Cardiac metastasis of a low-grade myofibroblastic sarcoma

A Systematic Review and Illustrative Case Presentation of Low-Grade Myofibroblastic Sarcoma (LGMS) of the Extremities

INTRODUCTION

Low-grade myofibroblastic sarcoma (LGMS) is a rare tumor entity which occurs in the subcutaneous and deep soft tissues; it is less common in the bone with a predilection for the extremities and the head and neck region. As confirming the diagnosis is difficult and treatment strategies are not standardized, we aimed to identify patient and tumor characteristics, and to summarize treatment strategies and their clinical outcomes to guide surgeons.

METHODS

Included were full articles reporting patients with histology of LGMS in the extremities, excluding tumors of the trunk. All patients underwent surgery but with different extend, from marginal to wide resection. Included studies should inform about local recurrence, metastasis, or evidence of disease, depending on the surgical treatment. We conducted a structured search using MEDLINE (via PubMed), Web of Science, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) to identify studies on low-grade myofibroblastic sarcoma of the extremities. Study designs like randomized controlled trials, systematic reviews, prospective trials, retrospective studies, and case reports were included. Prospective studies and comparative studies were not available at all. Therefore, meta-analysis was not possible and statistical analysis was purely descriptive.

RESULTS

Of the 789 studies identified from our initial search, 17 studies including 59 cases reported LGMS of the extremities with the surgical treatment and clinical outcome and were therefore analyzed. In addition, we present the rare case and surgical management of a 28-year-old male patient with residual LGMS of the thumb after an initial incomplete resection. The current literature suggests that a wide excision with R0 margins should be considered the standard treatment for LGMS. In cases where surgery leads to significant functional impairment, individual options like free tissue transfer from a donor site have to be considered. Therefore, we also present an illustrative case. For all selected case series and case reports, a high risk of confounding, selection bias, information bias, and reporting bias must be anticipated. Nevertheless, this systematic review provides a comprehensive overview on surgical treatment and clinical outcomes in LGMS surgery of the extremities.

Low-grade myofibroblastic sarcoma of the proximal femur: A case report and literature review

RATIONAL

Low-grade myofibroblastic sarcoma (LGMS) is an atypical type of tumor composed of myofibroblasts. LGMS in the femoral head neck junction is extremely rare and no case treated by hip arthroscopy was reported.

PATIENT CONCERNS

We reported a case of LGMS in the femoral head neck junction treated by hip arthroscopy. A 30-year-old female was admitted to our hospital with discomfort and pain after left hip sprained one year prior. Physical examination revealed swelling of the left hip and magnetic resonance images showed a soft tissue mass in the femoral head neck junction.

DIAGNOSIS

Via microscopy of pathological specimens, spindle cell proliferative lesions, atypia of some cells, and mitotic figures/pathological mitotic figures of some cells were observed. Immunohistochemistry revealed positive for smooth muscle actin, focally positive for CD34 and CD68, while negative for S-100, desmin, and anaplastic lymphoma kinase. The imaging, histomorphological and immunohistochemical features suggested a final diagnosis of LGMS of the proximal femur.

INTERVENTIONS

This patient underwent hip arthroscopy for excision of the soft tissue mass.

OUTCOMES

The clinical and imaging follow-up at 6 months postoperatively showed that surgery had achieved good clinical outcomes.

LESSONS

To the best of our knowledge, this is the first case report of LGMS in the femoral head neck junction treated by hip arthroscopy. Beyond the present case, other 120 cases from 58 literatures (1998-2022) are reviewed and discussed. The age of LGMS patients ranged from 11 months to 77 years and the male-to-female ratio was approximately 1.28:1. The location distribution of previously reported LGMS cases and the present case was as follows: Head&neck (45.90%), trunk (30.33%), and extremity (23.77%). Hip arthroscopic excision of LGMS may achieve relatively good clinical outcomes.

Case report: multi-modality imaging of a right ventricular fibroma in a teenager

Background

Cardiac fibroma is a rare primary benign tumour of the heart. It often causes arrhythmia, endangers the lives of patients, and has a worse prognosis than other benign tumours. We report a 14-year-old female patient with a right ventricular fibroma. Various preoperative imaging examinations showed that the lesion was benign, and postoperative pathology confirmed that the lesions were fibroma.

Case summary

A 14-year-old female patient visited her doctor for more than 5 months because of a heart murmur. Echocardiography revealed a slightly hyperechoic mass in the right ventricle, and on myocardial perfusion contrast imaging, the lesion showed equal enhancement. And the lesion also showed enhancement on contrast-enhanced gated cardiac computed tomography (CT). Contrast-enhanced magnetic resonance imaging (MRI) of the heart revealed that the lesion was isointense on T₁-weighted image (T₁WI), and isointense to slightly hyperintense on T₂-weighted image (T₂WI). The lesion was significantly homogeneously enhanced on a delayed enhancement scan. A positron emission tomography-CT (PET-CT) with 18F-fluorodeoxyglucose (18F-FDG) demonstrated that the mass showed lower levels of 18F-FDG uptake. These features suggested this lesion was a benign lesion. The postoperative pathology suggested the lesion was a right ventricular fibroma. The patient was discharged 14 days after surgery and remains disease-free and asymptomatic 14 months after surgery.

Discussion

Cardiac fibromas are histologically benign, but they can cause obstruction and malignant arrhythmia. The gold standard for diagnosing fibroma is pathology. However, in the absence of pathology, it is necessary to use various imaging methods to evaluate the lesions to distinguish between benign and malignant tumours.

Low-grade myofibroblastic sarcoma of the levator scapulae muscle: a case report and literature review

BACKGROUND

Low-grade myofibroblastic sarcoma (LGMS) is described as a distinct atypical myofibroblastic tumor often with fibromatosis-like features and predilection for the head and neck, especially the oral cavity and larynx. LGMS arising in the levator scapulae muscle is extremely rare.

CASE PRESENTATION

A 69-year-old woman was admitted to our hospital because she noticed a hard mass in her left neck six months prior. Magnetic resonance images (MRI) showed a soft tissue tumor of the left levator scapulae muscle. A core needle biopsy showed cellular fascicles or a storiform growth pattern of spindle-shaped tumor cells with minimally atypia. Immunohistochemistry revealed focally positive for α-smooth muscle actin (α-SMA), negative for S-100, and a low-grade spindle cell sarcoma was suspected. Following a biopsy, the tumor was resected with a wide surgical margin. Immunohistochemical staining was a positive for vimentin and α-SMA and negative for desmin, CD34, nuclear β-catenin, and h-caldesmon. LGMS diagnosis was determined based on the histopathological findings. The patient was alive with no evidence of disease eight years after the surgery.

CONCLUSIONS

To the best of our knowledge, this is the first case report of LGMS arising in the levator scapulae muscle. In addition to the case report, 48 reports with 103 LGMS cases are reviewed and discussed. In previous reports of LGMS, there were 43 females and 60 males, with a mean age of 43.0 years (range, 2-75). There were 13 (12.6%) patients aged < 18 years, 67 (65.1%) patients aged 18 to 59 years, and 23 (22.3%) patients aged ≥60 years. The average tumor size was 4.4 cm (range: 0.4-22.0). The commonest sites of LGMS was the tongue. Tumor growth patterns were evaluated in 52 cases, and 44 cases (84.6%) showed infiltrative growth patterns. Local recurrence was 26.7%, and distant metastasis was 4.4%. Because of the locally aggressive feature, it is important to diagnose LGMS with biopsy and to excise the tumor with an adequately wide margin.

Cardiac metastases from primary myxoid liposarcoma of the thigh: a case report

BACKGROUND

Myxoid liposarcoma is well known to have an unusual proclivity for extrapulmonary metastasis. However, cardiac metastasis of myxoid liposarcoma is very rare, even in patients with advanced disease.

CASE PRESENTATION

A 40-year-old man was diagnosed with myxoid liposarcoma of the right thigh and treated with wide resection. Two years after the surgery, a low-density area in the left ventricle was found on follow-up chest computed tomography, and was suspected of being metastatic disease. He underwent surgical treatment, and the lesion was pathologically confirmed as metastasis of myxoid liposarcoma. Fifteen months later, he complained of slight dyspnea and developed metastatic disease in the right atrium. He was treated with surgical excision, followed by radiotherapy. Although there was no recurrence in the heart since the second cardiac metastasectomy, multiple metastases occurred in the abdominal cavity, lungs, and muscles. He finally died of the disease 2 years after the second cardiac metastasectomy.

CONCLUSION

We experienced a case of primary myxoid liposarcoma in the thigh, accompanied by ectopic and metachronous cardiac metastases. Although this condition is rare, we should follow-up patients with myxoid liposarcoma, considering the possibility of cardiac metastasis.

Is there a role for chemotherapy and radiation in the treatment of patients with low-grade myofibroblastic sarcoma?

PURPOSE

Low-grade myofibroblastic sarcoma (LGMS) is a rare entity with a predilection for the head and neck. There are still no optimal treatment strategies for patients with LGMS. We retrospectively investigated the efficacies of chemotherapy and radiation treatment for patients with LGMS.

METHODS/PATIENTS

We obtained data from the Surveillance, Epidemiology, and End Result (SEER) database for 96 patients diagnosed with LGMS between 2001 and 2015. We used Kaplan-Meier curves and log-rank tests to estimate overall survival (OS) and Cox proportional hazard regression to identify prognostic factors.

RESULTS

The median age of the patients was 55.0 years. Twenty-two of the patients had LGMS in the head and neck region. Of the 96 patients, 86 (89.6%) received surgical treatment, 28 (29.2%) received radiation treatment, and 20 (10.4%) received chemotherapy. The mean OS was 125.2 [95% confidence interval (CI) 106.3-144.2] months. The 1, 3, 5, and 10-year OS rates were 88%, 77%, 70%, and 59%, respectively. Age greater than 60 years, positive nodal status, and no surgical treatment were independent prognostic factors for patients with LGMS, whereas chemotherapy and radiation treatment were not.

CONCLUSIONS

Surgical resection is the most effective therapy for LGMS. Chemotherapy and radiation had limited effects on survival improvement for patients with LGMS. Therefore, chemotherapy and/or radiation therapy should not be routinely performed in LGMS, especially for those with negative margins after surgery.

Low-grade Myofibroblastic sarcoma: clinical and imaging findings

Background

Low-grade myofibroblastic sarcoma (LGMS) is a rare type of tumor. Previous research has paid much attention to reporting pathological analyses of LGMS. However, only few systematic clinical and/or radiological studies have been conducted.

Methods

This study recruited 14 cases (8 males and 6 females) of LGMS. X-ray or computer tomography (CT) scan were performed on 11 cases. MRI was performed on 5 cases.

Results

X-Ray and CT scan: Five cases developed LGMS in bones, including 3 cases in the distal femur, 1 in the right shoulder blade, and another 1 in the right inferior ramus. Massive infiltrative and vermiform bone destruction with poorly-circumscribed lesion margins and partial soft tissue masses were observed. The other 9 cases were developed in soft tissues. Out of them, 4 cases presented slightly irregular hyper- or lower-density masses with poorly-circumscribed margins. 2 cases presented massive calcification and ossification. Significant enhancement was observed in 1 case, while no obvious enhancement was seen in the other 2 cases.

MRI: MR images of 5 cases revealed homogeneous iso- or hyper-signal intensity on T1WI and homogeneous or heterogeneous hyper-signal intensity on T2WI. Enhanced MRI revealed homogeneous enhancement in 2 cases and rim enhancement in 1 case.

Conclusions

Our findings show that LGMS is characterized by invasiveness, metastases and calcification. Different radiological tools should be employed to make an accurate diagnosis.

Indolent growth of low-grade myofibroblastic sarcoma of the cheek mimics benign lesions: A case report and literature review

Low-grade myofibroblastic sarcoma (LGMS) is a neoplasm of the soft tissue characterized by myofibroblastic differentiation. This type of tumor has been observed in various sites in the whole body, but frequently occurs in the head and neck region. It typically presents as a slow-growing painless mass, which is often mistaken for a benign lesion due to its indolent growth; however, LGMS is a malignant neoplasm. In the present study, a 43-year-old female presented with a 14-mm LGMS lesion in the buccal subcutaneous tissues of the buccinator muscle. The patient had initially noticed the lesion 2-months prior to presenting at the hospital. Following biopsy, the tumor was surgically resected and no recurrence or metastasis was observed during a follow-up time of 2 years. To the best of our knowledge, this case is the first report of LGMS located in the buccal subcutaneous tissue of the buccinator muscle. The present study a literature review of 55 cases of this tumor type in the head and neck region was conducted, revealing that the indolent growth of these lesions may contribute to a delay in diagnosis. The average time between the onset of clinical symptoms and hospital admission is 3.9 months, and this form of tumor is frequently misdiagnosed as a benign lesion. Therefore, the present study suggests that an incisional biopsy may be performed to rule out LGMS when clinicians encounter patients with the aforementioned indolent lesions anywhere in the body. In addition, the avoidance of radiotherapy is recommended following resection of the LGMS tumor, as it may induce LGMS recurrence.