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Journal of Maxillofacial & Oral Surgery 2008 Vol. 7 : No. 4

Case Reports - Cysts & Tumours

Lipoma in the Submandibular Region: A Case Report

Suhas Godhi, Sonia Goyal, Manish Pandit Abstract: Lipomas in the submandibular region are relatively rare. This case report presents a case of lipoma in submandibular region in a 35 year old Indian male. Lipomas and its variants are common soft tissue tumors but are not commonly are in the oral and maxillofacial region. Lipoma of the oral and maxillofacial region occurs most commonly in the parotid region, followed closely by buccal mucosa. It is composed of adult fat cells that are subdivided into lobule by septae of fibrous connective tissue. Surgical excision is the treatment of choice with recurrence not expected. Keywords: Lipoma and submandibular.
Introduction Lipoma is a common, slow growing, benign, encapsulated tumor of fatty tissue that is rare in the oral cavity. It was first reported in 1887 by Grosch.1 Lipomas are the most common soft tissue mesenchymal neoplasms, with 15 to 20% of the cases involving the head and neck region and 1% to 4% affecting the oral cavity. 2 Geschickter3 found only three oral tumors in a series of 440 lipomas. The lipoma represents 0.1% to 5% of all benign tumors of the mouth. They are usually found as long standing soft nodular asymptomatic swellings covered by normal mucosa. Oral lipomas affect predominantly the buccal mucosa, floor of mouth, tongue and lips.4 Histologically, they can be classified as simple lipomas or its variants such as fibrolipomas, Spindle Cell Lipomas (SCL), intramuscular lipomas, angiolipomas, salivary gland lipomas, plemorphic lipomas, myxoid lipomas and atypical lipomas. Angiolipomas and infiltrating lipomas are rarely found in the oral cavity. 4 According to Furlong et al lipoma of the oral and maxillofacial region occur most commonly in adult male in the parotid region, followed closely by buccal mucosa. This entity is rare in children.5 Case report A 35 year old male patient presented with a painless,gradually increasing, well defined, oval shaped extraoral swelling measuring, approximately 6x4 cm in left submandibular region with 13 years duration. On palpation, a soft rubbery mass could be felt and slipping sign was present. The transillumination test was negative. Medical history was noncontributory. The ultrasonograph revealed an elliptical mass in right submandibular region that was hyper-echoic relative to the adjacent muscle. Based upon the classical sign of slipping edge and ultrasonography the diagnosis of lipoma was made. The patient was admitted for excision of the mass under general anesthesia. Routine preoperative investigations were within normal limits. A submandibular incision was made, and a yellowish, soft encapsulated mass was removed by blunt dissection. The mass shelled out easily with no adhesion to adjacent structures. Postoperative recovery was uneventful. The patient was under

Suhas Godhi1, Sonia Goyal 2, Manish Pandit3

1 2

Professor Associate Professor 3 PG student Department of Oral and Maxillofacial Surgery, I.T.S Centre for Dental Studies and Research

Address for Correspondence: Suhas Godhi Department of Oral & Maxillofacial Surgery I.T.S Centre for Dental Studies & Research, Muradnagar Delhi-Meerut Road Ghaziabad 201 206, Uttar Pradesh Ph: 09899450488 E-mail: drgodhi@yahoo.com
Received for publication August 2008 Accepted after peer review December 2008 Available online Dec. 2008 at www.jmosi.com

followup for 22 months and showed no recurrence. Histological investigation showed the lesion to be macroscopically solid and consisting entirely of microscopically encapsulated fatty tissue with areas of fibrosis. The adipocytes are loosely arranged in large areas which show presence of empty cytoplasm and small nuclei. Discussion Lipoma presents clinically as a sessile or pedunculated mass which is slow growing, freely mobile, and may or may not have a yellow hue, depending on depth of localization and degree of fibrosis.6 De Visscher et al studied the clinical and histological characteristics of lipomas and fibrolipomas of the oral cavity. The male-female ratio for lipomas was 1.5:1, and for fibrolipomas 1:1.3. In most cases the only symptom was a painless, palpable tumour. The cheek was the most favoured site, followed by the tongue, floor of mouth and buccal sulcus and vestibule equally, lip, palate, gingiva and retromolar area. 7 The benign fatty tumor, the lipoma, is composed of adult fat cells that are

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Fig. 1: Preoperative frontal view of the patient photograph

Fig. 2: Exposure of the lesion

Fig. 3: Excision of lesion

Fig. 4: Specimen

Fig. 5: Lipoma Photomicrograph

subdivided into lobules by septae of fibrous connective tissue. It appears frequently in the subcutis of adults and is histologically indistinguishable from normal adipose tissue. The metabolism of lipoma differs from that of normal adipose tissue. 8 Various variants of lipoma such as chondrolipoma9, osteolipoma10, infiltrating lipoma 11 and spindle cell lipoma12-15 are reported in the literature. Lipomas in the submandibular region are relatively rare. Masaaki et al reported a case of lipoma in submandibular region in 67 year old male.16 Dattilo et al also reported lipomas in submandibular space. 17 Sialolipoma is a new variant of salivary gland lipoma first described in 2001. Ramer et al presented 2 cases of sialolipoma involving the soft palate and buccal mucosa of 2 female patients.18 Spindle cell lipoma is a distinct histological variant of lipoma. Clinically, it appears as a solitary, subcutaneous, circumscribed lesion. Spindle cell lipoma accounts for about 1.5% of all adipocytic tumours. Very few cases of intraoral SCL were found to be reported in literature. 13 According to Piattelli et al Spindle cell lipoma is a benign tumour composed by: (1) mature fat cells; (2) spindle cells; (3) a myxoid matrix separated by thick bands of birefringent collagen. Agoff et al reported the first case of intramuscular Spindle-cell

lipoma of the oral cavity. Oral SCLs are rare, and only four cases of intramuscular SCL exist in the literature. 14 According to Billings et al; Spindle cell lipoma is typically seen in the neck/ trunk region of middle aged and older men. Billings et al also described the largest series of oral spindle cell lipoma involving the tongue, buccal mucosa, floor of mouth, and lip. The patients (3M; 4F) ranged from 31 to 88 years of age. Immunohistochemical stains for CD34 highlighted the bland spindle cells in all cases. Spindle cell lipoma should be considered in the differential diagnosis of oral cavity mesenchymal tumors.15 Oliveros et al reported a case of a big oral fibrolipoma in a 72 year old woman. After surgery, a mass of 13 x 8 x 6 cm was obtained. The tumor had an implantation pedicle of 1 cm on the floor of the mouth. The microscopic evaluation showed the presence of polygonal cells grouped into nests and separated by fibrous connective tissue septa. 19 Lipomatous lesions of the parotid gland are rare. Lipomatous lesions accounted for only 1.3% of parotid tumors and occurred more frequently in males, at a ratio of 3:1. The most common presentation was that of a slowly enlarging, painless mass.20 Kindblom et al reported 21 cases of atypical lipoma. The tumors were mainly

composed of univacuolated fat cells without cellular or nuclear atypia, but also showed univacuolated fat cells with enlarged, moderately polymorphic, dark nuclei. In two of the tumors a few multivacuolated fat cells with scalloped nuclei were found. Small multinucleated cells with overlapping, peripherally arranged nuclei, reminiscent of so called floret-like cells as in pleomorphic lipoma, could occasionally be seen. Areas of generally delicate linear or patchy fibrosis with atypical nuclei were a common finding. 21 To facilitate the diagnosis of a lipoma, specific imaging such as ultrasound or Magnetic Resonance Imaging (MRI) is needed. According to Ahuja et al the characteristic sonographic appearance of head and neck lipomas is that of an elliptical mass parallel to the skin surface that is hyperechoic relative to adjacent muscle.22,23 CT scan shows a density from 83-143 Hamsfield units with well or bad defined margins depending on capsule. With MRI, it is possible to confirm the diagnosis by visualization of fat equivalent intensity values.24 Solitary lipomas and familial multiple lipomatosis are very well encapsulated. They are very slow growing and have the potential for recurrence if incompletely excised and a very remote chance for malignant changes. These can be freed from surrounding tissue without difficulty, but because of the fibrous nature of the capsule, its violation is more likely to occur with the suction technique. This may result in an inadequate resection, possibly leading to recurrence. Al-basti and El-Khatib reported the treatment of moderate (>4-10 cm) and large (>10 cm) lipomas with liposuction-assisted surgical extraction of the capsule via the same wound (1 cm in length).25 This capsule extraction was aimed at avoiding recurrence and evaluating the

468 histopathological nature of these swellings. There has been no recorded recurrence in six years postoperative followup. Bibliography 1. Grosch J: Studien ueber das Lipom. Dtsch Z Chir 1887; 26:307. 2. Ghandour K, Issa M: Lipoma of the floor of the mouth. Oral Surg Oral Med Oral Pathol 1992; 73: 59-60. 3. Geschickter CF: Lipoid tumors. Am J Cancer 1943; 21: 617. 4. Fregnani ER, Pire FR, Falzoni R, Lopes MA, Vargas PA: Lipomas of the oral cavity: clinical findings, histological classification and proliferative activity of 46 cases. Int J Oral Maxillofac Surg 2003; 32: 49-53. 5. Furlong MA, Smith JC, Childers EL: Lipoma of the oral and maxillofacial region: site and subclassification of 125 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004; 98: 441-450. 6. Greer R, Richarson J: The nature of lipomas and their significance in the oral cavity. Oral Surg 1973; 36: 551-557. 7. De Visscher JG: Lipomas and fibrolipomas of the oral cavity. J Maxillofac Surg. 1982; 10(3): 177-181. 8. Epivatianos A, Markopoulous AK, Papanayotou P: Benign tumors of adipose tissue of the oral cavity: a clinicopathlogical study of 13 cases. J Oral Maxillofac Surg 2000; 58: 11131117. 9. Hietanen J, Makinen J: Chondrolipoma of the tongue: a case report. Int J Oral

Journal of Maxillofacial & Oral Surgery 2008 Vol. 7 : No. 4 Maxillofac Surg 1997; 26: 127-128. 10. Castilho RM, Squarize CH, Nunes FD, Pinto DS: Osteolipoma: a rare lesion in the oral cavity. Br J Oral Maxillofac Surg 2004; 42: 363-364. 11. Ayasaka N, Chino T, Antoh M, Kawakami: Infiltrating lipoma of the mental region: report of case. Br J Oral Maxillofac Surg 1993; 31: 388-390. 12. Piattelli A, Rubies C, Fioroni M, Steches G: spindle-cell lipoma of the cheek: a case report. Oral Oncol 2000; 3: 495-496. 13. Garibaldi JA, Ragsdale BD, William K, Lopategui J: Spindle cell lipoma of the oral cavity. Journal of Maxillofacial and Oral Surgery 2007; 16: 74-78. 14. Piattelli A, Perrotti V, Fioroni M, Rubini C: Spindle cell lipoma of the floor of the mouth: report of a case. Auris Nasus Larynx. 2005; 32(2):205207. 15. Billings SD, Henley JD, Summerlin DJ, vakili S, Tomich CE: Spindle cell lipoma of the oral cavity. Am J Dermatopathol 2006; 28(1): 28-31. 16. Masaaki W, Mutsumi K, Kenichi N, Kazuyuki M, Katsuhiro, Hiroshi F, Motoyasu N: A case of lipoma in the submandibular region. Hokkaido Journal of Dental Science 1998; 19: 227-233. 17. Dattilo DJ, Ige JT, Nwana EJC: Intraoral lipoma of the tongue and submandibular space. J Oral Maxillofac Surg 1996; 54: 915-917. 18. Ramer N, Lumerman HS, Ramer Y: Sialolipoma: report of two cases and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007; 104(6): 809-813. 19. Oliveros-Chaparro C, BogarinRodrguez J, Snchez-Mndez M: Giant fibrolipoma of the floor of the mouth: Presentation of a clinical case. Invest Clin. 2001; 42(2): 147-152. 20. Ethunandan M, Vura G, Umar T, Anand R, Pratt CA, Macpherson DW, Wilson AW: lipomatous lesions of the parotid gland. J Oral Maxillofac Surg 2006; 64: 1583-1586. 21. Kindblom LG, Angervall L, Fassina AS: Atypical lipoma. Acta Pathol Microbiol Immunol Scand. 1982; 90: 27-36. 22. Ahuja AT, King AD, Kew J, King W, Metreweli C: Head and neck lipomas: sonographic appearance. Am J Neuroradiol 1998; 19: 505-508. 23. Zong LP, Zhao SF, Chen GF, Ping FY: ultrasonographic appearance of lipoma in the oral and maxillofacial region. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004; 98: 738-740. 24. Hohlweg-Majert B, Metzger MC, Dueker J, Schupp W, Schulze D: Salivary gland lipomas: ultrasonographic and magnetic resonance imaging. J Craniofac Surg. 2007; 18(6):1464-1466. 25. Al-basti HA, El-Khatib HA: The use of suction assisted surgical extraction of moderate and large lipomas: long term follow-up. Anesthetic Plast Surg 2002; 26: 114-117.

Source of Support: Nil, Conflict of interest: None declared.