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Journal of Dentistry and Oral Sciences ISSN: 2582-3736 Soman S, et al., 2020-J Dent Oral Sci Case Report

Pleomorphic of Buccal 1Senior Lecturer, Department of Oral & Mucosa: A Rare Clinical Entity Maxillofacial Surgery, MES Dental College, Malappuram, Kerala, India Sooraj Soman1, Ajay Das T2, Sachin Aslam A3 and Tom Thomas4 2Senior Lecturer, Department of Oral & Maxillofacial Surgery, MES Dental College, Abstract Malappuram, Kerala, India

Salivary gland tumors are rare tumors in the head and neck region and 3Professor, Department of Oral & (PA) is the commonest tumor. It Maxillofacial Surgery, MES Dental College, is a usually affecting parotid, submandibular or minor Malappuram, Kerala, India salivary glands. In minor salivary glands, palate and are the 4Senior Lecturer, Department of Oral & commonest sites. Histopathological examination and various imaging Maxillofacial Surgery,MES Dental College, techniques aid n diagnosis. Wide surgical excision is the treatment of Malappuram, Kerala, India choice. Here we present a rare case of PA of the buccal mucosa. *Corresponding Author: Sooraj Soman, Senior Lecturer, Department of Oral & Keywords: Buccal Mucosa; Salivary gland tumors; Pleomorphic Maxillofacial Surgery, MES Dental College, Adenoma Malappuram, Kerala, India.

Introduction Received Date: 10-02-2020 Published Date: 10-30-2020

Salivary gland tumors are uncommon and account for less than Copyright© 2020 by Soman S, et al. All 3% of all head and neck tumors. Pleomorphic Adenoma (PA) is rights reserved. This is an open access article distributed under the terms of the the most common tumor of the salivary gland. It is a benign Creative Commons Attribution License, mixed type of tumor as it has its origin from both epithelial and which permits unrestricted use, myoepithelial components. It accounts for almost 45–75% of all distribution, and reproduction in any medium, provided the original author and salivary gland tumors. It affects most commonly in the parotid source are credited. gland (70 – 80%), followed by minor salivary glands (10 to 15%), submandibular glands (10%) and very treatment for PA is wide surgical excision rarely in the sublingual gland (1%). Among of the lesion along with an adequate the minor salivary glands, the palate is the margin of normal tissue. Here we present a most common intraoral location followed rare case of pleomorphic adenoma of the by the lip, buccal mucosa and . It buccal mucosa. can occur in any age group but is mostly seen during the 4th to 6th decade of life with Case Report a slight female predilection (3:2). CT and A twenty-two-year-old female patient MRI are the gold standard imaging reported with a chief complaint of a modalities in diagnosis along with painless swelling in the cheek since one histopathological examination. The Soman S| Volume 2; Issue 4 (2020) | Mapsci-JDOS-2(4)-059 | Case Report Citation: Soman S, Das A, Aslam S, Thomas T. Pleomorphic Adenoma of Buccal Mucosa: A Rare Clinical Entity. J Dent Oral Sci. 2020;2(4):1-4. DOI: https://doi.org/10.37191/Mapsci-2582-3736-2(4)-059

and a half months. On clinical epithelial cells proliferating in a ductal examination, a solitary swelling was pattern, mostly filled with eosinophilic present on the right buccal mucosa in coagulum. Islands of cuboidal cells were relation to left maxillary bicuspids. The also seen in some foci, showing squamous swelling was firm in consistency, non- metaplasia and keratin pearl formation. fluctuant type with a positive slip sign. It Dense fibrovascular was non tender on palpation and the showed hyalinised and myxoid areas with overlying mucosa appeared normal in its some foci of adipocytes. The colour and texture. Regional lymph nodes aforementioned features were suggestive of were non palpable. Considering the size, Pleomorphic adenoma of the minor site and characteristics of the lesion a salivary gland (Figures 1-3). clinical diagnosis of was made. Figure 2: Excised Specimen. Excision of lesion was planned under local anaesthesia and an informed consent was obtained from the patient. Following all aseptic precautions, field block was administered with 2% Lignocaine with 1:100,000 Adrenaline. Incision was placed on the overlying mucosa and dissection was carried out to expose the lesion. Excision of lesion was performed in toto and closure was done using 3-0 Vicryl. The specimen was sent for histopathological examination. The wound healing appeared satisfactory on the first week’s Figure 3: Histopathological view. postoperative review. On macroscopic examination, the specimen showed a firm, greyish white nodule, with the cut surface showing white colour.

Figure 1: Intra oral clinical picture.

Discussion

PA is defined by WHO in 1972 as “a circumscribed tumour characterized by its

pleomorphic or mixed appearance clearly Histopathological examination revealed a recognizable epithelial tissue being well encapsulated lesion showing cuboidal intermingled with tissue of mucoid, Soman S| Volume 2; Issue 4 (2020) | Mapsci-JDOS-2(4)-059 | Case Report Citation: Soman S, Das A, Aslam S, Thomas T. Pleomorphic Adenoma of Buccal Mucosa: A Rare Clinical Entity. J Dent Oral Sci. 2020;2(4):1-4. DOI: https://doi.org/10.37191/Mapsci-2582-3736-2(4)-059

myxoid or chondroid appearance”. The delineation and is superior in diagnosis of term PA was proposed by Willis owing to lesions than CT. The various the pleomorphism in the histological differential diagnosis of PA of buccal appearance of the epithelial and mucosa includes lipoma, buccal abscess, mesenchymal cells of the tumor. These neurofibroma, sebaceous cyst, cells have ability to form fibrous, myxoid, mucoepidermoid , myo- mucoid, hyalinised, chondroid or osseous epithelioma or . Histological tissues. PA of minor salivary gland is not examination shows wide local surgical common and among them its occurrence excision with adequate margins of normal in buccal mucosa is still rare. The proper tissue is the treatment option for PA of diagnosis of PA is established on the basis buccal mucosa. For tumors involving the of detailed case history, physical superficial lobe of parotid, superficial examination, histopathological and with preservation of facial imaging techniques. The signs and nerve is indicated and if it involves the symptoms reported by patient may vary deep lobe of parotid, total parotidectomy based on the size and site of tumor. They with preservation of is done. If usually appear as a solitary well it occurs in palate the treatment option encapsulated tumor which is painless, slow should be wide local excision along with growing, firm, mobile mass which has periosteum and involved bone. It has an irregular shape. Even though not common, excellent prognosis of about 95% and it has a malignant transformation rate of recurrences are not uncommon, usually about 7%. The two common malignant due to insufficient safe margins or rupture variants of PA are Carcinoma ex of capsule and spillage of tumor cells in the Pleomorphic Adenoma and Metastasizing site. Moreover, recurrences as late as 6 benign . The various years following treatment has been investigation modalities include reported, so a long term systematic follow histopathological as well as imaging up is mandatory. Radiation therapy will be options. Histopathological investigations of little use as these tumors are radio include FNAC or excisional biopsies resistant, but it can be used as an adjuvant whereas the imaging modalities include therapy to prevent recurrence. USG, CT and MRI. FNAC is the most Conclusion preferred method in large tumors as it gives a clear histological picture and aid in PA of buccal mucosa is a rare diagnosis. Incisional biopsies are and its diagnosis is a daunting task even for contraindicated as it may lead to an experienced maxillofacial surgeon or recurrence of the tumor. USG provides a physician. It should also be considered in non-invasive and cheap option to the differential diagnosis of understand the size, extend and swellings/masses in cheek. Early diagnosis presence/absence of calcifications in the and proper surgical excision with safe lesion.MRI is better option in diagnosis as margins will provide excellent prognosis the irregular borders of tumor seen in CT but it warrants a systematic follow-up of a can be misinterpreted as a malignancy. CT minimum of 5 years to rule out recurrence can be useful to demonstrate the bony or transformation to malignancy. invasion. MRI gives better soft tissue Soman S| Volume 2; Issue 4 (2020) | Mapsci-JDOS-2(4)-059 | Case Report Citation: Soman S, Das A, Aslam S, Thomas T. Pleomorphic Adenoma of Buccal Mucosa: A Rare Clinical Entity. J Dent Oral Sci. 2020;2(4):1-4. DOI: https://doi.org/10.37191/Mapsci-2582-3736-2(4)-059

References

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Soman S| Volume 2; Issue 4 (2020) | Mapsci-JDOS-2(4)-059 | Case Report Citation: Soman S, Das A, Aslam S, Thomas T. Pleomorphic Adenoma of Buccal Mucosa: A Rare Clinical Entity. J Dent Oral Sci. 2020;2(4):1-4. DOI: https://doi.org/10.37191/Mapsci-2582-3736-2(4)-059