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Bajaj A, J Brain Neursci 2021, 5: 016 HSOA Journal of Brain & Neuroscience Research

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tissue concurrence. The neoplastic adipose tissue derivative depicts The Oleaginous Ossein- distinct foci of chondro- osseous metaplasia. Heterologous interstitial cells are absent [1,2]. A cellular neoplasm of distinctive morphology, Chondroid chondroid lipoma can be misdiagnosed as round cell or chondrosarcoma. With misinterpretation as a malignant neoplasm, Anubha Bajaj* irrelevant lymph node dissection, extensive tumour resection or amputation of incriminated areas can ensue. Cogent diagnosis and Consultant Histopathology, A.B. Diagnostics, New Delhi, India appropriate therapy of chondroid lipoma essentially lacks consensus [1,2]. Chondroid lipoma is an exceptional, benign neoplasm composed Disease characteristics of mature adipocytes, lipoblasts and intermingled myxochondroid stroma. Chondroid lipoma predominantly appears within third decade Chondroid lipoma predominantly appears within third decade of life wherein a female preponderance is observed. The neoplasm of life. A female preponderance is observed as an estimated 80% is predominantly situated within subcutaneous adipose tissue, instances are delineated in females with a female to male proportion submucosa, superficial muscular fasciaor as intramuscular lesion of 4: 1.Female preponderance implies the incrimination of hormonal within skeletal muscles of proximal extremities, limb girdles, trunk factors in disease pathogenesis. Median age of disease emergence is or head and neck. Micro-section displays a tumefaction composed 36 years wherein the neoplasm is discovered betwixt 14 years to 70 of fascicles, nests and sheets of eosinophilic, multi-vacuolated cells years. An obvious geographical or ethnic trend of disease occurrence variably admixed with mature adipocytes. The cellular component is absent [2,3]. Neoplastic discernment can occur within 6 days to 10 is enmeshed within a myxoid and chondroid-like stroma. Multi- years. Chondroid lipoma appears within the trunk (26.14%), lower vacuolated cells, akin to or cells of , are limbs (36.4%), upper limbs (13.64%), oral cavity (7.95%), feet (4.55%) imbued with adipose tissue and glycogen, as detected by Oil-red or uterus (1.14%). Nomenclature of chondroid lipoma is indicative of O and Periodic Acid Schiff’s (PAS) stains respectively. Chondroid pertinent histological pattern as the neoplasm distinctively comprises lipoma is immune reactive to S100 protein andvimentin. Tumefaction of mature adipose tissue cells, lipoblasts, cartilaginous chondroblasts depicts chromosomal translocation t(11;16), (q13;p13) besides and hyaline matrix. Stromal mucins detected within chondroid lipoma C11 or f95-MKL2 fusion genes. Chondroid lipoma requires a are indicative of chondroid differentiation [2,3]. demarcation from lipoma, neurofibroma, schwannoma, teratoma, myxoid chondrosarcoma or extra-skeletal chondrosarcoma. Magnetic Clinical elucidation Resonance Imaging (MRI) is beneficial in diagnosing chondroid Chondroid lipoma is predominantly situated within subcutaneous lipoma. Surgical eradication of the neoplasm is generally curative. adipose tissue, submucosa, superficial muscular fascia or as Preface intramuscular lesion within skeletal muscles of proximal extremities, limb girdles, trunk or head and neck. Chondroid lipoma is Lipomatous mesenchymal neoplasia are a common variety of infrequently discerned within oral cavity or myometrial leiomyomata. tumours wherein conventional lipoma is frequent. Albeit, The neoplasm represents as a painless, gradually progressive, well , or can be defined, non tender, subcutaneous nodule [2,3]. Chondroid lipoma misinterpreted as liposarcoma.Chondroid lipoma is designated as situated within trunks or limbs manifest as a painless nodule, although an exceptional, benign neoplasm composed of mature adipocytes, tenderness, tingling and radiating pain can concur. Painful lesions lipoblasts and intermingled myxochondroid stroma, initially scripted necessitate distinction from schwannoma or neurofibromatosis. Oral by Meis and Enzinger in 1993 [1]. Chondroid lipoma as a lipomatous chondroid lipoma represents as soft tissue polyps whereas intrauterine neoplasm recapitulates pseudo- like histology. Unique cellular neoplasms can engender unascertained vaginal bleeding. Chondroid population of chondroid lipoma denominates embryonal adipose lipoma is preponderantly composed of white, mature adipocytes with tissue intermixed with embryonal , thus signifying a dual an absence of true cartilaginous differentiation [3]. *Corresponding author: Anubha Bajaj, Consultant Histopathology, A.B. Diagnostics, New Delhi, India, E-mail: [email protected] Histological elucidation Citation: Bajaj A (2021) The Oleaginous Ossein- Chondroid Lipoma. J Brain Chondroid lipoma appears as solid, firm, yellowish or reddish- Neursci 5: 016. brown nodule of variable magnitude with definitive tumour margins. Received: January 07, 2021; Accepted: February 10, 2021; Published: Feb- Cut surface is yellow- brown, pearly, grey/white or reddish- brown ruary 17, 2021 with a gelatinous texture and occasional haemorrhagic foci. On Copyright: © 2021 Bajaj A. This is an open-access article distributed under the gross examination, a well encapsulated, lobulated, yellowish or terms of the Creative Commons Attribution License, which permits unrestricted whitish, partially covered neoplasm of 4 centimetre median use, distribution, and reproduction in any medium, provided the original author magnitude is discerned although tumour dimension can extend and source are credited. up to 11 centimetres. The elliptical or spheroidal tumefaction is Citation: Bajaj A (2021) The Oleaginous Ossein- Chondroid Lipoma. J Brain Neursci 5: 016.

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firm, mobile, non-fluctuant, depicts a non-breached extraneous arising from cell membrane, composed of granular, amorphous, capsule and lacks adherence to superimposed cutaneous surface fibrillary material are exemplified. Mitochondria and lysosomes are or adjacent soft tissue [3,4]. Upon capsular incision, lobular, insignificant [4,5] (Figures 1-8). yellowish or reddish- brown tumefaction is discerned which displays miniature foci of chalky white material. Frozen section delineates enlarged quantities of mature cartilage, foci of ossification and proliferating peripheral compartment composed of fibrous tissue and mature adipose tissue. Cellular atypia is absent. Ultrasound guided fine needle aspiration demonstrates accumulation of adipose tissue with focal differentiation and maturation of clusters of adipocytes of diverse magnitude. Mature lipocytes or lipoblast- like cells are disseminated within a chondromyxoid matrix. Adipoblasts are quantifiably detected along with foci of mature cartilage and . However, segregation from an atypical lipoma with foci of mature cartilage and ossification can be challenging [3,4]. Chondroidlipoma Figure 1: Chondroid lipoma depicting cords of small to medium, multi-vacu- is a well circumscribed neoplasm constituted by mature adipocytes, olated cells lacking cellular atypia, interspersedwithin a myxoid and chondroid chondroidtissue denominated by vacuolated, lipoblast-like or matrix [1]. chondroblastic cells and an encompassing myxo-hyaline matrix. Micro-section displaysa tumefaction composed of fascicles, nests and sheets of eosinophilic, multi-vacuolated cells variably admixed with mature adipocytes. The cellular component is enmeshed within a myxoid and chondroid-like stroma [3,4]. Well defined, tumorous aggregates and cords of miniature to medium sized, multi-vacuolated cells are discerned. The cellular component simulates lipoblasts, chondroblasts or cells of hibernoma cells. Nuclear outlines of tumour cells are complex. The encompassing, prominently chondromyxoid matrix demonstrates variable quantities of mature adipose tissue and exceptionally, metaplastic bone [4,5]. Chondroid lipoma is constituted by varying proportions of mature adipocytes, adipoblasts and transparent, mucoid, cartilaginous zones with focal ossification. Figure 2: Chondroid lipoma delineating aggregates and nests of miniature to Enlarged, mature adipocytes with vacuolated, lipid-rich cytoplasm and medium multi-vacuolated cells with uniform nuclei, lack of mitosis, foci of ma- compressed, eccentric nucleus are exhibited. Miniature adipoblasts ture adipose tissue and an intermixed chondro-myxoid matrix [2]. configure aggregates, fascicles, nests and cord- like arrangements. Adipoblasts with eosinophilic, multi-vacuolated cytoplasm exemplify several vacuoles of varying magnitude along with miniature nuclei demonstrating minimal anisocytosis and pleomorphism. Nucleolar and intra-nuclear pseudo-inclusions are observed [4,5]. Classic histologic pattern denominates distinct cellular categories such as mature adipose tissue cells, lipoblast- like cells with vacuolated cytoplasm and centric nuclei or elliptical to spheroidal cells with eosinophilic cytoplasm. Nuclei are minimally pleomorphic although mitotic activity is absent to minimal. The encapsulated neoplasm comprised of miniature, spheroidal cells articulates loosely cohesive sheets, clusters and cords intermingled withinmyxoid, hyalinised or cartilaginous intercellular matrix. Multi- vacuolated cells, akin to Figure 3: Chondroid lipoma demonstrating clusters of eosinophilic multi-vacu- chondroblasts or cells of hibernoma, are imbued with adipose tissue olated cells interspersed in a myxo-chondroid stroma and foci of mature adipose and glycogen, as detected by Oil-red O and Periodic Scid Schiff’s tissue [3]. (PAS) stains respectively [3,5]. Transparent, mucoid, cartilaginous - like zones along with variable, articulated matrices are numerous. Partial deposition of inter-cellular cellulose amidst mature adipocytes and adipoblasts is discerned. Vascular configurations are denominated although a typical, plexiform, vascular morphology, as detected in myxoidliposarcoma, is absent. With variable vascularity, prominent vasculature demonstrates diverging thickness of blood vessel walls [4]. Focal fibrosis, haemorrhage and haemosiderin pigment deposits are exhibited along with eosinophilic foci of fibrinous matrix. Cellular or nuclear pleomorphism or atypia are minimal or absent. Foci of mature hyaline cartilage are absent. On ultrastructural examination, abundant intracytoplasmic lipid and glycogen molecules are observed. Figure 4: Chondroid lipoma exhibiting aggregates of eosinophilic, multi-vac- Numerous pinocytotic vesicles are characteristically delineated uolated cells intermixed within a chondro-myxoid stroma and mature adipose within white adipocytes. Tumour cells recapitulate embryonal fat or tissue cells [4]. can minimally resemble embryonal cartilage. Knob- like protrusions

Volume 5 • Issue 1 • 016 J Brain Neursci ISSN: HBNR, Open Access Journal Citation: Bajaj A (2021) The Oleaginous Ossein- Chondroid Lipoma. J Brain Neursci 5: 016.

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Immune histochemical elucidation Miniature, vacuolated cells of chondroid lipoma are immune reactive to S100 protein where mature adipocytes are intensely immune reactive, in contrast to weakly reactive lipoblasts. As cells are immune reactive to vimentin, maturity and differentiation of adipoblasts is concurrent with immune reactivity to vimentin (93.75%) and S100 protein (93.33%). Certain tumours are variably and focally immune reactive to CD68 (64.29%) and cytokeratin (25.93%). Intracellular glycogen is detected by periodic acid Schiff’s (PAS) stain. Alcian blue and toluidine blue can highlight chondroitin Figure 5: Chondroid lipoma composed of accumulated, eosinophilic, multi-vac- uolated cells admixed within a myxoid and chondroid matrix besides foci of substrate. Immune reactive IV circumscribes tumour cell mature adipose tissue [5]. aggregates. Cyclin D1 is intensely immune reactive [5,6]. Cells are immune non reactive to Epithelial Membrane Antigen (EMA), Human Melanoma Black 45 (HMB45) antigen, Actin (SMA), Muscle Specific Actin (MSA) and Glial Fibrillary Acidic Protein (GFAP). Nuclear proliferation labelling index MIB-1 or Ki67 is below <1%. Although female preponderance is observed, the neoplasm is devoid of sex hormone related receptors such as oestrogen (ER), Progesterone (PR) or Androgen Receptors (AR) [5,6]. Cytogenetic analysis demonstrates chromosomal translocation t(11;16), a genomic alteration also exemplified in hibernoma. Chondroid lipoma frequently depicts chromosomal translocation t(11;16), (q13;p13) besides presence of C11 or f95-MKL2 fusion genes. Equilibrium chromosomal translocation of t(11;16), (q13;p12-13) is enunciated. Although lipoma and adjunctive hibernating neoplasia demonstrate Figure 6: Chondroid lipoma constituted by clumps of eosinophilic cells with chromosomal anomalies of 11q13, aberration 16p12-13 is absent, a multiple vacuoles, foci of mature adipose tissue and a myxo-chondroid matrix feature enunciated in chondroid lipoma [5,6]. [5]. Differential diagnosis Chondroid lipoma can be misdiagnosed and requires a demarcation from benign conditions as lipoma, neurofibroma, schwannoma or teratoma. Chondroid lipoma mandates a segregation from malignant neoplasia as myxoid chondrosarcoma or extra-skeletal chondrosarcoma which are constituted by mature chondrocytes, adipoblasts and mature adipocytes with an intermingled myxoid matrix. However, combined genetic, histopathological and Magnetic Resonance Imaging (MRI) can assist appropriate demarcation [6]. Chondroid lipoma necessitates a segregation from Lipoma with chondroid metaplasia, a neoplasm which exemplifies foci of true cartilage. Extra-skeletal chondroma,which is a benign neoplasm principally arising within Figure 7: Chondroid lipoma comprised of small cells with eosinophilic cyto- distal extremities. The neoplasm is composed of mature hyaline or plasm, multi-vacuolated cells commingled with myxo-chondroid matrix and a true cartilage and exhibits multinucleated giant cells. Tumour cells lack of atypia [6]. are devoid of intracytoplasmic vacuoles as discerned with mature adipose tissue [6,7]. Mixed tumour, which delineates foci of epithelial differentiation with keratin production and an absence of lipoblasts. Extra-skeletal myxoid chondrosarcoma, which is a predominantly lobulated tumefaction traversed by prominent fibrous tissue septa and circumscription with thin, peripheral capsule. Adipocytes and lipoblasts are usually absent. Mitotic figures and foci of necrosis are frequent. Chondroblasts constituting the tumour are spheroidal and delineate minimal or absent intracytoplasmic vacuoles or foci of mature adipose tissue [6,7]. Myxoidliposarcoma, which commonly appears in diverse sites. Microscopically, it lacks prominent cords or cellular clusters and is characteristically composed of true lipoblasts and is imbued with delicate, plexiform, capillary-rich matrix. Genetic Figure 8: Chondroid lipoma depicting cellular nests with eosinophilic, translocation t(12;16) is detected within the neoplasm. Aforesaid multi-vacuolated cytoplasm, abundant myxoid and chondroid matrix with few malignant delineate an inferior prognostic outcome and mature adipocytes [7]. therapeutically entail radical surgical manoeuvers with post operative radiotherapy [6,7].

Volume 5 • Issue 1 • 016 J Brain Neursci ISSN: HBNR, Open Access Journal Citation: Bajaj A (2021) The Oleaginous Ossein- Chondroid Lipoma. J Brain Neursci 5: 016.

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Investigative assay modality, hence the procedure may not be advantageous in routine analysis [8,9]. Chondroid lipoma lacks characteristic features of imaging on account of inconstant proportion of intermingled adipose tissue and Therapeutic options cartilage. On ultrasonography, a heterogeneous mass with minimal echo, uneven morphology, mildly enhanced intensity echo, irregular Chondroid lipoma as a clinically benign neoplasm can be internal echo and blurred outline is discerned [7]. Ultrasonography appropriately alleviated with localized surgical resection. Surgical of chondroid lipoma demonstrates a lobulated tumour architecture eradication of the neoplasm is generally curative. Chondroid lipoma due to several fibrous tissue membranes traversing the neoplasm can be suitably treated with simple surgical resection in the absence of with consequent poor quality images. The tumefaction is comprised postoperative adjuvant therapy. Surgical extermination of chondroid of abundant quantities of cartilage- like tissue, thus engendering lipoma is associated with adequate post-operative recovery and an intense echogenicity. Often, a heterogeneous, mixed signal is subsequent monitoring is unnecessary [10]. Diode laser therapy can delineated upon imaging due to content and variable morphology of be employed for eradicating tumour tissue situated in precarious cartilage- like foci, which preponderantly demonstrate an irregular zones as the oral cavity. Laser therapy is associated with lack of outline [7,8]. Plain radiography of chondroid lipoma indicates the intraoperative haemorrhage or subsequent suturing and demonstrates occurrence of calcific structures or ossification within the tumefaction minimal post-operative pain, haemorrhage, swelling or inflammation, although cartilaginous foci may not be ascertained. On Computerized in contrast to adjunctive techniques. Adoption of laser therapy is Tomography (CT), a minimal density shadow with an approximate accompanied by rapid wound healing [10]. The essentially benign value of -80 Hounsfield units is discerned. A nodular, density shadow neoplasm is devoid of tumour reoccurrence, metastasis or malignant of soft tissue and dot- like, high density shadow are delineated metamorphoses. Following surgical treatment, adjuvant therapy [7,8]. Chondroid lipoma requires diagnostic consideration even is unnecessary as extended monitoring reveals a lack of tumour with the emergence of non specific findings on radiography or CT. reoccurrence or metastasis [10]. Nevertheless, as an elevated proportion of false negative diagnosis is engendered with plain radiography or CT, routine employment of Figure References aforesaid manoeuvers is not recommended [7,8]. MRI is beneficial in 1. Image 1 Courtesy: Webpathology diagnosing chondroid lipoma. An admixture of enhanced and minimal 2. Image 2 Courtesy: Science direct signal intensities is detected upon T1 weighted imaging, Short-Time 3. Image 3 Courtesy: Histopathology.india.net Inversion Recovery (STIR) sequences and fat-suppression sequence whereas enhanced signal density is observed upon T2 weighted 4. Image 4 Courtesy: Pathology outlines imaging. Heterogeneous saturation of adipose tissue appears upon 5. Image 5 and 6 Courtesy: Basic medical key T2 weighted fat- saturated imaging [8,9]. Minimal signal intensity 6. Image 7 Courtesy: Journal of case reports and images upon T1 weighted imaging and enhanced signal intensity upon T2 7. Image 8 Courtesy: Indian Journal of Pathology and Microbiology weighted imaging are indicative of chondroid tissue. Enhanced signal intensity upon T1 weighted imaging are prohibited on STIR imaging, References thus suggesting concurrence of adipose tissue along with non uniform fat saturation upon T2 weighted fat- saturated imaging. A distinct, 1. Meis JM, Enzinger FM (1993) Chondroid lipoma: A unique tumour sim- “fat ring” sign is discerned upon contrast- enhanced and fat- saturated ulating liposarcoma and myxoid chondrosarcoma. Am J Surg Pathol 17: 1103-1112. imaging. The sign, indicative of cartilage tissue within tumour centric zone, depicts minimal signal intensity upon T1 weighted imaging, 2. Kindblom LG, Meis-Kindblom J (1995) Chondroid lipoma-an ultrastruc- enhanced signal intensity upon T2 weighted imaging and a delayed tural and immune histochemical analysis with further observations regard- ring or arc- shaped enhancement pattern following injectable contrast ing its’ differentiation. Hum Pathol 26: 706-715. agent. Circumscribing adipose tissue exhibits an intense signal 3. Huang C, Guo W, Qu W, Zhu Z, Li R (2019) Characteristics of chon- as compared to skeletal muscle upon T1 or T2 weighted imaging droid lipoma- a case report and literature review. Medicine (Baltimore) and heterogeneous fat saturation upon T2 weighted fat-saturated 98: e15587. imaging [8,9]. Single- Photon Emission Computerized Tomography 4. Fournel L, Rapicetta C, Fraternali A, Bellafiore S, Paci M, et al. (2018) Fi- (SPECT-CT) is an investigative option beneficially adopted in brous dysplasia of the rib mimicking a malignant bone tumour at SPECT/ separating diverse tumours. Elevated affinity for Fluorine Labelled- CT with 99m Tc-MDP. Clin Nucl Med 43: 346-348. 18Fluoro-Deoxy-Glucose (F-FDG) is observed wherein accumulation of aforesaid molecule is concurrent with enhanced glucose metabolism 5. Tatsiou Z, Mavropoulou S (2017) Chondroid lipoma of the breast- a rare within tissues and organs. Affinity for 18F-FDG is frequently case report. Virchows Arch 471: 63-64. discerned with malignant tumefaction or inflammatory conditions. 6. Ren S, Yue Y (2017) A case of atypical chondroid lipoma. Radiologic Pract Thus, employment of SPECT/CT with 18F-FDG is nonspecific in 32: 776-777. discerning chondroid lipoma [8,9]. SPECT-CT imaging depicts adjacent bone as a radioactive, concentrated shadow and enveloping 7. Kapse SUS, Javalgi A, Javalgi AP (2017) Chondroid lipoma in left thigh- a rare case report. J Clin Diagn Res 11: 17-18. soft tissue as an elliptical, minimally dense shadow with value of -86 Hounsfield units. Separation of various neoplastic components, 8. Yildiz A, Aydingoz U, Sökmensüer C, Karçaaltıncaba M (2015) Intramus- irregular density of soft tissue and enhanced tissue density are also cular chondroid lipoma- magnetic resonance imaging diagnosis by ‘fat observed along with density shadow of around 166 Hounsfield units ring’ sign. Balkan Med J 32: 107-110. with enhanced radioactivity uptake. The tumefaction displays an 9. Liu H, Long D (2015) Chondroid lipoma of the abdominal wall: one case affinity for Methylene-Diphosphonate (99m Tc-MDP), a molecule report. J Med Imag 25: 1013-1014. which is specific for bone or cartilage tissue. Therefore, application of 99m Tc-MDP is significantly superior than 18F-FDG in detecting 10. Yaranal PJ, Hegde V (2013) Chondroid lipoma of the thigh - a case report. Indian J Pathol Microbiol 56: 464-465. chondroid lipoma. Also SPECT/CT is an expensive investigative

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