EBV-negative follicular lymphomas, seemingly unrelated to her EBV-positive LPD oral disease. Yet, both occurred in the setting of severe immunosuppression from the primary immunodeficiency disorders.

Benign lymphoproliferative disorders in the immunosuppressed patient: an update

Immunosuppressed patients may be affected by a wide range of lymphoproliferative disorders (LPDs) ranging from self-limiting disorders to malignant lymphoid proliferations. These LPDs may be associated with systemic immune disorders, develop following organ transplantation or occur in the background of other forms of iatrogenic immunosuppression. Lymphotropic viruses, including Epstein-Barr virus (EBV) and human herpesvirus-8 (HHV8), have been associated with the pathogenesis of distinct LPDs. The resulting classification of this group of disorders is very complex and inconsistent, with several new and emerging entities. Consequently, the diagnosis of an LPD, especially in an immunosuppressed patient, and its subsequent clinical management usually represent an important pitfall in daily clinical and pathology work. Therefore, the aim of this review was to use the available literature to describe the clinicopathological features of the most important benign LPDs that may be diagnosed in the head and neck region of immunosuppressed patients. Original clinical and microscopic images were used to illustrate some of these entities.

Traumatic ulcerative granuloma with stromal eosinophilia: A puzzle

Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) is an ulcerative condition of the oral mucosa amid a chronic course and delayed healing. It is a reactive lesion that usually affects the tongue. TUGSE is a rare mucosal lesion to aid as an ulcer or an indurated submucosal mass and might cause diagnostic problems as it mimics a traumatic or neoplastic ulcer. However, chronic irritation from traumatic agents is well thought out to be a major initiating aspect. Histopathologically, it is categorized by an eosinophilic inflammatory infiltrate penetrating into the underlying muscle. It is significant to make out this mucosal lesion as it mimics malignant ulcers; the condition tends to resolve on its own. Thus, attentiveness of this entity is imperative to emphasize the accurate diagnosis of indurated ulcerated lesions and convey suitable and effective treatment. The present case highlights the clinical aspects, etiopathogenesis and histopathology of this unusual lesion.

Eosinophilic ulcer mimicking malignancy of the lower lip: A case report

Eosinophilic ulcer (EU) is a rare self-limiting chronic benign lesion of the oral mucosa. It is an uncommon and benign disease, which may leading to diagnostic difficulties. Biopsy is recommended to rule out any malignant etiology.

Traumatic ulcerative granuloma with stromal eosinophilia - clinical case report, literature review, and differential diagnosis

Background

Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) is a rare self-limiting condition of the oral mucosa. The lesion manifests as an isolated ulcer that can be either asymptomatic or associated with mild to severe pain, and in most cases, it affects the tongue. TUGSE lesions may mimic malignancy such as squamous cell carcinoma, CD30 positive lymphoproliferative disorder, or infectious diseases such as primary syphilis, tuberculosis, or Epstein-Barr virus mucocutaneous ulcer. Histologically dominating cells are lymphocytes, histiocytes, and eosinophils.

Case presentation

We describe a TUGSE case of a patient with a solitary ulcer on the lower left retromolar buccal plane. Upon presentation, the patient reported a swelling on the buccal mucosa of the left lower jaw since 1 year with rapid growth over the last days and mild pain while chewing. The diameter of the intraoral lesion on the lower left retromolar buccal plane was approximately 4 × 3 cm; the lesion presented as indurated base with a central superficial ulceration of 2 × 1 cm, indicative for a malignant process. Histologically, the ulceration showed an expanding, infiltrative, and vaguely granulomatous morphology, involving the superficial mucosa and the fatty tissue, and extended between the deep striated muscle fibers. The lesion was rich in lymphocytes, histiocytes, and eosionophils intermingled with activated T-blasts without phenotypic abnormalities. TUGSE was then diagnosed based on the phenotype (especially the lacking expression of CD30, the retained T-cell phenotype, and the absence of Epstein-Barr virus), the clinical presentation, and the morphology. Twenty-six months after diagnosis, no recurrence of the ulceration was seen.

Conclusions

As TUGSE may mimic malignancy or infectious diseases, biopsy is mandatory and should be combined with thorough clinical examination. A screening for infectious diseases (mainly syphilis, Epstein-Barr virus, and HIV infections) must be performed routinely. In most cases, the lesions resolve spontaneously, obviating the need of further actions other than clinical follow-up. The pathogenesis of TUGSE lesions is still under debate, although local traumatic events and a locotypic immune response have been suggested to be major contributing factors.

Traumatic Ulcerative Granuloma with Stromal Eosinophilia: CD30 analysis and clonality for T cell receptor gene re-arrangement

INTRODUCTION

Traumatic Ulcerative Granuloma with Stromal Eosinophilia (TUGSE) is a rare oral ulcerated lesion of uncertain etiology, showing eosinophil-rich granulation tissue, with occasional large atypical CD30 positive mononuclear cells. It had been suggested that it may represent an oral counterpart of cutaneous lymphomatoid papulosis, with a potential to evolve into CD30 + T cell lymphoma OBJECTIVES: To compare TUGSE and non-specific oral ulcers (NSU) clinically, histopathologically and by clonality analysis for T-cell receptor re-arrangement, aiming to determine whether TGUSE with atypical cells is a lymphomatous premalignant condition, and whether therapeutic approach should be radical or conservative.

MATERIALS AND METHODS

Retrospective archival analysis included 17 TUGSE and 8 NSU cases. Histopathological parameters included mean eosinophil number per high power field (HPF), presence of infiltration of deep soft tissues and presence of atypical cells. Immuno-morphometry comprised of the mean number of CD30+ atypical cells per HPF. T-cell receptor (TCR) gene rearrangement by polymerase chain reaction (PCR) was performed in all cases showing atypical cells. Clinical and follow up data were retrieved from files.

RESULTS

TUGSE showed a significantly higher mean eosinophil number/HPF in comparison to NSU (7.0 + 4.2 cells and 2.3 + 1.72, respectively; p < 0.001). Atypical cells were found in 9 (53%) cases of TUGSE and in only 1 (11%) case of NSU. CD30+ atypical cells were found in 7 (41%) cases of TUGSE and only in 1 (11%) case of NSU. Mean number of CD30+ cells/HPF was 0.23 + 0.19 (range 0 - 0.54 cells/HPF) for TUGSE. In the only NSU case with CD30+ cells, their density was 0.52/HPF. All lesions with atypical cells were polyclonal for TCR. All cases were self-limiting, with no recurrences, after 3-9 years (mean 4.6 years) follow up.

CONCLUSIONS

Analysis found no support to the suggestion that TUGSE with atypical cells represents the oral counterpart of lymphomatoid papulosis or predisposes the lesions for a hematolymphoid malignancy. Suggestions for radical therapeutic approach and long-term follow-up are probably unjustified, with no recurrences or malignancy recorded following conservative treatment alone for a period of up to 9 years of follow-up. Staining for CD30 and PCR for TCR gene rearrangement should be reserved only for rare cases with abundant large atypical cells and/or unusual clinical behavior.

Self-healing CD30- T-clonal proliferation of the tongue: report of an extremely rare case

Background

The etiology of traumatic ulcerative granulomas with stromal eosinophilia (TUGSE) is not clear, traumatic irritation having advocated as the most likely cause. TUGSEs are typically self-limiting slow-healing lesions of the oral mucosa with unclear pathogenesis, commonly manifesting as a rapidly developing, long-lasting ulcer.

Case presentation

Here we report a controversial case of a self-healing lesion of the tongue in a 57 year-old woman. A clonal T-cell proliferation and CD30 negative immunohistochemical (IHC) profile could be documented.

Discussion and conclusion

In view of the very peculiar clinical and histological features, a retrospective diagnosis of a TUGSE with scarce eosinophilic infiltrate (possibly in regression), displaying CD30- T-clonal proliferation was eventually rendered.

The patient did not report signs of recurrence after a 3-year follow-up period.

Ulcerated Lesions of the Oral Mucosa: Clinical and Histologic Review

Ulcerated lesions of the oral cavity have many underlying etiologic factors, most commonly infection, immune related, traumatic, or neoplastic. A detailed patient history is critical in assessing ulcerative oral lesions and should include a complete medical and medication history; whether an inciting or triggering trauma, condition, or medication can be identified; the length of time the lesion has been present; the frequency of episodes in recurrent cases; the presence or absence of pain; and the growth of the lesion over time. For multiple or recurrent lesions the presence or history of ulcers on the skin, genital areas, or eyes should be evaluated along with any accompanying systemic symptoms such as fever, arthritis, or other signs of underlying systemic disease. Biopsy may be indicated in many ulcerative lesions of the oral cavity although some are more suitable for clinical diagnosis. Neoplastic ulcerated lesions are notorious in the oral cavity for their ability to mimic benign ulcerative lesions, highlighting the essential nature of biopsy to establish a diagnosis in cases that are not clinically identifiable or do not respond as expected to treatment. Adjunctive tests may be required for final diagnosis of some ulcerated lesions especially autoimmune lesions. Laboratory tests or evaluation to rule out systemic disease may be also required for recurrent or severe ulcerations especially when accompanied by other symptoms. This discussion will describe the clinical and histopathologic characteristics of a variety of ulcerated lesions found in the oral cavity.

Recurrent Oral Eosinophilic Ulcers of the Oral Mucosa. A Case Report

Objective:

This article describes a case of an Oral Eosinophilic Ulcer (OEU) in an otherwise healthy 31-year-old white woman.

Introduction:

The importance of reporting this case was the presence of recurrent episodes with lesions appearing in different areas of the oral mucosa, a type of manifestation not commonly associated with this disease. A typical manifestation of OEU occurs as a single ulceration that goes into healing after an incisional biopsy, a procedure usually required for a proper diagnosis of the disease. In spite of trauma being suggested as the main culprit of OEU, the exact pathogenesis mechanism of this disease remains controversial.

Case report:

The pattern of the present case contradicts the usually common course of the disease, as the patient had experienced many recurrent episodes for almost 2.5 years, with the recurrences occurring even after biopsies performed during some of the relapses. Differential diagnosis included recurrent aphthous stomatitis, recurrent intra-oral herpes, autoimmune disease, Crohn’s disease and malignancy.

Conclusion:

Fortunately, the patient has been free of any recurrences for 1.5 years since the last biopsy was taken at the time she came to our clinic seeking treatment.

Eosinophilic ulcer of the tongue masquerading as malignant ulcer: An unexplored distinct pathology

Eosinophilic ulcer (EU) is a rare self-limiting chronic benign ulcerative lesion of the oral mucosa often misdiagnosed as oral malignancy. Its etiopathogenesis is ambiguous, but trauma plays an important role in the development. Microscopically, it is characterized by a polymorphic inflammatory infiltrate with a prominent eosinophilic component and large mononuclear cells extending deep into the submucosa, underlying muscle and salivary glands. We discuss a case of EU in a 55-year-old male, which presented with a symptomatic nonhealing ulcer on the right lateral border of the tongue and was further clinically misdiagnosed as malignant ulcer.

Oral Pyoderma Gangrenosum: Diagnosis, Treatment and Challenges: A Systematic Review

Pyoderma gangrenosum (PG) is a distinctive ulcerative skin disorder of unknown etiology, associated with an underlying systemic disease in up to 70% of cases. The condition is characterized by the appearance of one or more necrotic ulcers with a ragged undermined violaceous border and surrounding erythema. Lesions are often initiated by minor trauma. The condition can affect any anatomical site, however the head and neck are rarely involved. Although the oral cavity is subject to recurrent minor trauma through everyday activities such as mastication and oral hygiene, as well as during dental treatment, oral lesions appear to be extremely rare. In an effort to provide a detailed explanation of the oral manifestations of PG, a systematic search was conducted using medical databases. A total of 20 cases of PG with oral involvement were reported in the English and French literature. The objectives of this article are to present the pertinent diagnostic criteria and to discuss the differential diagnosis and therapeutic modalities.

Update from the 4th Edition of the World Health Organization of Head and Neck Tumours: Tumours of the Oral Cavity and Mobile Tongue

There have been several additions and deletions in Chapter 4 on Tumours of the oral cavity and mobile tongue in the 2017 fourth edition of the World Health Organization Classification of Tumours of the Head and Neck. This chapter excludes the oropharynx, which now is a stand-alone chapter acknowledging the uniqueness of the oropharynx from the oral cavity. New entries in Chapter 4 include rhabdomyoma, haemangioma, schwannoma, neurofibroma and myofibroblastic sarcoma in the section titled Soft tissue and neural tumours. Discussion of salivary gland entities have been reduced and includes mucoepidermoid carcinoma and pleomorphic adenoma as the other salivary gland types are discussed elsewhere. In the Haematolymphoid tumours section, like the salivary gland section, only tumors that commonly present in the oral cavity are discussed in Chapter 4. Excluded entities in the updated classification include papillary hyperplasia, median rhomboid glossitis, keratoacanthoma, focal oral mucinosis, and secondary tumors. This article will summarize the changes in the new classification since the 2005 edition focusing on selected entities that have had significant changes along with new entries.

Traumatic Ulcerative Granuloma with Stromal Eosinophila: A Case Report and Review of Pathogenesis

Traumatic Ulcerative Granuloma with Stromal Eosinophilia (TUGSE) is an uncommon condition considered to be a, reactive benign lesion of the oral mucosa, usually affecting the tongue. Its aetiopathogenesis is still uncertain. However, trauma has been found to be a contributing factor in a majority of the cases. Clinically, it often presents as an isolated ulcer or an indurated submucosal mass. Microscopically, it is characterized by a diffuse polymorphic cell infiltrate composed predominantly of eosinophils, B and T lymphocytes, macrophages, and large atypical cells involving the superficial mucosa and extending deep into the submucosa causing degeneration of the underlying muscle. TUGSE is rare and may be easily mistaken for a cancer or microbial infection, but it is self-limiting and tends to resolve spontaneously. Thus, awareness of this entity is important to emphasize the correct diagnosis of indurated ulcerated lesions and deliver appropriate and effective treatment. The present case highlights the clinical aspects, aetiopathogenesis and histopathology of this uncommon lesion.

Oral eosinophilic or traumatic ulcer: A case report and brief review

Eosinophilic ulcer of the oral mucosa is considered to be a benign, reactive, and self-limiting lesion, with unclear pathogenesis, manifesting as a rapidly developing solitary ulcer. We report a case of a 42-year-old man who presented with a chronic indurated ulcer of buccal mucosa adjacent to the right upper wisdom tooth. Histopathological examination showed polymorphic inflammatory infiltrate, rich in eosinophilis, involving the superficial mucosa, and the deeper muscle layer. Immunohistochemical analysis revealed single CD30+ cells scattered within an inflammatory infiltrate. The lesion was excised, and healing was uneventful with no recurrence in more than a year.

Traumatic ulcerative granuloma with stromal eosinophilia - Mystery of pathogenesis revisited

Oral ulcers are a common symptom in clinical practice. Among various causative factors, different types of ulcers in oral cavity exist. Among this, traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) appears to be quite neglected by the clinicians due to the limited knowledge and awareness. On reviewing with a detailed approach to titles and abstracts of articles eliminating duplicates, 40 relevant articles were considered. Randomized studies, review articles, case reports and abstracts were included while conference papers and posters were excluded. Of importance, TUGSE cases been reported only to a minimal extent in the literature. Lack of its awareness tends to lead clinicians to a misconception of cancer. Thus, this particular lesion needs to be differentiated from other malignant lesions to provide a proper mode of treatment. The present article reviews various aspects of the TUGSE with emphasis on the clinical manifestation, pathogenesis, histological, and immunohistochemical study. This study provides the clinician contemporaries, a humble expansion to their knowledge of the disease, based on the searched literature, enabling a more comprehensive management of this rare occurrence.

CD30-Positive T-Cell Lymphoproliferative Disease of the Oral Mucosa in Children: A Manifestation of Epstein-Barr Virus-Associated T-Lymphoproliferative Disorder

Eosinophilic ulcer of the oral mucosa (EUOM) is a very rare, benign, self-limiting ulcerative lesion of the oral cavity of unknown pathogenesis, and belongs to the same spectrum of CD30⁺ T-cell lymphoproliferative disease (LPD) of the oral mucosa. The etiology and pathogenesis of the disease are unknown. We report two cases in children who were initially diagnosed with EUOM and CD30⁺ T-cell LPD, respectively. However, retrospective analysis revealed that a majority of infiltrated atypical T cells were positive for Epstein-Barr virus (EBV). The present cases suggest that the pathogenesis and etiology of EUOM or CD30⁺ T-cell LPD occurring in children are different from those in adults. EUOM or CD30⁺ T-cell LPD in children is a manifestation of EBV-positive T-cell LPD, and should therefore be distinguished from the disease in adults.

Eosinophilic ulcer of the oral mucosa: report of a case with multiple synchronous lesions

Eosinophilic ulcer of the oral mucosa is considered to be a benign, reactive, and self-limiting lesion, with unclear pathogenesis, manifesting as a rapidly developing solitary ulcer. We report the case of a 52-year-old man who presented with 4 synchronous ulcerations of the tongue. Histopathological examination showed polymorphic inflammatory infiltrate, rich in eosinophils, involving the superficial mucosa and the deeper muscle layer. Immunohistochemical analysis revealed single CD30 cells scattered within an inflammatory infiltrate. All the lesions began to regress spontaneously within 1 week after biopsy. A 4-year follow-up showed no recurrence.

The spectrum of primary mucosal CD30-positive T-cell lymphoproliferative disorders of the head and neck

OBJECTIVE

To retrospectively investigate the clinicopathologic spectrum of primary mucosal CD30-positive T-cell lymphoproliferative disorders (PTCLDs) of the head and neck.

STUDY DESIGN

Archives of PTCLDs primarily arising in head and neck mucosa were reviewed. Immunostaining of CD20, CD3, CD4, CD8, CD30, CD56, anaplastic lymphoma kinase (ALK), epithelial membrane antigen (EMA), cytotoxic molecules (TIA-1, granzyme B, or perforin), and Ki67; in situ hybridization for Epstein-Barr virus; and T-cell receptor gene rearrangement analysis were performed.

RESULTS

Fourteen cases of primary mucosal anaplastic large cell lymphoma (M-ALCL) were identified, and no lymphomatoid papulosis (LyP) cases were found. All cases demonstrated atypical mononuclear neoplastic cells with diverse histology and cytomorphology. The typical immunophenotype of neoplastic cells was CD3-positive, CD4-positive, CD8-negative, CD30-positive, ALK-negative, and cytotoxic molecules-positive. Infiltration of inflammatory cells was common. All cases presented an indolent course, regardless of therapy.

CONCLUSIONS

PTCLDs of the head and neck provisionally included M-ALCL alone.

Mimics of cutaneous lymphoma: report of the 2011 Society for Hematopathology/European Association for Haematopathology workshop

The Society for Hematopathology and European Association for Haematopathology workshop, from October 27 to 29, 2011, in Los Angeles, CA, exhibited many exemplary skin biopsy specimens with interesting inflammatory changes mimicking features of cutaneous lymphoma. This article reviews features observed in cutaneous lymphoid hyperplasia, cutaneous drug reactions, lupus-associated panniculitis, pityriasis lichenoides, hypereosinophilic syndrome, histiocytic necrotizing lymphadenitis, traumatic ulcerative granuloma with stromal eosinophils, and pigmented purpuric dermatosis, as well as a brief review of the pertinent literature and discussion of submitted conference cases. For the pathologist, it is important to be aware of diagnostic pitfalls as well as the limitations of ancillary testing (eg, clonality studies). Finally, correlation with total clinical information, good communication with clinical colleagues, close clinical follow-up with rebiopsy, and prudent use of laboratory studies are vital and will likely offer the best path toward a correct diagnosis.

Eosinophilic ulcer of the tongue in an 80-year-old Iranian woman after a psychologically stressful event

Eosinophilic ulcer of the oral mucosa is a benign self-limiting, chronic lesion more frequently seen in the oral cavity or tongue that can mimic squamous cell carcinoma. The pathogenesis of this problem is unknown. In this paper, we present a case of an 80-year-old woman with eosinophilic ulcer of the tongue after a psychologically stressful event.

Mucosal CD30-positive T-cell lymphoproliferations of the head and neck show a clinicopathologic spectrum similar to cutaneous CD30-positive T-cell lymphoproliferative disorders

CD30-positive T-cell lymphoproliferative disorders are classified as cutaneous (primary cutaneous anaplastic large cell lymphoma and lymphomatoid papulosis) or systemic. As extent of disease dictates prognosis and treatment, patients with skin involvement need clinical staging to determine whether systemic lymphoma also is present. Similar processes may involve mucosal sites of the head and neck, constituting a spectrum that includes both neoplasms and reactive conditions (eg, traumatic ulcerative granuloma with stromal eosinophilia). However, no standard classification exists for mucosal CD30-positive T-cell lymphoproliferations. To improve our understanding of these processes, we identified 15 such patients and examined clinical presentation, treatment and outcome, morphology, phenotype using immunohistochemistry, and genetics using gene rearrangement studies and fluorescence in situ hybridization. The 15 patients (11 M, 4 F; mean age, 57 years) had disease involving the oral cavity/lip/tongue (9), orbit/conjunctiva (3) or nasal cavity/sinuses (3). Of 14 patients with staging data, 7 had mucosal disease only; 2 had mucocutaneous disease; and 5 had systemic anaplastic large cell lymphoma. Patients with mucosal or mucocutaneous disease only had a favorable prognosis and none developed systemic spread (follow-up, 4-93 months). Three of five patients with systemic disease died of lymphoma after 1-48 months. Morphologic and phenotypic features were similar regardless of extent of disease. One anaplastic lymphoma kinase-positive case was associated with systemic disease. Two cases had rearrangements of the DUSP22-IRF4 locus on chromosome 6p25.3, seen most frequently in primary cutaneous anaplastic large cell lymphoma. Our findings suggest mucosal CD30-positive T-cell lymphoproliferations share features with cutaneous CD30-positive T-cell lymphoproliferative disorders, and require clinical staging for stratification into primary and secondary types. Primary cases have clinicopathologic features closer to primary cutaneous disease than to systemic anaplastic large cell lymphoma, including indolent clinical behavior. Understanding the spectrum of mucosal CD30-positive T-cell lymphoproliferations is important to avoid possible overtreatment resulting from a diagnosis of overt T-cell lymphoma.

Clinical pathologic conference case 3: nodular fasciitis

Intraoral nodular nodular fasciitis is a rare entity that is important to recognize because it may simulate a malignancy clinically and histologically. The rapid growth and high mitotic index seen in nodular fasciitis may suggest a malignant neoplastic process, but it is generally considered to be a benign reactive proliferation. Recognizing the unique histologic features of nodular fasciitis is important to avoid a possible misdiagnosis as a malignancy, leading to unnecessary further treatment.

Traumatic ulcerative granuloma with stromal eosinophilia: a lesion with alarming histopathologic presentation and benign clinical course

Traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) is a chronic, benign, self-limiting lesion of the oral mucosa. Clinically, the ulceration is characterized by the presence of indurated elevated borders and may resemble pyogenic granuloma or even squamous cell carcinoma of the mouth. Pathogenesis of the lesion is unclear. Although it had been suggested that TUGSE may represent a CD30+ lymphoproliferative disorder, this theory is currently not supported by evidence. We are presenting a classic example of TUGSE, its clinical course, differential diagnosis, and treatment.