Verruciform xanthoma--biological profile of 282 oral lesions based on a literature survey with nine new cases from Japan

Verruciformes Xanthom an der linken Wange bei einer 56-jährigen Patientin – Diagnostik, Therapie und Nachsorge

The oral verruciform xanthoma (OVX) is a rare, benign lesion that occurs predominantly in the masticatory region of the oral cavity. The OVX is small, slow growing, and mostly free of clinical symptoms. The exact pathogenesis is unknown, and a viral etiology such as from a human papillomavirus (HPV) infection has not been proven. Although primarily observed in healthy individuals, there have been cases in patients with autoimmune diseases and with chronic graft-versus-host disease (GvHD). The treatment of choice is complete excision of the lesion. This case report showcases a successful surgical removal of an oral verruciform xanthoma on the left buccal mucosa in a 56-year-old patient with GvHD 14 years after allo-genic stem cell transplantation due to a Non-Hodgkin lymphoma.

Disparities in dermatology AI performance on a diverse, curated clinical image set

An estimated 3 billion people lack access to dermatological care globally. Artificial intelligence (AI) may aid in triaging skin diseases and identifying malignancies. However, most AI models have not been assessed on images of diverse skin tones or uncommon diseases. Thus, we created the Diverse Dermatology Images (DDI) dataset-the first publicly available, expertly curated, and pathologically confirmed image dataset with diverse skin tones. We show that state-of-the-art dermatology AI models exhibit substantial limitations on the DDI dataset, particularly on dark skin tones and uncommon diseases. We find that dermatologists, who often label AI datasets, also perform worse on images of dark skin tones and uncommon diseases. Fine-tuning AI models on the DDI images closes the performance gap between light and dark skin tones. These findings identify important weaknesses and biases in dermatology AI that should be addressed for reliable application to diverse patients and diseases.

Genital verruciform xanthoma: lessons from a contemporary multi-institutional series

AIMS

Verruciform xanthoma (VX) is an uncommon lesion, seen in the oral mucosa and rarely occurring at cutaneous genital sites. Reports of exceptional VX presentations dominate the literature; herein, we assess the clinical and histological features of a cohort of routine, consecutive cases.

METHODS AND RESULTS

Clinicopathological features of genital VXs from four academic centres were reviewed. A cohort of 25 lesions from 24 patients (22 male, two female; median age = 62 years), occurred on the scrotum (84%), penis (8%) and perineum/vulva (8%). VX was never suspected clinically; considerations ranged from fibroepithelial polyps to squamous cell carcinoma. Classic diagnostic criteria were present at least focally in each lesion, including verrucous architecture, prominent wedge-shaped parakeratosis extending between exophytic epidermal projections and neutrophils in the stratum corneum. Xanthomatous cells were present in all cases, but scattered to rare in 24%.

CONCLUSIONS

Consecutive genital VXs reliably exhibited classic histopathological features, although the essential finding of xanthomatous cells may be scarce. Our comparison to meta-analyses of published cases found relatively fewer penile and vulvar examples. Additionally, the median age was older than in published series, which have emphasised syndromic associations.

Oral verruciform xanthoma in chronic graft-versus-host disease patients

BACKGROUND

Verruciform xanthoma (VX) is an uncommon benign epithelial lesion which mainly appears in inflamed oral epithelium. In this study, our aim was to present new cases of oral VX (OVX) in chronic graft-versus-host disease (cGVHD) and review the literature.

METHODS

We conducted a retrospective chart review of cGVHD patients (2012-2019) to reveal cases of OVX. The demographics, medical background, clinical presentation, treatment provided, and follow-up were obtained. Additionally, Medline was searched using the terms "graft-versus-host disease," "verruciform xanthoma," and "oral." Of the articles, the above-mentioned demographic and clinical features were retrieved.

RESULTS

The patient pool included 133 oral cGVHD patients. Three cGVHD patients (males, aged 15-49 years, post-hematologic malignancy) were diagnosed with OVX. All patients had oral mucosal lichenoid lesions, but not in close proximity to the VX lesion. Medline searches revealed 9 cases of OVX in cGVHD patients reported in the literature. Eleven of the 12 patients had oral mucosal lichenoid lesions. Four patients had multiple OVX lesions. All lesions were asymptomatic. Six patients had lesions in the masticatory mucosa (hard palate and gingiva) and 4 patients had lesions in the buccal mucosa.

CONCLUSIONS

To the best of our knowledge, this is the largest published OVX in cGVHD series, including 12 patients. It appears that despite the higher prevalence in cGVHD patients relative to the general population, OVXs do not necessarily develop in sites with lichenoid lesions. It is advised that clinicians be familiar with the clinical and histological features in order to consider OVX in the differential diagnosis of oral lesions in cGVHD patients.

Oral Verruciform Xanthoma: A Series of 212 Cases and Review of the Literature

Verruciform xanthoma (VX) of the oral cavity is an uncommon, reactive lesion of unknown etiology. In this study, we present a large series of VX with analysis of demographics, clinical appearance, histologic presentation and extensive review of literature. To the best of our knowledge, this is the largest series of oral VX reported to date. Following IRB approval, all cases diagnosed as VX found in the archives of the University of Florida Oral Pathology Biopsy Service (1994-2018) were included. Patient age, gender, location, clinical appearance, clinical impression, and duration of each lesion was collected. A total of 212 cases were included in our database with a mean age of 61 years (range of 9-94), and a female: male ratio of 1.06:1. The most common location in descending order was the gingiva (n = 110, 51.2%), followed by palate (n = 41, 19.3%), buccal mucosa (n = 18, 8.5%), tongue (n = 20, 9.4%), vestibule (n = 13, 6.1%), lip (n = 4, 1.9%), floor of mouth (n = 3, 1.4%), and unspecified (n = 1, 0.5%). The lesions were most frequently pink in color, and most often described as bumpy, rough, verrucoid and/or papillary. Clinical impression in descending order was papillary (n = 67, 31.6%), not specified or unknown (n = 41, 19.3%), hyperkeratosis (n = 24, 11.3%), fibroma (n = 20, 9.4%), leukoplakia (n = 17, 8.0%), dysplastic lesion (n = 13, 6.1%), pyogenic granuloma (n = 7, 3.3%), granulomatous reaction (n = 5, 2.4%), lichen planus, VX (n = 4 each, 2.0%), pigmented, other lesions (n = 3 each, 1.4%), and salivary and periapical lesions (n = 2 each, 0.9%). Three of the lesions were recurrences. The demographics and clinical parameters of this case series were in concordance with that of previously published reports. In our series, only 4 cases were suspected as VX, demonstrating the lack of familiarity clinicians have with this lesion.

Verruciform xanthoma accompanying a cystic growth: A case report

Verruciform xanthoma, an uncommon, benign lesion with characteristic histopathological features, usually develops on the oral mucosa or genital area. We present an unusual case of verruciform xanthoma observed on the inguinal skin of a 52-year-old healthy man along with an underlying cystic component. The superficial lesion was a pedunculated nodule with a fissured surface and an 18-mm mound-like pigmented tumor underneath it. The histopathologically deep lesion was continuously attached to the superficial lesion. It was composed of fistula or sinus-like spaces and covered with acanthotic epithelium. The epidermis and upper dermis of both lesions showed identical histopathological findings: varying degrees of acanthosis, elongation of rete ridges, eosinophilic parakeratotic layer extending toward the dermis, and densely infiltrating foam cells confined to the papillary layer of the dermis. This finding of a cystic component in the deep dermis expands the histopathologic features of verruciform xanthoma.

Identification of NSDHL mutations associated with CHILD syndrome in oral verruciform xanthoma

OBJECTIVE

The aim of this study was to perform a systematic analysis of the nicotinamide adenine dinucleotide phosphate (NAD[P])-dependent steroid dehydrogenase-like (NSDHL) gene in cases of oral verruciform xanthoma (VX) and to test for the presence of mutations associated with congenital hemidysplasia with ichthyosiform nevus and limb defects (CHILD) syndrome.

STUDY DESIGN

DNA was extracted from archived paraffin-embedded tissue of oral VX and control cases. Polymerase chain reaction (PCR) was then used to screen exons 4 and 6 of the NSDHL gene for the presence of 4 known germline mutations associated with CHILD syndrome and 1 somatic mutation previously identified in VX lesions with no known association with CHILD syndrome.

RESULTS

Of the 16 oral VX tissue samples, 8 (50%) had known missense mutations associated with CHILD syndrome. Furthermore, 2 of these 8 tissue samples also had an additional missense mutation previously identified in cutaneous VX lesions. No mutations of exons 4 and 6 were found in the 5 negative control tissue samples.

CONCLUSIONS

NSDHL gene mutations associated with CHILD syndrome are common in sporadic oral VX cases, suggesting that these mutations confer a greater risk for the development of epithelial barrier defects that promote recurrent oral VX lesions and the potential for direct germline transmission of oral VX susceptibility.

Verruciform Xanthoma of the Oral Mucosa: A Series of Eight Typical and Three Anomalous Cases

In this series, there are 8 typical verruciform xanthomas of the oral mucosa and 3 anomalies, 1 polypoid, 1 florid, and 1 carcinomatous. All were characterized by infiltrates of CD68-positive xanthomatous histiocytes in the lamina propria. The 11 patients comprised 6 men and 5 women (mean age = 54.5 years, range = 40-69). Both keratinized and nonkeratinized sites were affected. A history of lichenoid inflammation was recorded in 5 patients. The polypoid xanthoma presented in a woman aged 54 years as a polyp of the labial commissure. The florid lesion affected the dorsum of the tongue of a man aged 54 years and at 20 mm was the largest of the 11 lesions, but the only one with candidal infection. The squamous cell carcinoma manifested as a papilloverrucous hyperkeratosis of the palatal gingiva in a man aged 69 years. The latter 2 (and 1 "typical" verruciform xanthoma) required re-excision, but none has since recurred.

A Guide to Yellow Oral Mucosal Entities: Etiology and Pathology

When faced with an uncertain clinical pathosis in the oral cavity, identifying the color of the mucosal lesion helps to narrow down a differential diagnosis. Although less common than red and white lesions, yellow lesions encompass a small group of distinct mucosal pathologic entities. Adipose tissue, lymphoid tissue, and sebaceous glands are naturally occurring yellow constituents of the oral cavity and become apparent with associated developmental or neoplastic lesions. Reactive and inflammatory lesions can create a yellow hue due to purulence, necrosis, and calcification. Some systemic diseases are known to deposit yellow bi-products such as amyloid or bilirubin into the oral mucosa of an affected person, and while not always yellow, unusual entities like verruciform xanthoma and granular cell tumor fall under the umbrella of yellow lesions given their occasional propensity to demonstration the color. This chapter aims to explore the unique group that is yellow lesions presenting in the oral mucosa.

Oral Verruciform Xanthoma of lateral border of tongue - a sheep in wolf's clothing

Oral Verruciform Xanthoma (OVX) is an uncommon benign lesion of the oral cavity. Most authors consider it to develop as a response to chronic local irritation. It usually presents as a pink, yellow or greyish flat mass occurring on the gingiva, alveolar ridge or hard palate. This paper reports to you the management of a case of Oral Verruciform Xanthoma occurring on the latero-ventral border of the tongue in a young male patient, which is a rare location for this lesion. It goes on to discuss the etiopathogenesis and clinical features of this rare lesion and emphasizes the importance of having a broad knowledge of oral pathologic lesions especially for lesions that resemble malignant or pre-malignant pathologies in the oral cavity.

Verruciform Xanthoma with Equivocal Exfoliative Cytological Diagnosis

Verruciform xanthoma (VX), a papillary or wart-like lesion of the mucosa, is histopathologically characterized by papillary projection of the epithelium and an aggregation of foam cells in the lamina propria. Here, we describe a case of VX in the posterior mandibular gingiva, initially suspected to be a benign lesion based on clinical findings and cytology prior to an excisional biopsy. The patient was a 62-year-old man who had visited a local dentist approximately 1 year earlier, presenting with a white lesion in the left posterior mandibular gingiva that resisted removal by scraping. The lesion was left untreated as there were no subjective symptoms. Thereafter, the surface of the lesion roughened and the patient was referred to our department for a comprehensive examination. A circumscribed, granular mass, 15-mm in diameter, with a red and white surface was observed in the left posterior mandibular buccal gingiva. Exfoliative cytology was performed. The diagnosis was a class III lesion. Excisional biopsy was performed under local anesthesia. Histopathological examination led to a diagnosis of VX. At 1 year postoperatively, the patient is making satisfactory progress without recurrence. Verruciform xanthoma is difficult to diagnose preoperatively, and is commonly resected under a clinical diagnosis of papilloma or benign tumor. A benign lesion was also initially suspected in the present case and cytological analysis performed to confirm absence of malignancy. The lesion could not be diagnosed as VX preoperatively. Verruciform xanthoma can be over-diagnosed based solely on cytological examination because it often involves cellular atypia reflecting its characteristic extension of rete pegs and keratinization of surface cells, indicating the need for care in arriving at a definitive diagnosis.

Oral verruciform xanthoma: Report of 13 new cases and review of the literature

BACKGROUND

Oral verruciform xanthoma (OVX) is a rare lesion. The purpose of the present study is to describe the clinical features of 13 OVXs and review all cases reported in the English literature.

MATERIAL AND METHODS

Thirteen cases of OVX diagnosed during a 47-year period were retrospectively collected. The patients gender and age, as well as the main clinical features of the lesions were retrieved from the biopsy request forms. Pubmed, Scopus and Google ScholarTM electronic databases were searched with the key word verruciform xanthoma. Only cases of histologically confirmed OVX were included in the study.

RESULTS

The 13 OVXs represented approximately 0.04% of 35,617 biopsies accessioned during the study period. They affected 13 patients, 8 males and 5 females with a mean age of 48.8±14 years. They mainly appeared as asymptomatic granular nodules or plaques, with elastic or normal consistency and white color, in the gingiva or hard palate. Literature review yielded 416 cases of OVX. With the addition of cases of the present study, 429 cases of OVX have been presented in the English literature. OVX has a slight male predominance with a male to female ratio of 1.4:1 and the majority of patients are in the 5th to 7th decade of life. Clinically, OVX mainly presents as an asymptomatic, single, papillary or granular plaque or nodule, with elastic or soft consistency and white, red or pink color. It measures approximately 1cm and is most commonly located on the gingiva, tongue, hard palate or buccal mucosa. The treatment of choice is surgical excision with little rates of recurrence.

CONCLUSIONS

Verruciform xanthoma is a rare lesion most often encountered on the ginigival mucosa. As its clinical presentation is not pathognomonic, it should be included in the differential diagnosis of verrucous or papillary lesions.

Oral Verruciform Xanthoma within Lichen Planus: A Case Report and Literature Review

Background

Verruciform xanthoma is an uncommon benign tumor, which exhibits a wide range of clinical patterns. The occurrence of the lesion in patients with immune-mediated mucocutaneous diseases may suggest a role of localized epithelial cell damage and chronic inflammation in its pathogenesis.

Case Report

A case of verruciform xanthoma on the tongue of a 56-year-old female with oral lichen planus is reported. An asymptomatic pink-white lesion with a granular surface was observed in the left lateral lingual border, which was closely associated with a white plaque and striae. An incisional biopsy was performed, and histologically, epithelial projections in a verrucous pattern were observed. In the subepithelial connective tissue, aggregates of foamy cells that exhibited immunoreactivity for CD68 were noted. The final diagnosis was verruciform xanthoma. The mucosa adjacent to the lesion demonstrated histopathological features consistent with lichen planus.

Conclusions

A total of twelve cases of oral verruciform xanthomas in patients with oral lichen planus including the present case have been reported in the literature. The clinician should be aware that verruciform xanthoma may mimic malignancy, and therefore, biopsy is required for definitive diagnosis to be established, especially when this tumor develops within conditions that show potential for malignant transformation.

Verruciform Xanthoma of a Lower Lip Lesion: A New Case and Review of the Literature

A non-smoking man in his seventh decade presented with a lesion he had had for about 5 years on the right external surface of the lip 1 mm from the vermilion border. On physical examination, a yellowish-coloured, non-tender, verrucous mass of 0.5 × 0.7 cm was observed. A histopathological examination of the first 3-mm punch biopsy was non-diagnostic. The histopathological evaluation of a second, 5-mm-deep punch biopsy made by a pathology expert in oral lesions revealed a diagnosis of verruciform xanthoma. The key to the diagnosis of verruciform xanthoma is to recognize xanthoma cells. However, these cells may be insufficient in number in small and superficial biopsy material and overlooked by a pathologist especially when lacking knowledge of this uncommon lesion. Verruciform xanthoma of the lower lip at the vermilion border is an extremely rare entity described in 5 cases worldwide to date. We aimed to bring verruciform xanthoma to readers' attention for a differential diagnosis of lower lip diseases and to prevent overdiagnosis and overtreatment of this lesion unfamiliar to otorhinolaryngologists.

Vegas (Verruciform Genital-Associated) Xanthoma: A Comprehensive Literature Review

INTRODUCTION

Verruciform xanthoma is a wart-like benign lesion. The classic histologic appearance consists of foamy histiocytes within elongated dermal papillae and epithelial acanthosis. The lesion most commonly occurs in the oral cavity, but has been reported in extra-oral sites such as the penis, scrotum, and vulva. The clinical and histologic characteristics of verruciform genital-associated (Vegas) xanthomas of the penis, scrotum, and vulva are reviewed.

METHODS

PubMed was used to search the following term: verruciform xanthoma. The relevant papers were obtained and reviewed.

RESULTS

There have been 193 cases of genital-associated verruciform xanthomas. There were 164 in men and 29 in women. Similar to verruciform xanthomas of the oral mucosa, they presented as asymptomatic lesions, demonstrated foam cells in the dermal papillae, and were typically managed successfully with surgical excision.

CONCLUSION

Verruciform xanthoma is a benign lesion characterized by a wart-like growth that is most commonly seen in the oral mucosa. Verruciform xanthomas of the genital region have been coined Vegas xanthomas. Vegas xanthomas have been reported in association with a variety of diseases, as well as in healthy individuals. Biopsy is required for diagnosis, and complete surgical excision is typically curative.

Verruciform xanthoma of the tongue

Verruciform xanthoma is a benign, soft tissue lesion occurring on the orogenital mucosa. Presentation of oral lesions can be pink, yellow, or gray raised plaque or papule with granular, papillary, or verrucous in nature. There are many theories proposed for the etiopathogenesis of verruciform xanthoma. Clinical observations may be misguiding as the lesion resembles malignant and premalignant lesions. Histopathological confirmation is essential for diagnosis and avoiding radical surgery. Once excised, the lesion does not recur. Here, we present a case report of verruciform xanthoma of the tongue in a 50-year-old female patient.

Verruciform xanthoma in the hard palate: a case report and literature review

Oral verruciform xanthoma (OVX) is an uncommon lesion that appears on the oral mucosa. The aim of this paper was to discuss the probable etiopathogenesis of OVX in the hard palate, reinforcing the importance of including this lesion in the differential diagnosis of verrucous lesions. A 43-year-old male smoker presented with a painless lesion with a verrucous surface and erythematous spots on the hard palate. Excisional biopsy revealed oral mucosa consisting of hyperkeratosis, acanthosis, and elongated rete pegs. Subjacent connective tissue showed numerous foam cells with clear cytoplasm and pyknotic nucleus, negative on periodic acid-Schiff staining. Immunohistochemical analysis revealed foam cells positive for anti-CD68 antibody, while anti-KI-67 antibody was restricted to the basal layer of the oral epithelium. A final diagnosis of OVX was established. The patient showed no signs of recurrence after seven months of follow-up. Physical trauma and smoking habits can be directly related to the etiology of verruciform xanthoma because the lesion is chronic and inflammatory with slow growth, and sites if high trauma are more often affected by such a lesion. The hard palate is the second most commonly affected site, and local trauma caused by smoking can be a cause of this type of lesion.

A Case of Verruciform Xanthoma Arising in the Tongue

Verruciform Xanthoma (VX) is a rare lesion of the oral cavity. Histologically, it is characterized by papillary or verrucous proliferation of squamous epithelium and numerous foam cells. VX arising in the tongue is comparatively rare, as most cases of VX in oral cavity occur in gingiva. A 65-year-old woman was referred to our clinic with a mass on the left side of the tongue. The lesion was yellowish, and its surface was granulated. The patient had neither tenderness nor any symptoms. The lesion was clinically diagnosed to be a benign tumor, and hence, biopsy was performed, according to which it was diagnosed as hyperparakeratosis. Based on this diagnosis, the tumor was excised under general anesthesia. Histopathologically, the tumor consisted of stratified squamous epithelium with parakeratosis and elongated rete ridges. Aggregation of foam cells was observed between and under the rete ridges. From these features, a diagnosis of VX was made. The patient has had no local recurrence as of three years post-operatively.

Verruciform xanthoma of the lip: A rarity

Verruciform xanthoma (VX) is an uncommon, benign, asymptomatic mucocutaneous lesion of an unknown etiopathology. It usually presents as a papule or single plaque with a verrucous or a papillomatous surface and pale yellowish to red in color. It occurs primarily on the masticatory mucosa of middle-aged individuals. We report a case of VX on the lip of a 59-year-old man. Histopathologically, VX is diagnosed by the presence of foam cells in the papillary region of the connective tissue. Differentiating a verrucous carcinoma from VX is important, especially in small superficial lesions, which may lead to inappropriate and excessive surgical intervention. Treatment of VX consists of simple surgical excision and recurrence is rare.

Clinicopathological and Immunohistochemical Characteristics of Verruciform Xanthoma of the Lower Gingiva: A Case Report

Verruciform xanthoma (VX) is a rare benign lesion and mainly effects the oral mucosa. This slow-growing asymptomatic lesion typically develops along the gingival margin of the masticatory mucosa, followed by the hard palate, tongue, buccal mucosa, floor of the mouth, alveolar mucosa, soft palate and junction between the hard and soft palate. Moreover, this lesion can also affect the skin and genital organs. Clinically, VX generally presents a sessile or pedunculated appearance, forming a papule or single plaque with verrucous or papillomatous mucosal growth. The colour (white, pink, grey, or yellow) depends on the thickness of the overlying epidermis. In fact, the clinical findings of VX are similar to those of verrucous carcinoma and other benign tumours, such as squamous papilloma, verruca vulgaris and mucosal fibroma. For this reason, clinical and histopathological examinations are essential for accurate differential diagnosis. Histologically, VX is characterized by parakeratosis, rete ridges of uniform depth and the accumulation of foam cells, which are also called "xanthoma cells". Here, we describe the clinicopathological and immunohistochemical findings of a VX located on the lower gingiva of a 64-year-old male patient.

Oral verruciform xanthoma: a clinicopathologic and immunohistochemical study of 20 cases

Verruciform xanthoma of the oral cavity is an uncommon benign lesion that usually affects the palate and gingiva mainly as a well-circumscribed solitary yellowish to whitish plaque or nodule, which is promptly recognized microscopically by identification of sub-epithelial foamy macrophages. The aim of this study was to evaluate the clinicopathologic and immunohistochemical features of 20 cases of oral verruciform xanthoma. All cases were evaluated by conventional hematoxylin/eosin staining and six of those were submitted to immunohistochemical reactions for CD68, CD63, CD163, syndecan-1 (CD138), S-100 protein and cytokeratins (CK) 8, 14 and 19. Oral verruciform xanthoma presented as yellowish papillary nodules affecting mainly the palate (30%), buccal mucosa (30%) and gingiva (25%) of middle-aged male patients. Most cases presented papillary epithelial hyperplasia and sub-epithelial foamy cells, which were immunopositive for CD68, CD63 and CD163 in all cases. The orange parakeratin superficial layer was negative for CK14 and presented a distinct granular membrane pattern of positivity for CD138. S-100 protein, CK8, and CK19 were negative.

Oral verruciform xanthoma

Verruciform xanthoma (VX) of the oral cavity is a benign mucosal growth that often presents as a pink, yellow or grey raised plaque or papule with granular, papillary or verrucous surface morphology. Intraorally this often presents on the masticatory mucosa and extraorally often involves the skin and anogenital mucosa. There are several proposed aetiological factors and the clinical features of VX can be misleading; clinically it can resemble malignancy. Histopathological diagnosis is a key for the correct management of this lesion. Excision of this lesion is curative.

Oral verruciform xanthoma: a case report and literature review

Oral verruciform xanthoma represents an uncommon entity, which affects mainly oral mucosa. This paper presents the major clinical and histological features of oral verruciform xanthoma and reports a case on the tongue. The differential diagnosis and a literature review are also provided in light of recent information.

Verruciform xanthoma of oral cavity- a case report

Verruciform xanthoma is an uncommon benign lesion of undetermined aetiology. It is a superficial normo-lipemic xanthoma, probably reflecting a multifactorial reactive and dystrophic process. Its clinical and pathological recognition and correct diagnosis is critical because it can occur in conjunction with other systemic and cutaneous inflammatory diseases; therefore, it necessitates further clinical assessment. We, hereby report a rare case of verruciform xanthoma in 46-year-old male patient with history of leukemia with emphasis on need of vigilant comprehensive analysis of clinicopathological and immunohistohemical finding to arrive at definitive diagnosis and for better understanding of pathogenesis.

Verruciform xanthoma: A view on the concepts of its etiopathogenesis

Verruciform xanthoma is a very uncommon papillary growth seen chiefly in the oral mucosa. The presence of foam cells in the connective tissue papillae between the epithelial rete ridges forms the hallmark in its diagnosis. There has been wide speculation and various hypotheses put forth in explaining the etiopathogenesis of verruciform xanthoma and the origin of foam cells. This article aims to update the different hypotheses in understanding the pathogenesis of the lesion.

Verruciform xanthoma of the palatal gingiva: a report of two cases

Verruciform xanthoma (VX) is a rare, benign lesion that presents in the oral cavity, skin, or genital organs as a verrucous, papillomatous, or flat papule with varying colors. VX has indistinct clinical features, making histopathological examination necessary for a definitive diagnosis. Histologically, VX is characterized by parakeratosis, rete ridges with uniform depth, and an accumulation of the foam cells, which are also known as the "xanthoma cells". These foam cells test positive for antibodies, such as CD-68 and vimentin; it is thought that VX foam cells are derived from the monocyte-macrophage lineage, and that VX's pathogenic mechanism is partly related to an immune mechanism. Nevertheless, the pathogenesis of VX remains unclear. VX can be treated by surgical excision; other medical, chemical, and radiological treatments are not required postoperatively. Recurrence and malignant transformation of VX are rare. Two patients, each with a mass of unknown origin on the palatal gingiva, were presented at our clinic. Excisional biopsies of the masses were performed for a histological diagnosis after clinical and radiological examinations. Histological examination confirmed a diagnosis of VX in both cases.

Oral verruciform xanthoma: a case report and literature review

Verruciform xanthoma is a benign mucocutaneous, uncommon, nonsymptomatic lesion of uncertain etiopathology, which occurs mostly on the oral mucosa of middle-aged individuals. Histopathologically, VX is diagnosed by presence of lipid-laden foam cells in papillary region of connective tissue. A 60-year-old male patient presented with a painless growth on the left buccal mucosa. On clinical examination a yellowish white exophytic lesion, measuring 11 × 7 mm in size, was found, which was cauliflower-shaped on inspection and painless on palpation. Histopathological examination revealed varying degrees of surface parakeratosis and the accumulation of numerous foam cells in the connective tissue papillae among the uniformly elongated epithelial ridges. On immunohistochemical staining, there was a neutrophilic infiltrate of the epidermis with CD68 positive xanthoma cells restricted to the papillary dermis, mixed with other chronic inflammatory cells.

A case of multiple verruciform xanthoma in gingiva

We present an unusual case of multiple verruciform xanthomas in the gingiva of a patient with no systemic diseases.

Verruciform xanthoma of the oral cavity - a case report

Verruciform Xanthoma (VX) is a relatively rare benign mucocutaneous lesion of unknown aetiology. VX occurs predominantly in oral cavity which also occasionally affects skin and genital mucosa. It was first reported in the oral cavity in 1971. This rare harmless lesion usually presents as sessile or pedunculated, appear as a papule or single plaque showing verrucous or papillomatous mucosal growth with variable color from reddish pink to gray. In majority of oral cases, it affects gingiva and alveolar mucosa that may be mistaken for benign, premalignant and malignant conditions. VX is diagnosed with certainly only on histopathologic examination. Histologically VX is characterized by the presence of parakeratinized epithelium showing papillary or verrucous growth with thin rete ridges and connective tissue papillae extending up to the surface. The papillae characteristically consist of foam cells also called xanthoma cells. Here we describe a case report of verruciform xanthoma occurring on the buccal mucosa in a 42-years old male patient along with its clinical, pathogenesis, histological features and treatment modalities discussed.

Verruciform xanthoma of the upper-extremity in the absence of chronic skin disease or syndrome: a case report and review of the literature

Verruciform xanthoma is a rare, benign lesion classically presenting on the oral mucosa or genital area. The etiology is not yet completely understood; however, verruciform xanthoma is often associated with (a) conditions of chronic inflammation or trauma, such as lichen sclerosis, recessive dystrophic epidermolysis bullosa, and pemphigus vulgaris, as well as in a setting of (b) chronic lymphedema, (c) chronic graft versus host disease, or (d) congenital epidermal nevi, such as those associated with the Congenital Hemidysplasia with Ichthyosiform nevus and Limb Defects (CHILD) syndrome. We report a case of a solitary verruciform xanthoma on the forearm of an 82-year-old man without history of chronic dystrophic skin disease or syndrome. In addition, a thorough literature review of extra-oral and extra-genital verruciform xanthomas is presented. On the basis of this review, we believe this case is an extremely rare presentation of a solitary verruciform xanthoma on the upper-extremity of an otherwise healthy individual.

Verruciform xanthoma: report of five cases

We describe five cases of verruciform xanthoma (VX). The patients, all males, presented with single warty verrucous lesions of 0.5–2 cm size that had been diagnosed clinically as viral warts (four cases) and leukoplakia (one case). Two patients had the lesion in the oral cavity, two on the genital mucosa, and one on the scrotal skin. Histopathology was diagnostic, with verrucous and papillomatous epidermal hyperplasia with the silhouette of a viral wart but with numerous foamy histiocytes packed in the elongated dermal papillae. Columns of deep parakeratosis and neutrophils in the upper spinous layers, with a dermal plasma cell infiltrate were the other histopathologic findings. Excision of the lesions was curative, without recurrences, in the two patients who had lesions in the oral cavity; follow-up was not available in the cases with genital lesions. VX is an uncommon but distinctive clinicopathologic entity affecting the oral and genital mucosa that may be mistaken for benign, premalignant, and malignant conditions. VX can be diagnosed with certainty only on histopathologic examination.

Verruciform xanthoma of buccal mucosa: A case report with review of literature

Verruciformxanthoma (VX) is an uncommon benign mucocutaneous lesion of unknown etiology. It appears as a papule or single plaque with verrucous or papillomatous surface and variable color from reddish pink to gray. It occurs primarily in the masticatory mucosa. Histologically, VX is characterized by the presence of parakeratinized epithelium with thin rete ridges and connective tissue papillae extending up to the surface. The papillae characteristically consist of foam cells, also called xanthoma cells. We report a case of VX in the buccal mucosa and discuss their clinical and histopathological findings.

Scrotal cutaneous verruciform xanthoma with monocyte chemoattractant protein-1 immunohistochemical study: a case report

Introduction

Verruciform xanthoma is a rare, benign lesion characterized by hyperkeratosis and aggregates of foam cell macrophages. Here, we describe a case of verruciform xanthoma on the scrotum, in which the immunohistochemical localization of monocyte chemoattractant protein-1, a chemokine of the C-C or beta family that has been shown to induce the recruitment of monocytes for injured tissue, was analyzed to determine which cells release chemoattractants for macrophages.

Case presentation

A 75-year-old Japanese man with a well-defined nodule on the left scrotum was admitted to the hospital. An excision biopsy revealed epidermal papillary proliferation with parakeratosis, hyperkeratosis, and infiltration of foam cell macrophages, whereby a pathological diagnosis of benign cutaneous verruciform xanthoma was made. Immunohistochemically, monocyte chemoattractant protein-1 was observed predominantly on cytokeratin AE1/AE3-positive differentiating keratinocytes in the prickle cell layer. However, while infiltrating macrophages were densely stained for monocyte chemoattractant protein-1, keratinocytes in the basal and parabasal layers were almost negative.

Conclusions

We demonstrated that keratinocyte-derived monocyte chemoattractant protein-1 plays an important role in the establishment of particular histological features of verruciform xanthoma. However, in the present case, unlike in previous reports, monocyte chemoattractant protein-1 immunostaining in keratinocytes in the basal and parabasal layers was not prominent. We speculate that in the active phase of verruciform xanthoma, when continuous stimuli that release monocyte chemoattractant protein-1 from keratinocytes to the surrounding stromal area are present, the apparent immunostaining of monocyte chemoattractant protein-1 can be underestimated because of the void created by accelerated keratinocyte release from the cytoplasmic fraction.

Oral verruciform xanthoma associated with chronic graft-versus-host disease: a report of five cases and a review of the literature

Verruciform xanthoma (VX) is an uncommon benign inflammatory mucocutaneous condition that chiefly occurs in the oral cavity. It is often associated with pre-existing epithelial and/or inflammatory disorder and is characterized histopathologically by papillary epithelial hyperplasia and the presence of foamy macrophages in connective tissue papillae. We report of a series of five cases with VX who concurrently had chronic oral graft-versus-host disease following hematopoietic stem cell transplantation.

Verruciform xanthoma and neurofibromatosis: a case report

We report an unusual case of verruciform xanthoma in a patient with neurofibromatosis and some clinical features of oral lichen planus.

Multiple atypical mucosal xanthomas in a dog similar to human verruciform xanthoma

A case of atypical mucosal xanthomas in a 14-year-old Shi-Tzu dog is reported. Grossly, 1-6-mm granular plaques or slightly elevated papillary nodules were found in the oral cavity (dorsal and ventral sides of the tongue, inner upper lip) and in the upper digestive tract (esophagus, stomach). Microscopically, subepithelial aggregates of large foamy cells were found in strong association with papillary epithelial hyperplasia. By immunohistochemistry, the majority of these cells tested positive for lysozyme and ACM1. The cells had cytoplasmic lipid content that stained positively with oil red O. These findings confirmed a monocyte/macrophage lineage. On the basis of macroscopic observations, microscopic changes, and the absence of a clinical metabolic defect, the condition in this dog appears similar to that of humans with oral verruciform xanthoma. The pathogenesis of these xanthomas in the dog remains obscure, although this condition appears to affect people and dogs with an Asian origin.