Retroperitoneal follicular dendritic cell sarcoma in a young woman: Diagnosis and treatment challenges

A Rare Case of Primary Follicular Dendritic Cell Sarcoma of the Kidney

The objective of this case report is to describe a rare case of primary follicular dendritic cell sarcoma (FDCS) of the kidney. FDCS is a rare soft tissue malignancy that most often presents intranodally with lymphadenopathy of the neck, mediastinum, and axilla. One-third of cases present extranodally and most commonly affect the liver, lung, and tonsils. To date, there have been few reports of retroperitoneal FDCS and, to the best of our knowledge, only two other reported cases with primary renal involvement. We present a 56-year-old female with end-stage renal disease on hemodialysis who presented to the hospital with a hypertensive emergency. Computed tomography (CT) of the abdomen was obtained revealing a left-sided renal mass and she subsequently underwent left radical nephrectomy. The pathologic features of the mass revealed oval to spindle cells with eosinophilic cytoplasm, dispersed vesicular chromatin, and small nucleoli found arranged in fascicles, whorls, and storiform patterns with occasional multinucleate forms. The neoplastic cells were immunoreactive to vimentin and expressed cell markers for CD23, CD35, and CD68. These features confirmed a final pathologic diagnosis of primary FDCS of the kidney. To our knowledge, this is the third case of primary renal FDCS reported in the literature. Extranodal FDCS is rare but does occur and needs to be on the differential diagnosis if pathologic features point to its diagnosis.

Follicular dendritic cells

Follicular dendritic cells (FDCs) are unique accessory immune cells that contribute to the regulation of humoral immunity. They are multitasker cells essential for the organization and maintenance of the lymphoid architecture, induction of germinal center reaction, production of B memory cells, and protection from autoimmune disorders. They perform their activities through both antigen-driven and chemical signaling to B cells. FDCs play a crucial role in the physiological regulation of the immune response. Dis-regulation of this immune response results when FDCs retain antigens for years. This provides a constant antigenic stimulation for B cells resulting in the development of immune disorders. Antigen trapped on FDCs is resistant to therapeutic intervention causing chronicity and recurrences. Beyond their physiological immunoregulatory functions, FDCs are involved in the pathogenesis of several immune-related disorders including HIV/AIDS, prion diseases, chronic inflammatory, and autoimmune disorders. FDCs have also been recently implicated in rare neoplasms of lymphoid and hematopoietic tissues. Understanding FDC biology is essential for better control of humoral immunity and opens the gate for therapeutic management of FDC-mediated immune disorders. Thus, the biology of FDCs has become a hot research area in the last couple of decades. In this review, we aim to provide a comprehensive overview of FDCs and their role in physiological and pathological conditions.

Follicular Dendritic Cell Sarcoma of the Tonsil: A Multimodality Approach

Follicular dendritic cell sarcoma (FDCS) accounts for < 0.4% of soft tissue sarcomas. Only 35 cases of tonsillar FDCS have been reported, and majority had localized presentation. We present a case of FDCS of the tonsil, wherein a well-coordinated trimodality approach provided good disease control in advanced disease. A 53-year-old man presented with a painless and enlarging neck mass of 11-month duration, with no other symptoms. Close examination revealed a 10 × 5 cm mass at the left carotid triangle, and a 3.2 × 2.2 cm mass at the left tonsillar fossa. Imaging revealed the tumor to be unresectable due to its attachment to the great vessels. There were no distant metastases. Biopsy and immunohistochemistry were initially deemed consistent with an undifferentiated sarcoma. Palliative chemotherapy was given using single agent doxorubicin and subsequent dacarbazine, resulting in partial response and stable disease, respectively. Pathological re-evaluation was pursued because of the uncharacteristic slow progression of the tumor, revealing diffuse positivity for CD21 and negative for CD1A and CD34, consistent with FDCS. The patient underwent three cycles of gemcitabine plus docetaxel resulting in 50% regression. This allowed dissection of level IB-V lymph nodes and subsequent radiotherapy for the neck and tonsillar mass, with weekly gemcitabine as a radiosensitizer. Evaluation 8 months post-treatment showed no signs of disease progression. Treatment-related complications included radiation dermatitis and swallowing dysfunction, which both resolved on follow-up. This case highlights the multidisciplinary management of a rare type of sarcoma in an uncommon anatomic location. Precise pathologic diagnosis is important in soft tissue sarcoma because of its therapeutic implications. For FDCS, effective response may still be achieved in the third-line setting.

Primary Follicular Dendritic Cell Sarcoma of Urinary Bladder

Follicular dendritic cell sarcoma is a rare malignant mesenchymal neoplasm composed of follicular dendritic cells. A subset of cases can be found at extranodal sites. Only 2 follicular dendritic cell sarcomas were previously reported in the urinary bladder. We report a follicular dendritic cell sarcoma that involved the urinary bladder of an 81-year-old woman, who presented with painless gross hematuria. The neoplasm was composed of large epithelioid cells with atypical nuclei, admixed with inflammatory cells. On immunohistochemistry, the neoplastic cells were reactive only for CD21, CD35, and vimentin. The tumor was considered unresectable due to its large size and proximity to the iliac vessels and the patient was treated with bortezomib, cyclophosphamide, and dexamethasone. Although a full course of chemotherapy was not completed due to adverse side effects, the tumor was reduced in size. A subsequent involved-field radiotherapy was performed. Three years postdiagnosis and 2 years after the radiotherapy treatment, a recurrent tumor was identified on imaging in the left posterolateral bladder wall. However, at that time the patient was found to have a newly developed advanced colonic adenocarcinoma. Three and a half months later she developed a bowel perforation and died.

Uncommon retroperitoneal tumour: follicular dendritic cell sarcoma

INTRODUCTION

Retroperitoneal Follicular Dendritic Cell Sarcomas represents rare tumours with aggressive biologic behaviour. Accurate diagnosis requires a combination of both morphological and immunohistochemical analyses.

PATIENTS AND METHODS

A 61-year-old man was referred to our Department with a left perinephric mass. Computed tomography scan showed a 5.5 cm circumscribed mass in front of the left renal vein abutting the first jejunal loop, with moderate heterogeneous contrast enhancement. Positron emission/computed tomography showed increased focal uptake in the lesion.

RESULTS

A retroperitoneal tumor located behind the first jejunal loop was found at laparotomy, encompassing the superior mesenteric vessels. Excision with en-bloc segmental small bowel resection was performed. Morphological and immunohistochemical analyses were consistent with Follicular Dendritic Cell Sarcoma.

CONCLUSIONS

Complete surgical resection in specialized multidisciplinary centers represents the treatment of choice for both primary or recurrent lesions since there is still no consensus on the role of adjuvant radio-chemotherapy.

Follicular Dendritic Cell Sarcomas: CT and MRI Findings in 20 Patients

OBJECTIVE. The objective of this study was to assess the imaging features of follicular dendritic cell sarcoma (FDCS) on CT and MRI. MATERIALS AND METHODS. The clinical data and pretreatment findings of 20 patients with pathologically proven FDCS on CT (n = 15), MRI (n = 7), or both (n = 2) were analyzed retrospectively. Tumor location, number, size, morphology, attenuation or signal intensity, margin, presence of metastases, and contrast enhancement were evaluated. RESULTS. FDCS originated from lymph nodes (n = 6) or a variety of extranodal sites (n = 14). The tumors were typically solitary and well-circumscribed. Extranodal lesions (mostly in the abdomen or mediastinum with mean diameter, 11.8 cm) were larger than nodal lesions (mean diameter, 6.5 cm). Nodal-type cases presented with homogeneous masses on CT and MRI. However, on CT, all extranodal tumors (n = 12) showed heterogeneous attenuation, of which 91.7% (11/12) contained areas of lower attenuation because of internal necrosis and 50.0% (6/12) showed calcifications. On MRI, primary hepatic or splenic tumors (n = 3) also appeared as large heterogeneous masses. Seven patients (35.0%) had advanced-stage disease, and intraabdominal extranodal cases were more likely to have regional lymphadenopathy (n = 4) and distant metastases (n = 5). Hypervascularity was seen in 90.0% (18/20) of patients and progressive enhancement was seen in 11 (78.6%) of 14 tumors with multiphase imaging. CONCLUSION. FDCS is a rare, mostly solitary, well-delineated malignancy. A nodal-type FDCS typically presents as a small homogeneous mass, whereas an extranodal FDCS in the mediastinum or abdomen manifests as a large heterogeneous mass with internal necrosis and calcifications accompanied by regional lymphadenopathy. Hypervascularity and progressive enhancement can be seen in the majority of tumors.

Follicular dendritic cell sarcoma in the right chest wall: A case report

RATIONALE

Follicular dendritic cell sarcoma (FDCS) is a rare malignant tumor that originates from germinal center follicular dendritic cells, and can occur at both nodal and extranodal sites. There are very few described cases of FDCS arising in the chest wall.

PATIENT CONCERNS

A 44-year-old male patient presented with a history of right chest wall pain for 5 months.

DIAGNOSES

Positron emission tomography/computed tomography showed a significant increase in F-fluorodeoxyglucose uptake and multiple small axillary lymph nodes without hypermetabolic lesions. Immunohistochemistry results of a core-needle biopsy indicated FDCS, which was consistent with the postoperative pathological examination.

INTERVENTIONS

The patient underwent tumor resection with lymphadenectomy of level I axillary nodes. No metastasis in the lymph nodes was observed in the postoperative pathological examination. The patient did not accept chemotherapy or radiotherapy.

OUTCOMES

After 18 months, the patient remains in good condition with no evidence of disease recurrence.

LESSONS

This report highlights a rare case of a FDCS arising in the chest wall. Accurate clinical diagnosis and staging of this rare malignant sarcoma is essential for the developmnt of effective treatment strategies. Preoperative F-fluorodeoxyglucose positron emission tomography/computed tomography scanning combined with core-needle biopsy could provide differentiation between benign and malignant tumors, as well as lymph node involvement and metastatic status.

Paraneoplastic pemphigus and myasthenia gravis as the first manifestations of a rare case of pancreatic follicular dendritic cell sarcoma: CT findings and review of literature

BACKGROUND

Follicular dendritic cell sarcoma (FDCS) is a rare neoplasm that originates from follicular dendritic cells in lymphoid tissue while paraneoplastic pemphigus (PNP) is an autoimmune blistering disease associated with neoplasms. Pancreatic FDCS associated with PNP and myasthenia gravis (MG) is even rarer and highly malignant. We present the clinical data, pathological materials and computed tomography (CT) features of a rare case of this disease.

CASE PRESENTATION

A 49-year-old woman presented with repeated ptosis of both eyelids, oral ulcers and erosions. Her laboratory results showed a slight elevation of CA125 and positivity of some autoimmune antibodies. CT revealed a round solid mass with central necrosis in the pancreatic tail. The solid component of the mass showed slight enhancement and serpentine feeding arteries in the arterial phase, moderate enhancement with a draining vein around the tumor in the portal venous phase and persistent enhancement in the delayed phase. Surgical resection was performed, and the pathological diagnosis was FDCS. However, the patient died of inability to excrete sputum and occlusion of the respiratory tract.

CONCLUSIONS

Pancreatic FDCS manifested as PNP and MG is very rare. Its CT features are not specific, and the disease should be differentiated from neuroendocrine tumors, solid pseudopapillary neoplasms and acinar cell carcinoma.

Paraneoplastic Pemphigus as a First Manifestation of an Intra-Abdominal Follicular Dendritic Cell Sarcoma: Rare Case and Review of the Literature

Background

Follicular dendritic cell sarcoma (FDCS) is an extremely rare malignant tumor caused by proliferation of antigen-presenting follicular dendritic cells. The tumor most commonly arises in lymph nodes, with fewer than 30% of cases originating in extranodal sites.

Case Presentation

We report the case of a 39-year-old previously healthy male patient who presented with paraneoplastic pemphigus in the setting of a large intraperitoneal mass with no associated lymphadenopathy. The biopsy results showed a cellular proliferation of mildly to moderately atypical oval-to-spindle-shaped cells admixed with a variably dense lymphoplasmacytic infiltrate suggestive of FDCS versus inflammatory myofibroblastic tumor. A pathology review following total resection of the abdominal mass confirmed the diagnosis of FDCS. The tumor cells showed positivity for CD35, CD21, CD45, and CD68, negative ALK staining, and limited smooth muscle actin immunoreactivity. The surgery was complicated by severe pneumonia and acidosis, resulting in a prolonged ICU stay and death.

Conclusion

It is essential to maintain a high index of suspicion for FDCS and include it in the differential diagnosis of a spindle cell neoplasm, especially in the setting of paraneoplastic pemphigus. The histological and immunohistochemical features should be sufficient to confirm the diagnosis of FDCS.