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Fibrolipoma – Causes, Symptoms, Diagnosis, Treatment

Fibrolipoma is benign soft tissue tumors which rarely occur in the oral or maxillofacial region [rx–rx], and which have been reported to be more frequent in the buccal and vestibular mucosa [rx], whereas the location described here is somewhat unusual. This is possibly because lipomas are thought to arise from fat cells which are not usually found, or are present only in minimal amounts in the thin soft tissue lining of this location. Moreover, the lingual side of the mandible is particularly exposed to masticatory trauma when the bolus is still hard and is compressed against the internal cortical bone of the mandible. Actually, trauma has also been suggested in lipoma pathogenesis, in addition to chronic infection and hormonal imbalance [rx].

Fibrolipoma is a benign tumour that rarely occurs in the oral and maxillofacial region, and is classified as a variant of conventional lipoma by the WHO [rx]. Overall, lipomas represent 1% to 4.4% of all benign lesions of the oral cavity, and most frequently occur in the buccal mucosa, lip, tongue, palate and floor of the mouth [rx–rx]. Several variants of lipoma have been described, including angiolipoma, chondroid lipoma, myelolipoma, spindle cell/pleomorphic lipoma, diffuse lipomatous proliferation (lipomatosis) and hibernoma [rx], some of which show distinctive clinicopathological features that are usually discernible only after histological examination. Liposarcoma of the oral cavity is exceedingly rare [rx], but this entity cannot be distinguished from its benign counterpart at clinical examination. Therefore, accurate histological examination is mandatory, and the differential diagnosis is based on the detection of a lack of lobular architecture, areas of prominent fibrosis and, most importantly, on the presence of multivacuolated adipose cells with indented nuclei (lip blasts), which are typically present in liposarcoma in variable proportions.

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Clinical alternatives to be considered in the differential diagnosis include other superficial capsulated or pseudo-capsulated lesions and tumors such as minor salivary pleomorphic adenomas, solitary neurofibromas, fibromas, granular cell tumors, leiomyomas and neurilemmomas [rx,rx], due to the similarity of their clinical manifestations.

Symptoms of Fibrolipoma

Lipoma with focally increased fibrous tissue
These must not contain atypical cells
This pattern may be seen in lipomas involving nerve
Focal fibrous tissue in a lipoma is a fibrolipoma and whereas focal fat in a predominantly fibrous lesion is a sclerotic lipoma

Diagnosis of Fibrolipoma

No diagnostic imaging was performed in the present case as it is not usually required in small, longstanding, superficial and well-defined swelling since they are easily evaluated by clinical examination. However, computed tomography, ultrasonography and magnetic resonance imaging have been proposed in difficult cases since they were shown to obtain specific findings in lipoma diagnosis [rx].

Physical examination revealed a palpable mass in Hoffa’s fat pad. Flexion of the knee appeared to be limited and pain also occurred when trying to mobilize the joint. The patient complained for these limitations especially during the last few months when the mass increased in size. A standard X-ray examination revealed osseous structure in the infrapatellar site.

Additionally, the ultrasound showed a well-defined mature adipose tissue with the overlying patellar tendon intact. The patient was then operated and a mass of 6 cm approximately in diameter was excised under general anaesthesia along with its pedicle base.

Furthermore, a CT, MRI, and a soft tissue ultrasonography were undertaken. According to the CT and MRI (Figures [rx] and [rx], a differential diagnosis between synovial osteochondromatosis, synovial sarcoma, and para-articular chondroma should be carried out.

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Treatment of Fibrolipoma

Conservative excision represents the first-choice surgical treatment of oral fibrolipomas. However, if clinical provisional diagnosis is highly indicative for oral lipoma due to pseudo-fluctuation, lack of pain on palpation, slow growth, a soft to fibrous consistency and yellowish appearance, the enucleation of sessile lesions may be performed [rx].

The treatment of fibro lipoma is exclusively surgical but, to the best of the authors’ knowledge, the use of diode laser surgery for oral fibro lipoma has not been reported previously. In comparison with conventional blade surgery, laser excision seems more convenient in view of several intra-operative advantages (such as the lack of bleeding, no requirement for suture) and postoperative advantages (for example, faster scar healing, no inaesthetic sequelae). Furthermore, regressive tissue changes due to the thermal cut of the diode laser are usually negligible, as noted in the current study, thus allowing adequate histological examination and correct diagnosis.

This kind of treatment is carried out through an incision of the overlying mucosa and by following a cleavage plane between the lesion and the peripheral healthy tissues unless chronic or acute traumas are reported. Actually, traumas may result in adherence, between the thin peripheral fibrous capsule of the tumor and the overlying mucosa, which may prevent such an intervention. In the current location, the third kind of approach was used with an intra-sulcular incision since it allowed the best access to the pathological tissue and optimal flap repositioning. Furthermore, such a flap has a lower risk of post-surgical wound dehiscence, while the incision of the alveolar mucosa on the lingual side of the anterior mandible usually makes removal of pathological tissue and suture stability more difficult. Moreover, although lipo-sarcomas of the oral cavity are very rare and cannot be distinguished from a benign lipoma in an early stage [rx,rx], intraoperatively this kind of approach allowed to assure that no involvement of the bone wall was present, although this was already indicated by the mobility on palpation and the negative radiographic appearance of the lesion.

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References