A clinical case of a “flaming” nevus in a pregnant woman
Purulent granulomas are non-tumorous excess formations of granulation tissue, which are formed as a result of a reaction to various stimuli by the type of hormonal changes, traumatic injuries, or local factors. These formations in the oral cavity are mainly formed in the gum region and more often in women in the second decade of life. Clinically, such a granuloma has the appearance of an exophytic tumor with a lobed or smooth surface, red or purple; soft, spongy consistency. Surface ulceration is not typical for this type of formation. Microscopically, the lesion is characterized by benign proliferation of the longitudinal endothelial vascular channels in the edematous stroma, in which inflammatory cells are often present.
Purulent granulomas that occur during pregnancy are called pregnant tumors. The prevalence of such lesions is 0.2-9.6%, and most often they appear after the first trimester of pregnancy, while growing rapidly, but usually regress after childbirth. Given the features of the development of education, in most cases there is no need for surgical intervention. However, in some cases, when such tumors violate the state of occlusion and concern patients due to their significant size, pain, or bleeding, iatrogenic intervention aimed at removing them can be performed only during the second trimester. But formations that were removed during pregnancy can often recur and reappear. After birth, the tumors usually disappear without a trace, but in cases where they do not regress on their own, additional surgical intervention may be necessary.
Yuan and colleagues described the relationship between the development of purulent granulomas and the influence of angiogenic factors during pregnancy. According to the authors, female sex hormones not only enhance the expression of angiogenic factors, such as fibroblast growth factor (FGF) and vascular endothelial growth factor (VEGF), but also reduce the level of cell apoptosis by reducing factor expression tissue necrosis alpha (tissue necrosis factor – TNF-alpha). In women with inherent purulent granulomas during pregnancy, much higher rates of FGF, VEGF, and a decreased level of TNF-alpha were found, which indicates the correctness of the theory proposed by Yuan.
A lesion resembling a spot from port, aka “flaming nevus”, or capillary hemangioma, is a congenital malformation of capillaries, the prevalence of which does not exceed 0.3-0.5%. The lesion, as a rule, manifests itself on the mucous membrane or on the skin in the form of pink or red erythematous spots, which can darken with age. The area of the head and neck is the most frequent localization of the “flaming” nevus, especially if the latter occurs in the structure of dermatomes V1 and V2.
Below is a clinical case of a 31-year-old patient with a “flaming” nevus, which grew into a huge tumor during pregnancy. The tumor affected the gum area on the left side of the upper jaw, the same area where the congenital capillary hemangioma used to be. The tumor did not regress after childbirth, so it had to be removed surgically after pregnancy.
A 31-year-old patient turned to the Department of Oral and Maxillofacial Surgery at the New York Presbyterian Hospital in the structure of Columbia University Medical Center for a huge neoplasm of the mouth that occurred during pregnancy and did not regress after the baby was born. A tumor in the area of the upper jaw gums on the left side was first noticed by her during the first trimester of pregnancy and continued to grow and increase in size over time. The obstetrician-gynecologist was aware of the pathology, but advised not to carry out any manipulations in the affected area until the pregnancy is completed. The patient also complained of frequent bleeding in the affected area.
A clinical examination revealed edema in the region of the left cheek, and a red-violet neoplasm was found in the gum region of a similar section of the upper jaw (photo 1). The tumor was soft and spongy, easily bleeding on palpation, and the borders of the lesion also spread to the area of palatal gums. On the left side of the vestibular gums, the patient also found capillary hemangioma, which was located next to the tumor-like formation, but, according to the woman, she was present from birth. Hemangioma was not limited to the areas of the gums and lips, but also spread to the skin of the face and left cheek. The left part of the vestibule of the oral cavity in the upper jaw also showed symptoms of hypervascularization.