This document provides information about a lecture on soft tissue tumors given by Dr. J.E. Bouquot. The lecture covers various soft tissue tumors including irritation fibroma, inflammatory papillary hyperplasia, giant cell fibroma, fibromatosis, and gingival fibrous hyperplasia. It discusses the etiology, clinical features, histopathology, treatment and other characteristics of each tumor type. The document also provides background information on Dr. Bouquot and references textbooks on oral pathology.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.
It is also called Oral Fibroma or Irritational Fibroma or Focal Fibrous Hyperplasia.
Fibroma is a benign neoplasm of fibrous connective tissue origin.
It is characterized by excessive proliferation of fibroblast cells with synthesis of large amount of collagen.
Although a large number of fibrous over-growths are found inside the oral cavity, most of these are reactive lesions occurring as a result of trauma or local irritation and therefore true fibromas are extremely rare.
Jain G et al (2017) stated that traumatic irritants include calculi, foreign bodies, overhanging margins, restorations, margins of caries, chronic biting, sharp spicules of bones, and overextended borders of appliances. Fibroma, a benign neoplasm of fibroblastic origin, is reactive in nature and represents a reactive hyperplasia of fibrous connective tissue in response to local irritation or trauma rather than being a true neoplasm.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.
It is also called Oral Fibroma or Irritational Fibroma or Focal Fibrous Hyperplasia.
Fibroma is a benign neoplasm of fibrous connective tissue origin.
It is characterized by excessive proliferation of fibroblast cells with synthesis of large amount of collagen.
Although a large number of fibrous over-growths are found inside the oral cavity, most of these are reactive lesions occurring as a result of trauma or local irritation and therefore true fibromas are extremely rare.
Jain G et al (2017) stated that traumatic irritants include calculi, foreign bodies, overhanging margins, restorations, margins of caries, chronic biting, sharp spicules of bones, and overextended borders of appliances. Fibroma, a benign neoplasm of fibroblastic origin, is reactive in nature and represents a reactive hyperplasia of fibrous connective tissue in response to local irritation or trauma rather than being a true neoplasm.
Dr. Ahmed M. Adawy, Professor Emeritus, Dep. Oral & Maxillofacial Surgery. Former Dean, Faculty of Dental Medicine
Al-Azhar University. Oral biopsy; why, when, and how? Biopsy is the removal of the tissue from the living organism for the purpose of microscopic examination and diagnosis. Looking for a definitive diagnosis is the aim of biopsy. Types of Biopsy include incisional, excisional, drill, fine needle and frozen section biopsy.
Gingival cyst of newborn /orthodontic courses by Indian dental academy Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
Dr. Ahmed M. Adawy, Professor Emeritus, Dep. Oral & Maxillofacial Surgery. Former Dean, Faculty of Dental Medicine
Al-Azhar University. Oral biopsy; why, when, and how? Biopsy is the removal of the tissue from the living organism for the purpose of microscopic examination and diagnosis. Looking for a definitive diagnosis is the aim of biopsy. Types of Biopsy include incisional, excisional, drill, fine needle and frozen section biopsy.
Gingival cyst of newborn /orthodontic courses by Indian dental academy Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
Benign connective tissue tumors 1/ dental implant courses by Indian dental ac...Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
www.indiandentalacademy.com
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.
Gaint cell lesions of bone/oral surgery courses by indian dental academyIndian dental academy
Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.
Tích hợp xương trong nha khoa
Jan Lindhe, Niklaus P. Lang, Thorkild Karring. Clinical Periodontology and Implant Dentistry, 5th edition, 2008, Blackwell Munksgaard.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
1. Oral & Maxillofacial Pathology II
DB 3702
Topic: Soft Tissue Tumors
Course Director: Dr. J. E. Bouquot
Room 3.094b; 713-500-4420
Jerry.Bouquot@uth.tmc.edu
Thursdays, 10:00 – 11:50 am
Room DB 132
2. This presentation created by
Dr. J. E. Bouquot
This presentation is intended for students of Dr. Jerry Bouquot.
Designated owners of the photographic images in this lecture
retain the copyrights for those images but have agreed to allow
their photos to be used for teaching. You are welcome to use this
presentation or portions thereof for your own teaching without
permission from the Maxillofacial Center, but permission is not
given for the publication of these photos in electronic or other
formats.
Disclaimer: Dr. Bouquot is Professor & Chair,
Department of Diagnostic Sciences,
University of Texas Dental Branch at Houston.
The information and opinions provided herein are,
however, his own and do not represent official opinion
or policy of the University of Texas.
3. For More Information: The Neville Book
Used in almost all U.S. dental schools; one of most popular books in dentistry,
1,100+ pictures (in color), published by W. B. Saunders
An unusual view of
the authors.
Brad Neville (South Carolina), Douglas Damm (Kentucky)
Carl Allen (Ohio), Jerry Bouquot (University of Texas, Houston)
4. Mars’ Rule:
An expert is anyone from out of town.
Neville at Home West Virginia
Neville in London
Weber’s Definition
An expert is one who
knows more and more
about less and less until he
knows absolutely
everything about nothing.
West Virginia
6. Bouquot at Lilly Pharmaceuticals, with his University of Minnesota class
7. White Water in West Virginia
The New River
Arrow points to Dr. Bouquot
8. Interpretation of
Lumps and Bumps
Mr. Big Mouth
Mario the Mouth Detective
Law of Revelation: The hidden flaw never remains hidden
Muir’s Law: When we try to pick out anything by itself, we find it
hitched to everything else in the universe
10. Basic Objectives for Individual Lesions
Identify the cause
-- Etiology; pathoetiology
-- Pathogenesis
-- Cell or tissue of origin
List the GALP
-- Gender predilection
-- Age predilection
Gingival Fibrous Hyperplasia
-- Location predilection
-- Prevalence (frequency)
Describe the typical clinical appearance
-- Unusual clinical variants
-- Look-alike lesions (differential diagnosis)
-- Systemic associations
-- Genetic associations
-- Drug, foreign material, etc.
11. Basic Objectives for Individual Lesions
Describe the basic microscopic features
Describe the biologic behavior (pathophysiology)
-- Rate and pattern of growth
-- Prognosis without treatment
Typical treatment(s) and the prognosis
of such treatment(s)
Describe unique variants or features
-- Microscopic
-- Physiologic
-- Clinical
-- Biological behavior
Peripheral Ossifying Fibroma
13. Mucosal Masses – Look at Base
Hyperplastic lingual tonsil
Duration
Rate of enlargement
Constancy of enlargement
Uniformity of expansion
Size
Pedunculated (on a stalk)
Irritation fibroma
Sessile (broad based), lobulated
Base
Surface integrity
Surface irregularities
Color/Blanching
Firmness/Fluctuation
Moveability
Pain/Tenderness
14. Mucosal Masses – Look at Location
Location
Granular Cell Epulis
Multiplicity
Skin/Other mucosa lesions
Patient age
Gender
Family history
Gingiva
Peripheral Giant Cell Granuloma
Anterior maxillary alveolus
Base
Surface Integrity
Surface irregularities
Color
Firmness
Moveability
Pain/Tenderness
15. Mucosal Masses – Look at Surface Integrity
Metastatic Adenocarcinoma
Duration
Rate of enlargement
Constancy of enlargement
Uniformity of expansion
Size
Fungating (ulcerated, lobulated mass)
Ulcerated
Base
Surface Integrity
Surface irregularities
Color/Blanching
Firmness/Fluctuation
Moveability
Squamous Cell Carcinoma
Pain/Tenderness
16. Mucosal Masses – Look at Surface Irregularities
Irritation Fibroma
Duration
Rate of enlargement
Constancy of enlargement
Uniformity of expansion
Size
Lobulated
Torus Palatinus
Smooth surface
Base
Surface Integrity
Surface irregularities
Color/Blanching
Firmness/Fluctuation
Moveability
Pain/Tenderness
17. Mucosal Masses – Look at Surface Irregularities
Condyloma Acuminatum Duration
Rate of enlargement
Constancy of enlargement
Uniformity of expansion
Size
Verruciform (pointed projections)
Papillary (finger-like projections)
Base
Surface Integrity
Surface irregularities
Color/Blanching
Firmness/Fluctuation
Moveability Verruca Vulgaris (Wart)
Pain/Tenderness
18. Mucosal Masses – Look at Color
Lipoma
Duration
Rate of enlargement
Constancy of enlargement
Uniformity of expansion
Size
Red (vascular)
Yellow (fat, keratin, pus, lymphocytes)
Base
Surface Integrity
Surface irregularities
Color/Blanching
Firmness/Fluctuation
Moveability Hemangioma
Pain/Tenderness
19. Mucosal Masses – Feel (Palpate) It
Hemangioma Duration
Rate of enlargement
Constancy of enlargement
Uniformity of expansion
Size
Soft, nonfluctuant
Soft, blanching
Base
Surface Integrity
Surface irregularities
Color/Blanching
Firmness/Fluctuation
Moveability
Pain/Tenderness Lipoma
20. Mucosal Masses – Look at Moveability
Thyroglossal Duct Cyst
Duration
Rate of enlargement
Constancy of enlargement
Uniformity of expansion
Size
Immovable
Freely movable
Base
Surface Integrity
Surface irregularities
Color/Blanching
Firmness/Fluctuation
Moveability
Pain/Tenderness Squamous Cell Carcinoma
21. Mucosal Masses – Look at Pain
Pericoronitis
Duration
Rate of enlargement
Constancy of enlargement
Uniformity of expansion
Size
Aching, tender to palpation
Sharp pain on palpation
Base
Surface Integrity
Surface irregularities
Color/Blanching
Firmness/Fluctuation
Moveability
Pain/Tenderness Masseter Hypertrophy
22. Mucosal Masses – Look at Underlying Bone
Location
Metastatic Esophageal Carcinoma
Multiplicity
Skin/Other mucosa lesions
Patient age
Gender
Family history
Underlying bone change
23. Mucosal Masses – Look at it All!
Crohn’s Disease Location
Multiplicity
Skin/Other mucosa lesions
Patient age
Gender
Family history
Underlying bone change
Base
Surface Integrity
Surface irregularities
Color/Blanching
Firmness/Fluctuation
Moveability Multiple Mucosal Neuroma Syndrome
Pain/Tenderness
25. Irritation Fibroma
Reactive Fibrous Hyperplasia;
Traumatic Fibroma
From acute or repeated trauma
-- Poor healing
-- “Exuberant scar tissue”
– May develop from pyogenic granuloma
-- Similar skin lesion: keloid
GALP:
– None (but 2x females for biopsied cases)
– 4th-6th decades = usual age
– Buccal > lip > tongue > gingiva
-- Most common soft tissue mass
-- 3rd most common mucosal
lesion in adults
-- 3rd most common oral lesion
– Prevalence: 12/1,000 adults
26. Irritation Fibroma
Reactive Fibrous Hyperplasia;
Traumatic Fibroma
Smooth-surface
Normal color
Painless nodule
May be pigmented
-- Melanosis of epithelium
Maybe: frictional keratosis
May be ulcerated (trauma)
Usually sessile
-- May be pedunculated
Usually <1 cm.
– May become 3-4 cm.
Full size within 6 months
-- Minimal increase after
-- Does not go away
– No malignancy risk
27. Irritation Fibroma
Histopathology & Treatment
Pedunculated or sessile
Dense, avascular fibrous stroma
No capsule
Epithelium often atrophic
Small numbers of lymphocytes in fibrous stroma, maybe
Treat: conservative excision, otherwise lasts forever
30. Leaf-Shaped Fibroma
Variant of Irritation Fibroma
Grows under a denture base
Flat, often with small papules along edges
6th most common mucosal lesion
-- Prevalence = 7/1,000, with strong female predilection
Problems: Cortical erosion; infarction (stalk gets twisted)
Treat same as for regular irritation fibroma
32. Epulis Fissuratum
Variant of Irritation Fibroma?
Reactive fibrous hyperplasia; inflammatory
fibrous hyperplasia; denture injury tumor;
denture epulis; redundant tissue
Etiology: repeating trauma from denture flange
GALP:
– None (but strong female in biopsied cases)
-- Middle-aged and older
– Anterior vestibule >
posterior vestibule >
anterior oral floor
-- 11th most common oral lesion
-- Prevalence = 4/1,000 adults
33. Epulis Fissuratum
Variant of Irritation Fibroma?
Linear, often lobulated
Painless fibrous mass
Base parallels alveolus
May have traumatic ulcer in depth of a fissure
May have multiple parallel masses (“redundant tissue”)
May have areas of papillary hyperplasia along edges
34. Epulis Fissuratum
Histopathology
Like irritation fibroma
More chronic inflammatory
cells
Acanthosis/degeneration
May have surface ulcer (traumatic ulcer)
May have inflammatory papillary hyperplasia of surface
36. Epulis Fissuratum
Pathophysiology & Treatment
Continues to elongate over time (and continued trauma)
– New parallel masses develop, may ulcerated
– No malignant transformation
-- Although it was once thought to be premalignant
Dual treatment:
-- Surgical excision
-- Replace/repair denture
-- Low recurrence
38. Inflammatory Papillary Hyperplasia
Papillary Hyperplasia of the Palate
Denture Papillomatosis
Repeated trauma from denture base
-- Especially in persons who sleep
with denture in place
-- Edema of connective tissue papillae
May be seen in non-denture patients with:
-- High arched palate
-- Immune deficiency (e.g. AIDS)
GALP:
– 2x female
– Middle-age and older
– Hard palate, under denture
-- 15th most common mucosal lesion
-- Prevalence = 3/1,000 adults
39. Inflammatory Papillary
Hyperplasia
Clinical Features
Multiple painless fibrous papules
-- Scattered across hard palate
-- Concentrated in the midline
-- Burning? Candidiasis
Early lesions are:
-- Edematous
-- Erythematous
40. Inflammatory Papillary Hyperplasia
Histopathology
Old papules: like small irritation fibroma
Early: edematous granulation tissue
-- With chronic inflammatory cells
Pseudoepitheliomatous hyperplasia:
-- Can look like squamous cell carcinoma
41. Inflammatory Papillary
Hyperplasia
Pathophysiology & Treatment
Continues indefinitely
-- Even with new denture
-- Edematous lesions may
disappear
No malignant potential
-- Although once considered premalignant
Dual treatment:
-- Conservative surgical excision or laser/electrosurgical removal
– And replace or repair denture
-- Take denture out overnight
Treat early (edematous) case: Keep denture out (2+ weeks)
Antifungals, if burning
Antibiotics, maybe?
43. Giant Cell Fibroma
Variant of Irritation Fibroma
Etiology: unknown
-- Not related to trauma
GALP:
– Slight female
– Younger persons
-- 2-5% of fibrous oral
masses
– 50% on gingiva
Small, often lobulated
Smooth or pebbled
Painless nodule
< 5 mm in size
45. Retrocuspid Papilla
Variant of Giant Cell Fibroma?
Small fibrous gingival nodule
More frequent in children (25%)
-- 6% of adults
Behind mandibular cuspid
Often bilateral
Same giant fibroblasts as giant cell fibroma
47. Fibromatosis
Juvenile Aggressive Fibromatosis
Extraabdominal Desmoid
Etiology: unknown (neoplasm?)
GALP:
– None
– Children and young adults
– Mandibular gingiva
-- Rare in mouth
Painless, firm mass
-- Often lobulated
May destroy underlying bone
May be ulcerated
48. Fibromatosis
Histopathology, Pathophysiology, Treatment
Fibrous stroma many spindle cells
-- Streaming fascicles
– Not encapsulated
– Cells are mature
-- Cells more numerous than normal
Can grow to considerable size
May destroy underlying bone
Maybe great local disfigurement
No metastasis
Aggressive fibromatosis
Treat: wide excision
-- Including affected bone
– 1/4 recur with this treatment