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Case Report Soft-Tissue Chondroma of Anterior Gingiva: A Rare Entity Dhana Lakshmi Jeyasivanesan , Shameena Pazhaningal Mohamed , and Deepak Pandiar Department of Oral Pathology and Microbiology, Government Dental College, Kozhikode, India Correspondence should be addressed to Dhana Lakshmi Jeyasivanesan; [email protected] Received 12 November 2017; Accepted 30 January 2018; Published 13 March 2018 Academic Editor: Giuseppe Colella Copyright © 2018 Dhana Lakshmi Jeyasivanesan et al. is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Soft-tissue chondroma is a rare, benign, slow-growing tumor made up of heterotopic cartilaginous tissue. It occurs most commonly in the third and fourth decades in the hands and feet. Oral soft-tissue chondromas are uncommon and soft-tissue chondroma of gingiva is extremely uncommon. Here, we report an unusual case of soft-tissue chondroma of gingiva in a 50-year- old woman. 1. Introduction Soft-tissue chondroma is a rare soft-tissue tumor. It is also called extraskeletal chondroma or chondroma of soft-tissue parts. Soft-tissue chondromas constitute only 1.5% of benign soft-tissue tumors [1]. ey arise principally in extremities (96%)with72%intheupperlimb,24%inthelowerlimb,2% in the head and neck, and 2% in the trunk [2]. Oral soft-tissue chondromas are uncommon. If it occurs intraorally, then the most common intraoral site is tongue. In the oral cavity, only few cases of soft-tissue chondroma have been reported in the English literature till date, with very few cases in the gingiva [2–6]. is report describes an unusual case of soft-tissue chondroma occurring in the gingiva. 2. Case Report A 50-year-old female patient reported to the Department of Oral Pathology and Microbiology, Government Dental Col- lege, Kozhikode, with a chief complaint of swelling on gums in the upper front tooth region for 4 years. e patient recalled an initial small swelling in the upper front tooth region. Now, the swelling has grown slowly to a size of 3 × 2.5 cm. She has neither consulted any physician nor did she have any dis- comfort due to the lesion. ere was no relevant past medical history. Presently, the lesion has caused an obvious bulge of the upper lip. 2.1.ClinicalFindings. On examination, a firm ovoid swelling of size 3 × 2.5 cm was found on the attached gingiva with respect to 11 and 12 extending from free marginal groove inferiorly to the buccal sulcus superiorly (Figure 1). e marginal gingiva was uninvolved. No ulceration of the skin or the oral mucosa was observed. Silness and Loe plaque index was used to assess the plaque status of the patient which was 1.2 (fair). Since the lesion presented as a firm painless well-circumscribed swelling in the anterior gingiva and additionally the patient had a fair Silness and Loe plaque index, reactive lesions due to chronic low-grade irritation (dental plaque and food impaction) like peripheral ossifying fibroma, healing pyogenic granuloma, peripheral giant cell granuloma, and giant cell fibroma were considered as dif- ferential diagnoses. Also, fibroma and peripheral odonto- genic tumors were considered. Considering the indolent painless nature of the swelling, malignancies were not in- cluded in the differential diagnoses. e commonest reactive lesion found more commonly in females, exclusively in gingiva and not in any other oral mucosal location, is pe- ripheral ossifying fibroma. Hence, it was topmost in our list of differential diagnoses. Next, other reactive lesions like healing pyogenic granuloma, peripheral giant cell granu- loma, and giant cell fibroma were considered. A fibroma is most common in buccal mucosa, and peripheral odonto- genic tumors are extremely rare in occurrence. Hence, they both were considered last in the list of differential diagnoses. Hindawi Case Reports in Dentistry Volume 2018, Article ID 3642827, 5 pages https://doi.org/10.1155/2018/3642827

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  • Case ReportSoft-Tissue Chondroma of Anterior Gingiva: A Rare Entity

    Dhana Lakshmi Jeyasivanesan , Shameena Pazhaningal Mohamed ,and Deepak Pandiar

    Department of Oral Pathology and Microbiology, Government Dental College, Kozhikode, India

    Correspondence should be addressed to Dhana Lakshmi Jeyasivanesan; [email protected]

    Received 12 November 2017; Accepted 30 January 2018; Published 13 March 2018

    Academic Editor: Giuseppe Colella

    Copyright © 2018 Dhana Lakshmi Jeyasivanesan et al. )is is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in anymedium, provided the original work isproperly cited.

    Soft-tissue chondroma is a rare, benign, slow-growing tumor made up of heterotopic cartilaginous tissue. It occurs mostcommonly in the third and fourth decades in the hands and feet. Oral soft-tissue chondromas are uncommon and soft-tissuechondroma of gingiva is extremely uncommon. Here, we report an unusual case of soft-tissue chondroma of gingiva in a 50-year-old woman.

    1. Introduction

    Soft-tissue chondroma is a rare soft-tissue tumor. It is alsocalled extraskeletal chondroma or chondroma of soft-tissueparts. Soft-tissue chondromas constitute only 1.5% of benignsoft-tissue tumors [1]. )ey arise principally in extremities(96%) with 72% in the upper limb, 24% in the lower limb, 2%in the head and neck, and 2% in the trunk [2].

    Oral soft-tissue chondromas are uncommon. If it occursintraorally, then the most common intraoral site is tongue. Inthe oral cavity, only few cases of soft-tissue chondroma havebeen reported in the English literature till date, with very fewcases in the gingiva [2–6]. )is report describes an unusualcase of soft-tissue chondroma occurring in the gingiva.

    2. Case Report

    A 50-year-old female patient reported to the Department ofOral Pathology and Microbiology, Government Dental Col-lege, Kozhikode, with a chief complaint of swelling on gums inthe upper front tooth region for 4 years.)e patient recalled aninitial small swelling in the upper front tooth region. Now, theswelling has grown slowly to a size of 3× 2.5 cm. She hasneither consulted any physician nor did she have any dis-comfort due to the lesion. )ere was no relevant past medicalhistory. Presently, the lesion has caused an obvious bulge of theupper lip.

    2.1.Clinical Findings. On examination, a firm ovoid swellingof size 3× 2.5 cm was found on the attached gingiva withrespect to 11 and 12 extending from free marginal grooveinferiorly to the buccal sulcus superiorly (Figure 1). )emarginal gingiva was uninvolved. No ulceration of the skinor the oral mucosa was observed. Silness and Loe plaqueindex was used to assess the plaque status of the patientwhich was 1.2 (fair). Since the lesion presented as a firmpainless well-circumscribed swelling in the anterior gingivaand additionally the patient had a fair Silness and Loe plaqueindex, reactive lesions due to chronic low-grade irritation(dental plaque and food impaction) like peripheral ossifyingfibroma, healing pyogenic granuloma, peripheral giant cellgranuloma, and giant cell fibroma were considered as dif-ferential diagnoses. Also, fibroma and peripheral odonto-genic tumors were considered. Considering the indolentpainless nature of the swelling, malignancies were not in-cluded in the differential diagnoses.)e commonest reactivelesion found more commonly in females, exclusively ingingiva and not in any other oral mucosal location, is pe-ripheral ossifying fibroma. Hence, it was topmost in our listof differential diagnoses. Next, other reactive lesions likehealing pyogenic granuloma, peripheral giant cell granu-loma, and giant cell fibroma were considered. A fibroma ismost common in buccal mucosa, and peripheral odonto-genic tumors are extremely rare in occurrence. Hence, theyboth were considered last in the list of differential diagnoses.

    HindawiCase Reports in DentistryVolume 2018, Article ID 3642827, 5 pageshttps://doi.org/10.1155/2018/3642827

    mailto:[email protected]://orcid.org/0000-0001-8079-1874http://orcid.org/0000-0003-2358-6385https://doi.org/10.1155/2018/3642827

  • 2.2. Radiological Findings. IOPA showed mild alteration inthe trabecular pattern in relation to 11 and 12 (Figure 2).

    2.3. Pathological Findings. With all the above differentialdiagnoses in mind, the tumor was excised under local anes-thesia. )e diagnostic clue of the lesion is “histological ex-amination showed well-circumscribed lobulated mass(Figure 3) of cartilaginous tissue with no cellular atypia, ne-crosis, or vascular invasion. Chondrocytes showed no nuclearpleomorphism or size variation. )ere was no binucleation ormultinucleation (Figure 4)”. Immunohistochemically, most ofthe tumor cells were positive for vimentin and S100 protein(Figures 5 and 6). For academic interest, toluidine blue stainingwas done, which showed typical metachromatism (Figure 7).)e lesion was diagnosed as a chondroma of the gingiva.

    3. Discussion

    Chondroma is a benign tumor composed of mature hyalinecartilage. Most commonly, chondromas are centrally locatedin bone and such tumors are called enchondromas. Lessoften they are distinctly eccentric and cause the overlyingperiosteum to bulge. )is type has been called periostealchondroma [7]. Extraskeletal chondromas occur in threevariants: articular, paraarticular, and soft-tissue chondromas[8]. When chondroma arises from soft tissue without at-tachment to the underlying bone, it is known as soft-tissuechondroma or chondroma of soft parts. Soft-tissue chon-droma was first described by Baumuller in 1883, and sincethen, around 200 cases have been reported in the worldliterature. )ey commonly arise as painless slow-growingswelling in the extremities, especially in the hands and feet. Itcan also be seen in the dura, larynx, pharynx, oral cavity,skin, parotid gland, and fallopian tube [9].

    Soft-tissue chondroma of the oral cavity is uncommon;very few [2–6] cases have been reported in the English lit-erature. )e tongue is the most common site for soft-tissuechondroma followed by the buccal mucosa, hard palate,gingiva, soft palate, and lips. Patients’ age ranged from 3 to 79years old (average 36.4 years old) [3]. )ere is a femalepreponderance.)e lesion has a slow and indolent course andoccasionally is present for many years [10]. )e mean diseaseduration was 6.86 years [3]. Lesions range from 1.5mm to45mm (average 14.7mm) in size. Clinically, the lesion ap-pears as a solitary, firm, slow-growing, and painless mass [11].

    Radiograph of soft-tissue chondroma in general mayshow an unmineralised soft-tissue mass or a soft-tissue masswith calcification typical of cartilage tumors [7]. Calcifica-tions are seen in 33% to 70% of soft-tissue chondromas.Often, the densest calcification is in the center of the tumormass [1]. )e bones around the lesion are rarely affected.)ebest radiologic modality is MRI, as it can define the extent,the contour, the shape, and the intensity of the tumor inaddition to its relation to the surrounding structures andcalcifications, if any [12]. Although Chung and Enzingerreported that the tumor never involved the underlyingbones, compression deformity, bone remodeling, bone

    Figure 1: Intraoral view of lesion in anterior maxillary region.

    Figure 2: Intraoral periapical radiograph showing mild alterationin the trabecular pattern in relation to 11 and 12.

    Figure 3: Photomicrograph showing lobulated mass of cartilagi-nous tissue (H&E, 10x).

    2 Case Reports in Dentistry

  • erosion, or bone sclerosis due to the soft-tissue tumor havealso been reported [1].

    Grossly, chondromas of soft tissues are well encapsulatedwith lobular architecture. Biopsy frequently reveals a benignlobulated cartilaginous tumor composed of mature hyalinecartilage, with remarkable cellularity and prominent calcifi-cation [13]. Within the chondroid lobules, chondrocytes arein lacunae and have a tendency to cluster with large amountsof intervening chondroid matrix.)is clustering arrangementis typical of soft-tissue chondromas and synovial chon-dromatosis but is not unique to them [7].)e external borderof the tumor is usually well delineated from the adjacenttissues. )e chondrocytes are located in rounded spaces andhave usually single nucleus. )e tumor can demonstratemarked cellularity, binucleated cells, and mitoses [14]. )esefindings may lead to the misdiagnosis of chondrosarcoma;however, the location and characteristic clustering arrange-ment should lead to a correct diagnosis. Chunky or powdery

    calcification is typical of soft-tissue chondroma. It may befocal or involve the lesion diffusely [7]. It is necessary todifferentiate other soft-tissue tumors from chondroma, espe-cially in the presence of calcification. It is also important tomakea differential diagnosis that considers malignancies. Fibrosis,myxoid content, and occasionally, hemorrhage are also seen insoft-tissue chondromas. Less frequently, there are granuloma-tous reactions and giant cells. Necrosis is rather rare [1].

    Immunohistochemically, the tumor cells are positive forvimentin and S100 and negative for epithelial and myoe-pithelial markers [9]. )e present case showed positivity forS100 and vimentin (Figures 5 and 6).

    3.1. ToluidineBlue Stain. Majority of the dyes stain tissues indiffering degrees of intensity of the same color; however,certain tissue components, which in the presence of certainbasic dyes, will stain a color other than that of the originalcolor of the dye. Such staining reaction is known as met-achromasia, and the dyes exhibiting metachromatic prop-erties are known as metachromatic dyes. Toluidine bluestains tissues based on the principle of metachromasia. It is

    Figure 6: Immunostaining showing positivity for S100 (H&E, 10x).

    Figure 7: Toluidine blue staining showing typical metachromasiaof cartilage.

    Figure 4: Photomicrograph showing no cellular atypia (H&E, 40x).

    Figure 5: Immunostaining showing positivity for vimentin (H&E,10x).

    Case Reports in Dentistry 3

  • a basic, metachromatic dye with high affinity for acidic tissuecomponents, thereby staining tissues rich in DNA and RNA.It is used to highlight the principal tissue components thatexhibit metachromasia like mucin, cartilage, and mast cellgranules. Attached to DNA or RNA, in chromatin or Nisslsubstance, this dye appears blue (the original color of thedye). Attached to glycosaminoglycans, in mast cell granulesor cartilage matrix, the dye displays a purple metachromaticcolor [15]. In our case also, the nucleus has taken blue colorand the matrix of the cartilage has taken purple colordemonstrating the principle of metachromasia which is thecharacteristic of a cartilage (Figure 7).

    3.2. )eories of Soft-Tissue Chondroma. )ere are severaltheories explaining the origin of soft-tissue chondromas ofhead and neck. Sood et al. concluded that they arise due tometaplastic change from the adipose tissue. Dahlin and Sal-vador suggested a synovial origin. While Uehara, Rosenfeld,Kurzer, and Becker postulated that they arise due to the ac-tivation of heterotopic cartilaginous tissue [2]. Several authorshave proposed various histogenetic theories to explain theorigin of cartilage in the soft tissues of the oral cavity, but theexact cause of such cartilaginous masses is unknown [3, 16].

    (1) Embryonal theory: according to this theory, cartilageis developed from the heterotopic fetal cartilaginousremnants.

    (2) Metaplastic theory: According to this theory ofhistogenesis, development from the pluripotentmesenchymal cells is presumed either de novo orstimulated by some type of trauma, irritation, orchronic inflammation. In the present case, theprobable cause of origin of the tumor could be due tometaplasia arising out of chronic irritation and in-flammation triggered by plaque. Hence, it is in ac-cordance with metaplastic theory.

    According to Kho and Chen, there are reports ofmultiple soft-tissue chondromas as a result of an autosomal-dominant inheritance. Recently, nonrandom clonal changesof chromosomes 6, 11, and 12 have been implicated in theetiology of soft-tissue chondroma [13].

    4. Conclusion

    Soft-tissue chondromas are characterized by benign clinicalbehaviour. Surgical excision is the treatment of choice [3].Once excised adequately, would rarely recur. )us, recurrenceis not exceptional [11]. )ey can show worrying radiologic andhistological pictures simulating chondrosarcoma. Positive di-agnosis can only be provided by the histopathological exam-ination. Surgical treatment is the only successful solution, butrecurrence is not uncommon.)e present lesion was removedcompletely. After a 12-month follow-up, there were no signs ofrecurrence and there was no evidence of complications.

    Disclosure

    Dr. Dhana Lakshmi Jeyasivanesan is currently at theDepartment of Oral Pathology, Tamilnadu Government

    Dental College and Hospital, Chennai, India. Dr. ShameenaPazhaningal Mohamed is currently at the Department ofOral Pathology, Government Dental College, )rissur,India. Dr. Deepak Pandiar is currently at the Faculty ofDental Sciences, Institute of Medical Sciences, BanarasHindu University, Varanasi, India.

    Conflicts of Interest

    )e authors declare that there are no conflicts of interestregarding the publication of this article.

    References

    [1] H. T. Hondar Wu, W. Chen, O. Lee, and C. Y. Chang,“Imaging and pathological correlation of soft-tissue chon-droma: a serial five-case study and literature review,” ClinicalImaging, vol. 30, no. 1, pp. 32–36, 2006.

    [2] M. T. Khadim, M. Asif, and Z. Ali, “Extraskeletal soft tissuechondromas of head and neck region,” Annals of PakistanInstitute of Medical Sciences, vol. 7, pp. 42–44, 2011.

    [3] T. Kawanoa, S. Yanamoto, G. Kawasaki, A. Mizuno, S. Fujita,and T. Ikeda, “Soft tissue chondroma of the hard palate: a casereport,” Asian Journal of Oral and Maxillofacial Surgery,vol. 23, no. 2, pp. 92–95, 2011.

    [4] P. Vescovi, M. Meleti, E. Merigo et al., “Soft tissue chondromaof the oral cavity: an extremely rare tumour localized on thehard palate,” Case Reports in Medicine, vol. 2014, Article ID414861, 5 pages, 2014.

    [5] A. Attakkil, V. )orawade, M. Jagade et al., “Chondroma oftongue: a rare case report & review of literature,” InternationalJournal of Otolaryngology and Head & Neck Surgery, vol. 3,no. 6, pp. 359–363, 2014.

    [6] R. Nehete, A. Nehete, S. Singla, and S. Sankalecha, “Soft tissuechondroma of hard palate associated with cleft palate,” IndianJournal of Plastic Surgery, vol. 45, no. 3, pp. 550–552, 2012.

    [7] K. K. Unni and C. Y. Inwards, “Chondroma,” in Dahlins Bonetumors, K. K. Unni, Ed., pp. 22–39, Lippincott Williams andWilkins Publishers, Philadelphia, PA, USA, 6th edition, 2009.

    [8] R. A. Marcial-Seoane, M. A. Marcial-Seoane, E. Ramos, andR. A. Marcial-Rojas, “Extraskeletal chondromas,” Bolet́ın de laAsociación Médica de Puerto Rico, vol. 82, no. 9, pp. 394–402,1990.

    [9] D. Podder, V. Monappa, and P. Shetty, “Soft tissue chon-droma: a rare tumor presenting as a cutaneous nodule,” OurDermatology Online, vol. 6, no. 2, pp. 173–175, 2015.

    [10] J. Falleti, R. De Cecio, A. Mentone et al., “Extraskeletalchondroma of the masseter muscle: a case report with reviewof the literature,” International Journal of Oral and Maxil-lofacial Surgery, vol. 38, no. 8, pp. 895–899, 2009.

    [11] O. Norris and P. Mehra, “Chondroma (cartilaginous chori-stoma) of the tongue: report of a case,” Journal of Oral andMaxillofacial Surgery, vol. 70, no. 3, pp. 643–646, 2012.

    [12] M. Bahnassy and H. Abdul-Khalik, “Soft tissue chondroma:a case report and literature review,” Oman Medical Journal,vol. 24, pp. 296–298, 2009.

    [13] E. A. Gomes, J. J. Saliba, E. P. Junior, G. A. M. Saliba,C. M. D. S. Coelho, and A. C. D. M. Almeida, “Soft tissuechondroma case report and review of the literature,” RevistaBrasileira de Cirurgia Plástica (RBCP)–Brazilian Journal ofPlastic Surgery, vol. 30, no. 3, pp. 477–481, 2015.

    [14] M. Smida, W. Abdenaji, W. Douira-Khomsi, N. Nessib,I. Bellagha, and M. B. Ghachem, “Childhood soft tissue

    4 Case Reports in Dentistry

  • chondroma. Two cases report,” La tunisie Medicale, vol. 89,no. 4, pp. 379–382, 2011.

    [15] G. Sridharan and A. A. Shankar, “Toluidine blue: a review ofits chemistry and clinical utility,” Journal of Oral and Max-illofacial Pathology, vol. 16, no. 2, pp. 251–255, 2012.

    [16] R. Batra, “)e pathogenesis of oral choristomas,” Journal ofOral and Maxillofacial Surgery, Medicine, and Pathology,vol. 24, no. 2, pp. 110–114, 2012.

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