3 May 2007 – Case of the Week #82

 

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Case of the Week #82

 

Clinical History

 

A 57 year old man had papillary lesions on his palate, which were excised:

 

Micro images: image #1#2#3#4

 

What is your diagnosis?

 

 

 

 

 

 

 

 

 

 

 

 

 

  

 

 

 

 

 

 

 

 

 

Diagnosis:

 

Verruciform xanthoma

 

Discussion

 

Verruciform xanthoma is a rare lesion of the oral mucosa that usually occurs in the gingiva or alveolar ridge.  It occurs less commonly on the penis or scrotum.  It is considered reactive (AJSP 1998;22:479), although a multifocal lesion was reported in a child with a systemic lipid disorder (AJSP 1989;13:309).  It is probably not HPV related (APMIS 2005;113:629, Archives 2005;129:e62, but see Am J Dermatopathol 2000;22:447).

 

Grossly, verruciform xanthoma appears as a raised granular or verrucous lesion.  Histologically, the characteristic finding is foamy macrophages within dermal papillae.  The foam cells are immunoreactive for CD68, vimentin and Factor XIIIa, and negative for S100 and weak/negative for keratin.  The overlying epidermis is either verruciform, papillary or flat (Oral Oncol 2003;39:325).  No epithelial atypia is present.

 

The differential diagnosis includes squamous cell carcinoma, verrucous carcinoma and condyloma accuminatum.  All of these entities lack prominent foamy macrophages.  In addition, the lack of atypia rules out squamous cell carcinoma.  Verrucous carcinoma is composed of lobules of mature squamous epithelium with minimal atypia, but they are ulcerating or fungating.  Condyloma accuminatum has prominent koilocytosis in the upper epidermis that is not found in verruciform xanthoma.

 

Excision is adequate treatment, and these tumors do not recur (J Formos Med Assoc 2007;106:141).

 

 

Nat Pernick, M.D., President
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