Low-Grade Fibromyxoid Sarcoma of the Head and Neck: A Clinicopathologic Series and Review of the Literature

Supraclavicular Artery Island Flap for Treatment of Cervical Wound Defects and Persistent Cerebrospinal Fluid Leaks: A Technical Note and Systematic Review of the Literature

BACKGROUND

Soft tissue defects and persistent cerebrospinal fluid (CSF) leaks can create complications after cervical spinal surgery. The supraclavicular artery island (SAI) flap is useful in closing tissue defects, particularly in these complex surgeries and multiple reinterventions. However, technical reports in this context are scarce. We describe application of the SAI flap technique to control persistent CSF leak in the first documented instance (to our knowledge) of a low-grade fibromyxoid sarcoma (LGFMS) in the cervical epidural space. Additionally, we conducted a comprehensive review of PubMed, Embase, and Google Scholar from their earliest records through December 17, 2023 using combined terms, "supraclavicular artery island flap AND spine" and "supraclavicular AND flap AND spine".

TECHNICAL NOTE

A 56-year-old woman with arm pain and weakness presented with a cervical epidural mass extending from C4-C6 and associated spinal cord compression. She underwent a 3-level corpectomy and tumor resection. Primary dural closure was impossible due to the dural invasion, and reintervention with an SAI flap and definitive lumboperitoneal shunting were required to control and seal the CSF leak.

SYSTEMATIC LITERATURE REVIEW

Seven case reports describing SAI flap for spinal surgery complications were identified. The indications in those cases were correcting esophageal and hypopharyngeal perforations after cervical fusion and discectomy and persistent soft tissue coverage after cervical instrumentation.

CONCLUSIONS

The SAI flap technique provided wound defect coverage in this case and is suitable for addressing issues such as persistent CSF leaks or soft tissue coverage after cervical spine surgery.

Low-grade fibromyxoid sarcoma in laryngopharynx: the first case report in the literature

Low-grade fibromyxoid sarcoma is a rare mesenchymal neoplasm with distinctive histopathological features. Although it typically arises in the deep soft tissues of the trunk and extremities, its occurrence in the head and neck region is exceedingly rare. We present the first documented case of low-grade fibromyxoid sarcoma in the laryngopharynx, expanding the spectrum of this rare tumor's anatomical localization. The clinical, radiological, and histopathological features of this unique case are discussed, highlighting the diagnostic challenges and therapeutic considerations associated with this uncommon presentation.

Novel KMT2B gene mutation in MUC4 positive low-grade fibromyxoid sarcoma

BACKGROUND

Low-grade Fibromyxoid Sarcoma(LGFM)is a rare fibrosarcoma, which mainly occurs in young people and is mostly seen in the trunk and limbs. The tumor is usually FUS-CREB3L2 fusion caused by t(7;16)(q32-34;p11)chromosome translocation, and rarely FUS-CREB3L1 and EWSR1-CREB3L1 fusion. MUC4 diffuse strong positive can be used as a specific index of LGFM. LGFM is similar to Sclerosing Epithelioid Fibrosarcoma(SEF) and may have the same origin.

CASE PRESENTATION

We report a case of LGFM in the chest wall. A female who is 59 years old. In 2016, CT showed dense nodule shadow and focal thickening of the left pleura, the patient underwent surgery, Pathological report that low to moderate malignant fibrosarcoma(fibromyxoid type). The CT re-examination in 2021 showed that the tumors on the left chest wall were significantly larger than before. Pathological examination showed the disease is composed of alternating collagen like and mucinous areas. Under high-power microscope, the tumor cells are consistent in shape, spindle or short spindle, and the tumor cells are arranged in bundles. In local areas, the density of tumor cells is significantly increased, mixed with collagen fibers, and small focal SEF appear. The result of immunohistochemistry showed that SMA, Desmin, CD34, STAT6, S100, SOX10, HMB45 and Melan A were negative, EMA was weakly positive, MUC4 was diffuse and strongly positive, and Ki67 index was low (3%).

CONCLUSION

Sequencing results showed that MET, EGFR, KMT2B and RET gene were mutated in LGFM, and KMT2B gene had cancer promoting effect, but there was no literature report in LGFM, which may be of certain significance for the diagnosis and treatment of LGFM.

Low-grade fibromyxoid sarcoma of the breast: genetic characterization and immunohistochemical comparison to morphologic mimics

Spindle cell lesions of the breast elicit a specific, relatively limited differential diagnosis, and accurate classification often requires careful morphologic evaluation and immunohistochemical workup. Low-grade fibromyxoid sarcoma (LGFMS) is a rare malignant fibroblastic tumor with deceptively bland spindle cell morphology. Involvement of the breast is exceedingly rare. We examined the clinicopathologic and molecular characteristics of three cases of breast/axillary LGFMS. In addition, we interrogated the immunohistochemical expression of MUC4, a commonly used marker of LGFMS, in other breast spindle cell lesions. LGFMS presented in women at 23, 33, and 59 years of age. Tumor size ranged from 0.9 to 4.7 cm. Microscopically, they were circumscribed nodular masses composed of bland spindle cells with fibromyxoid stroma. Immunohistochemically, tumors were diffusely positive for MUC4 and negative for keratin, CD34, S100 protein, and nuclear beta-catenin. Fluorescence in-situ hybridization demonstrated FUS (n = 2) or EWSR1 (n = 1) rearrangements. Next-generation sequencing identified FUS::CREB3L2 and EWSR1::CREB3L1 fusions. MUC4 immunohistochemistry performed on 162 additional breast lesions demonstrated only weak and limited expression in a subset of cases of fibromatosis (10/20, ≤30% staining), scar (5/9, ≤10%), metaplastic carcinoma (4/23, ≤5%), and phyllodes tumor (3/74, ≤10%). MUC4 was entirely negative in cases of pseudoangiomatous stromal hyperplasia (n = 9), myofibroblastoma (n = 6), periductal stromal tumor (n = 3), and cellular/juvenile fibroadenoma (n = 21). LGFMS can rarely occur in the breast and should be considered in the differential diagnosis of breast spindle cell lesions. Strong and diffuse MUC4 expression is highly specific in this histologic context. Detection of an FUS or EWSR1 rearrangement can confirm the diagnosis.

Non-Squamous Cell Carcinoma of the Larynx: A State-of-the-Art Review

(1) Background: Non-squamous cell laryngeal carcinoma includes endothelial tumors, such as minor salivary gland tumors, lymphoepithelial tumors, neuroendocrine tumors, soft and hard tissue sarcomas, and malignant melanomas. (2) Methods: A state-of-the-art review using the MEDLINE/PUBMED, Google Scholar, Ovid Medline, Embase, and Scopus electronic databases was performed. (3) Conclusions: In order to optimize overall treatment outcomes, a multidisciplinary, patient-centered approach to the management of non-SCC of the larynx must be adopted universally; a national or international registry on non-SCC laryngeal cancer can be useful to improve understanding about the behavior of this kind of tumor.

Non-squamous Laryngeal Cancer

The pathology of non-squamous carcinoma of the larynx is broad and there is a wide differential diagnosis. The most common presenting symptoms for laryngeal malignancies, both squamous and non-squamous, are hoarseness and dyspnea. Presentation with persistent or worsening symptoms and a submucosal lesion should raise suspicion for a non-squamous malignancy of the larynx. Accurate histology determines the most appropriate treatment and has an impact on prognosis.

The Recent Advances in Molecular Diagnosis of Soft Tissue Tumors

Soft tissue tumors are rare mesenchymal tumors with divergent differentiation. The diagnosis of soft tissue tumors is challenging for pathologists owing to the diversity of tumor types and histological overlap among the tumor entities. Present-day understanding of the molecular pathogenesis of soft tissue tumors has rapidly increased with the development of molecular genetic techniques (e.g., next-generation sequencing). Additionally, immunohistochemical markers that serve as surrogate markers for recurrent translocations in soft tissue tumors have been developed. This review aims to provide an update on recently described molecular findings and relevant novel immunohistochemical markers in selected soft tissue tumors.

Low-Grade Fibromyxoid Sarcomas with the Maxillary Sinus Localization: A Case Report and Review of the Literature

A low-grade fibromyxoid sarcoma (LGFMS) is an extremely rare tumor first described by Evans in 1987. LGFMS is a type of soft tissue sarcoma characterized by a deceptively benign histological appearance but completely malignant behavior. LGFMS is usually seen in the deep soft tissues of the extremities and trunk. We have examined many reviews, case reports and case series previously published in PubMed and Google Scholar. To date, only five cases have been reported in the maxilla. LGFMS generally affects young adults, but it can also be seen in children and older adults. A radical surgical approach is the most recommended treatment option. LGFMS has a very low mitotic activity; therefore, it is considered that neither chemotherapy nor radiotherapy has a significant effect on long-term LGFMS prognosis. However, to date, there has been no study suggesting any protocol for the follow-up of patients with LGFMS. In this report, we present a case with LGFMS located in the maxillary sinus, in which despite radiotherapy following extensive surgical excision, the tumor recurred in a short period of three months and reached its former size.

TIMP3::ALK fusions characterize a distinctive myxoid fibroblastic tumor of the vocal cords: a report of 7 cases

We report 7 cases of an indolent, variably myxoid tumor of the vocal cords, characterized by overt cellular atypia with large cells containing intranuclear and intracytoplasmic vacuoles, delicate curvilinear vessels, and sparse inflammatory infiltrate. Six patients were male, aged 15 to 65 years, and 1 patient was a 54-year-old female. All tumors were located in the superficial portion of the vocal cord. One patient suffered a recurrence that was completely resected; all patients with available follow-up data currently have no evidence of disease. The tumors contained alternating areas with myxoid stroma and more compacted regions with tumor cells organized in short fascicles, interwoven with delicate curvilinear vasculature. Overt cellular atypia with large cells containing intranuclear and intracytoplasmic vacuoles or resembling ganglion cells was present in all cases but mitoses and necrosis were absent. ALK immunostaining was positive in all cases, while most tumors were negative for smooth muscle actin. Targeted RNA-sequencing revealed an identical TIMP3::ALK fusion with exon 1 of TIMP3 gene being fused with exon 12 of ALK gene in all analyzable cases. For various reasons discussed, it remains unclear whether this tumor represents a mere subtype of IMT or a separate entity. Nevertheless, it is a morphologically distinct and diagnostically challenging lesion that needs to be recognized by surgical pathologists in order to prevent overdiagnosis in this clinically very delicate area.

Low-Grade Fibromyxoid Sarcoma Featuring an Unusual EWSR1-CREB3L2 Gene Fusion: Report of a Rare Case Arising in the Parotid Gland

Low-grade fibromyxoid sarcoma (LGFMS), also known as Evan's tumor, is a fibroblastic tumor with a deceptively bland morphology but a high metastasizing potential and late recurrence. It presents clinically as a slowly growing mass in the deep soft tissue of extremities and trunk. Morphologically, it shows a biphasic pattern with alternating fibrous and myxoid areas, whorling growth pattern, hypocellularity, and bland fibroblasts with curvilinear or arcuate vessels in between. Collagen rosettes with central hyalinization is a helpful feature but not specific. MUC-4 is the most sensitive immunostain in LGFMS. The majority of cases harbor a gene fusion in FUS - CREB3L2. Herein, we present a 23-year-old female patient with a slow growing painless mass in the left parotid gland, which was later diagnosed as LGFMS. Involvement of the head and neck region by LGFMS is uncommonly encountered. To date, only two cases within the parotid gland have been described.

Update on MR Imaging of Soft Tissue Tumors of Head and Neck

This article reviews soft tissue tumors of the head and neck following the 2020 revision of WHO Classification of Soft Tissue and Bone Tumours. Common soft tissue tumors in the head and neck and tumors are discussed, along with newly added entities to the classification system. Salient clinical and imaging features that may allow for improved diagnostic accuracy or to narrow the imaging differential diagnosis are covered. Advanced imaging techniques are discussed, with a focus on diffusion-weighted and dynamic contrast imaging and their potential to help characterize soft tissue tumors and aid in distinguishing malignant from benign tumors.

Head and Neck Low-Grade Fibromyxoid Sarcoma: A Clinicopathologic Study of 15 Cases

Low-grade fibromyxoid sarcoma (LGFMS) is an uncommon mesenchymal tumor usually arising in the lower extremities and trunk. Only rare examples in the head and neck region have been reported. Fifteen cases of head and neck LGFMS were retrieved. MUC4 was performed on all cases. Results for smooth muscle actins, β-catenin, desmin, S100 protein, Epithelial membrane antigen (EMA) and STAT6 immunohistochemistry, as well as FUS rearrangement status, were recorded when available. Sites included neck (8), supraclavicular region (4) and orbit (1), parapharyngeal space (1) and lower lip (1). The age of the patients ranged from 3 to 97 years (median, 26 years). Tumors displayed classical morphologic features of LGFMS, as described. All cases (15/15) were positive for MUC4, and all cases tested (4/4) harbored FUS rearrangement. Variable positivity for EMA was identified in one case. Follow-up was available in 11 patients, ranging from 2 to 240 months (mean 71.4 months; median, 44 months). Three tumors recurred locally; none metastasized. In conclusion, although distinctly uncommon, LGFMS may arise in the head and neck region and should be distinguished from other more common spindle cell tumors in these locations. The morphologic, immunohistochemical and molecular genetic features of head/neck LGFMS are identical to those occurring elsewhere. The long-term metastatic risk of LGFMS in these locations remains to be fully elucidated.

Low-grade fibromyxoid sarcoma of the parapharyngeal space: an unusual location

Low-grade fibromyxoid sarcoma (LGFMS) is an uncommon soft-tissue malignancy. LGFMS preferentially affects trunks and extremities of young adults; however, occasional cases have been reported in different sites of head and neck region including oral cavity, larynx and oropharynx. LGFMS usually exhibit areas of collagenised and myxoid stroma with appearance of spindle cells in whorling pattern. It is a challenge to diagnose it accurately as most of the time it is misdiagnosed as benign neoplastic entity of spindle cells. There have been only few isolated cases of LGFMS reported in head and neck region and LGFMS originating from the parapharyngeal space has never been reported before. We recently experienced a case of low grade fibomyxoid sarcoma in parapharyngeal space of neck. LGFMS have the propensity to locally recur and to metastasise. Due to its rarity in head and neck region, there are no well-established treatment and follow-up guidelines.

A slow-growing anterior maxillary mass

A 43-year-old-male with no medical conditions presented to his dentist with a left maxillary swelling present for 1 year. His physical exam revealed a 2-cm × 2-cm, poorly demarcated, firm mass in the left anterior maxilla causing mobility of the associated teeth. He had a bluish discoloration of the anterior maxillary mucosa. A computed tomographic scan demonstrated a homogeneous and uniformly radiolucent, well-defined mass in the left anterior maxilla primarily involving the alveolus and the roots of teeth 7-12. The mass caused expansion and tooth displacement. An incisional biopsy was done and MUC 4 staining was diffusely positive so the diagnosis of low-grade fibromyxoid sarcoma (LGFMS) was made. He underwent wide local excision and reconstruction with a fibula free flap and a three-dimensionally printed, implant-retained prosthesis. The final pathology confirmed the diagnosis of LGFMS, stage pT4aN0M0, with negative margins. The patient had no evidence of recurrence at 1-year follow-up.

Case Report: An extremely rare occurrence of recurrent inguinal low-grade fibromyxoid sarcoma involving the scrotum

Low-grade fibromyxoid sarcoma (LGFMS) is a rare sarcoma subtype. The most common tumor locations are the deep soft tissue of extremities or trunks. We report a rare case of recurrent LGFMS in the inguinal region involving the scrotum and both testicles. A 38-year-old male patient reported a history of multiple nodular lesions in the left inguinal region accompanied by local inflammation. The patient was submitted for local resection of the lesion at our institution, with histopathological diagnosis of LGFMS. He missed his follow-up, returning with a large bulge in the left inguinal region involving the scrotum with signs of tissue necrosis and local purulent discharge. Surgical exploration was performed and the patient underwent tumor resection in the left inguinal region and the entire scrotum, with bilateral orchiectomy, with the margins enlarged to the right inguinal region and proximal surface of the penis. Local reconstruction was performed with a left fascia lata tensor muscle flap and ipsilateral thigh coverage using partial skin graft. On microscopic examination, the tumor showed spindle cells arranged in bundles, with abundant collagen and myxoid stroma with interspersed prominent vessels. The immunohistochemical study carried out showed immunoreactivity with Ki67 (<5%), immunonegativity with desmin and S100, confirming the diagnosis of LGFMS. Postoperative recovery was good and no recurrence was seen after two years. The patient is in good health, realizing multidisciplinary outpatient follow-up and performing continuous testosterone replacement. Surgical resection with negative margins for localized disease remains the standard treatment for LGFMS.

Low-grade fibromyxoid sarcoma of the maxillary sinus

BACKGROUND

Low-grade fibromyxoid sarcoma (LGFMS) is a rare malignant tumor. Moreover, only 3 cases of LGFMS originating from the nasal cavity and/or paranasal sinuses have been published so far.

METHODS

Two patients with histologically confirmed LGFMS of the maxillary sinus were primarily treated by open and endoscopic surgery. In one case adjuvant radiotherapy was indicated because of the uncertainty of the surgical margins.

RESULTS

Both surgeries were technically demanding and accompanied by significant bleeding from the tumors. Despite the extensive interventions there were no postoperative complications and no significant morbidity of the patients. There is no evidence of the disease 148 and 65 months after the treatment.

CONCLUSIONS

Regardless of the excellent post-treatment results, based on our experience, preoperative embolisation of the tumor should be considered prior to the surgical resection.

Prognostic factors for laryngeal sarcoma and nomogram development for prediction: a retrospective study based on SEER database

Background

Laryngeal sarcoma is an extremely rare malignant tumor of larynx and usually reported as case reports or small series. At present, there is no research based on big data about the prognostic factors affecting laryngeal sarcoma. Our study aimed to investigate the prognostic survival factors of laryngeal sarcoma and develop a comprehensive nomogram for predicting the survival of laryngeal sarcoma.

Methods

Data were obtained from the Surveillance, Epidemiology, and End Results (SEER) database to find patients diagnosed with laryngeal sarcoma from 1998 to 2016. The data were obtained using SEER Stat 8.3.5 software, collated, and analyzed by Excel 2016 software and SPSS (v25.0). Kaplan-Meier curves were used for survival analysis. The variables obtained by univariate analysis were introduced into the Cox proportional hazard model for multivariate analysis. The risk factors affecting the prognosis of laryngeal sarcoma were obtained (P<0.05 indicated statistical significance). The independent prognostic factors of laryngeal sarcoma were integrated and used to construct a nomogram.

Results

A total of 381 patients with laryngeal sarcoma were included. The median age of diagnosis was 67 years. The proportion of patients who had received surgical treatment was 62.73%, while 22.31% of patients had received no surgery. The 1-, 3-, 5-, and 10-year survival rates were 87%, 76%, 61%, and 45%, respectively. The median survival time was 102.35 months. Univariate analysis showed that increased age, primary site, pathology, pathological grade, and surgical treatment were significantly correlated with patient survival time and were risk factors for the patients' prognosis. Race, gender, and even lymph node metastasis were not significantly correlated with patient prognosis. The risk factors obtained from the univariate analysis were incorporated into the Cox risk model for multivariate analysis, the independent risk factors for prognosis of patients were: age (HR 1.569, 95% CI: 1.358–1.813, P<0.005), pathology (HR 0.834, 95% CI: 0.734–0.948, P<0.005), pathological grade (HR 1.433, 95% CI: 1.164–1.764, P<0.001), surgical treatment (HR 0.778, 95% CI: 0.696–0.870, P<0.000), primary site was excluded (P=0.092). We included all the risk factors from the multi-factor analysis to construct a nomogram, and the C-index value was 0.73, indicating that it was well-calibrated in the medium and long term.

Conclusions

Laryngeal sarcoma is a rare malignant tumor of the larynx, which most often affects people between the ages of 50 and 79 and males. Our study shows that age, pathology, pathological grade, surgical treatment may be the risk factors for patients’ prognosis. Based on this, we constructed a nomogram model with a prediction accuracy of 73% that could help clinicians make decisions on an individual basis.

Soft Tissue Special Issue: Fibroblastic and Myofibroblastic Neoplasms of the Head and Neck

Fibroblastic and myofibroblastic neoplasms of the head and neck encompass a group of rare tumor types with often overlapping clinicopathologic features that range in biologic potential from benign to overtly malignant. Even neoplasms with no metastatic potential may provide significant therapeutic challenges in this region due to the unique anatomy of the head and neck. This review will cover the following entities, highlighting important clinical aspects of each neoplasm and then focusing on their characteristic histomorphology, immunophenotype, and molecular alterations: nodular and cranial fasciitis, fibrous hamartoma of infancy, nasopharyngeal angiofibroma, nuchal-type and Gardner fibromas, desmoid fibromatosis, dermatofibrosarcoma protuberans and giant cell fibroblastoma, solitary fibrous tumor, inflammatory myofibroblastic tumor, low-grade myofibroblastic sarcoma, infantile fibrosarcoma, low-grade fibromyxoid sarcoma, and sclerosing epithelioid fibrosarcoma. While some of these neoplasms characteristically arise in the head and neck, others are rarely described in this anatomic region and may therefore be particularly difficult to recognize. Distinction between these entities, however, is crucial, particularly as the molecular pathogenetic basis for these neoplasms are being rapidly elucidated, in some instances allowing for targeted therapeutic approaches.

Cytomorphologic findings of low-grade fibromyxoid sarcoma

INTRODUCTION

Low-grade fibromyxoid sarcoma (LGFMS) is a rare fibroblastic tumor characterized by a prolonged clinical course and malignant biological behavior. Given its deceptively bland cytomorphology, a diagnosis can be quite challenging notably on fine-needle aspiration (FNA). In an attempt to shed light on some of the distinctive cytomorphologic characteristics, this study was conducted to review all cases of LGFMS in our database, correlating available clinical data, immunohistochemical findings, and molecular analysis.

MATERIALS AND METHODS

This series included 20 FNAs from 18 patients with a histologically confirmed LGFMS diagnosis from 3 large academic institutions. Detailed cytomorphologic analysis for each case was documented in conjunction with corresponding clinical characteristics and provided ancillary testing.

RESULTS

Out of 14 adequate FNA samples, 9 (64.2%) demonstrated a mixture of fibrous and myxoid pattern; the majority of cases were composed of deceptively bland tumor cells with rare nuclear pleomorphism and nuclear membrane irregularities. A MUC4 immunostain was performed on 5 specimens; all tested positive (100%). FUS rearrangement was detected in 4 out of 5 cases (80%). Follow-up information revealed 5-year recurrence in 1 case and metastatic disease in 2 cases, to the lung/pleura (8 years) and fourth rib (1 year), respectively.

CONCLUSIONS

The presence of bland spindle cells and associated with myxoid matrix material, in the appropriate clinical setting, can suggest LGFMS and direct additional confirmatory testing. A definitive diagnosis of LGFMS on FNA requires adequate sampling, familiarity with key cytomorphologic features, acquisition of diagnostic material for a cell block preparation and ancillary testing, and clinicoradiologic correlation.

Cellular Myxoma of the Vocal Cord: A Case Report and Review of the Literature

Myxomas are rare in the vocal cords. A 69-year-old man was admitted with one-year history of progressive dysphonia. Laryngoscopy revealed a polypoid mass on the right vocal cord. The diagnosis was cellular myxoma. A review of the literature including the present case revealed eleven reported cases of myxoma. Ten cases were classic myxoma. To the best of our knowledge, cellular myxoma has not been previously reported in the vocal cord. Hypercellularity does not affect the behavior of cellular myxoma. However, its recognition is important to prevent confusion with the group of low-grade myxoid sarcomas. Cellular myxoma should be considered in the differential diagnosis of any vocal cord mass.

A case report of paravertebral low-grade malignant fibrous myxoid sarcoma

RATIONALE

Low-grade malignant fibrous myxoid sarcoma (LGFMS) is a malignant tumor that originates from soft tissues and has specific clinical and histopathological characteristics. Paravertebral LGFMS is rarely reported.

PATIENT CONCERNS

A 60-year-old woman had pain in the lower back and right anterior thigh for more than 3 years.

DIAGNOSIS

Paravertebral LGFMS.

INTERVENTIONS

Tumor resection, vertebral canal decompression and pedicle screw fixation.

OUTCOMES

The tumor was excised, and the vertebral arch was fixed with pedicle screws at the root. Chemoradiotherapy was not performed. Her postoperative visual analogue scale (VAS) score decreased from 7 points at admission to 2 points at follow-up. The patient was discharged at postoperative day 13, and no recurrence was observed at the 6-month follow-up.

LESSONS

Although LGFMS is rare, it should be considered in differential diagnosis of other soft tissue tumors to avoid misdiagnosis and inappropriate treatment.

Primary Sarcomas of the Larynx: A Single Institutional Experience with Ten Cases

Sarcomas infrequently arise in the larynx where the vast majority of tumors are of epithelial origin. Given their rarity, studies of these lesions are limited in number. In this series, we describe our institutional experience with ten primary sarcomas of the larynx encountered over an 18 year period, comprising 1.9% of all laryngeal malignancies observed in this timeframe. The cases include four chondrosarcomas and one example each of osteosarcoma, embryonal rhabdomyosarcoma, undifferentiated spindle cell sarcoma, well-differentiated liposarcoma, Kaposi sarcoma, and synovial sarcoma. Patients included nine males and one female, with a mean age of 59 years (range 34-75). The mean clinical follow-up time was 3.4 years (range 0-12 years). Clinically, all patients presented with vocal and/or respiratory symptoms, and all received surgical treatment with the exception of the case of Kaposi sarcoma. Of the nine patients who underwent surgical excision, two, both chondrosarcomas, experienced local recurrence. No instances of distant metastasis or death of disease had occurred at the time of preparation of this manuscript. In conclusion, primary sarcomas of the larynx are rare but tend to present with early symptoms. This likely allows for earlier detection and intervention as compared to their counterparts in other deep soft tissue locations. Pathologically, it is important, although difficult in some cases, to distinguish these neoplasms from sarcomatoid carcinoma and reactive processes. Careful morphologic and immunohistochemical evaluation, as well as correlation with the clinical and radiologic findings, is important for accurate tumor classification.

Non-epithelial tumors of the larynx: case series of 12 years

PURPOSE

Laryngeal neoplasms are almost always epithelial in origin and squamous cell carcinoma is the most common tumor of the larynx. Non-epithelial tumors make a small subset of laryngeal neoplasms. We present the experience of a single institution to define clinical presentations and outcomes.

MATERIALS AND METHODS

The pathology archives and clinical records of our center with the diagnosis of laryngeal tumors between the 2005 and 2018 were reviewed. Age, gender, symptoms, location of the tumor, histopathological diagnosis, treatment modality and disease status were discussed.

RESULTS

657 patients were diagnosed with laryngeal tumor between 2005 and 2018 and 13 patients with non-epithelial tumors were identified. The majority of the patients were male. The age ranged between 13 and 93 years. The most common tumor localizations were vocal cords and subglottis. Seven patients were diagnosed with malignant tumors and six patients had benign tumors. Chondrosarcoma was the most common malignant mesenchymal tumor. Others were leiomyosarcoma, fibrosarcoma and liposarcoma. The most common benign non-epithelial tumors were schwannoma and hemangioma. Plexiform neurofibroma and granular cell tumor were the other benign tumors. Eleven patients underwent excisional biopsy. One patient underwent partial laryngectomy and one had total laryngectomy. Three cases presented with recurrent tumor. Among the recurrent cases, two were malignant tumors.

CONCLUSION

Non-epithelial tumors of the larynx are rare and have a wide histological diversity. Immunohistochemical studies are of great importance in the diagnosis of these tumors. Primary mesenchymal tumors of the larynx should be kept in mind in differential diagnosis.

Primary orbital low-grade fibromyxoid sarcoma - A case report

An 18-year-old female presented with rapidly progressive proptosis of the left eye for one month and grade II relative afferent pupillary defect. Orbital imaging showed a well-defined homogenous extraconal mass in close relation to the lateral rectus muscle and extending up to the superior orbital fissure, associated with bony erosion. An incisional biopsy was performed, with the histopathology demonstrating stellate to spindle-shaped tumor cells (fibroblasts) embedded in a richly myxoid matrix. A diagnosis of low-grade fibromyxoid sarcoma (LGFS) was made. The patient was treated by stereotactic external beam radiotherapy. Here, we report a case of LGFS which, to the best of our knowledge, is the first at an orbital location.

Ear and Temporal Bone Pathology: Neural, Sclerosing and Myofibroblastic Lesions

Neural, sclerosing, and myofibroblastic lesions of the ear and temporal bone present diagnostic challenges for both clinicians and pathologists due to significant overlap in their clinical presentations, histologic appearances, and immunohistochemical profiles. While some of these lesions, such as schwannomas, are relatively common, others are rendered even more difficult because they are encountered very rarely in routine surgical pathology practice. This review is intended to provide an update on the pathology of some of the most commonly encountered primary diagnostic entities for the ear and temporal bone, and includes the following neural lesions: schwannoma, meningioma, and encephalocele/meningocele. Sclerosing lesions that will be discussed include spindle cell and sclerosing rhabdomyosarcoma, sclerosing epithelioid fibrosarcoma, and sclerosing paraganglioma. Finally, myofibroblastic lesions that will be reviewed are nodular fasciitis, IgG4-related disease, and solitary fibrous tumor. For each of these lesions, the differential diagnosis and useful ancillary tests will be discussed in the context of a broad range of additional primary and secondary lesions.

Role of ancillary techniques in profiling unclassified laryngeal malignancies

Laryngeal biopsies, contrary to biopsies from many other sites of the body, very often contain minute amounts of tumour tissue that may consist of morphologically undifferentiated tumour only. In haematoxylin- and eosin-stained sections, there may be no indicative features of what specific tumour entity that is present. In the larynx, particularly small round cell neoplasms, primary or metastatic, often cause a diagnostic dilemma and where an incorrect diagnosis can induce substantial clinical consequences for the patient (e.g., primary neuroendocrine carcinomas vs metastatic variants, certain sarcomas). If sufficient/representative material has been obtained, the application of immunohistochemistry and/or molecular techniques should in virtually every case reveal the true nature of the malignancy. In cases with sparse amount of material, and therefore a limited number of sections to be cut, a careful and thoughtful stepwise approach is necessary to ascertain a reliable diagnosis, or at least guide the clinician to the most likely diagnoses. With today's advanced and widely available technology with an abundance of markers to discriminate different tumours, the use of the term "undifferentiated" should be largely unnecessary. In the exceptional, and indeed exceedingly rare cases, when a classification is not possible, even after repeat biopsy, we suggest that the laryngeal neoplasm is better termed "unclassified malignant neoplasm" rather than "undifferentiated malignant neoplasm".

Fibromyxoma of the Jaw: Case Report and Review of the Literature

We report a case of fibromyxoma of the mandible, a rare benign odontogenic tumor. Our patient presented in the first trimester of pregnancy with a large mass in the right body of the mandible exhibiting displacement of teeth and destruction of an extensive area of the mandibular bone. The mass was biopsied and diagnosed as a fibromyxoma. The large size of the tumor dictated a wide mandibular resection. We will review the clinical, radiographic, and histologic features of fibromyxoma and discuss its differential diagnoses. In addition, we will provide an overview of patient management. Fibromxyoma is a benign gnathic tumor that can be locally aggressive. To ensure appropriate treatment, it is important to distinguish this neoplasm from other mimickers in which myxoid, spindle mesenchymal cell proliferation is prominent.

Sclerosing Epithelioid Fibrosarcoma of the Jaw: Late Recurrence from a Low Grade Fibromyxoid Sarcoma

Sclerosing epithelioid fibrosarcoma (SEF) is an uncommon variant of fibrosarcoma that is characterized by a distinct morphology. It most frequently presents in the deep soft tissues of the lower extremities, often in intimate association with fascia and periosteum, although reports of the head and neck involvement have been reported. A minority of cases show morphological, immunohistochemical and molecular overlap with low grade fibromyxoid sarcoma (LG-FMS). Herein, we describe a case of a bland spindle cell neoplasm presenting in the jaw that was initially incompletely excised. Over the course of 20 years the tumor subsequently recurred with a SEF morphology. Molecular testing performed on both specimens subsequently confirmed the presence of an EWSR1-CREB3L1 gene fusion. This report highlights the diagnostic difficulty with LG-FMS, particularly in unusual anatomic locations; reiterates the potential for the uncommon EWSR1-CREB3L1 fusion product in LG-FMS; and, reaffirms the potential for progression and/or overlap between LG-FMS to SEF over time.