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Xanthomatous lesion of the mandible
Int. J. Oral Maxil/@c. Surg. 1993, 22:236 237 Printed in Denmark. All rights reserved
Copyright ~3 Munksgaard 1993 lntemational]ouma/of
Oral &~ YaxillofacialSurgery ISSN 0901-5027
Xanthomato us lesion of the mandible
P, J. Slootweg ~, J. G. N. Swart 2, N. van Kaam a ~Department of Pathology, University Hospital, Utrecht, 2Department of Oral Surgery, IJsselland Hospital, Capelle a.d. Idssel, and SLaboratory for Pathology and Cytology, Rotterdam, the Netherlands
Report of a case P J. Slootweg, J. G. N. Swart, N. van Kaam." Xanthomatous lesion o f the mandible. Report o f a case. Int. J. Oral Maxillofac. Surg. 1993; 22. 236 237. © M u n k s g a a r d , 1993 Abstract. X a n t h o m a t o u s lesions o f the j a w b o n e are rare a n d ill-defined. In the case presented, infiltration of the m a n d i b u l a r b o n e m a r r o w by a b u n d a n t f o a m cells was c o m b i n e d w i t h extensive reactive b o n e formation.
X a n t h o m a t o u s lesions are characterized by the presence of f o a m cells which are lipid-containing m a c r o p h a g e s . M o s t often, these lesions occur in the skin. W h e n f o u n d in bone, they f o r m p a r t o f nonossifying f i b r o m a or benign fibrous h i s t i o c y t o m a 4. I n the jaw, these lesions are extremely rare 1, a n d as f o a m cells m a y also be f o u n d in l o n g - s t a n d i n g inf l a m m a t o r y processes or areas o f hemorrhage, xanthomatous lesions quite often elude a n a p p r o p r i a t e diagnostic label. T h e present case serves to illustrate some differential diagnostic problems.
paraffin-wax sections could be made. HEstained slides showed coarse trabeculae composed of lamellar as well as woven bone, exhibiting pronounced reversal lines and coalescing to form an anastomosing network. The intervening marrow spaces contained densely packed foam cells, cholesterol granuloma with multinncleated giant cells, and areas of old and fresh hemorrhage (Figs. 2 and 3). There was also deposition of amorphous calcified material, sometimes with a tiny bony fragment in its center. Osteoid seams with an osteoblastic rim were scarce. The intralesional bone was continuous with the preexistent attenuated cortical bone.
Key words: xanthoma; non-X histiocytosis. Accepted for publication 21 February 1993
Discussion As m e n t i o n e d before, the presence o f f o a m cells in bone lesions suggests a diagnosis o f nonossifying f i b r o m a or benign fibrous h i s t i o c y t o m a 4. T h e a b u n d a n t b o n e f o r m a t i o n in the present case, however, rules o u t b o t h diagnoses. F i b r o u s dysplasia is a b o n e - f o r m i n g lesion t h a t m a y c o n t a i n f o a m cells b u t only very focally a n d in a d d i t i o n to areas showing a m o r e typical h i s t o m o r phology 2. T h e intermingling o f lamellar a n d plexiform bone, as exemplified by
Case history A 49-year-old man presented for diagnosis and treatment of a painless bony swelling of the lower left mandible of unknown duration. Teeth and mucosal lining in the involved area of the mouth were normal. Radiographs (Fig. 1) showed an ill-defined radiopacity, at the mandibular angle below the level of the mandibular canal, which was causing deformation of the mandibular contour. The mandibular canal was not displaced cranially. The lesion was explored, and curettage yielded brown, gritty material that was submitted for pathologic examination.
Pathologic findings Because of the presence of calcified material, the tissue had to be demineralized before
Fig. 1. Radiograph showing ill-defined radiopacity at left mandibular angle.
Mandibular x a n t h o m a
by these authors to represent benign fibrous histiocytoma with reactive bone formation 3. However, in agreement with others 1, we think these lesions have an inflammatory reactive genesis, as exemplified by areas of old and fresh hemorrhage and cholesterol clefts with giant cells. The initial event leading to this apparently reactive process cannot be inferred from the histologic slides.
Fig. 2, Micrograph showing irregularly contoured bony fragments with intervening marrow spaces containing closely packed foam cells (HE, x 100).
References
1. GALE AE, FREEDMANPD, KERPEL SM, LUMERMANH. Benign fibrous histiocytoma of the maxilla. Oral Surg Oral Med Oral Pathol 1989: 68:444 50. 2. DAHLIN De, UNNI KK. Bone tumors: general aspects and data on 8542 cases. Springfield: Charles C. Thomas, 4th ed. 1986: 417-18. 3. HARSANYI BB, LARSSON A, Xanthomatous lesions of the mandible: osseous expression of non-X histiocytosis and benign fibrous histiocytoma. Oral Surg Oral Med Oral Pathol 1988: 65: 551-66. 4. Huvos AG. Bone tumors. Diagnosis, treatment and prognosis. 2rid ed. Philadelphia: WB Saunders, 1991: 484.
Fig. 3. Micrograph show•ng marrow fibrosis, foam cells, and cholesterol clefts enclosed by bone (HE, x 100).
the present case, is also not compatible with a diagnosis of fibrous dysplasia. We have been able to find only two
237
similar cases in the literature that were also characterized by foam cells and bone formation; these were considered
Address: P. J. Slootweg Department o f Pathology H04.312 University Hospital PO Box 85500 3508 GA Utrecht The Netherlands
Copyright ~3 Munksgaard 1993 lntemational]ouma/of
Oral &~ YaxillofacialSurgery ISSN 0901-5027
Xanthomato us lesion of the mandible
P, J. Slootweg ~, J. G. N. Swart 2, N. van Kaam a ~Department of Pathology, University Hospital, Utrecht, 2Department of Oral Surgery, IJsselland Hospital, Capelle a.d. Idssel, and SLaboratory for Pathology and Cytology, Rotterdam, the Netherlands
Report of a case P J. Slootweg, J. G. N. Swart, N. van Kaam." Xanthomatous lesion o f the mandible. Report o f a case. Int. J. Oral Maxillofac. Surg. 1993; 22. 236 237. © M u n k s g a a r d , 1993 Abstract. X a n t h o m a t o u s lesions o f the j a w b o n e are rare a n d ill-defined. In the case presented, infiltration of the m a n d i b u l a r b o n e m a r r o w by a b u n d a n t f o a m cells was c o m b i n e d w i t h extensive reactive b o n e formation.
X a n t h o m a t o u s lesions are characterized by the presence of f o a m cells which are lipid-containing m a c r o p h a g e s . M o s t often, these lesions occur in the skin. W h e n f o u n d in bone, they f o r m p a r t o f nonossifying f i b r o m a or benign fibrous h i s t i o c y t o m a 4. I n the jaw, these lesions are extremely rare 1, a n d as f o a m cells m a y also be f o u n d in l o n g - s t a n d i n g inf l a m m a t o r y processes or areas o f hemorrhage, xanthomatous lesions quite often elude a n a p p r o p r i a t e diagnostic label. T h e present case serves to illustrate some differential diagnostic problems.
paraffin-wax sections could be made. HEstained slides showed coarse trabeculae composed of lamellar as well as woven bone, exhibiting pronounced reversal lines and coalescing to form an anastomosing network. The intervening marrow spaces contained densely packed foam cells, cholesterol granuloma with multinncleated giant cells, and areas of old and fresh hemorrhage (Figs. 2 and 3). There was also deposition of amorphous calcified material, sometimes with a tiny bony fragment in its center. Osteoid seams with an osteoblastic rim were scarce. The intralesional bone was continuous with the preexistent attenuated cortical bone.
Key words: xanthoma; non-X histiocytosis. Accepted for publication 21 February 1993
Discussion As m e n t i o n e d before, the presence o f f o a m cells in bone lesions suggests a diagnosis o f nonossifying f i b r o m a or benign fibrous h i s t i o c y t o m a 4. T h e a b u n d a n t b o n e f o r m a t i o n in the present case, however, rules o u t b o t h diagnoses. F i b r o u s dysplasia is a b o n e - f o r m i n g lesion t h a t m a y c o n t a i n f o a m cells b u t only very focally a n d in a d d i t i o n to areas showing a m o r e typical h i s t o m o r phology 2. T h e intermingling o f lamellar a n d plexiform bone, as exemplified by
Case history A 49-year-old man presented for diagnosis and treatment of a painless bony swelling of the lower left mandible of unknown duration. Teeth and mucosal lining in the involved area of the mouth were normal. Radiographs (Fig. 1) showed an ill-defined radiopacity, at the mandibular angle below the level of the mandibular canal, which was causing deformation of the mandibular contour. The mandibular canal was not displaced cranially. The lesion was explored, and curettage yielded brown, gritty material that was submitted for pathologic examination.
Pathologic findings Because of the presence of calcified material, the tissue had to be demineralized before
Fig. 1. Radiograph showing ill-defined radiopacity at left mandibular angle.
Mandibular x a n t h o m a
by these authors to represent benign fibrous histiocytoma with reactive bone formation 3. However, in agreement with others 1, we think these lesions have an inflammatory reactive genesis, as exemplified by areas of old and fresh hemorrhage and cholesterol clefts with giant cells. The initial event leading to this apparently reactive process cannot be inferred from the histologic slides.
Fig. 2, Micrograph showing irregularly contoured bony fragments with intervening marrow spaces containing closely packed foam cells (HE, x 100).
References
1. GALE AE, FREEDMANPD, KERPEL SM, LUMERMANH. Benign fibrous histiocytoma of the maxilla. Oral Surg Oral Med Oral Pathol 1989: 68:444 50. 2. DAHLIN De, UNNI KK. Bone tumors: general aspects and data on 8542 cases. Springfield: Charles C. Thomas, 4th ed. 1986: 417-18. 3. HARSANYI BB, LARSSON A, Xanthomatous lesions of the mandible: osseous expression of non-X histiocytosis and benign fibrous histiocytoma. Oral Surg Oral Med Oral Pathol 1988: 65: 551-66. 4. Huvos AG. Bone tumors. Diagnosis, treatment and prognosis. 2rid ed. Philadelphia: WB Saunders, 1991: 484.
Fig. 3. Micrograph show•ng marrow fibrosis, foam cells, and cholesterol clefts enclosed by bone (HE, x 100).
the present case, is also not compatible with a diagnosis of fibrous dysplasia. We have been able to find only two
237
similar cases in the literature that were also characterized by foam cells and bone formation; these were considered
Address: P. J. Slootweg Department o f Pathology H04.312 University Hospital PO Box 85500 3508 GA Utrecht The Netherlands