Case report:
A 55 years male presented to the head and neck oncology department with
complaints of swelling in the left lateral border of the tongue for the
last four yearsalongwith a cytotopathology report of FNAC suggesting the
diagnosis of Pleomorphic Adenoma. To begin with, the swelling initiated
as asmall nodule which gradually increased to its present size over the
period of four years. There was no history of trauma, pain, burning
sensation, difficulty in swallowing,and change in speech quality.There
was no significant past and family history.
The vitals were normal at the time of arrival. On examination, there was
a firm nodular swelling of 2 x 1.5 cm size located in the left lateral
border of the tongue with normal mucosa (fig.1). There was no ulceration
and no signs of inflammation over the swelling. Similarly, lymph nodes
were not palpable in the neck.
Magnetic Resonance Imaging (MRI) of the tongue was ordered that showed a
well-defined, oval-shaped, soft tissue lesion within the tongue on the
left side (fig. 2a, 2b). This post-gadolinium-enhanced lesion measured
about 18 x 19 mm in size and was seen about 19 mm distal to the tip of
the tongue (fig. 2c). No evidence of restricted diffusion wasnoted. The
lesion was seen extending to the distal edge of the tongue with no
evidence of extension across the midline, into the surrounding tissue
and overlying teeth and bone. Additionally, multiple small lymph nodes
were visible in levels I (IA right side 9 x 13mm), II (IIA right side 10
x 12 mm), and III (9 x 10 mm right side) of the neck bilaterally.
The patient was admitted to the hospital and scheduled for elective
surgery for the removal of the lesion. The pre-anesthetic evaluation
revealed normal vitals and examination findings. All hematology
(Complete Blood Count, Prothrombin Time), biochemistry (Liver function
Test, Renal Function Test) and serology (for HIV, Hepatitis B and
Hepatitis C) were normal. A real-time RT-PCR was negative for SARS CoV
2.The patient underwent a left partial glossectomyto remove the lesion
under general anesthesia.Intra-operative and postoperative periods were
uneventful. Post-operatively patient was managed conservatively.
On gross examination, specimen of size 5 x 3.4 x 2.5 cm was received
(fig. 3). It was well-circumscribed, grey-white, tanned solid mass with
unremarkable mucosal findings. The tumor was unifocal and located at the
left lateral border of the tongue with a size of 2.3 x 2 x 2.2 cm.
Grossly, all mucosal, soft tissue, and deep margins (anterior,
posterior, lateral, medial, superior, inferior, and deep) were
uninvolved by the tumor. The distance from the closest mucosal margin
was 0.7 cm (anterior), and from the deep margin was 0.2 cm.
Under microscopy, the sections showed sub-mucosal circumscribed nodular
lesion composed of clear cells of variable size arranged in sheets (fig.
4a). These cells had eccentric nuclei with abundant vacuolated clear
cytoplasm suggesting the diagnosis of clear cell neoplasm, which
contradicted the initial diagnosis of pleomorphic adenoma (fig. 4b, 4c).
No necrosis, increased mitosis, and atypia were appreciated.But
thin-walled capillaries were observed between these clear cells. Further
evaluation by immunohistochemistry showed positivity for S100, CDK4,
MDM2 (fig. 5a, 5b, 5c) with 2% Ki-67 but negativity for CK favoring the
histomorphological diagnosis of well differentiated liposarcoma.
On discharge, the patient washaemodynamically stable, and his wound was
healing well. The post disease status of the patient was evaluated after
the diagnosis of well-differentiated liposarcoma by F18 FDG PET CT Scan,
which was within the normal limit.