A Case of Dermatofibroma of the Upper Lip

doi:10.5021/ad.2010.22.3.333

Ann Dermatol. 2010 August; 22(3): 333–336.

Published online 2010 August 5. doi: 10.5021/ad.2010.22.3.333

PMCID: PMC2917691

A Case of Dermatofibroma of the Upper Lip

Hye In Lee, M.D., Jin Woong Lee, M.D., Tae Young Han, M.D., Kapsok Li, M.D., Chang Kwun Hong, M.D., Seong Jun Seo, M.D., and Kye Yong Song, M.D.¹

Department of Dermatology, College of Medicine, Chung-Ang University, Seoul, Korea.

¹Department of Pathology, College of Medicine, Chung-Ang University, Seoul, Korea.

Corresponding author.

Corresponding author: Seong Jun Seo, M.D., Department of Dermatology, Chung-Ang University Medical Center, 224-1 Heukseok-dong, Dongjak-gu, Seoul 156-755, Korea. Tel: 82-2-6299-1525, Fax: 82-2-823-1049, Email: drseo/at/hanafos.com

Received June 1, 2009; Revised October 14, 2009; Accepted November 11, 2009.

Abstract

Dermatofibroma (DF) is a common benign mesenchymal tumor composed of fibroblastic and histiocytic cells. It occurs anywhere on the body surface but has a propensity for the extremities. To our knowledge, DF arising in the oral cavity, especially on the lip, is quite rare. DFs of the head and neck region have been known to be most often of the cellular type and frequently recur, so a wider initial excision is recommended. Herein we report a case of DF in a 41-year-old female who presented with a deep-seated nodule on her upper lip.

Keywords: Dermatofibroma, Lip

INTRODUCTION

Dermatofibroma (DF), also known as benign fibrous histiocytoma (BFH), is a common benign mesenchymal tumor composed of fibroblastic and histiocytic cells¹. DF occurs anywhere on the body surface but has a propensity for the extremities. To our knowledge, DF arising in the oral cavity or perioral region is quite rare, and its long-term clinical behavior has yet to be elucidated. Herein we reported the clinical, microscopic, and immunohistochemical aspects of a case of DF of the upper lip.

CASE REPORT

A 41-year-old female came to our department for evaluation of a hard nodule on her upper lip that had been noted 4 months earlier. Her medical and family histories were noncontributory. She denied any history of trauma to the lesion. Clinical examination revealed a rubbery, firm, non-mobile nodule, 1.0 cm in diameter, on the upper lip (Fig. 1). The appearance of the overlying labial mucosa and skin was normal. There was no pain or tenderness. Excision biopsy was performed, and the specimen was stained with hematoxylin-eosin.

Fig. 1

Rubbery, firm, non-mobile nodule, 1.0×1.0 cm in diameter, on the upper lip with normal overlying labial mucosa and skin.

Microscopically, a poorly defined, non-encapsulated, nodular tumor was observed throughout the depth of the dermis. Histological findings showed acanthosis of the epidermis and a poorly defined, non-encapsulated deep dermal tumor (Fig. 2A) composed of fibroblastic spindle cells without atypia and pleomorphism in a storiform pattern, separating the dermal collagen, with a few histiocytes in both the superficial (Fig. 2B) and deep portions of the tumor (Fig. 2C). Immunohistochemical stains for CD34, factor XIIIa, CD68 and smooth muscle actin (SMA) were then performed on sections of the tumor. CD34 was negative in fibroblastic spindle tumor cells and positive in vessels (Fig. 3A), factor XIIIa was positive in only a few dendritic cells and negative in fibroblastic cells (Fig. 3B), CD68 was weak in spindle cells and strong in histiocytes (Fig. 3C), and SMA was strong in fibroblastic spindle cells (Fig. 3D). As a result of clinical and pathologic findings, the diagnosis was interpreted as DF.

Fig. 2

(A) Histological findings show acanthosis of the epidermis and a poorly defined non-encapsulated deep dermal tumor (H&E, ×20). (B, C) The tumor was found to be composed of fibroblastic spindle cells in a storiform pattern, separating dermal (more ...)

Fig. 3

(A) CD34 was negative in fibroblastic spindle cells and positive in vessels (×200). (B) Factor XIIIa was positive in only a few dendritic cells and negative in fibroblastic cells (×200). (C) CD68 was weak in spindle cells and strong in (more ...)

DISCUSSION

DF is a common benign dermal fibrohistiocytic tumor that presents as a firm, red-brown nodule. There has been controversy about the pathogenesis of DF. Whether DF is a true neoplasm or reactive hyperplasia induced by mechanical stimuli is still unclear². Prolonged sun exposure, traumatic injury and chronic infection have been suggested as possible causative agents. DF occurs anywhere on the body surface, most commonly on the extremities, and usually on the lower legs. Involvement of the oral mucosa is quite rare. There have been a few published reports of DF that involved the oral and maxillofacial regions³^-⁷. Gray et al.⁶ reviewed the literature on oral and perioral DF and reported that the buccal mucosa/vestibular region was the most commonly affected site. Also, cases of DF/BFH of the tongue, gingiva, mandible, maxilla, lower and upper lip have been described. Yamada et al.⁷ reported a case of BFH of the upper lip in an infant. Five cases of DF of the lip have been reported in the literature (Table 1)³^,⁵^-⁷.

Table 1

Summary of 6 cases of benign fibrous histiocytoma of the lip reported in the literature

Histologically, the epidermis demonstrates hyperplasia, hyperpigmentation of the basal layer, and elongation of the rete ridges ("dirty fingernail" sign), which are separated by a clear (Grenz) zone from the tumor in the dermis. The tumor itself is composed of fibroblast-like spindle cells, histiocytes, and blood vessels in varying portions.

DF has a variable immunohistochemical profile. Early lesions are highly reactive for macrophage markers such as CD68⁸. Most cells in early phase DFs have been found to react with factor XIIIa, a marker of normal dermal dendrocytes. This reactivity is mostly seen at the periphery of the tumor, continuously diminishes with aging of the lesion, and is completely absent in atrophic variants⁹. Other variably expressed markers include smooth muscle actin, CD56, and NSE. Labeling for SMA is most prominently seen in myofibroblastic DF¹⁰. Variable reactivity is seen with vascular markers such as factor VIII or CD31. Exceptional cases with characteristic histologic features of DF show diffuse reactivity for CD34¹¹; other rare cases express S-100 protein. Mentzel et al.¹² reported that tumor cells of facial DF showed immunoreactivity for factor XIIIa in 13 out of 17 cases and a focal immunepositivity for CD68 in 6 out of 10 cases; Mentzel et al.¹² also showed that spindle-shaped tumor cells in 16 out of 19 neoplasms stained at least focally positive for SMA. The more cellular forms of DF tend to express SMA, whereas the lesions with more epithelioid cells and giant cells tend to express histiocytic markers.

The main differential diagnoses of spindle cell neoplasms arising on the face, especially the oral cavity, include nodular fasciitis, low-grade myofibroblastic sarcoma, and neurofibroma. Nodular fasciitis may also present as spindle cells ordered in a storiform configuration, similar to that seen in DF, but the fascicles are separated by a myxoid stroma, mitoses are frequent and immunohistochemical staining for S-100 antigen is reactive¹³. Low-grade myofibroblastic sarcoma is characterized morphologically by ill-defined fascicles of atypical, spindle-shaped myofibroblastic tumor cells that infiltrate preexisting structures in a diffuse pattern. Spindle-shaped tumor cells of DF do not stain positively for desmin, a marker that is frequently expressed in cases of low-grade myofibroblastic sarcoma¹⁴. Neurofibroma is composed of elongated spindle-shaped S-100 protein-positive tumor cells containing fusiform nuclei¹⁵. Cellular fibrous histiocytoma, the cellular variant of DF, must be especially distinguished from dermatofibrosarcoma protuberans (DFSP). DFSP is generally characterized by more uniform spindle cells and a more prominent storiform pattern than that seen in DF. CD34 staining is usually diffusely positive in DFSP and negative in most forms of DF. However, some DFs may express CD34, and some DFSP may express factor XIIIa¹⁶. Paradoxically, cellular atypia is often more pronounced in cellular fibrous histiocytoma than in DFSP, and factor XIIIa staining is often negative.

DFs arising on the face, including the oral cavity, are more often of the cellular type, extend into the subcutaneous fat or muscle, and frequently recur¹². Therefore, a wider initial excision is recommended, and local excision is the definitive treatment for DF of the head and neck region. Because oral DFs are rare and the long-term clinical behavior has yet to be elucidated, regular clinical follow-up is recommended.

References

1. Calonje E, Mentzel T, Fletcher CD. Cellular benign fibrous histiocytoma. Clinicopathologic analysis of 74 cases of a distinctive variant of cutaneous fibrous histiocytoma with frequent recurrence. Am J Surg Pathol. 1994;18:668–676. [PubMed]

2. Calonje E. Is cutaneous benign fibrous histiocytoma (dermatofibroma) a reactive inflammatory process or a neoplasm? Histopathology. 2000;37:278–280. [PubMed]

3. Hillis RE, Beasley JD., 3rd Fibrous histiocytoma of the lip: report of a case. J Oral Med. 1975;30:81–83. [PubMed]

4. Hoffman S, Martinez MG., Jr Fibrous histiocytomas of the oral mucosa. Oral Surg Oral Med Oral Pathol. 1981;52:277–283. [PubMed]

5. MacLeod SP, Jones JL. Fibrous histiocytoma of the lip secondary to trauma: report of a case. J Oral Maxillofac Surg. 1992;50:1091–1093. [PubMed]

6. Gray PB, Miller AS, Loftus MJ. Benign fibrous histiocytoma of the oral/perioral regions: report of a case and review of 17 additional cases. J Oral Maxillofac Surg. 1992;50:1239–1242. [PubMed]

7. Yamada H, Ishii H, Kondoh T, Seto K. A case of benign fibrous histiocytoma of the upper lip in a 6-month-old infant. J Oral Maxillofac Surg. 2002;60:451–454. [PubMed]

8. Senear FE, Caro MR. Histiocytoma cutis. Arch Derm Syphilol. 1936;33:209–226.

9. Nestle FO, Nickoloff BJ, Burg G. Dermatofibroma: an abortive immunoreactive process mediated by dermal dendritic cells? Dermatology. 1995;190:265–268. [PubMed]

10. Zelger BW, Zelger BG, Rappersberger K. Prominent myofibroblastic differentiation. A pitfall in the diagnosis of dermatofibroma. Am J Dermatopathol. 1997;19:138–146. [PubMed]

11. Zelger B. It's a dermatofibroma, CD34 is irrelevant! Am J Dermatopathol. 2002;24:453–454. [PubMed]

12. Mentzel T, Kutzner H, Rütten A, Hügel H. Benign fibrous histiocytoma (dermatofibroma) of the face: clinicopathologic and immunohistochemical study of 34 cases associated with an aggressive clinical course. Am J Dermatopathol. 2001;23:419–426. [PubMed]

13. Shlomi B, Mintz S, Jossiphov J, Horovitz I. Immunohistochemical analysis of a case of intraoral nodular fasciitis. J Oral Maxillofac Surg. 1994;52:323–326. [PubMed]

14. Beer M, Eckert F, Schmöckel C. The atrophic dermatofibroma. J Am Acad Dermatol. 1991;25:1081–1082. [PubMed]

15. Regezi JA, Zarbo RJ, Tomich CE, Lloyd RV, Courtney RM, Crissman JD. Immunoprofile of benign and malignant fibrohistiocytic tumors. J Oral Pathol. 1987;16:260–265. [PubMed]

16. Goldblum JR, Tuthill RJ. CD34 and factor-XIIIa immunoreactivity in dermatofibrosarcoma protuberans and dermatofibroma. Am J Dermatopathol. 1997;19:147–153. [PubMed]

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