Myxoid liposarcoma of the buccal vestibule
B. Azaz, N. Casap Department of Oral & Maxillofacial Surgery The Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel
A case report B. Azaz, N. Casap." Myxoid liposarcoma of the buceal vestibule. A case report. Int. J. Oral Maxillofac. Surg. 1991," 20." 308-309. Abstract. A case o f a m y x o i d l i p o s a r c o m a in the buccal vestibule o f the m a n d i b l e is presented. T h e patient, a n 86-year-old w o m e n , h a d 2 local recurrences after initial excision a n d died several m o n t h s later. T h e literature is briefly reviewed.
L i p o s a r c o m a is a m e s e n c h y m a l t u m o u r usually a p p e a r i n g in the lower extremities a n d the retroperitoneal space 8, ~2, b u t rarely occurring in the oral cavity. T h e r e are only 25 cases r e p o r t e d in the literature 3, 4, 5, z~ A case is presented o f a m y x o i d type l i p o s a r c o m a a p p e a r i n g in the left buccal vestibule of the mandible.
Case report An 86-year-old woman came to the OMF Surgery clinic with a painless swelling of 2 months' duration in the left cheek. She suffered from hypertension, diabetes mellitus, and ischaemic heart disease. On extra-oral examination a slight swelling in the left cheek was seen. The regional lymph nodes were not enlarged on palpation. The swelling measured 3 x 2 x 2 cm and was covered by the buccal mucosa adjacent to the left mental foramen. The mass was mobile, well circumscribed and appeared to be not adherent to the mucosa or the bone.
The tnmour was removed under local anaesthesia, via a vestibular incision (Fig. 1). The tumour was encapsulated by a thin capsule of lobulated appearance. Histologically, the tumour was classified as a myxoid type liposarcoma (Fig. 2). Metastasis was ruled out on the basis of clinical examination, blood and urine analyses, chest x-ray, and bone, spleen and liver scanning. The patient at this point refused to be re-operated and was discharged. Three months later the lesion appeared again but this time was accompanied by dysaesthesia of the left lower lip. Radiographic examination including a panorex, peri-apical and occlusal film revealed no bony involvement. The patient this time was brought under general anaesthesia and the tumour excised. It appeared to be well encapsulated. Frozen sections indicated that the margins were free of tumour, which was confirmed by the histological examination. Irridimn needles were inserted in the area and the patient was subjected to 2700 cGy for 24 h, followed by field radiation of 4000 cGy.
Fig. 1. Pseudo-encapsulated liposarcoma partially dissected.
Key word: liposarcoma. Accepted for publication 15 July 1991
Four months later the tumour appeared again involving the entire cheek. CT examination showed involvement of the masseter muscle (Fig. 3). The patient refused to undergo major surgery and died 3 months later due to excessive bleeding and infection (Fig. 4).
Discussion The m o s t c o m m o n l y f o u n d i n t r a o r a l location o f l i p o s a r c o m a is the cheek. O f 25 r e p o r t e d i n t r a o r a l liposarcomas, 16 were located in the cheek, 3 in the floor o f the m o u t h , a n d 6 in various o t h e r locations o f the oral cavity 4, s, 21 T h e t u m o u r occurs in patients f r o m 6 m o n t h s 2° to 90 years o f age 17 with a m e a n o f 43.3 years a n d a slight predilection for males 3' 18. M a n y a t t e m p t s h a v e b e e n m a d e to classify this t u m o u r o n the basis o f histopathology6, 7, s, 9, ~0, H, ~2. A t p r e s e n t the classification o f ENZINGER 7 is gener-
Fig. 2. Myxoid type of liposarcoma (HE × 85).
Myxoid liposarcoma o f the buecal vestibule EVANS et al. 1~ reassessed 30 cases t h a t were d i a g n o s e d as well-differentiated liposarcoma. N i n e lesions t h a t did n o t recur or metastasize could be reclassified as "atypical l i p o m a " , a b e n i g n neoplasm. M y x o i d or well-differentiated lipos a r c o m a h a s a better p r o g n o s i s t h a n r o u n d cell or the p l e o m o r p h i c types 3' s. T h e m y x o i d type is the m o s t c o m m o n o f all l i p o s a r c o m a s a c c o u n t i n g for 50% o f all l i p o s a r c o m a s f o u n d in the entire b o d y including the h e a d a n d neck region 2. T h e m y x o i d type rarely metastasizes b u t tends to recur locally 22. M o s t a u t h o r s describe l i p o s a r c o m a o f the oral cavity as a well-defined lesion which s o m e t i m e s can be pseudo-encapsulated 1, 4, 13, 15, 16, 18, 20, 21, 22. Despite this
Fig. 3. CT showing involvement of the entire cheek.
ally accepted: 1) m y x o i d liposarcoma; 2) r o u n d cell liposarcoma; 3) p l e o m o r p h i c liposarcoma; a n d 4) well-differentiated liposarcoma, sub-classified into lipomalike, sclerosing, i n f l a m m a t o r y a n d dedifferentiated types 8' 9, 12 A c c o r d i n g to SAtn~DERS et alY, lipos a r c o m a o f the h e a d region appears to be m o r e aggressive t h a n neck t u m o u r s . I n fact they seem to be m u c h m o r e aggressive t h a n liposarcomas occurring elsewhere in the body.
fact satellite t u m o u r s a n d infiltrative g r o w t h deep into the tissues, is common. Several a u t h o r s suggested t h a t there m i g h t be a place for r a d i o t h e r a p y in welldifferentiated or m y x o i d liposarcomas 8' ~4,~9. The literature does n o t provide evidence t h a t c h e m o t h e r a p y is o f a n y use. T h e case described presented diagnostic a n d surgical p r o b l e m s because a m a l i g n a n c y was n o t suspected. The initial t r e a t m e n t therefore was p r o b a b l y n o t adequate, a l t h o u g h it remains quest i o n a b l e w h e t h e r the p a t i e n t could have b e e n saved if m o r e extensive surgery h a d been carried out.
1. AMARJIT S, SINGH A, NAGPAL BL, GAM-
Bm GS. Liposarcoma of the cheek. J. Oral Surg. 1978: 36: 811-813. 2. BATSAKIS JG, REGEZI JA, RICE DH. The pathology of head and neck tumors: fibroadipose tissue and skeletal muscle, Part 8. Head Neck Surg 1980: 3:145 68. 3. DAHL EC, HAMMOND HL, SEQUEIRA E. Liposarcomas of the head and neck. J Oral Maxillofac Surg 1982: 40: 6747. 4. DOMINGUEZ FV, GUGLIELMOTTI MB, FLORES MC, DE LA GARZA MLG. Myxoid liposarcoma of the cheek. J Oral Maxillofac Surg 1990: 48: 395-7.
No. 3. World Health Organization, Geneva, 1969: 20. 8. ENZINGER FM, WEISS SW. Soft tissue tumors. St. Louis: C. V. Mosby, 1988: 346-82. 9. ENZINGER, FM, WINSLOW DJ. Liposarcoma: - study of 103 cases. Virchows Arch Pathol Anat 1962: 335:367 88. 10. EVANS HL. Liposarcoma, a study of 55 cases with reassessment of its classification. Am J Surg Pathol 1979: 3:507 23. 11. EVANS HL, SOULE EH, WINKELMANN RK. Atypical lipoma, atypical intramuscular lipoma, and well differentiated retroperitoneal liposarcoma. Cancer 1979: 43: 574-84. 12. HAJDU SI. Pathology of soft tissue tumors. Philadelphia: Lea & Febiger, 1979: 250-89. 13. OTTE T, KLEINSASSERO. Liposarcoma of the head and neck. Arch Otorhinolaryngol 1981: 232: 285-91. 14. PACK GT, PXERSONJC. Liposarcoma; a study of 105 cases. Surgery 1954: 36: 68%712. 15. RAMON Y, HOROWITZ Y, OBERMAN M, FREEDMAN A. Liposarcoma of the buecal mucosa. Int J Oral Surg 1977: 6: 226-8. 16. SABEGHI EM, SAUK JJ JR. Liposarcoma of the oral cavity. Clinical tissue culture and ultrastructure study of a case. J Oral Pathol 1982: 11: 263-75. 17. SAUKJJ JR. Liposarcoma of the head and neck. J Oral Surg 1971: 19: 38-40. 18. SAUNDERS JR, JAQUES DA, CASTERLINE PF, PERCARPIO B, GOODLOE S JR. Liposarcomas of the head and neck: a review of the literature and addition of four cases: Cancer 1979: 43: 162-8. 19. STOUT AR Liposarcoma: The malignant tumor of lipoblasts. Ann Surg 1944: 119: 86-107. 20. SuzuKI H, NAGAYAMA M, KANEDA T, OKA T. Liposarcoma of the cheek in an infant. J Oral Maxillofac Surg 1984: 42: 180-4. 21. WATANABEI, SATOH M, YAMANEG, HORIUCm T, SHIMONO M. Liposarcoma arising from the cheek of the aged. Report of a case and review of literature. Gerodontics 1985: 1: 148-51. 22. WESCOTTWB, CORRELLRW. Multiple recurrences of a lesion at the base of the tongue. J Am Dent Assoc 1984: 108: 2315.
5. EIDINGER G, KATSIKERISN, GULLANE P.
Liposarcoma: Report of a case and review of the literature. J Oral Maxillofac Surg 1990: 48: 984-8. 6. ENTERLINE HT, CULBERTSON JD, ROCHLl~ DB, BRADYLW. Liposarcoma. A clinical and pathological study of 53 cases. Cancer 1960: 13: 932-50. 7. ENZINGER FM, LATTES R, TORLONE H.
Fig. 4. Tissue breakdown caused by liposarcoma.
Histological typing of soft tissue tumors. International Classification of Tumors.
B. Azaz Dept. of Oral and Maxillofacial Surgery The Hebrew University-Hadassah School of Dental Medicine RO.B. 1172, Jerusalem Israel