DIAGNOSIS : Traumatic Ulcerative Granuloma with Stromal Eosinophilia – TUGSE
DISCUSSION
A small but vital organ , the tongue plays an essential role in many aspects of daily living . From aiding in mastication and swallowing to functioning in speech and taste , there is no shortage of its importance . The constant usage of one ’ s tongue , along with bathing it in various carcinogens , makes it susceptible to a broad range of impairments , such as traumatic injuries , infectious diseases , and malignancies . Globally , as evidenced by several epidemiological studies , the prevalence of tongue lesions nears 18.5 %. 1 Additionally , many of these lesions can have clinically indistinguishable presentations that require a combination of thorough medical history-taking , patient interviewing , diagnostic testing , clinical correlation , and knowledge of pathology to correctly diagnose and treat . With roughly 50 % of oral cancers in the United States occurring on the tongue , specifically the posterolateral and ventral portions , having a swift and accurate diagnosis is highly imperative . 2 When a process has the potential to be diagnosed as squamous cell carcinoma , incisional biopsies should be performed to allow the exact location of the squamous cell carcinoma to be seen if a referral to a head and neck surgeon is required after the biopsy .
Upon reviewing all factors of this patient ’ s case , traumatic ulcerative granuloma with stromal eosinophilia ( TUGSE ) and squamous cell carcinoma ( SCC ) were favored on the differential diagnosis , but an infectious etiology could not be ruled out without proper diagnostic testing . TUGSE is a reactive benign ulceration of oral mucosa , usually affecting the tongue , of somewhat uncertain etiology , but deep-seated trauma to skeletal muscle is postulated to be a contributing factor in a majority of cases . 2
Although the patient in this case denied trauma to the tongue , TUGSE could not be entirely ruled out , as idiopathic cases have been reported . Submission of the biopsy specimen for histopathologic analysis returned the diagnosis of TUGSE . These lesions have been reported to heal spontaneously or after incisional biopsy . For lesions that do not heal completely after biopsy , excision , topical / local steroids , mouthwashes , curettage , and cryotherapy have been reported as therapeutic approaches . 3
Given the history of this case , especially considering the patient ’ s previous tobacco use and illicit drug use , SCC was considered as a possible diagnosis . Being the most common oral cancer , SCC accounts for over 95 % of cases of oral cancer , and 50 % of oral cancers occur on the tongue . 2 , 4 Oftentimes , SCC presents as a deeply ulcerated , indurated mass with raised , rolled borders . There may or may not be associated lymphadenopathy , pain , paresthesia , or anesthesia . Histologically , SCC is characterized by invasive islands of malignant epithelial cells present in the underlying fibrous connective tissue . In cases of well-differentiated SCC , the malignant epithelial islands may show keratin pearl formation . 5 The prognosis and treatment for SCC depends on tumor-node-metastasis ( TNM ) staging . Treatment of early-stage SCC may include surgery with or without intensity-modulated radiation . Advanced-staged SCC treatment may consist of surgery then intensity-modulated radiation therapy or chemoradiation . 2 In SCC , early and accurate diagnosis of the disease improves patient survival , making biopsies at the initial stages of the disease imperative for better prognosis . 2
Figure 2 Figure 3A Figure 3B
Figure 2 : The surface of the biopsy specimen was covered by ulcerated hyperparakeratinized stratified squamous epithelium . A : The superficial aspects of the epithelium demonstrated superficial bacterial colonization ( black arrow ) and normal dorsal tongue papillae ( white arrow ). B : There is a full-thickness epithelial ulceration , where the surface of the specimen is covered by a fibrinous exudate suspending inflammatory cells ( line ).
Figure 3 : There is a variable inflammatory cell infiltrate in the biopsy specimen . A : Just below the fibrin of the ulcer , there is a dense subacute inflammatory cell infiltrate , which contains many neutrophils ( black arrows ), just below the fibrin . Many eosinophils ( white arrows ) are present in the inflammatory cell infiltrate , even extending down into the skeletal muscle ( black open arrow ), which is required to make the diagnosis of traumatic ulcerative granuloma with stromal eosinophilia ( TUGSE ). B : Deeper in the specimen , there is chronic inflammatory cell infiltrate , composed of mainly lymphocytes ( black triangles ) and plasma cells ( white triangles ). Scattered neutrophils and eosinophils are present in the deeper portions of the specimen as well , but not in the same concentration as closer to the ulceration .
34 MAY / JUNE 2024 | PENNSYLVANIA DENTAL JOURNAL