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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 8  |  Issue : 3  |  Page : 166-169

Granular cell tumor (Epulis): Simple excision is the treatment of choice


1 Department of Surgery, Faculty of Medicine, Umm Al-Qura University, Makkah; Department of Surgery, King Faisal Specialist Hospital and Research Centre, Jedda, Saudi Arabia
2 Division of Pediatric Surgery, Al Sadiq Hospital, Saihat, Saudi Arabia

Date of Web Publication6-Aug-2019

Correspondence Address:
Dr. Osama A Bawazir
Department of Surgery, Faculty of Medicine, Umm Al-Qura University, P. O. Box 715, Makkah 21955; Department of Surgery, King Faisal Specialist Hospital and Research Centre, P. O. Box 40047, MBC: j-40, Jeddah 21499
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.JCN_60_19

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  Abstract 


Background: Epulis, which is also called granular cell tumor (GCT), is a rare tumor of the newborn. Aims and Objectives: to evaluate the outcome of surgical management of (GCT) and the efficacy of simple excision in neonates at our centers. Materials and Methods: We reviewed the medical records of 10 patients who had simple excision for granular cell tumor (GCT) in the period from 2006 to 2019. Result: This report describes 10 patients with GCT. All were newborns (nine females and one male). They presented with a mass of variable size protruding from the mouth and in five this interfered with feeding. In 7 patients, the mass was solitary, but three had two lesions. One had two masses arising from the maxillary alveolar ridge; one had two masses one arising from the maxillary alveolar ridge, while the other arising from the mandibular alveolar ridge and the third had two masses arising from the mandibular alveolar ridge. All were treated surgically with simple excision which was curative and on a mean follow-up of 3 years (10 months–6 years); there was no noticeable defect in the gum. Conclusion: Simple excision is the treatment of choice of epulis. It is simple, safe, and curative.

Keywords: Epulis, granular cell tumor, simple excision


How to cite this article:
Bawazir OA, Al-Salem AH. Granular cell tumor (Epulis): Simple excision is the treatment of choice. J Clin Neonatol 2019;8:166-9

How to cite this URL:
Bawazir OA, Al-Salem AH. Granular cell tumor (Epulis): Simple excision is the treatment of choice. J Clin Neonatol [serial online] 2019 [cited 2019 Sep 21];8:166-9. Available from: http://www.jcnonweb.com/text.asp?2019/8/3/166/264042




  Introduction Top


Epulis is a rare tumor of the newborn. It is also known as granular cell tumor (GCT) of the newborn or Neumann's tumor. Epulis arises from the mucosa of the gingiva most commonly from the anterior part of the maxillary alveolar ridge; although, it has been described as arising from the mandibular gingiva.[1],[2],[3],[4],[5] It is generally seen as a mass protruding out of the newborn child's mouth and may interfere with respiration or feeding.[6],[7] Epulis is seen much more commonly in females with a marked female preponderance of 8:1.[8],[9],[10] The treatment is prompt surgical resection with a good prognosis. The tumor is often misdiagnosed before surgery because of its rarity and lack of awareness by clinicians. The differential diagnosis includes as follows: hemangioma, lymphangioma, fibroma, rhabdomyoma, and heterotopic gastrointestinal cysts. This is a report of 10 newborns with epulis outlining their clinical aspects as well as the histologic features and treatment.


  Patients and Results Top


Ten newborns with epulis were treated. All were females except one. Their mean birth weight was 3.2 kg (2.9–3.8 kg). All were the product of full-term normal vaginal delivery except one who was born at 37 weeks' gestation. All presented with a mass protruding from the mouth and arising from alveolar ridges [Figure 1]. The size of the mass was variable from 2 cm to 7.5 cm [Table 1]. All had a single mass, but three neonates had two lesions. The first patient had two masses arising from the maxillary alveolar ridge; the second patient had two masses one arising from the maxillary alveolar ridge, whereas the other from the mandibular alveolar ridge and the third patient had two masses arising from the mandibular alveolar ridge [Figure 2] and [Figure 3]. In five of them, the mass also interfered with feeding. All masses were excised surgically and sent for histology. The masses were excised using simple excision by shaving it off the surface of the gum using both sharp and blunt dissection. There was no need to excise any part of the gum, and the raw surface of the gum was left to heal without sutures or flaps. The histology was consistent with GCT and composed of polypoid masses covered by stratified squamous epithelium with the core containing clusters of polygonal cells with granular cytoplasm and small central nuclei. Tumor cells were large with abundant granular acidophilic or foamy cytoplasm and oval nuclei with no evidence of atypia or malignancy.
Figure 1: Clinical photographs showing two newborn girls with a granular cell tumor arising from the maxillary alveolar ridge

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Table 1: Clinical features of patients with granular cell tumor

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Figure 2: Clinical photographs showing a newborn boy with a large granular cell tumor arising from the maxillary alveolar ridge and a smaller one arising from the mandibular alveolar ridge. Note also the intraoperative photograph showing the base of the tumors and their narrow attachment to the alveolar ridge which makes their excision easier

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Figure 3: Clinical photographs showing two newborn girls with granular cell tumor. (a) Two granular cell tumors arising from the maxillary alveolar ridge and (b) two granular cell tumors arising from the mandibular alveolar ridge

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All were discharged home on the same day of surgery except one who was kept under observation and was discharged on the 3rd postoperative day. Postoperatively, all did well and on a mean follow-up of 3 years (10 months–6 years); there was complete healing of the gum with no apparent alveolar defect.


  Discussion Top


Epulis or congenital GCT, is a rare tumor of the newborn. It is seen as a mass arising in the mouth from the alveolar ridge. It arises more commonly from the maxillary alveolar ridge and usually around the canine incisor. It is seen commonly in females with a female-to-male ratio of (8:1). This was the case in our series as there were nine females and only one male. The size of the lesion is variable, and it can reach up to 8 cm as in one of our patients. Large tumors and because of size can obstruct the airway but more commonly interfere with feeding and require immediate surgical excision.[6],[7] This was the case in five of our patients where the mass interfered with feeding, and in one of our patient, the mass size reached 7.5 cm in size.

Epulis is seen only in the newborn and commonly present as a single mass protruding from the mouth and is a different entity from other GCTs. Epulis is distinguished from other oral soft-tissue tumors by its maxillary or mandibular alveolar location. Epulis rarely present as two masses arising from the maxillary alveolar ridge or one arising from the maxillary alveolar ridge and the other from the mandibular ridge.[5] Seven of our patients had a single mass, but three had two lesions. One had two masses arising from the maxillary alveolar ridge; one had two masses one arising from the maxillary alveolar ridge, while the other arisen from the mandibular alveolar ridge and the third had two masses arising from the mandibular alveolar ridge.

Grossly, the typical appearance of epulis is a smooth, pedunculated mass that is pink in color. The histologic findings in congenital epulis however resemble those of GCTs. There is a striking histologic similarity of granular cells of gingival GCTs and the far more common GCT arising at any other site. The gingival GCTs contain cells that are virtually indistinguishable by light microscopy alone from those seen in GCTs, but immunohistochemical analysis shows that, unlike other GCT, the tumor cells in congenital epulis are negative for S100 protein. This is a distinguishing histological feature.[2],[5],[8],[9],[11] There are also several distinguishing features of gingival GCTs, such as predilection for newborn females, anterior maxillary location, presence at birth, plexiform arrangement of capillaries, and lack of pseudoepitheliomatous hyperplasia.[2]

The treatment of congenital epulis is surgical excision which can be safely done in the first few days after delivery or sooner if it is causing respiratory compromise or if it interferes with feeding.[6],[7] These are benign tumors and the treatment should be simple but complete excision. Conservative excision usually results in cure without sequelae. There are rare reports of recurrence, but these are due to incomplete excision. Radical surgery should be avoided as this may be complicated by injury to the alveolar ridge and result in abnormal dental development. There are those who advocate surgical excision and extrapolation of Millard's gingivoperiosteoplasty technique to reconstruct the associated alveolar defect with restoration of alveolar ridge continuity.[12],[13] We feel this is an extensive and unnecessary treatment for a simple and benign condition. All our patients were treated with simple surgical excision and none of them required gingivoperiosteoplasty to reconstruct the alveolar defect. This was the case even in the patients with very large epulis. These tumors are usually pedunculated which makes their excision simple. On follow-up, all our patients showed a completely healed wound with no apparent alveolar defect.


  Conclusion Top


Epulis is an extremely rare and benign tumor. It is seen in newborns as a mass protruding from the mouth and commonly arising from the maxillary alveolar ridge. It is usually solitary but rarely can present as two separate masses either both arising from the maxillary alveolar ridge or one from the maxillary alveolar ridge and the other from the mandibular alveolar ridge. It is seen commonly in females and can reach a large size that can interfere with feeding and or respiration. Physicians caring for these patients should be aware of this and simple surgical excision which is curative is the treatment of choice.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kanotra S, Kanotra SP, Paul J. Congenital epulis. J Laryngol Otol 2006;120:148-50.  Back to cited text no. 1
    
2.
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3.
Mueller DT, Callanan VP. Congenital malformations of the oral cavity. Otolaryngol Clin North Am 2007;40:141-60, vii.  Back to cited text no. 3
    
4.
Merrett SJ, Crawford PJ. Congenital epulis of the newborn: A case report. Int J Paediatr Dent 2003;13:127-9.  Back to cited text no. 4
    
5.
Sharma D, Murki S, Pratap T, Leelakumar V. Twin congenital epulis in the alveolar ridge of the maxilla and mandible in a newborn: A rare and interesting case. BMJ Case Rep 2014;2014. pii: bcr2014206490.  Back to cited text no. 5
    
6.
Eppley BL, Sadove AM, Campbell A. Obstructive congenital epulis in a newborn. Ann Plast Surg 1991;27:152-5.  Back to cited text no. 6
    
7.
Kumar P, Kim HH, Zahtz GD, Valderrama E, Steele AM. Obstructive congenital epulis: Prenatal diagnosis and perinatal management. Laryngoscope 2002;112:1935-9.  Back to cited text no. 7
    
8.
Rainey JB, Smith IJ. Congenital epulis of the newborn. J Pediatr Surg 1984;19:305-6.  Back to cited text no. 8
    
9.
Lapid O, Shaco-Levy R, Krieger Y, Kachko L, Sagi A. Congenital epulis. Pediatrics 2001;107:E22.  Back to cited text no. 9
    
10.
Kumar S, Prasad C, Thomas M, Koshy S. Congenital epulides: A rare case report. Indian J Dent Res 2014;25:806-8.  Back to cited text no. 10
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11.
Takahashi H, Fujita S, Satoh H, Okabe H. Immunohistochemical study of congenital gingival granular cell tumor (congenital epulis). J Oral Pathol Med 1990;19:492-6.  Back to cited text no. 11
    
12.
Lukash FN, Schwartz M, Grauer S, Tuminelli F. Dynamic cleft maxillary orthopedics and periosteoplasty: Benefit or detriment? Ann Plast Surg 1998;40:321-6.  Back to cited text no. 12
    
13.
Millard DR Jr., Latham RA. Improved primary surgical and dental treatment of clefts. Plast Reconstr Surg 1990;86:856-71.  Back to cited text no. 13
    


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