Metastasizing hyalinizing spindle cell tumour with giant rosettes: report of a case with long survival

Low-grade fibromyxoid sarcoma of anterior abdominal wall

Low grade fibromyxoid sarcoma (LGFMS) is a rare soft tissue tumor, having metastatic potential and high local recurrence rate despite its low grade histologic findings. This tumor of deep and subcutaneous soft tissues occurs in 3rd and 5th decade of life. Diagnosis of LGFMS remains problematic because of its bland looking histologic features that can be potentially confused with other benign or low grade soft tissue tumors. We report here a rare case report of low grade fibromyxoid sarcoma of anterior abdominal wall.

Orbital hyalinizing spindle cell tumor with giant rosettes

PURPOSE

To evaluate the clinical and histopathologic characteristics of orbital hyalinizing spindle cell tumor with giant rosettes (HSCTGR).

METHODS

Interventional case series of 2 patients, aged 4 and 9 years referred to the Ocular Oncology Unit. Both patients presented with slowly progressive proptosis with dimness of vision in the second patient. CT was performed for both patients followed by excision of the masses. Histology was performed on tissue sections.

RESULTS

CT revealed a localized tumor in the first case and extensive mass extending to the optic canal in the second patient. Histologic analysis revealed features of HSCTGR with characteristic spindle-shaped cells with giant rosettes with hyalinized foci. Tumor cells were positive for vimentin in both cases and focal S100 positivity in first case. However, the second case showed a higher Ki-67 index compared to the first case, suggestive of moderately high proliferative activity. After excision, neither of the tumors demonstrated local recurrence, and both patients were without regional or distant metastases. Mean clinical follow-up was 12 months.

CONCLUSIONS

HSCTGR involving the orbit has not been previously reported in the literature. We report 2 cases of orbital presentation at a much younger age than has been shown in patients with this type of tumor in other areas of the body. Complete excision of this tumor with close follow-up is the preferred treatment. HSCTGR should be considered in the differential diagnosis of orbital fibrous tumor presenting as painless progressive proptosis.

Sclerosing epithelioid fibrosarcoma: case presentation and a systematic review

In sclerosing epithelioid fibrosarcoma (SEF), a rare variant of low-grade fibrosarcoma, treatment results and therapeutic options are poorly characterized. We systematically analyzed the data of all 89 patients (43 female, 46 male; mean age, 47 years [range, 14-87 years]) reported in the literature concerning clinical presentation, histopathology, differential diagnosis, treatment, survival rates, and prognosis, and we present an additional case. Information detailing treatment, disease control, and followup was available in 60 (67%), 75 (84%), and 68 patients (76%), respectively. Case history was variable with one-third of patients reporting a painful, enlarging mass. Ten patients (13%) presented with metastases, 23 (31%) had metastases develop after diagnosis, and 28 (37%) had local recurrence. Low cellularity, mild pleomorphy, and sclerotic hyaline matrix of SEF suggest a benign clinical behavior, and cell morphology allows for the wide differential diagnosis of benign, pseudosarcomatous, and malignant proliferations. In addition to surgery, 11 patients (15%) had chemotherapy, 22 (29%) had postoperative radiation therapy, and three (4%) had a combination of both. Twenty-three patients (34%) died from their disease after a mean of 46 months, 24 (35%) were alive with disease, and 20 (31%) were alive without evidence of disease. Patients with SEF of the head and neck had the worst prognosis.

LEVEL OF EVIDENCE

Level III, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Hyalinizing spindle cell tumor with giant rosettes arising in the lung: Report of a case with FUS-CREB3L2 fusion transcripts

Hyalinizing spindle cell tumor with giant rosettes (HSCT) is a very uncommon mesenchymal tumor that has similar morphological and biological features to the low-grade fibromyxoid sarcoma (LGFMS). Lung involvement of HSCT is extremely rare, and only one case has been reported in the English-language literature. Reported herein is a case of primary pulmonary HSCT that had FUS-CREB3L2 fusion transcripts, a product of characteristic chromosomal abnormality t(7;16)(q33;p11) of HSCT and LGFMS. The patient was a 50-year-old woman who had a large solitary mass in the lung. Histologically, it was composed of bland spindle cells with variable cellularity deposited in a densely hyalinized stroma alternating with myxoid areas. Characteristic collagen rosettes were scattered in the cellular areas. Reverse transcription-polymerase chain reaction (RT-PCR) assay using formalin-fixed, paraffin-embedded tissue detected FUS-CREB3L2 fusion transcripts. Despite its bland morphology, it is known as low-grade sarcoma and its recognition in the lung would be helpful for accurate diagnosis and proper management of this rare tumor. RT-PCR for detection of FUS-CREB3L2 fusion transcripts is a useful method for differential diagnosis of primary pulmonary HSCT.

Schwannoma with neuroblastoma-like rosettes: an unusual morphologic variant

In the past ten years, seven cases of schwannomas with giant fibrillar rosettes or perivascular rosettes have been reported. As these unusual variants of schwannomas had areas with hyperchromatic, small round cells recapitulating the appearance of a neuroblastoma, they received the descriptive name of neuroblastoma-like schwannomas. We herein report two additional cases of this unique variant of schwannoma and provide differential diagnostic considerations.

Hyalinizing spindle cell tumor with giant rosettes with pulmonary metastasis after a long hiatus: a case report

Hyalinizing spindle cell tumor with giant rosettes (HSCTGR) is a recently described tumor, which is regarded as an unusual variant of low-grade fibromyxoid sarcoma. Proof of a metastatic potential was lacking. The patient in the report was a 35-yr-old woman who showed multiple bilateral pulmonary nodules with massive pleural effusion in the right side. She had a history of a mass excision in the right thigh 11 yrs ago at another hospital, which was reported as a "leiomyoma". Two years before this presentation, the patient received a routine chest radiograph which demonstrated bilateral multiple pulmonary nodules. A lobectomy of the left upper lung was performed. The histological findings revealed a well-circumscribed nodule that was characterized by a spindle-shaped fibrous to hyalinized stroma with criss-crossing short fascicles and giant collagen rosettes surrounded by a rim of spindle-shaped cells. Electron microscopy confirmed the fibroblastic nature of the tumor. This case, in addition to at least two other cases reported in the literature, demonstrates that the HSCTGR is a malignant neoplasm with the capacity to metastasize after a long hiatus.

Primary mediastinal hyalinizing spindle cell tumor with giant rosettes

We describe herein a unique case of primary mediastinal hyalinizing spindle cell tumor with giant rosettes that occurred in a 41-year-old man. The clinical and pathologic features together with a brief review of the literature are reported.

Primary sclerosing epithelioid fibrosarcoma of the sacrum: a case report and review of the literature

Sclerosing epithelioid fibrosarcoma is a rare tumour characterised histologically by a predominant population of epithelioid cells arranged in strands and nests, embedded in a fibrotic and hyalinised stroma. It is a low grade tumour with an indolent course. A 48 year old woman presented with a painful swelling over her back for six months. Investigation and biopsy revealed features of sclerosing epithelioid fibrosarcoma involving the left half of the sacrum, left sacro-iliac joint, and posterior part of the left ilium. Preoperative radiotherapy and wide location excision of the tumour were followed by metastatic recurrence of the tumour in the lung and scalp six years after initial presentation. The tumour showed typical histology of sclerosing epithelioid fibrosarcoma. The radiological features confirmed its primary location in the sacrum. The patient declined chemotherapy and died of disseminated disease eight years after initial presentation. Review of the literature confirms the fact that sclerosing epithelioid fibrosarcoma, despite its low grade, is a clinicopathologically distinct tumour with full malignant potential, the recurrence, metastasis, and mortality rate being 48%, 60%, and 35%, respectively. Sclerosing epithelioid fibrosarcoma can occur as a primary bone tumour, the clinical behaviour of which is probably similar to its soft tissue counterpart.

Hyalinizing Spindle Cell Tumor with Giant Rosettes: A Case Report

Hyalinizing spindle cell tumor with giant rosettes (HSCTGR) is characterized by both giant rosette-like structures with collagen cores sparsely distributed throughout the tumor and fibromyxoid stroma. It is a rare low-grade sarcoma with indolent behavior, and wide excision with long-term follow-up is the best treatment. Although originally considered a distinct entity, it is now regarded as a variant of low-grade fibromyxoid sarcoma. We present a case of HSCTGR arising in the deep soft tissue of the left knee in a 50-year-old woman and provide a brief review of the literature for comparison.

Low-grade fibrosarcoma (hyalinizing spindle cell tumor with giant rosettes) with pulmonary metastases at presentation: case report and review of the literature

Hyalinizing spindle cell tumor with giant rosettes (HSCT) is presently considered a low-grade fibrosarcoma and is also considered a variant of low-grade fibromyxoid sarcoma by some. None of the HSCTs in the original series had manifested malignant behavior in the form of metastasis, but since that initial report, 2 patients have been reported with pulmonary metastases and another patient with multiple pulmonary nodules in the absence of an identifiable primary tumor. Our patient is the second recorded case of HSCT with pulmonary metastases at the time of diagnosis. A needle biopsy of the axillary mass in the present case consisted mainly of densely hyalinized collagen, whereas the lung nodules had the characteristic giant collagen rosettes surrounded by a bland spindle cell stroma. This case, in addition to at least 2 others in the literature, has demonstrated that the HSCT is a malignant neoplasm with the capacity to metastasize; however, the presence and even persistence of metastatic lesions in the lung has not altered to date an otherwise indolent clinical course. The fact should not be overlooked that the HSCT is a recently reported entity whose natural history and nosology are subjects of continuing observation, study, and discussion.

Hyalinizing spindle cell tumor with giant rosettes: report of a case showing remarkable myofibroblastic differentiation

We examined the proliferative activity and the differentiation line of tumor cells in a case of "hyalinizing spindle cell tumor with giant rosettes" (HSCGR). A 6 cm tumor within the right deltoid muscle of a 58-year-old female was found by physical and radiographical examinations. A biopsy revealed the histological features of a spindle cell tumor with rosette-like structures. Wide excision was done under the diagnosis of HSCGR. The tumor presented as a gray-whitish, solid mass with focal pseudocystic degeneration. Immunohistochemically, the tumor cells were diffusely positive for vimentin and were also focally positive for S-100, but negative for desmin and alpha-smooth muscle actin. The cells stained positively for Ki-67 with even distribution, there being a correlation with the cellularity of the areas, with a labeling index ranging from 0.3 to 0.5%. In addition, flow cytometry revealed an almost normal diploid DNA pattern and 5.8% S-phase fraction, indicating low proliferative activity. Ultrastructurally, many tumor cells displayed discontinuous basal lamina, pinocytotic vesicles, dilated rough endoplasmic reticulum, and microfilaments with focal dense bodies. The main component of the rosette was collagenous fibrils with normal diameter and normal periodic banding. We interpreted this case of HSCGR as a low grade fibrosarcoma with remarkable differentiation of myofibroblastic lineage, and with focally accumulated, morphologically normal collagenous fibrils.

Hyalinizing spindle cell tumor with giant rosettes of the broad ligament

BACKGROUND

Hyalinizing spindle cell tumor with giant rosettes (HSTGR) is a rare, recently described tumor that most commonly occurs in the peripheral deep soft tissues.

CASE

A 53-year-old woman was operated on because of a mass in the broad ligament which was first noted 17 years previously. The tumor showed typical features of HSTGR. Two years after surgery, the patient is alive with no evidence of disease.

CONCLUSIONS

To our knowledge, the present case is the first description of HSTGR occurring in the broad ligament. Despite its bland morphology, HSTGR is a low-grade sarcoma, most probably a variant of low-grade fibromyxoid sarcoma. A wide resection of the tumor and prolonged follow-up are needed because patients may develop late metastases.

Sclerosing epithelioid fibrosarcoma: a study of 16 cases and confirmation of a clinicopathologically distinct tumor

Sclerosing epithelioid fibrosarcoma (SEF) is an uncommon tumor of deep soft tissues, originally described in 1995 by Meis-Kindblom et al. In the current study, the authors identified 16 cases of SEF in the pathology files of their institutions and studied their pathologic features and disease course. The group consisted of six male and 10 female patients (age range, 14-55 years; mean age, 40 years), and the tumors were located in a limb or limb girdle (n = 7), base of the penis (n = 1), back or chest wall (n = 3), and head and neck (n = 5). Tumor size ranged from 3.7 to 22 cm (mean, 8.9 cm). Histologically, the SEFs were composed predominantly of small to moderate-size round to ovoid, relatively uniform cells, often with clear cytoplasm, embedded in a hyalinized fibrous stroma. The only consistent immunohistochemical finding was a strong, diffuse reactivity of tumor cells for vimentin. Ultrastructural analysis performed in eight cases confirmed their fibroblastic nature. Bone invasion and tumor necrosis, features not reported before, were found in six cases each. Treatment consisted of intralesional excision (n = 2), attempted wide local excision (n = 11), and amputation (n = 3), with either adjuvant radiation therapy (n = 9) or chemotherapy (n = 3). Follow-up of at least 1 year in 14 cases revealed persistent disease or local recurrence in seven patients (50%), and distant metastasis in 12 patients (86%). Eight patients (57%) died of disease 16 to 86 months after diagnosis. Five patients were alive with disease as of last follow-up. SEF shares some pathologic features with two other fibrosing fibrosarcomas, low-grade fibromyxoid sarcoma and hyalinizing spindle cell tumor with giant rosettes, but in the authors' experience behaves clinically as a fully malignant sarcoma.

Hyalinising spindle cell tumour with giant rosettes: report of a case with unusual features including original histological and ultrastructural observations

Hyalinising spindle cell tumour with giant rosettes (HSCTGR) is an uncommon, recently described low-grade sarcoma which shares many histological features with low-grade fibromyxoid sarcoma (LGFMS). We report a case of HSCTGR occurring in the deep soft tissues of the thigh of a 46-year-old woman, that presented as a slowly growing, painless mass. Microscopically the tumour was composed of spindled stromal cells amongst which were scattered so-called collagen rosettes. The distinctive feature of this case was the previously unreported finding of lymphoid cells of T-cell phenotype admixed with fibrohistioctyic cells in the cellular cuff surrounding the collagenous core of the rosettes. The case was further unusual in that it included focal areas of increased cellularity with a mitotic count of up to three per 10 high-power fields. While the latter feature has been associated with increased recurrences and metastases in LGFMS, it is not known whether the significance is similar in HSCTGR. The spindled stromal cells showed ultrastructural features of poorly differentiated fibroblasts, while those at the edges of the rosettes showed features of altered fibroblasts, some with a fibrohistiocytic appearance. These findings support the interpretation that HSCTGR forms part of the spectrum of sarcomas showing fibroblastic differentiation.

Fibrosarcomatous dermatofibrosarcoma protuberans with giant rosettes

A rare case of dermatofibrosarcoma protuberans, which contained low-grade fibrosarcoma with giant rosettes in its recurrence areas is described. The giant rosettes lying in the fibrosarcomatous area produced a pattern similar to that of so-called hyalinizing spindle cell tumor with giant rosettes. The transitions between the tumor components were gradual, and both primary and recurrent lesions showed diffuse immunoreactivity for CD34. The presence of giant rosettes in fibrosarcomatous areas of dermatofibrosarcoma protuberans suggests a possible histogenetic relationship between fibrosarcomatous areas of DFSP and hyalinizing spindle cell tumor with giant rosettes.

Low-grade fibromyxoid sarcoma and hyalinizing spindle cell tumor with giant rosettes: a clinicopathologic study of 73 cases supporting their identity and assessing the impact of high-grade areas

Low-grade fibromyxoid sarcoma (LGFMS) is a rare sarcoma characterized by bland histologic features and a paradoxically aggressive clinical course. The hyalinizing spindle cell tumor with giant rosettes (HSCT) is a closely related tumor characterized by the presence of giant collagen rosettes. Only a single example of a metastasizing HSCT has been reported. A small subset of both LGFMS and HSCT display areas of increased cellularity and atypia which qualify as intermediate- to high-grade sarcoma; the significance of these features has not been definitively assessed. We present the clinicopathologic features of 77 cases of LGFMS and HSCT to determine the degree of overlap of these two lesions, their biologic behavior, and the significance of the occasional presence of intermediate- to high-grade sarcoma within both. The patients (33 female, 40 male) ranged from 3 to 78 years of age (median, 34 yrs). Fourteen cases occurred in patients less than 18 years of age. The tumors measured from 1 to 23 cm (median, 4.5 cm) and occurred predominantly in the trunk and lower extremities in both the deep (66 cases) and superficial (7 cases) soft tissues. In 15 cases, the tumor was present > 1 year before diagnosis. All tumors showed predominantly the typical hypocellularity and bland cytologic features of typical LGFMS; however, areas of hypercellularity and nuclear enlargement and hyperchromatism were identified in 12 of 73 (16%) and 7 of 73 (10%), respectively. Necrosis and mitotic activity >5/50 high-powered fields (HPF) were present in 6 of 73 (8%) and 5 of 73 (7%), respectively. Epithelioid areas were present in 33 of 73 (45%) and rosettes in 22 of 73 (30%). Follow up (54 cases; range, 2-192 mos; median, 24 mos; mean, 38 mos) showed 5 recurrences, 3 metastases, and 1 death. The diagnosis of LGFMS or HSCT was made prospectively in 51 patients; none had metastatic disease. Two of the metastatic tumors were LGFMS and one was a HSCT. LGFMS may occur more often in the pediatric population and show a much wider histologic spectrum than previously thought. A significant number of LGFMS possess inconspicuous collagen rosettes characteristic of HSCT, indicating that these two tumors are ends of a common spectrum rather than distinct entities. HSCT, like LGFMS, are low-grade sarcomas with metastatic potential. The presence of focal areas of intermediate- to high-grade sarcoma does not portend a worse outcome in the short term. The better prognosis reflected in this study compared with previous ones might reflect the fact that all were initially diagnosed as sarcomas and treated with aggressive surgery. The fact that the only three patients to develop metastatic disease were patients whose LGFMS or HSCT was identified retrospectively supports this concept.