Differential Diagnosis Of Solitary Lesions Research Articles

Verruciform Xanthoma of the Buccal Gingiva: Two Cases With Different Clinical Presentations

IntroductionVerruciform xanthoma is an uncommon, benign, asymptomatic lesion commonly affecting the attached tissues in the oral cavity, especially the gingiva. Clinical presentation can be variable and requires biopsy to confirm the diagnosis.Case SeriesTwo cases of verruciform xanthoma in a 21‐year‐old male and a 46‐year‐old female are reported, emphasizing the need for thorough comprehensive analysis of all oral lesions. The clinical features, differential diagnoses, typical and atypical histological features, and potential etiology are presented.ConclusionsVerruciform xanthoma should be considered in the differential diagnosis of solitary lesions in the oral cavity with a papillary, granular, or verrucous surface texture, and confirmed with histopathological examination. Continued monitoring for recurrence at routine examination is necessary especially in sites where the lesion may not have been completely excised.

Solitary Cutaneous Myofibroma on the Sole: An Unusual Localization

Dear Editor: A 61-year-old man presented with several years of history of a solitary cutaneous mass on his left sole. A clinical examination revealed a 26×22 mm sized, skin-colored, firm, asymptomatic subcutaneous nodule (Fig. 1). General laboratory screening, including a complete blood count, renal and liver function tests and lipid levels, were within normal limits. A histopathological examination showed a well-circumscribed mass composed of spindle cells that were arranged in interlacing fascicles or whorls. The spindle cells had elongated nuclei, inconspicuous nucleoli and eosinophilic cytoplasm, resembling smooth muscle cells (Fig. 2). As a result of immunohistochemical staining, these cells were found to be positive for smooth muscle actin, but negative for S-100 protein and desmin. On Masson trichrome staining, many spindle cells with red cytoplasmic stain were found to be dispersed among the blue collagen bundles. Based on both clinical and histological features, a diagnosis of solitary cutaneous myofibroma was made. Fig. 1 26×22 mm sized, skin-colored, firm, asymptomatic subcutaneous nodule on the left sole. Fig. 2 (A) Skin biopsy showed a relatively well-circumscribed tumor in the dermis (H&E, Scanning view). (B) The tumor consists of spindle cells arranged in interlacing fascicles or whorls (H&E, ×100). (C) These spindle cells had pale ... Solitary cutaneous myofibroma is a circumscribed benign neoplasm of superficial soft tissue in adolescents and adults; it represents the adult counterpart of infantile myofibromatosis1. Clinically, it typically presents as a painless, slow-growing, firm cutaneous or subcutaneous nodule with an occasional bluish hue. There is a predilection for it to occur on the head and neck, shoulder girdle, lower extremity and hand2,3. Oral and genital solitary cutaneous myofibromas have also been identified. Plantar involvement is exceptionally rare, and there has been only one case of solitary cutaneous myofibroma affecting the sole in the literature3. Histological findings reveal a distinctive appearance, well recognized in children but much less so in adults. It manifests as a biphasic pattern or a zoning arrangement of two cell types4. Among them, the hemangiopericytomatous components, which are typical of infantile myofibromatosis, may sometimes be inconspicuous or even absent in adult lesions, as in our case3. Spindle cells have eosinophilic cytoplasm arranged in short bundles and fascicles resembling leiomyoma. These cells demonstrate features of both myofibroblasts and fibroblasts. Myofibroblastic differentiation of the tumor cells is supported by their immunophenotype. The spindle cells are desmin negative, but smooth muscle actin positive. The Masson trichrome stain, in which thick fibrous bundles with random, irregularly intersecting angles are prominent, can be used to assist in differentiating myofibromas from smooth muscle lesions5. In contrast, smooth muscle lesions show delicate fibrous tissues surrounding the smooth muscle cells and in the septa between the smooth muscle masses. The limited follow-up of solitary cutaneous myofibromas suggests that they tend to follow a benign clinical course with no evidence of recurrence or metastasis1-3. To our knowledge, our case represents only the second report of a solitary cutaneous myofibroma occurring on the sole. We suggest, even though it is very rare, that solitary cutaneous myofibroma should be considered in the differential diagnosis of solitary lesions involving the sole.

Xanthogranuloma on the penis of an adult: An unusual localization

To the Editor: A 44-year-old man was referred to our department with a 1-month history of lesions on his glans penis. A clinical examination revealed two well defined, orange-yellow to skin-colored, dome-shaped, smooth, 5- to 7-mm asymptomatic papules (Fig 1). General laboratory screening, including lipid levels, renal and liver function tests, and a complete blood count, were within normal limits. A biopsy specimen from one of the papules showed a dermal infiltrate composed of macrophages, neutrophils, lymphocytes, and fibroblasts, along with foam cells and Touton giant cells (Fig 2). A diagnosis of xanthogranuloma (XG) was made. An ophthalmology examination revealed no abnormalities. Two months after the biopsy, the papules disappeared spontaneously and no obvious relapse has been noted.Fig 2Infiltrate composed of macrophages, neutrophils, and lymphocytes, along with foam cells and Touton giant cells. (Hematoxylin–eosin stain; original magnification: ×100.)View Large Image Figure ViewerDownload Hi-res image Download (PPT)XG is an unusual form of non–Langerhans cell histiocytosis that typically affects children and less frequently adults, with the peak incidence being in the late twenties to early thirties, with an equal sex distribution.1Rodriguez J. Ackerman A.B. Xanthogranuloma in adults.Arch Dermatol. 1976; 112: 43-44Crossref PubMed Scopus (104) Google Scholar, 2Whitmore S.E. Multiple xanthogranulomas in an adult: case report and literature review.Br J Dermatol. 1992; 127: 177-181Crossref PubMed Scopus (15) Google Scholar Clinically, it presents as well defined, firm, yellow-red, dome-shaped, asymptomatic papules or nodules, most frequently located on the head and trunk. Penile involvement is exceptionally rare, and there have been only three cases of XG affecting the penis in the literature.3Quintana de la Rosa J.L. Antón Badiola I. Ortiz Rey J. Juvenile xanthogranuloma of the penis.Actas Urol Esp. 2008; 32 ([in Spanish]): 659-661Crossref PubMed Google Scholar, 4Hautmann R.E. Bachor R. Juvenile xanthogranuloma of the penis.J Urol. 1993; 150: 456-457PubMed Google Scholar, 5Laguna Urraca G. Concha López A. Tudela Patón M.P. Verruciform xanthoma of the penis.Actas Urol Esp. 1990; 14 ([in Spanish]): 210-213PubMed Google Scholar Histologically, it is characterized by a dense histiocytic infiltrate within the papillary dermis occasionally extending into the reticular dermis and subcutaneous tissue. The cellular infiltrate includes spindle cells, giant cells (typically of the Touton type), lymphocytes, eosinophils, and neutrophils. Immunohistochemical studies are positive for vimentin, CD68, and factor XIIIa, and negative for S100, CD34, and CD1a.To our knowledge, our case represents the fourth report of XG occurring in the penis of an adult. Xanthogranuloma should be considered in the differential diagnosis of solitary lesions involving the penis. To the Editor: A 44-year-old man was referred to our department with a 1-month history of lesions on his glans penis. A clinical examination revealed two well defined, orange-yellow to skin-colored, dome-shaped, smooth, 5- to 7-mm asymptomatic papules (Fig 1). General laboratory screening, including lipid levels, renal and liver function tests, and a complete blood count, were within normal limits. A biopsy specimen from one of the papules showed a dermal infiltrate composed of macrophages, neutrophils, lymphocytes, and fibroblasts, along with foam cells and Touton giant cells (Fig 2). A diagnosis of xanthogranuloma (XG) was made. An ophthalmology examination revealed no abnormalities. Two months after the biopsy, the papules disappeared spontaneously and no obvious relapse has been noted. XG is an unusual form of non–Langerhans cell histiocytosis that typically affects children and less frequently adults, with the peak incidence being in the late twenties to early thirties, with an equal sex distribution.1Rodriguez J. Ackerman A.B. Xanthogranuloma in adults.Arch Dermatol. 1976; 112: 43-44Crossref PubMed Scopus (104) Google Scholar, 2Whitmore S.E. Multiple xanthogranulomas in an adult: case report and literature review.Br J Dermatol. 1992; 127: 177-181Crossref PubMed Scopus (15) Google Scholar Clinically, it presents as well defined, firm, yellow-red, dome-shaped, asymptomatic papules or nodules, most frequently located on the head and trunk. Penile involvement is exceptionally rare, and there have been only three cases of XG affecting the penis in the literature.3Quintana de la Rosa J.L. Antón Badiola I. Ortiz Rey J. Juvenile xanthogranuloma of the penis.Actas Urol Esp. 2008; 32 ([in Spanish]): 659-661Crossref PubMed Google Scholar, 4Hautmann R.E. Bachor R. Juvenile xanthogranuloma of the penis.J Urol. 1993; 150: 456-457PubMed Google Scholar, 5Laguna Urraca G. Concha López A. Tudela Patón M.P. Verruciform xanthoma of the penis.Actas Urol Esp. 1990; 14 ([in Spanish]): 210-213PubMed Google Scholar Histologically, it is characterized by a dense histiocytic infiltrate within the papillary dermis occasionally extending into the reticular dermis and subcutaneous tissue. The cellular infiltrate includes spindle cells, giant cells (typically of the Touton type), lymphocytes, eosinophils, and neutrophils. Immunohistochemical studies are positive for vimentin, CD68, and factor XIIIa, and negative for S100, CD34, and CD1a. To our knowledge, our case represents the fourth report of XG occurring in the penis of an adult. Xanthogranuloma should be considered in the differential diagnosis of solitary lesions involving the penis.