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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: drshubhangi2502@gmail.com

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