Title: benign soft tissue lesion

Summary

26 years old Malay gentleman presented left cheek swelling, no pain; gradually increase in size causing discomfort while eating and disfigurement of the face. Physical examination revealed

palpable, soft, non-tender mass at left cheek.

Introduction

a. Background of the study

Fibrous histiocytoma (FH) is a benign tumour composed of a mixture of fibroblastic and

histiocytic cells. This tumour most frequently occurs in the dermis, but is also

sporadically found in soft tissue and parenchymal organs. The benign FH usually

originates in sun-exposed skin and in orbital tissues, whereas the occurrence of this lesion

in deep soft tissues of the head and neck has rarely been reported. The term cutaneous FH

is usually used to refer to all superficial tumours of skin regardless of appearance. Similar

lesions involving subcutis or deep structures will only be referred as Fibrous

Histiocytoma1,2

b. Rational and significance of choosing the case

Benign soft tissue lesion is not very common among the population yet from time to time

such case appears. Therefore, this is a very good opportunity to study the nature and

presentation of such illness.

Furthermore, lack of references result lack of knowledge among the medical student

about such cases. Therefore, this study can serve as a reference point for the medical

student in the future.

History of admission

a. Patient biography

Name initials : MR. TA Age : 26 y/oSex : MaleReligion : IslamCivil status : SingleRace : MalayOccupation : DraughtsmanAdmission : 22/2/2009Clerking : 22/2/2009

b. Chief complaintPatient presented with left cheek swelling

History of presenting illness

Mr. TA complains of having left tissue swelling that cause him discomfort during eating and disfigurement if his face. This patient was a known case of left tissue swelling since eight years ago and according to the patient, the size of lesion is gradually increasing since four years back. Patient however denied any pain from the swelling –only experiencing discomfort.

Mr. TA used to seek medical attention at Hospital Gua Musang about three years ago, after noticing the size gradually increases. However, he default the treatment three years ago due to the schedule of the treatment was interrupting his work schedule. He re-seek the treatment again after two years after noticing the swelling was getting larger and larger.

He was then admitted into the surgical ward for observation and scheduled for elective surgery for removal of the soft tissue swelling of the left cheek.

Review of system

system finding

Cardiovascularno significant findings such as palpitation, lower limb oedema, orthopnea, syncope, dizziness, etc.

EndocrineNo significant findings such as moon features, exophthalmos, tremor, acromegaly, etc.

GastrointestinalNo significant findings such as diarrhoea, constipation, altered bowel movement, etc.

GenitourinaryNo significant findings such as dysuria, oliguria, haematuria, incontinence, nocturia, etc.

HematopoieticNo significant findings such as pallor, jaundice or bleeding tendency, etc.

Musculoskeletal No significant findings such as myalgia, arthralgia or arthritimyalgia, arthralgia or arthritis, etc.s, etc.

NeurologicNo significant findings such as recurrent headaches, fits, blurring of vision or drowsiness, etc.

RespiratoryNo finger clubbing, no accessory muscle used during respiration, no shortness of breath, no noisy breathing, no hemoptysis, no night sweats.

Skin, hair, nailsNo significant findings. The skin colour is normal according to his race; with hair growth distribution is normal. Nail is normal, no clubbing, koilonychia, leukonychia, etc.

Head and neck

Normal head size, shape and symmetry; no skull enlargement, bossing, etc. no significant findings of the neck such as webbing, goitre, etc. Left cheek swelling noted.

Comprehensive health history

a. Past medical/ surgical historyThis is Mr. TA first hospitalization. Patient has no significant surgical history. He had no other significant medical history, no hypertension or diabetes mellitus. Plus, he completed the immunization according to MoH immunization program, and additional immunization for hepatitis as previous job requirement.

b. Social historyMr. TA was currently working as draughtsman at JKR Ampang. He was staying in Kuala Lumpur and usually travels Kuala Lumpur – Kota Bharu for his treatment. He claimed to not smoke, do not sexually active and do not drink alcohols.

c. Family historyHe is the eldest of four siblings. He denies of any family history of hypertension, diabetes mellitus, malignancy, etc.

d. Allergy and medication historyPatient claimed had no known allergy to food or medication yet.

Physical Examination and assessment

a. GeneralPatient appearance matches his description of age and race; 26 years old Malay gentleman with light brown skin. His mental status was normal whereas he was alert. Conscious –time and place oriented, and comfortable. He was breathing normally and able to communicate with the examiner. He was well nourished and fit; height 169 cm and weight of 61 kg. His body mass index is 21.33kg/m2 –ideal. His posture was normal and no abnormal gait pattern can be seen.

Inspection of the hand revealed no clubbing, peripheral cyanosis or nicotine stain. No swelling or tenderness of the wrist. No wasting of muscle or flapping tremor. The hand was warm and dry. The radial pulse were palpable, beats per minute, it is regular rhythm and good volume. There was no radio-radial delay or radio-femoral delay and there was also no collapsing pulse.

Examination of patient face revealed palpable mass at left cheek. The swelling was soft and non-tender. It is solid and not movable. There was no bruit or any vessel dilatation surrounding the swelling.

Examination of the eye shows no sign of ptosis, constricted pupil and loss of sweating. No jaundice noted on the sclera and the conjunctiva was not pale. The tongue was moist and no central cyanosis seen. Oral hygiene was good.

Hi vital signs were as recorded;

Blood pressure : 121/73 mmHgHeart rate : 81 beat per minuteRespiratory rate : 26 breaths per minuteTemperature : 37°C

Impression: no remarkable findings, patient was stable. There was a mass at left cheek in form of benign lesion. It is non-tender and soft.

b. Cardiovascular assessment

Inspection JVP demonstrated; no elevation, no chest deformities, no visible pulsation except at the fifth left intercostals space at mid clavicular line –apex pulsation, no dilated vein noted.

Palpation Apex beat palpable at fifth left intercostals space at or medial to mid clavicular line. No loss cardiac dullness, palpable thrills or parasternal heaves.No pulsation at aortic and pulmonic areas, no pulsation at tricuspid area. Full pulsation at apical area. Pulsation at epigastric area.

PercussionDullness along the cardiac border

Auscultation Full and rapid pulsation. 81 bpm BP: 121/73 mmHgThe sounds on aortic and pulmonic areas; lub sound on apex and dub sounds on tricuspid area.1st and 2nd heart sounds were audible without presence of murmur. All peripheral pulses were present.

Impression: no remarkable findings

c. Respiratory assessment

Inspection Anterior; breathing normally. No chest deformities. ThereNo chest deformities. There was also no dilated vein. The chest was was also no dilated vein. The chest was slightly deviated to the right from the chest symmetry during respiration –not asymmetrical. No accessory muscle used while breathing. Posterior; spine is vertically aligned, the shape and symmetry of chest are normal.

Palpation Anterior; the skin is intact, equal warmth on both side. No masses noted. No tracheal deviationPosterior; no masses or tenderness; equal warmth on each side. Chest expanded symmetrically

Percussion No significant finding noted. Cardiac dullness and liver dullness at fifth intercostals space.

Auscultation Anterior; no significant finding noted. No crepitation or ronchi, the breathing sound was normal

Impression: no remarkable findings.

d. Abdominal assessment

Inspection No distension noted, move symmetry with respiration. Umbilical centrally located and inverted. No previous scar, localized swelling, distended vein, or pulsation noted.

Palpation Soft, non tender. No organomegaly; liver, spleen are normal. No other masses noted. Kidneys are not ballotable

Percussion Upper border of the liver was at right fifth intercostals space, with liver span of 12cm. spleen percussion was not demonstrated. No shifting dullness or fluid thrills.

Auscultation Bowel sound present and normal

Impression: unremarkable findings

e. Musculoskeletal examination

Generally, muscle size and side comparison appears normal. Muscle tone and strength also appears normal. Joints can be moved well and no pain noticed.

Impression: no remarkable findings

f. Nervous examinationPatient was alert and conscious. No slurred speech or abnormal behaviour. He is well oriented to time, place and person. No cerebellar signs present –nystagmus, past-pointing. Gait was stable

Impression: unremarkable findings

Summary

26 years old Malay gentleman presented left cheek swelling, no pain, gradually increase in size causing discomfort while eating and disfigurement of the face. Physical examination revealed palpable, soft, non-tender mass at left cheek.

Provisional diagnosis

Benign soft tissue lesion

Patient presented with swelling of the left. The swelling was not painful; it is gradually increases in size. It’s been there since 8 years ago.

Physical examination and assessment revealed that the patient had palpable mass at the left cheek. It is non-tender and soft. The lesion is not movable and solid –it is most likely a benign lesion.

Differential diagnosis

diagnosis Positive relevant Negative relevant

parotitisLeft tissue swelling, discomfort during eating

Not accompanied by fever, lesion is not tender and it was soft.

Cancer of gumLeft tissue swelling, gradually increases in size.

Lesion is non-tender and not movable; lesion are not fixed to the gum –suspended at the cheek.

Investigation

Investigation Reason to support

Full blood count

The total white cell count is raised above normal in 85% of patients and three quarters have an abnormal differential white cell count, having more than 75% neutrophils. Only 4% of patients with appendicitis have both a normal white cell count and a normal Neutrophil count. The white cell count, however, is raised in many other conditions, so although highly sensitive, it has poor specificity any diseases.

HPETo study the histological features if the tissue whether it is benign or malignant in nature.

Computer tomographyTo study the characteristic of the lesion from inside and out by 3D imaging

Full blood count

Blood Count

Result Interpretation Normal range

WCC 12.9 Normal 4.5-13.5 x 109 /L

RBC 5.1 Normal 4.0-5.4 x 1012 /L

Hb 13.1 Normal 11.5-14.5 g/dL

HCT 38.8 Normal 37.0-45.0 Ratio

MCV 77.5 Normal 76.0-92.0 fL

MCH 25.5 Normal 24.0-30.0 Pg

MCHC 30.8 Normal 28.0-33.0 g/dL

Platelet 240 Normal 150-400 109 /L

Neutrophil 74.99.7

Normal 40.0-75.02.9-7.9

%109/L

Lymphocyte 21.02.7

Normal 20.0-45.01.8-4.0

%109/L

Monocyte 3.10.4

Normal 2.0-10.00.2-0.8

%109/L

Eosinophil 0.80.1

Normal 0.0-5.00.04-0.44

%109/L

Basophil 0.20.03

Normal 0.0-2.00.0-0.2

%109/L

Impression: no remarkable findings

HPE study

Findings: HPE study shows haemorrhagic streaks at the tissue lining the area of lesion. However the findings do not shows any features of malignancy and there is no sign of necrosis in the tissue lesions. The tissue was pinkish in volume.

Impression: findings were not compatible with the diagnosis of a lymph node, but were rather indicative of a benign vascular lesion.

Computer tomography scan

Findings: CT scan shows homogenous enhancement of mass on right cheek. It revealed a

mass of soft tissue, the dimensions of which were 3 x 3.5 cm. The lesion had well-

defined borders, not infiltrating the surrounding tissues.

Impression: findings consistent with benign soft tissue swelling at left cheek

Final diagnosis

Benign soft tissue lesion

1) Patient presented with swelling of the left. The swelling was not painful; it is gradually increases in size. It’s been there since 8 years ago.

2) Examination of patient face revealed palpable mass at left cheek. The swelling was soft and non-tender. It is solid and not movable. There was no bruit or any vessel dilatation surrounding the swelling

3) HPE study shows haemorrhagic streaks at the tissue lining the area of lesion. However the findings do not shows any features of malignancy and there is no sign of necrosis in the tissue lesions whereas CT scan shows homogenous enhancement of mass on right cheek. It revealed a mass of soft tissue, the dimensions of which were 3 x 3.5 cm

Principal management

1) Admission into surgical ward2) Continuous observation3) Schedule for incisional removal of lesion under anaesthesia

Clinical course and progression

Patient was admitted for further management of benign soft tissue lesion. He was

kept under observation while waiting for the surgery. HPE study and CT scan was done

prior to the surgery for confirmation of the lesion location and its parameter. The lesion

itself was about 3x3.5 cm in dimension.

Patient went for surgery –removal of lesion by excision under anaesthesia. The

surgery was uneventful, the lesion was removed. Mr. TA was stabile and do not

experiencing any complication from post-surgery. The lesion was whitish and of

fibroelastic consistency. It was totally excised under local anaesthesia.

Mr. TA was complying to the prophylaxis treatment and the progress of healing

went properly. He was able to tolerate orally after three days and do not complain any

discomfort from the removal of the lesion from his face. The patient condition was stabile

and there was no complication from the surgery. Patient was discharge after day three

post surgery and it was uneventful.

Discussion

Benign fibrous histiocytoma was not known as a clinical entity before 1970 when, as a

result of the development of immunohistochemical techniques and electronic microscopy,

differential diagnosis became feasible3,4 The diagnosis of FH may be difficult clinically

when the lesion is located in the deep tissues, and is frequently confirmed after local

excision. Histopathologically, this tumour is a neoplasm of histiocytic origin and is

composed of a biphasic cell population of histiocytes and fibroblasts

According to others, the histiocyte originates from an undifferentiated mesenchymal stem

cell 5. In this case, immunohistochemistry was performed for differential diagnosis,

showing similar features on microscopic examination

The most important diagnostic distinction is the separation of this tumour from

aggressive forms of fibrohistiocytic neoplasms, including dermatofibrosarcoma

protuberans and malignant fibrous histiocytoma 6,7. As with benign fibrous histiocytoma,

the diagnosis of malignant fibrous histiocytoma frequently relies upon

immunohistochemistry and electron microscopy to differentiate it from other lesions. The

difference between benign and malignant fibrous histiocytoma is usually obvious,

because the latter is a pleomorphic, deeply situated tumour with numerous typical and

atypical mitotic figures and prominent areas of hemorrhage and necrosis.

Benign fibrous histiocytoma of the non-cutaneous soft tissues of the head and neck most

often develops as a painless mass with specific symptoms caused by interference with the

normal anatomy and physiology of the area in which they arise 1,6. These findings are

consistent with Mr. TA presentation of painless mass.

This patient presented a mass on the cheek, associated with swelling, without other

symptoms. Most lesions were treated by local excision without sacrificing structures that

would cause major functional or cosmetic morbidity. This patient was submitted to

complete local excision with clear margins without any morbidity. These lesions have no

metastatic potential and generally good prognosis. Of the cases with follow-up reported

in the literature, only 2 (11%) out of 18 had a recurrence after a local excision 1,8. The

reason for these recurrences is unknown, as is the adequacy of the margins of resection.

Conclusion

Fibrous histiocytoma (FH) is a benign tumour composed of a mixture of fibroblastic and

histiocytic cells. The term cutaneous FH is usually used to refer to all superficial tumours

of skin regardless of appearance. This tumour of the head and neck usually develops as a

painless mass with specific symptoms caused by interference with the normal anatomy

and physiology of the area in which they are found. The management for fibrous

histiocytoma is local excision with clear margins without any morbidity. These lesions

have no metastatic potential and generally good prognosis.

References

1. Bielamowicz S, Dauer MS, Chang B, Zimmerman MC. Non-cutaneous benign fibrous histiocytoma of the head and neck. Otolaryngol

2. Batsakis JG. Fibrous lesions of the head and neck: Benign, malignant and indeterminate. In: Batsakis JG, editor. Tumours of the head and neck. 2nd edn.

3. Hong KH, Kim YK, Park JK. Benign fibrous histiocytoma of the floor of the mouth. Otolaryngol Head Neck Surg 1999;121:330-3

4. Kamino H, Salcedo E. Histopathologic and immunohistochemical diagnosis of benign and malignant fibrous and fibrohistiocytic tumours of the skin. Dermatol Clin 1999;17:487-505.

5. Wilk M, Zelger BG, Nilles M, Zelger B. The value of immunohistochemistry in atypical cutaneous fibrous histiocytoma. Am J Dermatopathol 2004;26:367-71.

6. Blitzer A, Lawson W, Zak FG, Biller HF, Som ML. Clinical-pathological determinants in prognosis of fibrous histiocytoma of the head and neck. Laryngoscope 1981;91:2053-70.

7. Chen TC, Kuo T, Chan HL. Dermatofibroma is a clonal proliferative disease. J Cutan Pathol 2000;27:36-9.

8. Fletcher CD, Gustafson P, Rydholm A, Willen H, Akerman M. Clinicopathologic re-evaluation of 100 malignant fibrous histiocytomas: prognostic relevance of subclassification. J Clin Oncol 2001;19:3045-50.