Giant fibrolipoma of the cheek: report of a case

Scivetti M^*, Di Cosola M^*, Lo Muzio L^***, Pilolli GP^*, Maiorano E^**, Capodiferro S^*,
Vignoletti F^****, Favia GF^*

^* Department of Dental Sciences and Surgery
^** Department of Pathological Anatomy and Genetics University of Bari, Italy
^**** Department of Dental Sciences and Surgery University of Foggia, Italia
^**** Department of Medicine and Oral Surgery. Dental school. University Complutense of Madrid, Spain.

Correspondence

ABSTRACT

Lipomas are common soft tissue mesenchymal neoplasms, rare in the oral cavity, representing 1% of all benign oral tumors. Fibrolipoma is a histological variant of the classic lipoma which normally affects buccal mucosa, floor of the mouth, tongue and lips. In this article is presented a rare case of fibrolipoma of the cheek and are discussed all the aspects of diagnosis, histology and surgical treatment, according to literature data.

Key words: Lipoma, benign neoplasm, fibrolipoma, cheek.

Introduction

Lipomas are common soft tissue mesenchymal neoplasms, rare in the oral cavity, accounting 1% of all benign oral tumours (1-3).

Fibrolipoma is a histological variant of simple lipomas: literature has reported similar incidence of these two neoplasms, although some studies found that the great majority of cases in oral cavity were lipomas. Oral lipomas affect primarily the buccal mucosa, floor of the mouth, tongue and lips (3).

Although the trauma could be an etiologic factor in lipomas occurring in other parts of the body, intraoral lipomas are of unknown etiology. Rarely they could be a part of multiple lipomatosis (2).

Intra-oral fibrolipomas usually appear as round-ovoidal nodules in the sub-mucosa, which cause a slow-growing swelling of the area involved; other possible presentations are as a long-standing, soft and free movable mass, sessile or sometimes attached by a little pedicle. A thin normotrophyc mucosa covers the neoplasm with a vascular superficial pattern and for the high percentage of fat tissue inside it can appear of a grey-yellow colour. For the absence of clinical symptoms like pain or bleeding and for the long-standing and benign behaviour, patients are usually not alarmed till the mass reaches big dimension or for pain and blooding caused by the pinching during the mastication.

Case report

A 57 years old man was referred to the Department of Dentistry and Surgery for a mass of the right cheek jutting out of the mouth. The patient became aware more than 1 year before referral. The growth was slow but steady over the (time) interval. He had a story of smoking (20 cigarettes/die for 30 year) and no ethanol abuse. Medical history included hypertension for ten year and no previous head and neck surgery or radiation treatment. Physical examination revealed a soft, non-tender mass of 4 cm in diameter in the retro-commissural mucosa of the right cheek (Fig. 1).

The mass had a little pedicle and was covered by a thin epithelium with a superficial vascular pattern. The surface presented a disomogeneous pattern with an alternation of ulcerative and hyperkeratinizated areas, probably related to the chewing trauma. Patient was able to extrude the neoplasm out of the mouth (Fig. 2).

The surgical treatment consisted in excision of the mass through an elliptical incision in the base of the pedicle that appeared fibrous with little blood vessels. The primary closure of the surgical defect was achieved without difficulty and the postoperative recovery was uneventful. The specimen was sectioned (Fig. 3), fixed in a buffered solution of 10% formalin and submitted to the microscopic examination.

Histological findings revealed a normal epithelium, with rare areas of hyperkeratinization due to the chewing trauma, overlying mature adipose tissue interspersed by broad bands and fascicles of dense connective with the presence of the capsule (Fig. 4). The pathologist’s diagnosis was benign fibrolipoma. Three years after surgery there was no evidence of recurrence.

Discussion and conclusions

Lipomas are quite rare benign mesenchymal neoplasms of the mouth, with 15 to 20% of the case involving the head and neck region and 1 to 4% affecting the oral cavity. They represent 0.1 to 5% of all benign tumours of the mouth. Predominant localizations are buccal mucosa, floor of the mouth, tongue and lips (2). Cheek localizations are rare, in particular in the retro-commissural region, where they arise from the Bichat fat tissue. This neoplasm is usually slow-growing and with a benign behaviour, as shown by rare evidence of recurrence (3). Histologically lipomas are classified in classic lipomas and mixed variants (fibro-, angio-, myo-, spindle cells lipomas). Lipomas usually consist of mature fat cells surrounded by a fibrous capsule. Oral cases are more common in males in contrast with the whole body where lipomas are twice as common in females. Fibrolipomas differed from the classic variant because the mature adipose tissue was interspersed by bands of connective tissue. Spindle cell lipomas are an uncommon variant of lipoma first recognized by Enzinger & Harvey in 1975. It consists of variable numbers of spindle cells, adipocytes, collagen bundles and myxoid interstizial matrix. Spindle cells fail to stain for S-100 protein, a-smooth muscle actin or desmin. Angiolipomas and myolipoma are rare in the mouth; angiolipomas, unlike conventional lipomas, is sometimes painful (3-6). It should be considered also the liposarcoma lipoma-like variant, for the similar pathological and clinical features. Regarding the proliferative activity, literature reported differences in PCNA and Ki67 in several histological benign groups; usually, fibrolipomas have a greater proliferative rate than other variants but, although Ki67 and PCNA are increased than in simple variants and these features would suggest faster growing pattern, this feature is not reflected in a worst prognosis or probability of recurrence after surgical approach (3).

Differential diagnosis may include many benign mesenchymal tumours like fibromas, simple lipomas, minor salivary gland tumours either benign or malign. According to the literature, it is difficult to value the real incidence of this neoplasm because is painless and for the slow-growing clinical appearance. In fact, the patient referred to clinician only when it was symptomatic and for aesthetic or functional problems.

Caution is required during the surgical excision which deserves attention particularly in oro-facial district where it is important to value the aesthetic and functional modification caused by terapy. The possibility of recurrences, though rare, are tightly related to the state of surgical borders and it’s clear that a complete surgical excision is simpler in small lesions than in greater ones. In our case, the presence of a peduncle has made easier the excision but a complete approach in a sessile mass of this dimension could have heavy aesthetic and functional repercussions. In conclusion, it is better to intervene in early stage of the pathology in order to avoid surgical morbidity.

Correspondence
Dr. Michele Di Cosola
Department of Dental Sciences
University of Bari - piazza Giulio Cesare, 11
70124 Bari - Italy
tel.: +39 (080) 5478173
fax: +39 (080) 5478743
e-mail: dicosola@libero.it

Acepted for publication: Octubre 2005

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