J Oral Maxillofac 48:395-397.
of the Cheek
DDS, DR ODoNT,t F.V. DOMINGUEZ, DDS, DR ODONT,* M.B. GUGLIELMOTTI, M.C. FLORES, DDS,$ AND M.L.G. DE LA GARZA, DDS, DR ODONT~ Liposarcoma is the most common soft tissue sarcoma of adulthood.‘*2 Its incidence ranges from 16% to 20% of all malignant soft tissue tumors.1.3-7 Although all body regions may be involved, the most frequent sites are the lower limb and retroperitoneurn.’ Because of this predilection for sites below the waist, liposarcoma is rarely found in the head and neck.‘s-‘O Pack and Pierson’ did not find any evidence of liposarcoma in the head and neck in their studies of 105 cases. Enzinger and Weiss’ series of 1,067 liposarcomas included 60 (5.6%) in the head and neck.’ In 1977, Baden and Newman reviewed the literature on liposarcoma of the oropharyngeal region and singled out 40 cases, adding two of their own.3 Intraoral liposarcoma is exceedingly rare.9.1’ The majority of intraoral liposarcomas are located in the cheek, 11.13-24but several cases have been reported in the floor of the mouth,3*25*26 soft palate,27328 mandible,“’ lip,3o and the gingiva.31 It is a tumor of adulthood, with an incidence peak between age 40 however, cases in children as and 60 years 3*9,26*32; young as 8 months have been reported. 1*16~20.26.3’333 Liposarcoma is slightly more common in males (55%) than in females.3*9*26.32*34There is no evidence that liposarcoma has a predilection for any particular race or geographic region.’ Most intraoral liposarcomas have a diameter of 5 to IO cm. The appearance of the tumor varies considerably, depending on its histologic type.’ The presence of a variety of cell types in liposarcoma, both morpho* Assistant Professor of Oral Pathology, Department of Oral Pathology, Paculty of Dentistry, Buenos Aires University, Argentina. t Assistant Professor of Oral Pathology, Department of Oral Pathology, Faculty of Dentistry, Buenos Aires University, Argentina. $ Oral Surgeon, Oral Surgery Outpatient Clinic of San Juste’s Hospital, Buenos Aires, Argentina. 8 Assistant Professor of Oral Pathology, Department of Oral Pathology, Nueva Leon University, Monterrey, Mexico. Address correspondence and reprint requests to Dr Guglielmotti: Catedra de Anatomia Patobgica, Facultad de Odontologia, Marcel0 T. de Alvear 2142-2A, 1122 Buenos Aires, Argentina. 0 1990 American geons
of Oral and Maxillofacial
logic and cytochemical, is indicative of the totipotentiality of mesenchymal cells. l9 Enzinger’ proposed a classification divided into four groups: myxoid, round cell, well-differentiated, and pleomorphic. A case of myxoid liposarcoma located in the left cheek is presented. Report of a Case A 63-year-old white man was referred to the oral surgery outpatient clinic of San Juste’s Hospital, Buenos Aires, for treatment of a mass in the left cheek. He had noticed a progressive but painless swelling for the past 3 months. The patient had a history of accidental trauma to his face 10 years previously. On clinical examination, his face was asymmetric and exhibited a well-circumscribed enlargement of the left cheek. The swelling was approximately 6 cm in diameter, rounded, with a lobulated surface and normal overlying skin (Fig 1). The lesion was rubbery hard, freely mobile, and nontender. Further intraoral examination proved noncontributory. The cervical lymph nodes were not enlarged. General physical examination showed the patient to be within normal limits. The clinical impression was lipoma. A needle biopsy performed under local anesthesia failed to provide sufficient tissue for diagnosis. Exploratory surgery with eventual removal of the lesion was indicated. Excision of the tumor mass was performed via a cutaneous incision. The lesion was extirpated without difficulty. Wound closure and healing were uneventful. The specimen was submitted for histologic diagnosis. Macroscopically, the excised specimen consisted of a nodular, apparently encapsulated mass with a lobulated surface (Fig 2). The largest dimensions were 5 x 5 x 2.5 cm. The cut surface was firm, yellowish-white, with a central white area. The lesion was enclosed in an adherent capsule. The histologic examination showed a lobulated and infiltrative neoplasm composed of pleomorphic fat cells lying in an abundant myxoid stroma (Fig 3). The tumor was composed predominantly of stellate or spindle cells. Many of the myxoid cells contained fat vacuoles in their cytoplasm and were closely related to a capillary plexus (Fig 4). Following PAS and alcian blue staining, the extracellular stroma exhibited pools of acid mucopolysaccharides. Nuclear pleomorphism was detected and giant nuclei were a frequent finding (Fig 5). A diagnosis of myxoid liposarcoma was made. The patient was sent to the Oncologic Institute to be reoperated and have Bichat’s fat pad removed as a preventive measure. Biopsies were taken from the periphery of the operative wound and sent for histologic diagnosis; the peripheral tissues were free of tumor. The patient’s postoperative course was satisfactory and, after 36 months, no evidence of recurrence has been seen.
OF THE CHEEK
FIGURE 3. Photomicrograph showing myxomatous areas, “signet-ring” tumor cells, anisonucleosis, and hyperchromasia. (Hematoxylin-eosin stain. Original magnification, X 100.)
FIGURE 1. Mass of the left cheek with normal overlying skin.
Discussion Liposarcomas of the oropharyngeal regions are exceedingly rare. ‘9,27 To date, only 15 cases of cheek liposarcoma have been reported.“~‘3~24 Their silent growth, deep location, circumscription, and firm but resilient texture often suggest a diagnosis of benign soft tissue neoplasm,3 as in the case presented here. This circumscription or encapsulation of the tumor is more apparent than real, and not infrequently satellite or daughter nodules are sequestered in the vicinity of the main tumor mass.’ Thus, since the tumor in our patient had been enucleated as a single mass, a new and more extensive surgical procedure was performed which failed to disclose any foci of residual tumor. The possible significance of trauma in the development of liposarcoma is difficult to assess.’ Most investigators doubt the existence of such a relationship.’ Myxoid liposarcoma is the most common type of liposarcoma; it accounts for approximately 40% to
50% of all liposarcomas. ’ Of the 35 oropharyngeal tumors analyzed by Baden and Newman, 71.4% were myxoid liposarcomas.3 The rate of metastasis of liposarcoma of the head and neck correlates well with the histologic type. Myxoid liposarcoma, for unknown reasons, tends to produce secondary lesions on the serosal surfaces of the pleura, the pericardium, and the diaphragm, sometimes alone or in combination with metastases to the viscera.’ Baden and Newman3 reported that the highest S-year survival rate was found in patients with well-differentiated myxoid liposarcoma, and the lowest in those with round-cell liposarcoma. The well-differentiated liposarcoma responds well to local excision, as reported in reviews of the literature.3 The prognosis for the patient in our case is con-
FIGURE 4. Photomicrograph shows the close association between neoplastic mesenchymal cells and vasculature. Note the ceils with hyperchromatic and giant nuclei. (Hematoxylin-eosin stain. Original magnification, X300.)
DOMINGUEZ ET AL
FIGURE 5. Photomicrograph showing a giant hyperchromatic nucleus and the typical signet-ring tumor cells with peripherally compressed hyperchromatic nuclei. (Hematoxylin-eosin stain. Original magnitication, X300.)
sidered good in view of the apparent adequate initial surgery and the more extensive local dissection that followed. Examination of the patient for recurrence must be continued for many years. References 1. Enzinger FM, Weiss SW: Soft tissue tumors. St Louis, MO, Mosby, 1983, pp 242-279 2. Kindblom LG. Angervall L, Suendsen P: Liposarcoma. A clinicopathologic, radiographic and prognostic study. Acta Path01 Microbial Stand 253: 1, 1975 3. Baden E, Newman R: Liposarcoma of the oropharyngeal region: Review of the literature and report of two cases. Oral Surg 44:889, 1977 4. Lattes R: The fatty tumors. JAMA 205:597, 1%8 5. Reszel PA, Soule EH, Coventry MB: Liposarcoma of the extremities and limb girdles: A study of 222 cases. J Bone Joint Surg 48A:229, 1966 6. Russell WO, Cohen J, Enzinger FM: A clinical and pathological staging system for soft tissue sarcomas. Cancer 40:1562, 1977 7. Stout Al’, Lates R: Tumors of the soft tissues, in Atlas of Tumor Pathology. Washington, DC, Armed Forces Institute of Pathology, 1967, pp 116-126 8. Kindblom LG. Angervall L, Jarlstedt J: Liposarcoma of the neck. A clinicopathologic study of four cases. Cancer 42:774, 1978 9. Pack GT, Pierson JC: Liposarcoma: Study of 105 cases. Surgery 36:687, 1954
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