Based on the histopathological report (Figure 2), the patient underwent a wide local excision under general anesthesia and the specimen was subjected to histopathological examination. The size of the lesion had increased to 4x3x2 cm and had become exophytic in nature (Figure 3), meaning that the lesion had undergone some changes after incisional biopsy which prompted to be an aggressive lesion. On histopathological examination of the excisional biopsy specimen, the section showed tissue lined by stratified squamous epithelium, and the subepithelium showed nodules of proliferating cells. Individual cells are spindle shaped with vesicular nuclei, clear to eosinophilic cytoplasm. Background showed fibromyxoid stroma. Mild increase in mitotic activity seen. Few bony spicules & normal salivary gland also noted. The overall picture was suggestive of “reparative fibromyxoid proliferation”.

Wide local excision of lesion was done (Figure 4) followed by closure with vicryl 3-0 (Figure 5). The patient showed no signs of recurrence in 10 months follow up.

DISCUSSION

While there are no universally accepted treatment recommendations for the management of fibromyxoma, it is important to consider the aggressive nature of this neoplasm in patient management decisions. Although the recommended treatment is usually surgical excision, approaches differ depending on the size of tumor and include conservative surgical excision, enucleation and curettage, curettage with and without electrical or chemical cautery, en bloc resection and wide resection with and without bone grafting.  Recurrence rates between 25% and as high as 43% are reported for gnathic fibromyxomas [6]. This is strongly related to the nature of the lesion, presenting without a sheath, thus making the complete removal difficult In some studies, a high rate of recurrence is documented after conservative therapy. This is attributed to the incomplete removal of the lesion rather than the intrinsic biological behavior of the lesion [7]. Due to the tumor’s local aggressive biological behavior and high potential for recurrence, wide surgical resection is recommended. Radiotherapy is generally agreed to be ineffective in the treatment of fibromyxoma [8].

Myxomas/fibromyxomas are usually located intraorally most often in the posterior regions of the mandible, its angle and ramus and rarely extraorally [9]. The maxilla and anterior region of the mandible are rarely affected. The lesion can be diffused or well defined, uni- or multilocular. It is characterized by a mucous or gelatinous grayish-white tissue that replaces the spongy bone and displaces the cortical plates of the jaws. Root displacement and resorption may be present. It may refer to hard and also to soft tissues.

Previous theories stress that the lesion derives from the neural sheath or is the result of degeneration of fibromas, lipomas and so forth, due to the chronic irritation and the degenerative processes following tissue anoxemia. Recent studies advocate that myxomas/fibromyxomas arise from the mesenchymatous tissue of the dental follicle, thus being described as odontogenic with fibroblasts playing the major role in cell dispersal [10]. This explanation fails to describe soft tissue myxomas. They probably arise from supportive structures of the teeth like the gingiva and the periodontal ligament.

CONCLUSION

In conclusion, fibromyxoma is a rare neoplasm. The radiological examination by means of CT and MRI plays an important role in the diagnosis of a fibromyxoma and in the differential diagnosis from other pathological entities such as the ameloblastoma. Its management is surgical and ranges from enucleation and curettage to complete resection and peripheral osteotomy according to its size. Patients must be monitored for at least two years postoperatively in order to diagnose possible recurrence.

CONFLICT OF INTEREST

There is no conflict of interest.

ACKNOWLEDGEMENT

All authors have viewed and agreed to the submission.

PATIENT CONSENT

Patient consent has been obtained for photograph.