European Journal of Cardiovascular Medicine

Face...the identity of a Person, The beauty of a Person....Face, the most powerful part for communication and expression. It is part of body which we care the most. Lesions of face include lesions of skin,scalp,facial bones,eye,nose,ear,salivary and oral cavity. These lesions are noticed in early stage being the most exposed part of body. These lesions are also very painful because of the cosmetic value. They could be neoplastic or non-neoplastic. The diagnostic test for these lesions must be the one which is minimally invasive, accurate and rapid. In such scenario, cytology plays very important role to decide nature of lesion whether it is infective, benign or malignant. It uses a small needle to gather cells and give us clue for deciding line of management. It confirms the clinically and radiologically suspected diagnosis. In this view, we are presenting series of few lesions which were diagnosed on FNAC with the aim to study role of FNAC in Face lesions

We evaluated total 15 face lesions in this duration. Face included forehead, facial bones, eye, lacrimal gland, nose, cheek, lips and salivary gland. Majority were female with peak age 45 years. Lesions varied from inflammatory cystic lesions, benign and malignant. Lesions included 4 epidermal cyst,1 sialoadenitis,5 pleomorphic adenoma,2 squamous cell carcinoma,1 solitary fibrous tumor,1giant cell tumor of mandible and 1 case of metastasis of follicular carcinoma thyroid in facial bone and orbit.

(Table 1)

Table 1 showing characteristics of the study samples (N=15)

FNAC is a fast and simple diagnostic procedure with high level of sensitivity and specificity for mass lesions. We studied 15 cases of Face lesions with clinical suspicion of infective to malignant. FNAC is advised before biopsy to have diagnostic clue. It guides regarding plan of surgical. procedure. It also helps in staging of malignancy also by guiding lymph node status. At times,in cystic lesions ,it can become therapeutic procedure also.

Out of these15 cases, we are discussing 4 interesting rare cases here in which FNAC was really helpful.

Case 1: Solitary fibrous tumour

Case 1: 27-year female came with complaint of slowly growing swelling in the medial canthus of left eye for 2 years. She also complains of epiphora i.e. watering from eyes for 6 months. No history of local trauma. On examination, it was soft, non-tender swelling. Based on clinical finding, the diagnosis was lacrimal sac tumor . Invesigations were advised. CT: Large 25X28mm well defined isodense mass lesion in left nasolacrimal fossa causing mild compression of left nasal bone and inferomedial aspect of left Globe. Suggestive of mucocele, D/D Neoplasm of Lacrimal Sac. FNAC was done. Smears were paucicellular showing spindle shaped cells with bland chromatin. Features were suggestive of Benign Mesenchymal Neoplasm. Typing of tumor on cytology was not possible. So histopathology was advised. Wide local excision was done and sample was received in histopathology section.It was well capsulated globular mass with firm grayish white surface on cut section. On histopathology, capsulated tumor having haphazardly arranged tumor cells with hypo and hypercellular areas were seen with focal hemangiopericytoma like areas. Mitosis was not evident. In a section, lacrimal gland lining of stratified columnar epithelium was also seen. Histopathology diagnosis of Benign Spindle cell tumor was given. Immunohistochemistry (IHC) was advised. On IHC, VIMENTIN and S100 were negative and CD34 and STAT6 were positive. So final diagnosis of Solitary Fibrous Tumor was given. Follow up after 6 months was done and there was no recurrence.

Discussion: Solitary fibrous tumour (SFT) is a fibroblastic tumor classified as an intermediate (rarely metastasizing) tumor according to World Health Organization Classification of Tumors of Soft tissue and Bone, 5th edition. It is characterized by a prominent, branching, thin-walled, dilated (staghorn)vasculature and NAB2-STAT6 gene rearrangement. Uptil now, 90 cases of orbital SFTs have been reported [1]. SFTs can be found anywhere in the orbit, but they are rarely described in the lacrimal gland. Only 15 such cases of SFT in the lacrimal gland and lacrimal gland fossa have been reported [2].

Histopathology reveals well-circumscribed lesions with proliferation of round, fusiform, or spindle cells in a number of different patterns, usually with little atypia or mitotic activity. Immunohistochemical staining shows positivity for CD34, CD99, Bcl-2, and epithelial membrane antigen, but these are not specific for SFTs and can be found in other tumors. STAT6 has been found to be a more specific marker for SFTs [3] STAT6 IHC stain has emerged as a useful surrogate marker of NAB2-STAT6 gene fusion with excellent sensitivity and specificity [4].

Case 2: Metastases thyroid profile

Case 2- 42-year male complained of right preauricular swelling since 6 months. There was no other complaint. On examination, it was firm, non-mobile, non-tender swelling of 3x4 cm. Radiological investigations were done. CT-Heterogenously enhancing soft tissue lesion over temporomandibular joint with significant bony erosion and destruction is seen in adjacent portion of medial cranial fossa. Infiltration in right pterygoid, right masseter also seen. Lesion is extending intracranially with extradural compartment with thickness measuring 4mm.Suggestive of Infective/Neoplastic lesion. FNAC was performed. Smears shown abundant cellularity comprising of round, oval, spindle cells with bland chromatin dispersed singly and attached to fibrovascular fragment. Plenty osteoclastic giant cells, few pigment laden macrophages were also seen suggesting diagnosis of Giant Cell Tumor(GCT) of Temporomandibular Joint .It was confirmed on histopathology. Serum calcium and alkaline phosphatase levels were found to be normal. So, hyperparathyroidism was ruled out.

Discussion: GCTs are usually benign but have been known to be locally aggressive and occasionally metastasize, especially to the lung. Very rarely, GCTs may turn into sarcoma. GCT is a neoplasm of stromal-like neoplastic cells that are able to recruit macrophage and multinucleate osteoclast like giant cells. This lesion constitutes 5% of all primary bone tumors. The frequency of occurrence is 25% in the epiphyses of long bones and 2% in the craniofacial bones [5]. Craniofacial bone involvement has been reported to occur in the mandible, temporal bone, maxilla, occipital and sphenoid [6]. Differential diagnoses of GCTs are osseous lesions that are giant cell rich. It is important to consider lesions such as giant cell reparative granuloma, hyperparathyroidism, non-ossifying fibroma, chondroblastoma, solid areasof aneurysmal bone cyst, malignant fibrous histiocytoma and osteogenic sarcoma. Total removal without adjuvant radiotherapy for the treatment of cranial GCTs is effective for local treatment of disease [7].

Case 3. Giant cell tumour

Case3-

50 years female complain of swelling over temporal aspect of right orbit since 3months.There was congestion in the right eye along with proptosis of eyeball for which she visited the hospital. On examination, swelling was diffuse 4x5 cm,soft to firm. Radiology investigations were carried out.CT-Heterogenously enhancing bony lytic lesion with extensive soft tissue component measuring 6x5x5 cm epicentered in right temporal fossa .It is associated with significant bony destruction of frontal bone on right side, right Squamous temporal bone, right zygomatic process, right greater wing of sphenoid, apex roof and posterolateral wall of right orbit. Similar expansile lytic lesion seen involving greater wing of sphenoid measuring 2x3x2 cm on left side also without soft tissue component. Suggestive of Malignant Neoplastic etiology-Metastasis from unknown Primary. FNAC from temporal swelling was done which showed follicular cells arranged in repetitive microfollicular pattern. Detailed history of patient was asked for primary. Patient was radiologically investigated for primary and solid cystic nodule of 2x2x1 was found in left lobe of thyroid. Thyroid was aspirated under USG guidance. Cytology was showing similar morphology as in subcutaneous nodule. So final diagnosis of Metastasis of Follicular Carcinoma in soft tissue was given. Patient was not willing for operation. So discharge against medical advice was given.

Discussion: Thyroid cancers are having four major histological subtypes, papillary, follicular, medullary, and anaplastic. The most common is papillary thyroid cancer (PTC) followed by follicular thyroid cancer (FTC). Together, papillary and follicular cancers are termed as differentiated thyroid cancer (DTC)which is 90% of all thyroid cancers. Despite an overall excellent prognosis in patients of DTC, 5-23% of patients have distant metastasis, which confers them relatively poor prognosis in spite of adequate treatment [7].

FTC is a malignant neoplasm of the follicular cells. The most common mutation is RAS point mutation. There is an estimated 6-20% incidence of distant metastasis with follicular thyroid carcinoma. Metastasis to the bone occurred at 42%, followed by the lungs at 33%, and then to the lymph nodes at 8% [8]. Bone metastases from FTC are more often to the long bones, such as the femur and flat bones, particularly the pelvis and sternum. Skull metastasis from extremely rare, accounting for 2.5% of all bone metastasis, the majority of skull metastasis from thyroid cancers is of the FTC, followed by PTC [7]. Management of metastatic follicular thyroid carcinoma is done with surgery and radioiodine ablation.[8]

Case 4: Pleomorphic adenoma

Case4-

72-year male complain of swelling over mucosal surface of upper lip for 6 months. On examination it was2x2 cm soft to firm, pinkish intraoral mass. CT-Enhancing mass of 3x3 cm in upper lip region with erosion of maxillary bone posteriorly, suggestive of Neoplastic etiology.FNAC was perfomed. Smears revealed classical fibrillary chondromyxoid stroma alongwith plenty myoepithelial cells, plasmacytoid cells, suggesting the diagnosis of Pleomorphic Adenoma (PA). The diagnosis was confirmed on histopathology.

Discussion: Oral cavity lesions are mostly squamous epithelial origin or mesenchymal origin.Minor salivary gland tumor are seen very less in number. Pleomorphic adenoma (PA) is the most frequent benign salivary gland neoplasm, occurring most frequently in the parotid gland among the major salivary glands and in the palatine gland among the minor salivary glands. The occurrence of a PA in a lip is rare.[9] Histologically it is a complex tumor showing epithelial and myoepithelial cells in mucopolysacchride stroma. Mesechymal cells are myxoid, cartilaginous. PAs, especially of the lips, tend to be left untreated for a relatively long period of time before medical attention is sought, because they develop slowly and are rarely accompanied by ulceration or pain. The clinical differential diagnosis of swelling of the lip includes cystic diseases (e.g., mucocele, dermoid cyst, epidermoid cyst), benign tumors (e.g., fibroma, hemangioma, lipoma, schwannoma), and malignant tumors [e.g., squamous cell carcinoma (SCC), mucoepidermoid carcinoma, adenoid cystic carcinoma]. Differential diagnosis of PA in the upper lip is canalicular adenoma and it preferentially occurs in the upper lip.[9] Canalicular adenoma lacks chondroid or myxoid matrix, distinguishing it from PA. Histologically, canalicular adenomas differ from PA by showing tumor cell beading and intraluminal squamous balls or morules.[10] The best treatment modality is complete wide surgical excision. However, PA can recur after several years of surgical excision.In addition, the transformation to the malignant state is possible, and thus long‑term follow‑up is must.

FNAC is very useful procedure in face lesions because of easy accessibility of target sites and minimally invasive procedure. Being inexpensive, safe, outdoor procedure, rapid reportability and repeatability of procedure make it a investigation of choice in facial lesions. Early diagnosis of nature of lesion help to decide line of management as early as possible. Use of cell block technique wherever needed extend its utility in IHC also for typing of tumor .

1. Shen J, Li H, Feng S, Cui H. Orbital solitary fibrous tumor: a clinicopathologic study from a Chinese tertiary hospital with a literature review. Cancer Manag Res. 2018;10:1069–78
2. Gheorghisan-Galateanu et al. Cystic appearance - a new feature of solid fibrous tumours in the lacrimal gland: a case report with literature review.Diagnostic Pathology (2019) 14:63
3. Alomi O. Parikh et al , Bilobed flap reconstruction after en-bloc removal of solitary fibrous tumor of the lacrimal sacAmerican Journal of Ophthalmology Case Reports 30 (2023) 101835
4. Tariq et al. The many faces of solitary fibrous tumor;diversity of histological features, differential diagnosis and role of molecular studies andsurrogate markers in avoiding misdiagnosisand predicting the behavior Diagnostic Pathology (2021) 16:32
5. G V V Giri, Gheena Sukumaran, C Ravindran, Malathi Narasimman Giant cell tumor of the mandible, Journal of Oral and Maxillofacial Pathology Vol. 19 Issue 1 Jan - Apr 2015
6. Elias Boutros, Dr. Mohamed Sabe-Alarab,Dr. Fawaz Jaber, Dr. Jehad Kharfan, Giant cell tumors in temporomandibular joint region involving lateral skull base: A literature review, International Journal of Medical and Health Research,Volume 4; Issue 2; February 2018;
7. Jun Shen et al,Case Report Skull metastasis from follicular thyroid carcinoma: report of three cases and review of literature; Int J Clin Exp Pathol 2015;8(11):15285-15293
8. Yang C M (August 30, 2022) Metastasis of Follicular Thyroid Carcinoma to Skull Base: A Case Report. Cureus 14(8):
9. Koki Umemori1 et al,Lip pleomorphic adenomas: case series and literature review Gland Surg 2022;11(10):1730-1740
10. Taiwo, et al.,Pleomorphic adenoma of the upper lip: A case report. Saudi J Med Med Sci 2018;6:32-5.