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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 Age Sex Religion Civil status Race Occupation Admission Clerking
: : : : : : : : :
MR. TA 26 y/o Male Islam Single Malay Draughtsman 22/2/2009 22/2/2009
b. Chief complaint Patient 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 Cardiovascular Endocrine Gastrointestinal Genitourinary Hematopoietic Musculoskeletal Neurologic finding no significant findings such as palpitation, lower limb oedema, orthopnea, syncope, dizziness, etc. No significant findings such as moon features, exophthalmos, tremor, acromegaly, etc. No significant findings such as diarrhoea, constipation, altered bowel movement, etc. No significant findings such as dysuria, oliguria, haematuria, incontinence, nocturia, etc. No significant findings such as pallor, jaundice or bleeding tendency, etc. No significant findings such as myalgia, arthralgia or arthrit is, etc. No significant findings such as recurrent headaches, fits, blurring of vision or drowsiness, etc. No finger clubbing, no accessory muscle used during respiration, no shortness of breath, no noisy breathing, no hemoptysis, no night sweats. No 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. 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.
Skin, hair, nails
Head and neck
Comprehensive health history a. Past medical/ surgical history This 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 history Mr. 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 history He is the eldest of four siblings. He denies of any family history of hypertension, diabetes mellitus, malignancy, etc. d. Allergy and medication history Patient claimed had no known allergy to food or medication yet.
Physical Examination and assessment
a. General Patient 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 Heart rate Respiratory rate Temperature : : : : 121/73 mmHg 81 beat per minute 26 breaths per minute 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. 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. Dullness along the cardiac border Auscultation Full and rapid pulsation. 81 bpm BP: 121/73 mmHg The 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 deformit ies. There 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. Anterior; the skin is intact, equal warmth on both side. No masses noted. No tracheal deviation Posterior; no masses or tenderness; equal warmth on each side. Chest expanded symmetrically No significant finding noted. Cardiac dullness and liver dullness at fifth intercostals space. 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. Soft, non tender. No organomegaly; liver, spleen are normal. No other masses noted. Kidneys are not ballotable 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. 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 examination Patient 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 parotitis Positive relevant Left tissue swelling, discomfort during eating Left tissue swelling, gradually increases in size. Negative relevant Not accompanied by fever, lesion is not tender and it was soft. Lesion is non-tender and not movable; lesion are not fixed to the gum ±suspended at the cheek.
Cancer of gum
Reason to support 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. To study the histological features if the tissue whether it is benign or malignant in nature. To study the characteristic of the lesion from inside and out by 3D imaging
Full blood count
HPE Computer tomography
Full blood count Blood Count WCC RBC Hb HCT MCV MCH MCHC Platelet Neutrophil Result 12.9 5.1 13.1 38.8 77.5 25.5 30.8 240 Interpretation Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal range 4.5-13.5 4.0-5.4 11.5-14.5 37.0-45.0 76.0-92.0 24.0-30.0 28.0-33.0 150-400 40.0-75.0 2.9-7.9 20.0-45.0 1.8-4.0 2.0-10.0 0.2-0.8 0.0-5.0 0.04-0.44 0.0-2.0 0.0-0.2 x 109 /L x 1012 /L g/dL Ratio fL Pg g/dL 109 /L % 109/L % 109/L % 109/L % 109/L % 109/L
74.9 9.7 Lymphocyte 21.0 2.7 3.1 Monocyte 0.4 0.8 Eosinophil 0.1 0.2 Basophil 0.03
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 welldefined 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 ward 2) Continuous observation 3) 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 consistent with Mr. TA presentation of painless mass.
. These findings are
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
reason for these recurrences is unknown, as is the adequacy of the margins of resection.
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 reevaluation of 100 malignant fibrous histiocytomas: prognostic relevance of subclassification. J Clin Oncol 2001;19:3045-50.
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