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J Oral Maxillofac Surg70:349-353, 2012

Traumatic Ulcerative Granuloma WithStromal Eosinophilia: Report of a Case

and Literature ReviewIoulia Chatzistamou, MD, PhD,*

Ipatia Doussis-Anagnostopoulou, MD, PhD,†

George Georgiou, MD, PhD,‡ Harry Gkilas, DDS,§

George Prodromidis, DDS,� Maria Andrikopoulou, MD,¶ and

Alexandra Sklavounou, DDS, PhD#

Traumatic eosinophilic granuloma with stromal eosinophilia is a rare entity that affects the oral mucosaand has a controversial etiologic pathogenesis. Histologically, these lesions are characterized by a denseand deeply infiltrative lymphoproliferation showing epitheliotropic characteristics and massive eosino-philia. Frequently, a population of mitotically active, atypical mononuclear cells can be noted. This reportdescribes a case of traumatic eosinophilic granuloma with stromal eosinophilia in the floor of the mouthof an 88-year-old man. The phenotypic and genotypic profiles of the inflammatory infiltrate and largeatypical mononuclear cells, using immunohistochemical and polymerase chain reaction-based molecularanalysis, were analyzed.© 2012 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 70:349-353, 2012

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raumatic eosinophilic granuloma with stromal eosin-philia (TUSGE) is a rare clinicopathologic entity withnknown etiology that affects the oral mucosa andften manifests as an ulcer with elevated and indu-ated margins.1-4 Clinically, it may mimic squamous

cell carcinoma and other malignant lesions.2 It usually

Received from the University of Athens, Athens, Greece.

*Lecturer, Department of Basic Sciences, Dental School.

†Assistant Professor, Laboratory of Histology and Embryology,

Medical School.

‡Research Associate, Clinic of Hematology, Laiko Hospital.

§Research Associate, Department of Oral Medicine and Pathol-

ogy, Dental School.

�Research Associate, Department of Oral Medicine and Pathol-

ogy, Dental School.

¶Research Associate, Department of Oral Medicine and Pathol-

ogy, Dental School.

#Professor, Department of Oral Medicine and Pathology, Dental

School.

Dr Chatzistamou and Dr Doussis-Anagnostopoulou contributed

equally to this work.

Address correspondence and reprint requests to Dr Chatzista-

mou: Department of Basic Sciences, Dental School, University of

Athens, Thivon 2, Goudi 11527, Athens, Greece; e-mail: ihatzist@

med.uoa.gr

© 2012 American Association of Oral and Maxillofacial Surgeons

278-2391/12/7002-0$36.00/0

oi:10.1016/j.joms.2011.03.026

349

ffects the tongue; however, other sites such as theingiva and vestibular mucosa may be involved.3 Itsathogenesis and its relation to trauma are still un-lear. Various terms have been used to describeUSGE, including eosinophilic ulcer, eosinophilicranuloma of soft tissue, ulcerative eosinophilicranuloma, and traumatic ulcerative granulomaith stromal eosinophilia.3

Histologically, TUSGE usually involves the superfi-cial mucosa, but often it extends to the deeper musclelayer and is characterized by a diffuse polymorphicinflammatory infiltrate that is rich in eosinophils andaccompanied in some cases by a population of largeatypical mononuclear cells, whose origins have beena matter of debate.3-7 According to Alobeid et al,4 thenature of this entity and its relation to other disordersare controversial, and the term TUSGE covers a het-erogenous group of reactive and neoplastic lesions. Ithas also been suggested that TUSGE is a CD30� lym-phoproliferative disorder.4-7

Clinical Presentation

An 88-year-old man was referred to the Clinic ofOral Medicine in the Dental School of University ofAthens because of a solitary ulcer that was painful onpalpation on the floor of the mouth with firm androlled-up margins. The ulcer was in proximity to themargins of an old partial denture that had been re-

moved for a period of 1 month (Fig 1). Smoking was

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350 TRAUMATIC ULCERATIVE GRANULOMA

not a factor. Extraoral examination did not show anypathologic findings. No regional lymphadenopathycould be found. An incisional biopsy was performed.One week after the biopsy, the ulcer showed signs ofremission; 4 weeks later, the residual ulceration dis-appeared. In 6 months of follow-up, the lesion hadnot recurred. The patient remains on a regular fol-low-up program.

Methods

The tissue specimen was fixed in formalin and thenembedded in paraffin. Five-micrometer sections fromthe paraffin blocks were cut and stained with hema-toxylin and eosin for microscopic examination orused for immunohistochemistry. Immunohistochem-ical analysis was performed according to standardprocedures. Briefly, sections were deparaffinized inxylene and rehydrated through graded alcohols.Endogenous peroxidase activity was blocked by 3%hydrogen peroxide in methanol (10 minutes) andwashed in phosphate buffered saline. After incuba-tion with 10% nonimmune goat serum (10 minutes)to block nonspecific binding, slides were incubatedwith the primary antibody for 1 hour to 3 hours in amoist chamber at room temperature, according to themanufacturer’s instructions and the results of prelim-inary experiments. Sections were washed in phos-phate buffered saline and incubated with biotinylatedantimouse immunoglobulin G (10 minutes), followedby incubation with avidin-biotin complex and horse-radish peroxidase reagents (10 minutes) at room tem-

FIGURE 1. Clinical presentation of the ulcer on the floor of themouth of an 88-year-old patient.

Chatzistamou et al. Traumatic Ulcerative Granuloma. J OralMaxillofac Surg 2012.

perature, and then counterstained with hematoxylin. n

POLYMERASE CHAIN REACTION ANALYSIS

DNA ExtractionGenomic DNA was extracted from the paraffin-em-

bedded tissue using a DNA tissue mini kit (Qiagen,Valencia, CA). DNA quality and quantity were measuredusing ultraviolet spectrophotometry.

Detection of T-Cell and B-Cell ReceptorRearrangementsExtracted DNA was subjected to multiplex poly-

merase chain reaction (PCR) fragment analysis for thedetection of human immunoglobulin VH locus (Ig-VH)lonal rearrangement and for the detection of T celleceptor (TCR)� and TCR� clonal rearrangements us-ng the IGH, TCR�, and TCR� Gene Clonality Assays,espectively (InVivoScribe Technologies, Huissen,he Netherlands). A DNA sample (1 �g) was analyzed

wice using 3 multiplex PCR primer sets for the de-ection of clonal B-cell populations, 3 multiplex PCRrimer sets for the detection of TCR� clonal rearrange-ent, and 2 multiplex primer sets for the detection ofCR� clonal rearrangement according to BIOMED 2oncerted Action BMH4-CT98-3936 primer sequencesnd instructions. The amplification products were ana-yzed on an automated sequencer (CEQ-8000, Beckmanoulter, Brea, CA).

Results

HISTOPATHOLOGIC FINDINGS

Microscopic examination showed extensive ulcer-ation of the squamous cell epithelium, with a denseinflammatory submucosal infiltrate that extendeddeep into the submucosa, causing degeneration of theunderlying muscle. The infiltrate consisted of smallround lymphocytes, numerous histiocytes, eosino-phils, neutrophils, plasma cells, and aggregates oflarge mononuclear cells with irregular nuclear con-tours, fine chromatin, small nucleoli, and abundantcytoplasm (Fig 2). The infiltrated area of tissue waswell vascularized, with no signs of angiocentricity ornecrosis.

IMMUNOHISTOCHEMICAL ANALYSIS

The lymphocytic infiltrate was composed of a mix-ture of small B (CD20�) and T (CD3�, CD5�, CD43�)ymphocytes, with a predominance of the T-cell com-onent. In addition, many cells were positive forD68 and vimentin, which were morphologicallyonsistent with macrophages.The large atypical cells were positive for B-cellarkers (CD20, bcl-6) and focally for the activationarker CD30 (Fig 3), and approximately 10% showed

pstein-Barr virus (EBV) positivity. These cells were

egative for leucocyte common antigen (LCA), ana-

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CHATZISTAMOU ET AL 351

plastic lymphoma kinase (ALK), S-100, human mela-noma black-45 (HMB-45), pankeratin, and epithelialmembrane antigen (EMA). Interestingly, the prolifer-ation marker Ki-67 was very low (�5%).

MOLECULAR ANALYSIS

Spectra-typing multiplex PCR fragment analysis indi-cated the presence of a monoclonal B-cell populationand a monoclonal T-cell population. PCR productsshowed prominent peaks, reflecting the presence of amonoclonal B-cell population. Similar results were ob-tained using framework (FR)1, FR2, or FR3 primers.

PCR products showed prominent peaks, reflectingthe presence of a monoclonal T-cell population. Similarresults were obtained using Tube A (V�1-8, V�10 �

ultiple J� regions) or Tube B (V�9, V�11 � multiple J�regions) sets of primers.

Discussion

TUSGE is a rare, chronic, self-limited lesion of theoral mucosa.1-8 Clinically, it manifests as an ulcer withelevated and indurated margins. The clinical presen-tation mimics that of squamous cell carcinoma, andthe differential diagnosis may also include traumaticneuroma, granular cell myoblastoma, lymphoma, lym-phangioma, salivary gland tumors, and other malig-nant lesions.1 Tongue is the most commonly affectedite; however, other areas such as the lip, palate,ingival, vestibular mucosa, and the floor of theouth are rarely involved.1 It can be asymptomatic or

FIGURE 2. Sections of the dense inflammatory infiltration of thelesion were stained with hematoxylin and eosin (magnification,�40). The large atypical mononuclear cells (asterisks) and eosin-ophils (arrows) are displayed.

Chatzistamou et al. Traumatic Ulcerative Granuloma. J OralMaxillofac Surg 2012.

ccasionally associated with pain. Pediatric to geriat-

ic and male and female patients are equally affected.he lesion is usually unifocal, although multifocal

esions and recurrences have been reported.Microscopically, TUSGE is characterized by a dense

olymorphic inflammatory infiltrate extending intohe underlying muscle. The dominant cell types aremall lymphocytes, macrophages, and numerous eo-inophils. The presence of the latter is not fully un-erstood because most traumatic oral ulcerations areevoid of eosinophils. It has been suggested thatosinophils represent a tissue reaction to some un-nown antigen.6

The pathogenesis of TUSGE is controversial. Al-though trauma was considered to have a major role inits pathogenesis, obvious trauma could not be shownin most cases.

The origin of the large cells has also been a matterof debate. Regezi et al,6 in a study of 8 cases, detectedthe macrophage marker CD68 or the dendrocytemarker factor XIIa, whereas El-Mofty et al,5 in a seriesof 38 cases, found that the atypical large cells werepositive only for vimentin, which they believed indi-cated a myofibroblastic origin. The positivity of thelarge cells for CD30 has also been reported.4,7 CD30 is

transmembrane protein with an extracellular do-ain homologous to the tumor necrosis factor/nerve

rowth factor receptor superfamily, originally de-cribed on Reed-Sternberg cells.8 CD30 is commonlyxpressed on activated B and T cells,8 in certain

lymphoproliferative disorders including anaplasticlarge cell lymphoma, in primary cutaneous T-cell lym-phoproliferative disorders, lymphomatoid granuloma-tosis, and classic Hodgkin lymphoma.9,10 Conversely,

D30 expression has also been found in non-neo-lastic disorders such as atopic dermatitis,11 drugeactions,12 scabies,13 and non-neoplastic cutane-

ous conditions rich in neutrophils and eosino-phils,14 indicating that CD30� cells could also be acomponent of a reactive process.

Cases of TUSGE containing CD30� atypical cellsssociated with positivity of T-cell markers7 or with

detected T-cell monoclonality3,4 suggest that theseesions may represent the oral counterpart of primaryutaneous CD30� lymphoproliferative disorders. This

hypothesis would be consistent with the nonaggres-sive clinical behavior of these lesions, even in caseswhere a monoclonal rearrangement was found andthe case fulfilled the histologic criteria for lym-phoma.3 In the present case, the inflammatory infil-trate of TUSGE contained aggregates of large atypicalmononuclear cells that expressed B-cell markers andwere positive for CD30, and a monoclonal B-cell pop-ulation was detected by PCR analysis. These findingssuggested that this lesion may be an atypical lym-phoproliferative disorder of B-cell origin of the oral

mucosa and implicate, for the first time to our knowl-

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352 TRAUMATIC ULCERATIVE GRANULOMA

edge, a monoclonal B-cell population in this particularsetting. The molecular finding of a second T-cellmonoclonal population was surprising, because therewere neither morphologic nor immunohistochemicalfindings in favor of a neoplastic T-cell infiltration.Therefore, the reason for the T-cell monoclonalityremains elusive. A challenging possibility could be thepresence of a rearrangement in T- and B-cell receptorsthat occurred in an early precursor stage of the cells,in a manner that the B-cell phenotype was moreprominent than the T-cell phenotype.

Whether the presence of monoclonality is relatedto a true B- or T-cell neoplasm in the present caseremains a point for discussion. The morphologic, im-munohistochemical, and molecular data are in favorof an atypical lymphoproliferative disorder of B-cellorigin, although the low proliferation rate and un-

FIGURE 3. Immunohistochemical staining of the dense inflammatoactivated B and T cells (CD30), and D, T-cell origin (CD3). Positiv

Chatzistamou et al. Traumatic Ulcerative Granuloma. J Oral Ma

eventful follow-up are unusual. The specific microen-

vironment, created by the rich inflammatory compo-nent in this particular setting, may have a role to playin the outcome of the lesion, as in other entities richin infiltrating cells, such as Hodgkin lymphoma.15

However, because cases of TUSGE are rare, completedata from more cases should be collected; and fol-low-up of patients for prolonged periods are crucial toachieve the correct diagnosis of each case and toavoid possible overtreatment.

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