September 2019 HSC Section 1 Congenital and Pediatric Problems

Benign and Malignant Pediatric Oral Lesions

significant morbidity, can be characterized by simply performing an excisional biopsy or complete excision, whereas more extensive lesions can be evaluated by incisional biopsy. Cystic or fluid-filled lesions can be evaluated using fine needle aspiration. When infectious etiologies are suspected, these lesions and aspirate can be sent for aerobic, anaerobic, mycobacterial, and fungal cultures as well as Gram stain. Vascular-appearing lesions certainly require imaging; biopsy of suspected vascular le- sions is usually not recommended due to risk of bleeding. Arterial vascular lesions may also be further categorized using MRI or CT angiography. 5,6 In patients with oral lesions for which systemic etiologies are suspected, directed viral testing should be considered as appropriate; for example, in patients with risk factors and suspicion for immunosuppression, HIV testing should be considered. Furthermore, laboratory tests, including a basic metabolic panel and complete blood cell count, should be collected for these patients. Patients should also be seen in co- ordination with pediatric subspecialists who manage the systemic disease consid- ered, that is, pediatric oncology, pediatric infectious disease, or others. Vascular lesions comprise a significant proportion of benign masses occurring in the oral cavity in the pediatric population. The International Society for the Study of Vascular Anomalies has classified vascular lesions into 2 categories: benign vascular tumors and vascular malformations. 7 Because growth characteristics and treatments differ between these 2 groups, accurate diagnosis is of utmost importance. Infantile hemangioma Infantile hemangiomas (IHs) are the most common vascular tumors in childhood. Found in approximately 1% of all newborns in the United States, IHs along with lymphangiomas account for up to 30% of oral cavity tumors in the pediatric popu- lation and are seen in the lip, cheek, and tongue. 8 They are associated with prema- ture low-birth-weight infants, white ethnicity, and female gender. 9 Classically, IHs are not present at birth but appear within 2 months and undergo a period of rapid proliferation and expansion. Approximately 50% of all IHs gradually involute by 5 years of age. 10 Diagnosis is made with a thorough history and physical examina- tion. Most mucosal hemangiomas present as a raised red lesion that is rubbery on palpation. Conservative management is recommended for all IHs due to its propensity for invo- lution. The presence of uncontrolled bleeding, ulceration, infection, airway obstruc- tion, or risk of severe cosmetic deformity, however, should warrant active medical and surgical management. The b -adrenergic receptor blocker propranolol, with a target dose of 1 mg/kg/d to 3 mg/kg/d given 3 times daily after a screening EKG for 6 months to 12 months, is appropriate for most cases. 11 Systemic or oral steroids have been shown effective in up to 60% of cases. 12 Surgical management should be considered in cases refractory to medical management or in large IHs and may include carbon dioxide laser treatment, sclerotherapy, or pulse dye laser therapy in addition to surgical excision. 8,12,13 Lymphatic malformations Lymphatic malformations (LMs), otherwise known as lymphangiomas or macrocystic LMs (formerly cystic hygromas), involve the presence of low-flow vascular anomalies caused by defective embryologic development. 14 Mucosal lesions appear as small and cystic with a salmon roe appearance. 15 In contrast to hemangiomas, LMs are BENIGN LESIONS Vascular Lesions

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