Oral Verruciform Xanthoma: A case report

By Dr P Dhanrajani (p1954sa@yahoo.com.au)
BDS, MDS, MSc, MSC, FRACDS, FDSRCS, FFDRCSI. Oral Surgeon

Dental News September 2018

A 49 years old male patient presented to the oral surgery clinic with a history of a plaque like lesion on the right ventral aspect of the tongue. It was of 2 to 3 years duration, yellowish-grey, well demarcated, slightly raised and demonstrated a verrucous surface with no evidence of
ulceration (Fig 1). He was medically fit and a non-smoker. Extra-oral examination was non-significant.

A clinical diagnosis of idiopathic leukoplakia was made and option of biopsy was discussed. The patient consented for biopsy and the lesion was excised completely under local anaesthetic. Post-operative phase was uneventful. I have reviewed him during 12 months follow-up with no signs of any recurrence.

Figure 1: Clinical photograph showing yellowish grey slightly raised well-demarcated area.

Histological examination revealed mucosal verrucous hyperplasia with parakeratosis and collections of foamy histiocytes in the subepithelial stromal papillae (Fig 2).

These are highlighted in a CD68 histiocytic marker immunoperoxidase stain, confirming the diagnosis of oral verruciform xanthoma (Fig 3). No fungal elements were seen in PAS-stained sections. The features are not those of Fordyce spots. There is no epithelial dysplasia or evidence of malignancy.

The differential diagnosis is important as it can clinically resemble malignancy. Differentials include verrucous carcinoma, squamous cell carcinoma, squamous papilloma, verruca vulgaris, condyloma and leukoplakia. The verrucous architecture and exophytic nature of this lesion could mimic malignancy clinically and therefore biopsy becomes mandatory. A reassuring clinical feature is that the lesions tend to be soft on palpation, unlike a malignant process which is firm. The presence of foamy cells is characteristic of VX, which tend to accumulate in between rete ridges in the connective tissue.

Figure 2: H&E stain photomicrograph X 200 showing foamy cells in stromal papillae immediately beneath the epithelium.

Figure 3: Immunostain photomicrograph X 100 showing foamy cell can be seen darkly stained in the stromal papillae.

Acknowledgments

The assistance of Associate Professor Hedley Coleman, Senior Staff Specialist, Tissue Pathology & Diagnostic Oncology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead NSW 2145, Australia, and Dr Peter Cropley, Anatomical Pathologist, Laverty Pathology, 60 Waterloo Road, North Ryde NSW 2113, Australia, in establishing the pathological diagnosis is acknowledged.