Title: benign soft tissue lesion

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 : MR. TA

Age : 26 y/o
Sex : Male
Religion : Islam
Civil status : Single
Race : Malay
Occupation : Draughtsman
Admission : 22/2/2009
Clerking : 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 finding

no significant findings such as palpitation, lower limb oedema,

Cardiovascular
orthopnea, syncope, dizziness, etc.
No significant findings such as moon features, exophthalmos,
Endocrine
tremor, acromegaly, etc.
No significant findings such as diarrhoea, constipation, altered
Gastrointestinal
bowel movement, etc.
No significant findings such as dysuria, oliguria, haematuria,
Genitourinary
incontinence, nocturia, etc.
No significant findings such as pallor, jaundice or bleeding
Hematopoietic
tendency, etc.

Musculoskeletal No significant findings such as myalgia, arthralgia or arthritis,

arthritis, etc.

No significant findings such as recurrent headaches, fits, blurring

Neurologic
of vision or drowsiness, etc.
No finger clubbing, no accessory muscle used during respiration,
Respiratory no shortness of breath, no noisy breathing, no hemoptysis, no
night sweats.
No significant findings. The skin colour is normal according to his
Skin, hair, nails 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,
Head and neck
goitre, etc.
Left cheek swelling noted.

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/m 2 –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 : 121/73 mmHg

Heart rate : 81 beat per minute
Respiratory rate : 26 breaths per minute
Temperature : 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.
Palpation 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.
Percussion
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 deformities. 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.
Palpation 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
Percussion No significant finding noted. Cardiac dullness and liver
dullness at fifth intercostals space.
Auscultation 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.
Palpation Soft, non tender. No organomegaly; liver, spleen are
normal. No other masses noted. Kidneys are not ballotable
Percussion 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.
Auscultation 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 Positive relevant Negative relevant

parotitis Not accompanied by fever,

Left tissue swelling,
discomfort during eating
Cancer of gum
Left tissue swelling,
gradually increases in size.
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.

Investigation

Investigation 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
Full blood count
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
HPE
benign or malignant in nature.
To study the characteristic of the lesion from inside and out
Computer tomography
by 3D imaging
Full blood count

Blood Result Interpretation Normal range

Count
WCC 12.9 Normal 4.5-13.5 x 109 /L
RBC 5.1 Normal 4.0-5.4 x 1012 /L
Hb 13.1 Normal 11.5-14.5 g/dL
HCT 38.8 Normal 37.0-45.0 Ratio
MCV 77.5 Normal 76.0-92.0 fL
MCH 25.5 Normal 24.0-30.0 Pg
MCHC 30.8 Normal 28.0-33.0 g/dL
Platelet 240 Normal 150-400 109 /L
Neutrophil 74.9 Normal 40.0-75.0 %
9.7 2.9-7.9 109/L
Lymphocyte 21.0 Normal 20.0-45.0 %
2.7 1.8-4.0 109/L
Monocyte 3.1 Normal 2.0-10.0 %
0.4 0.2-0.8 109/L
Eosinophil 0.8 Normal 0.0-5.0 %
0.1 0.04-0.44 109/L
Basophil 0.2 Normal 0.0-2.0 %
0.03 0.0-0.2 109/L

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 well-
defined 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
6,7
protuberans and malignant fibrous histiocytoma . 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
1,6
normal anatomy and physiology of the area in which they arise . These findings are
consistent with Mr. TA presentation of painless mass.
 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
1,8
in the literature, only 2 (11%) out of 18 had a recurrence after a local excision . The
reason for these recurrences is unknown, as is the adequacy of the margins of resection.

Conclusion

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

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fibrous histiocytoma of the head and neck. Otolaryngol
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Otolaryngol Head Neck Surg 1999;121:330-3
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benign and malignant fibrous and fibrohistiocytic tumours of the skin. Dermatol Clin
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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.
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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.
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evaluation of 100 malignant fibrous histiocytomas: prognostic relevance of
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