Angioleiomyoma which was initially classified as vascular leiomyoma has been reclassified as a tumor of perivascular origin with its etiology still being uncertain. It is a rare entity to be observed in head and neck region with an incidence of less than 0.06%. In the oral cavity its origin from the gingiva is rare. Clinical presentation of pathologies may vary and oral cavity being a constituent of mixed tissues there may be pathologies found which are seen in other parts of body. Thus, histopatholgy plays an important role in diagnosis of these rare lesions. Present a rare case of large angioleiomyoma arising from gingiva.
Angioleiomyoma of head and neck region accounts for an incidence of less than 0.06%.
Morphological findings along with immunohistochemical results are helpful for better differentiation between various lesions.
The most indicated treatment is conservative surgical excision.
Use of buccal pad of fat enhances the surgical management.
Angioleiomyoma which was initially classified as a vascular benign tumor of smooth muscle (leiomyoma) has been reclassified as a tumor of perivascular origin by WHO in 2013 [ , , ]. The common sites for it’s occurrence include uterus, gastrointestinal tract, skin and subcutaneous tissue whereas one of the unusual site involved may be oral cavity [ ]. Of all the angioleiomyomas, less than 0.06% is found to be associated with head and neck region [ ]. Middle-aged males have a higher prevalence of angioleiomyoma [ ].
Clinically, angioleiomyoma appear as a well-defined, painless, gradual growing swelling which is a feature similar to many other lesions, hence the diagnosis can be derived on only basis of histolopathologic findings which includes characteristics features of proliferation of mature smooth muscle cells and numerous blood vessels [ ]. In cases of unclear histologic features, further specific immunohistochemistry is used [ ].
The present report describes an unusual case of large angioleiomyoma arising from the gingiva.
A 17yrs old male presented with a growth in the left posterior mandible since 3 months which had gradually increased to a size of 4 × 3cm. On examination patient appeared normal with no extra-oral abnormality. On palpation there was a single, firm and tender left submandibular lymph node. Intra-orally, a well defined pedunculated, oval soft tissue mass with smooth surface noted arising from the lingual interdental gingiva between mandibular left 1st and 2nd molars ( Fig. 1 ). The boundaries between the growth and normal tissue were relatively clear. It was non-tender, firm in consistency with presence of bleeding on probing. It was freely movable with no adhesion to the surrounding tissue. No restriction in tongue movements noted. Grade 2 mobility observed with respect to mandibular left 1st and 2nd molars. Fine needle aspiration cytology (FNAC) of the lesion was performed which was suggestive of a granulation tissue growth. On the basis of clinical evaluation, diagnostic hypothesis of peripheral giant cell granuloma was made. Clinical differential diagnosis focused on ruling out pyogenic granuloma, central giant cell granuloma, fibroma, peripheral ossifying fibroma and mesenchymal tumor.
Further investigations included radiographic evaluation with mandibular occlusal view x-ray ( Fig. 2 ) and orthopantamogram (OPG) which revealed periodontal ligament widening with respect to 36 to mandibular left 1st and 2nd molars and increase interdental gap between them.
Incisional biopsy was performed under local anesthesia and the histopathological report with the use of immunohistochemical (IHC) markers was suggestive of angioleiomyoma. IHC study was positive for vimentin and smooth muscle actin (SMA) and negative for cytokeratin, epithelial membrane antigen (EMA) and S100.
The tumor was excised with 1cm clear margin under general anesthesia along with extraction of 36, 37 and 38 and closure of the defect done using buccal fat pad ( Fig. 3 , 4 ). The specimen was sent for histopathological analysis.