University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 96
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Abstract : Fibrous histiocytoma, is rare tumor of the oral cavity. It is a cellular tumor mostly occurring on the orthokeratinized skin surface. It is also seen in other non-cutaneous areas. The benign form is more commonly seen as compared to the malignant variety. The benign form responds very well to excision alone, having almost no recurrence. Its clinical appearance resembles that of a pyogenic granuloma or traumatic fibroma, thus making it difficult to diagnose accurately. These two cases highlight the presentation of the tumor on the gingiva and its surgical management.
1Shubhangi Gupta (Post Graduate Student) Department of Periodontics, Kothiwal Dental College 2and Research Centre and Hospital, Moradabad, Aditya Law (Post Graduate Student) Department of
3Periodontics, Kothiwal Dental College and Research Centre and Hospital, Moradabad, Neha Joshi (Senior Lecturer) Department of Periodontics, Kothiwal Dental College and Research Centre
4and Hospital, Moradabad, Manvi Chandra Agarwal (Reader) Department of Periodontics, Kothiwal Dental College and Research Centre and Hospital, Moradabad
INTRODUCTION A neoplasm is a tumor, which literally
means 'new growth'[1].'Tumour' is the most common term
that is heard in medical field, which not only terrifies the
patient, but also sets off an alarm in the mind of the clinician.
Based on their clinical behavior, these tumors are divided into
two types: benign, which are considered to be relatively
innocent, denoting the fact that they are amenable to local
surgical excision; and malignant, those which can metastasize
to distant regions.
There are diverse presentations of these benign and malignant
tumors in the entire body, with the oral cavity being no
exception. Benign tumors seen in the oral cavity include
fibroma, pyogenic granuloma, papilloma, pleomorphic
adenoma, etc. Some tumors which are more commonly seen
in other parts of the body canrarely present in the oral cavity
and one such tumor is fibrous histiocytoma (FH).
FH, not so common tumor of the oral cavity, is a
fibrohistiocytic tumor (Recognized by WHO), which is
composed of cell population of fibroblasts and
histiocytes[2,3]. They can be cutaneous, non-cutaneous or
fibrous histiocytic tumors of bone. The most damaging are
the cutaneous type which originate in the sun-exposed skin.
The non-cutaneous typeare more common in the lower
extremities (50%) and also in the retroperitoneum
(20%)[4,5]. The presentation of this tumor in the oral cavity
has been reported in relation to buccal mucosa, vestibule,
tongue, and floor of the mouth. Rare occurrences are also seen
in the nasal cavity and paranasal sinuses, larynx, trachea,
temporomandibular joint and submandibular gland[6]. They
usually present as a solitary, painless growth which enlarges
slowly over a period of several months[6,7].
These two case reports describe the atypical presentation of
this tumor in less commonly affected areas i.e. in gingiva, and
in particular, its association with the edentulous space.
CASE REPORT 1:
A 21-year old male patient, reported to the department of
Periodontics with a chief complaint of bleeding gums from
the lower left region of the mouth for the last 1 month. He
noticed bleeding while brushing and on chewing food from
that side. His medical and dental history was non-
contributory. On clinical examination, an oval, well
FIBROUS HISTIOCYTOMA : A RARE PRESENTATION IN THE ORAL CAVITY - TWO CASE REPORTS
Journal of Dental Sciences
University
Key Words : fibrous histiocytoma, benign tumor, oral cavityExophytic growth
Source of support : NilConflict of Interest : None
Case Report
circumscribed, firm, exophytic, sessile growth was noticed in
the interdental region between #36 and 37, extending to the
buccal and lingual side (Figure 1(a), (b)). The growth was
reddish pink in colour, and had a pebbled appearance. On
palpation, the growth was soft in consistency and it bled
readily on probing.
Figure 1(a) Figure 1(b)
The intraoral periapical radiograph (IOPA) showed an
evidence of angular bone loss between #36 and #37 (Figure
2). Routine blood investigationsrevealed no abnormality.
Based on the history and clinical findings, a provisional
diagnosis of pyogenic granuloma was made
Figure 2
After phase I periodontal therapy, total surgical excision was
planned.
Incision was taken using no. 11 BP blade at the line of
demarcation circumferentially around the growth, both on the
buccal and the lingual side (Figure 3(a), (b)). The lesion was
excised, a full-thickness flap was raised and the base of the
lesion was cauterized, followed by osteoplasty (Figure 4).
The wound was closed with a 4-0 silk suture. Postoperative
instructions were given and the patient was kept on
amoxicillin 500mg thrice daily for 5 days,and paracetamol
500mg was prescribed for 2 days. 10ml of 0.2% chlorhexidine
mouthwash was advised twice daily for 10 days
Figure 3(a) Figure 3(b)
Figure 4
The excised tissue (Figure 5) was sent for histopathological
analysis Post- operative healing was satisfactory when
evaluated 10 days later. (Figure 6(a), (b))
Figure 5
Figure 6 (a) Figure 6 (b)
HISTOPATHOLOGICAL EVALUATION
Haematoxylin and eosin staining showed the presence of
stratified epithelium overlying the fibrous connective tissue.
The connective tissue also contained proliferating blood
vessels, dense chronic inflammatory cells, spindle cells and
histiocytes arranged in a fasicular pattern, round cells and
some necrotic areas (Figure 7).
According to these histopathological findings, a diagnosis of
fibrous histiocytoma was made.
Figure 7
CASE REPORT 2: A 60-year old female patient, reported to
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the department of Periodontics with the chief complaint of a
swelling in the lower front tooth region for the past 2 years.
The patient was wearing a faulty prosthesis, which was fixed
to the adjacent teeth for the past 6 years. She had noticed a
small swelling below her denture, which suddenly increased
in size. The prosthesis was subsequently removed and the
swelling increased to the present size. Pain was associated
with the swelling while brushing and it used to subsided on its
own. There was no relevant medical history.
On clinical examination a well-defined, pedunculated,
reddish swelling was seen on the edentulous ridge, extending
from mesial surface of #32 to the mesial surface of #43 even
extending on the lingual side, and was of 12x13mm in
dimension(Figure 8(a), (b)). On palpation, the swelling was
firm in consistency and slight movable in a mesio-distal
direction. The tooth adjacent to the growth #32 showed grade
III mobility.
Figure 8 (a) Figure 8 (b)
An orthopantomogram (OPG) and IOPA was taken and it
showed no evidence of angular or horizontal bone loss around
the base of the lesion. However, #32 showed bone loss
extending to the apex (Figure 9, 10).
Based on the history and the clinical appearance, a provisional
diagnosis of pyogenic granuloma was made.
Figure 9 Figure 10
Phase-I periodontal therapy was done and keeping in mind the
vascular nature of the lesion, surgical excision was planned
using electrocautery (Figure 11). Electrocautery tips were
used to excise the growth from the base (Figure 12).Tooth #32
was extracted after the excision. A periodontal dressing was
placed. Post-operative instructions were given and the patient
was kept on amoxicillin,500mg thrice daily for 5 days and
paracetamol500mg was prescribed for 2 days. 10 ml of 0.2%
chlorhexidine mouthwash was advised twice daily for 10
days. The excised tissue (Figure 13) was sent for
histopathological evaluation. Post-operative healing was
satisfactory when evaluated after 1 week.
Figure 11
Figure 12 Figure 13
HISTOPATHOLOGICAL EVALUATION
Hematoxylin and eosin sections revealed the presence of
parakeratinized stratified squamous epithelium overlying a
connective tissue matrix.
The connective tissue showed proliferating fibroblasts and
multiple histiocytes. Cords and islands of odontogenic
epithelial cells could be appreciated at various places within
the stroma. Proliferating endothelium lined the blood vessels,
and lymphatic channels were also seen (Figure 14).
According to these histopathological findings, a diagnosis of
fibrous histiocytoma was made.
Figure 14
DISCUSSION
Fibrous histiocytomas commonly lesions of the skin, have
been reported less frequently in the interdental papilla and
edentulous sites. The other intraoral sites reported in literature
included the labial mucosa of lower lip, buccal mucosa,
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tongue, and maxillary tuberosity. In the first case report, there
was involvement of the lingual gingiva between #36 and #37,
which posed a threat of damage to the lingual nerve during the
removal of the lesion. Clinically, the amount of bone
destruction did not correlate to what was assumed based on
the radiological findings. Therefore, osteoplasty was carried
out instead of regenerative osseous surgery. The etiology of
FH is obscure. Chronic irritation, continuous trauma and
spontaneous development have been reported[4,8,9].
Initially, the term 'fibrous histiocytoma' was used known for
both, the benign and the malignant varieties. Later, the
malignant one was re--classified as a “wastebasket of
undifferentiated pleomorphic sarcomas” accounting for no
more than 5% of adult soft tissue sarcomas[10].
The treatment of choice for oral fibrous histiocytoma (OFH)
is surgical excision[4]. The prognosis is good, if completely
excised and for this reason flap was reflected for complete
curettage in case 1. A periodic follow-up should always be
maintained to check for its recurrence.
Both the patients in the above cases are on periodic re-
evaluation since last 1 year. There has been satisfactory
healing and no recurrence in both cases.
CONCLUSION:
FH are rarely seen in the gingiva, and even rarer is their
association with an edentulous site. Within the oral cavity, it is
important to include fibrous histiocytomas in the differential
diagnoses of pyogenic granulomas, as their clinical
presentation is quite similar, as is their line of treatment.
ACKNOWLEDGEMENT:
I am using this opportunity to express my gratitude to
everyone who supported me throughout the work for the
article. I am thankful for their aspiring guidance, invaluably
constructive criticism and friendly advice during the paper
work. I am sincerely grateful to the department of oral
pathology, Kothiwal dental college and research centre for
helping me in this case.
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CORRESPONDING AUTHOR:
Dr. Shubhangi Gupta
Post Graduate Student,
Flat no 1072, UF apartment
Sector-6, plot no 9, dwarka
New Delhi -110075
Email: [email protected]
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