lipoma in children

lipoma in children

1. A Rare Case of Introral Lipoma in a 33 Months Old Child and a Review Priyanka Agarwal, Swati Patil and Minal Chaudhary Department of Oral pathology, Sharad Pawar Dental College, Wardha , Maharashtra, India Dentistry 2014,

2. INTRODUCTION A lipoma is a benign soft tissue tumor composed of adipose tissue (body fat) enclosed in a capsule of connective tissue. Lipoma is a mesenchymal neoplasm, representing at least one-third of all benign tumors . It is the most common benign form of soft tissue tumor. It may be arranged in lobules separated by fibrous septa.

3. Definition Lipomas are single or multiple subcutaneous tumours, easily recognizable by the soft, round/lobulated shape they have. They do not develop into cancer as they are made of fat cells with the same morphology as normal ones and can’t propagate. T hey can appear everywhere but are usually found on the chest, the neck, the arms and the back They are the most common non-cancerous growth of soft tissue.

4. EPIDEMIOLOGY Lipomas are commonly found in adults from 40 to 60 years of age but can also be found in younger adults and children. In the oral and maxillofacial region its occurrence is less frequent, representing about 0.5% to 5% of all benign oral tumours The most commonly affected extra- cutaneous sites are the breast and thyroid

5. Lipomas tend to run in families, so genetic factors likely play a role in their development While the exact etiology of lipomas remains uncertain, an association with gene rearrangements of chromosome 12 has been established in cases of solitary lipomas . Two etiologic factors and pathogenetic links between soft-tissue trauma and adipose tissues growth had been discussed in the literature. The first possibility is the herniation of the buccal fat pad with subsequent epithelialization , termed “ traumatic pseudolipoma .” Etiology

6. This usually results from direct impact, has a relatively short natural history of presentation and commonly occurs in young children . The second possibility suggests lipoma formation is due to deposition and differentiation of adipocytes , mediated by cytokine release, secondary to trauma and hematoma formation. These lesions are termed “post-traumatic lipomas .” The average time between soft-tissue trauma and lipoma formation is almost 3 years and occurs more commonly in the fourth to sixth decade.

7. Classification There are many methods of classification: Based on location Superficial subcutaneous lipomas , the most common type of lipoma, They lie just below the surface of the skin Adenolipomas are lipomas associated with sweat glands . Angiolipoleiomyomas are acquired, solitary, asymptomatic nodules, characterized histologically by well-circumscribed subcutaneous tumors composed of smooth muscle cells, blood vessels, connective tissue, and fat . Angiolipomas painful subcutaneous nodules having all other features of a typical lipoma.

8. Chondroid lipomas are deep-seated, firm, yellow tumors that characteristically occur on the legs of women . Corpus callosum lipoma is a rare congenital brain condition that may or may not present with symptoms . This occurs in the corpus callosum Hibernomas are lipoma of brown fat . Intradermal spindle cell lipomas are distinct in that they most commonly affect women and have a wide distribution, occurring with relatively equal frequency on the head and neck, trunk, and upper and lower extremities

9. Neural fibrolipomas are overgrowths of fibro-fatty tissue along a nerve trunk, which often leads to nerve compression. Pleomorphic lipomas , like spindle-cell lipomas, occur for the most part on the backs and necks of elderly men and are characterized by floret giant cells with overlapping nuclei. Spindle-cell lipomas are asymptomatic, slow-growing subcutaneous tumors that have a predilection for the posterior back, neck, and shoulders of older men.

10. CLINICAL FEATURES Most lipomas are small (under one centimeter diameter) but can enlarge to sizes greater than six centimeters. Localized Lobular Fluctuant Exhibit “Slip sign”. (They move easily when pressure is placed on them) Skin free. Soft vascularized On examination they do not exhibit differential warmth. Lipomas are usually painless soft and non tender.

11. Oral lipomas are usually soft, smooth-surfaced nodular masses that can be sessile or pedunculated . The first description of an oral lesion was provided by Roux in 1848. In his review of alveolar masses, Roux referred to the oral lesion as a “yellow epulis ” A subtle or more obvious yellow hue often is detected clinically, deeper lesions may appear pink. Buccal mucosa and buccal vestibule are most common sites in the oral cavity. Tongue, floor of the mouth and lips are less common sites. Among the most common mucocutaneous lesions observed in people with this syndrome are small papular lesions in the palate and gingiva with up to3 mm extension, which have a tendency to coalesce, papillomatous and verrucous lesions in the buccal mucosa, fissured tongue and cutaneous multiple lipomas Oral features:

12. Oral lipomas located on the buccal mucosa may not represent true tumours, but rather herniation of the buccal fat pad through the buccinators muscle. Such cases may occur subsequent to local trauma in young children or the surgical removal of third molars in older patients The lesion is usually non-tender, soft, and almost typically superficial in depth; but may infiltrate the muscle, become fixed to the surrounding tissue, and, therefore, unmovable. Deeply occurring lesions may produce only a slight surface elevation and may be well encapsulated, more diffuse, and less delineated than the superficial variety. This more diffuse form generates the clinical impression of a fluctuant tumor

13. Risk factor Being between 40 and 60 years old. Although lipomas can occur at any age, they're most common in this age group. Lipomas are rare in children. Having certain other disorders. People besides Cowden Syndrome, multiple lipomas may also be seen in neurofibromatosis, Gardner Syndrome, encephalocraniocutaneoud lipomatosis , multiple familial lipomatosis and Proteus Syndrome

14. Diagnosis Lipomas are not dangerous. However, since they are very similar to liposarcomas, it is important to diagnose them. Usually, they are not painful and develop slowly. However, if they develop internally, they may affect organ and nerves and cause symptoms. Those symptoms may be pain, swelling foul-smelling discharge of the lipoma. Lipomas are diagnosed quite easily by visual examination bec to their characteristic dome-shaped. Upon palpation, they are soft and easily movable under the skin, without any pain. In case of doubt whether it’s a lipoma or a liposarcoma, a biopsy can be performed. If the biopsy reveals liposarcoma, CT and MRI are to be performed.

15. The histopathology remains the gold standard in the diagnosis of lipoma. Most oral lipomas are composed of mature fat cells that differ little in microscopic appearance from the normal fat cells that surround the tumour . The cell varies slightly in shape and size and is somewhat larger, measuring upto 200 nm in diameter. The tumour is usually well circumscribed and may appear as a thin fibrous capsule. A distinct lobular arrangement of the cells is also often seen . Histopathology

16. Microscopically, it is not possible to distinguish these lipomas from normal adipose tissue, despite their different metabolism (they are not used as an energy source as is normal adipose tissue), probably due to high lipoprotein lipase activity in neoplastic lipoma cells Few lipomas show rearrangements of 12q, 13q, and 6p chromosomes. Because of the histologic similarity between normal adipose tissue and lipoma, accurate clinical and surgical information is very important in making a definitive diagnosis Microscopically

17. Moreover, the cells of oral lipomas appear to differ metabolically from normal fat cells despite being histologically similar. Therefore, a person subjected to a starvation diet will lose fat from normal fat deposits in the body, but not from the lipoma. Furthermore, when lipoprotein lipase activity is reduced, fatty acid pre- cursors are incorporated into lipoma fat at a more rapid rate than into normal fat

18. Differential Diagnosis These include:- Fibrosarcomas Abcesses (Localized) Cold abcesses Neurofibromas Hernias Pappiloma Sebaceous cysts (contain sebum. Affect the s.glands ) Epidermoid cysts (contain keratin and fat) Nodular fasciitis Erythema nodosum Nodular subcutaneous fat necrosis Haematoma

19. COMPLICATIONS Myxomatous degeneration Saponification Calcification Infection Ulceration Intussusception & intestinal obstruction Some sources claim that malignant transformation can occur while others say this has yet to be convincingly documented.

20. Treatment of Lipomas

21. Treatment Being harmless, they are removed only by request of the patient or if the doctor judges it necessary. Different methods are available depending on some factors such as : Size of lipoma Number of tumours Location of tumour Patient’s personal history of skin cancer Patient’s family history of skin cancer Whether or not the lipoma is painful Therefore, as methods, we have Surgery Liposuction and squeeze technique Injections of steroid hormones

22. Suspicious Signs that warrant immediate removal If the lump suddenly starts to grow very large Greater than 5 cm in diameter Located in the extremities, retroperitoneally , in the groin, in the scrotum or in the abdominal wall Deep (beneath or fixed to superficial fascia ) Exhibiting malignant behaviour (invasion into nerve or bone)

23. Surgical excision of Lipomas They can be left alone. They may need to be removed for cosmetic reasons, because of compression of surrounding structures or if the diagnosis is uncertain Lipomas are normally removed by simple excision. The removal can often be done under local anaesthetic , and takes fewer than 30 minutes. This cures the great majority of cases, with about 1–2% of lipomas recurring after excision . Because lipomas generally do not infiltrate into surrounding tissue, they can usually be shelled out easily during excision .

24. Liposuction is another option if the lipoma is soft and has a small connective tissue component. Liposuction typically results in less scarring; however, with large lipomas it may fail to remove the entire tumor, which can lead to re-growth.

25. Injection of steroid hormones Local injections of steroid hormones can be made in order to shrink the lipoma. However, this method does not get rid of it. The exact mechanism of action behind it is still unknown. In every case, involutional lipoatrophy was observed with evidence of macrophages in close proximity to altered adipocytes. Those macrophages where observed engulfing altered adipocytes. A speculation was made that injection of steroid hormones lead to an inflammatory response with secondary macrophage activation and productions of cytokines.

26. Outcome The outcome of lipomas is excellent. There’s a possibility of recurrence if the removal is incomplete. As a benign tumour, there’s no chance of it spreading. Subcutaneous lipomas never present any risk while internal lipomas may lead to some complication if not remove such as bleeding, ulceration (gastrointestinal tract). Finally, worsening of the tumour into a malignant form is very rare and have been reported only for bone and kidneys lipomas.

27. A 33 year old patient’s mother complained that her child was reluctant to eat since 3 days. History revealed that the patient had vigorous habit of chewing toothbrush since 3 months for 3 hours daily. The parent’s do not give any history of pain. An intraoral examination, however, revealed a well-defined, pedunculated mass 2.5 cm × 2 cm in size protruding from right buccal mucosa, extending from the distal aspect of 85 to the retro-molar region on that side. Case Report

28. On palpation the growth was non-tender, soft in consistency, fluctuant and non emptiable . In keeping with the above findings, a provisional diagnosis of irritational - fibroma was made, while pyo-genic granuloma, peripheral giant cell granuloma, and granular cell myoblastoma were considered as differential diagnoses. The surface was smooth. Since there was no bony attachment at the base, the radiograph was not taken.

29. Histopathological examination disclosed the presence of sheets of mature adipocytes containing clear cytoplasm and eccentric nucleus, with no evidence of cellular atypia or metaplasia .’ A distinct lobular arrangement of the cells was seen, with intervening fibrovascular connective tissue septa. Based on the histopathological features, the diagnosis of lipoma was made.

30. A male patient, aged six years, came to the Department claimed that he was not able to close his mouth for the past week for an assessment. Removed of the bicycle incident, no other history was found to be significant. An intraoral examination, however, revealed a well-defined, pedunculated growth of normal mucosal colour in the right buccal mucosal region, extending from the distal aspect of 85 to the retro-molar region on that side. A rare case of intraoral lipoma in a six year-old child: a case report International Journal of Oral Science (2011)

31. In palpation, the growth was non-tender and firm in consistency. It measured 3 cm × 1.5 cm in size, with no visible fluctuations of pseudo-membranous slough appearing on its periphery. In keeping with the above findings, a provisional diagnosis of irritational fibroma was made, while pyogenic granuloma, peripheral giant cell granuloma, and granular cell myoblastoma were considered as differential diagnoses. Surgical excision is the current treatment for oral lipomas. The surgical approach is dependent on the site of the tumor and the desired cosmetic result. This patient’s lipoma was approached intraorally and, due to its small size, a complete excision was made. No postoperative complications resulted from the procedure .

32. Intraoral Myolipoma in a 6-Year-Old Child: ARare Case Report Sumit Goel IJSS Case Reports & Reviews | October 2015 A 6-year-old female patient reported with the chief complaint of swelling in the right cheek since 5 years. On examination, there was a single diffuse swelling causing facial asymmetry on right side of face. On intraoral examination, there was single well-defined swelling 3 cm × 3.5 cm extending from right commissure of the lip to pterygomandibular raphe and from the upper right buccal vestibule to lower right buccal vestibule.

33. On the basis of history and clinical examination, the clinical diagnosis of soft tissue tumor (lipoma, minor salivary gland neoplasm) was made. Excision of the lesion was done under general anesthesia and the specimen was sent for histopathologic examination. Submitted H and E stained sections revealed suggestive of myolipoma

34. It can be concluded from above discussion that the penetrating injuries of soft tissues of oral cavity or lesions occurring from it should be considered potentially serious . Proper evaluation of such lesions or injuries is important before coming to final diagnosis and treatment modality. C onclusion

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