Calcifying Fibrous Tumor of the Gastrointestinal Tract

Jejunal calcifying fibrous tumor: A jigsaw puzzle with a pool of diagnostic dilemma

ABSTRACT

Calcifying fibrous tumor (CFT) is a very rare benign fibroblastic tumor featuring a wide anatomical distribution and mimicking various spindle cell tumors. CFT has been documented in soft tissues, gastrointestinal tract (GIT), neck, adrenal glands, and pleura. Within the GIT, it is reported in the stomach, small bowel, large intestine, stomach, esophagus, and appendix. The occurrence of CFTs in the gastrointestinal tract presents a diagnostic dilemma, firstly due to the rarity of the lesion and secondly, due to the occurrence of a variety of other stromal lesions in the gastrointestinal tract with histological features that overlap with CFT. In the jejunum, it is extremely rare. We present one such rare case of jejunal CFT at an unusual age, complicated by jejuno-jejunal intussusception resulting in acute intestinal obstruction.

Case report: A large gastric calcifying fibrous tumor treated with endoscopic submucosal excavation

Gastric calcifying fibrous tumor (CFT) is a rare benign mesenchymal tumor. Several previous studies have reported surgical resection for gastric CFT larger than 20mm for the difficulty in preoperative diagnosis. Here, we report a rare case of large gastric CFT treated with endoscopic submucosal excavation (ESE). A 70-year-old woman presented with recurrent epigastric pain and underwent endoscopy, which revealed a 35mm-sized submucosal tumor in the gastric body. ESE was performed after imaging examination and endoscopic ultrasonography. En bloc resection was achieved, but due to the specimen's substantial size and difficulty in mincing, it posed challenges for removal through the mouth. Finally, the specimen was temporarily placed in the stomach and was completely removed two days later. The diagnosis was confirmed based on pathological and immunohistochemical findings. There was no recurrence during the patient's 11-month follow-up. We provided a case report related to the diagnosis and endoscopic treatment for large gastric CFT. In addition, our experience of temporarily leaving a large postoperative specimen, considered a benign lesion, in the stomach for later removal was successful but requires appropriate timing to avoid blockage of the gastrointestinal tract.

Endoscopic resection for calcifying fibrous tumors of the gastrointestinal tract

BACKGROUND

Calcifying fibrous tumors (CFTs) are rare mesenchymal lesions that can occur in various sites throughout the body, including the tubular gastrointestinal (GI) tract.

AIM

To analyze the clinical findings of 36 patients with GI tract CFTs to provide guidance for diagnosis and treatment.

METHODS

This retrospective study included 36 patients diagnosed with CFTs of the GI tract. We collected demographic and clinical information and conducted regular follow-ups to assess for local recurrence.

RESULTS

The stomach was the most commonly involved site, accounting for 72.2% of the 36 CFTs. Endoscopic mucosal resection (n = 1, 2.8%), endoscopic submucosal dissection (n = 14, 38.9%), endoscopic full-thickness resection (n = 16, 44.4%), and submucosal tunneling endoscopic resection (n = 5, 13.9%) were used to resect calcifying fibrous tumors. Overall, 34 (94.4%) CFTs underwent complete endoscopic resections with a mean procedure time of 39.8 ± 29.8 min. The average maximum diameter of the tumors was 10.6 ± 4.3 cm. No complications, such as bleeding or perforation, occurred during an average hospital stay of 2.9 ± 1.2 d. In addition, two patients developed new growth of CFTs near the primary tumor sites, and none of the patients developed distant metastases during the follow-up period.

CONCLUSION

GI tract CFTs are rare and typically benign tumors that can be effectively managed with endoscopic procedures.

OUP accepted manuscript

Calcified fibrous tumor (CFT) is a rare benign tumor of mesenchymal origin. Between 1988 and 2019, a total of 272 CFT cases were reported. CFTs can be seen in all anatomical regions with soft tissue. Histologically, mononuclear inflammatory infiltrates and the presence of psammomatous calcification in dense hyalinized collagen are characteristic features of the tumor. Currently, if the tumor is located in only one focus, surgical removal is recommended. Although CFT is a benign tumor, it may cause complications. Diagnosis is often difficult due to the confusion of tumor findings with many diseases. We present a patient with CFT, whose omental lesions were detected on abdominal computed tomography, and the diagnosis was confirmed by histopathological examination.

Calcifying fibrous tumor of the pancreas: A case report

A calcifying fibrous tumor (CFT) is a rare benign mesenchymal tumor characterized by a hypocellular fibroblastic proliferation with associated chronic inflammation and variably prominent calcification. Gastrointestinal (GI) tract is the most common predilection site of CFT. English-language literature reveals approximate 50 such reports of GI-CFTs. In addition, the most frequently identified sites of the GI tract are stomach, small bowel, and colon. However, CFT has not been reported in the pancreas. In addition, we present the first pancreatic-CFT in this case report.

Calcifying fibrous tumor of the gastrointestinal tract: A clinicopathologic review and update

Calcifying fibrous tumor (CFT) is a rare mesenchymal lesion that has been documented throughout the gastrointestinal tract. Gastrointestinal CFTs may occur at virtually any age, with a predilection for adults and for females. They occur most commonly in the stomach and the small and large intestines. CFTs are most often found incidentally, cured by local resection, and have a low risk of recurrence. Histology shows three characteristic features: Spindle cell proliferations within a densely hyalinized stroma, scattered calcifications, and lymphoplasmacytic inflammation. CFTs are immunoreactive for CD34, vimentin and factor XIIIa, helping to distinguish them from other benign mesenchymal neoplasms. The differential diagnosis of CFTs includes sclerosing gastrointestinal stromal tumor, leiomyoma, schwannoma, solitary fibrous tumor, inflammatory myofibroblastic tumor, plexiform fibromyxoma, fibromatosis, sclerosing mesenteritis, and reactive nodular fibrous pseudotumor. The pathogenesis of CFTs remains unclear, but some have hypothesized that they may be linked to IgG4-related disease, inflammatory myofibroblastic lesions, hyaline vascular type Castleman disease, sclerosing angiomatoid nodular transformation of the spleen, or trauma.

Calcifying Fibrous Pseudotumor of the Pancreas in a Patient With Metastatic Mammary Lobular Carcinoma and Gastric Gastrointestinal Stromal Tumor: A Previously Undescribed Benign Mimic of Metastatic Disease

Calcifying fibrous pseudotumor, a benign spindle cell tumor, has not been reported previously in the pancreas. Herein, we report a case of pancreatic calcifying fibrous pseudotumor in a 74-year-old female with a history of metastatic breast carcinoma and gastric gastrointestinal stromal tumor (GIST), both confounding the diagnosis and rendering it more challenging. Microscopic examination showed a well-demarcated, paucicellular, densely fibrotic tumor with widespread dystrophic calcifications and sparse, cytologically bland polygonal and spindle cells. Histologic and immunohistochemical work-up helped to exclude relevant differential diagnoses, including metastatic carcinoma, solitary fibrous tumor, inflammatory myofibroblastic tumor, and GIST. 

Calcifying Fibrous Tumor of the Mesentery: A Case Report and a Review of the Literature

Background:

Calcifying fibrous tumor (CFT) is a rare entity, with a distinctive histological presentation, initially reported as childhood fibrous tumor with psammoma bodies. It is a benign hypocellular fibrous neoplasm calcifications and lymphoplasmacytic infiltrate. The CFTs may involve many sites, including gastrointestinal tract, pleura, abdominal cavity, and neck. The diagnosis might be challenging due to histological overlaps with other mesenchymal tumors. The prognosis is good. We describe herein the case of a 53-year-old woman with an incidentally diagnosed CFT of the mesentery.

Case presentation:

A 53-year-old woman presented to the surgery department with a 2-year history of an anterior abdominal hernia. A computed tomographic scan of the abdomen failed to demonstrate any evidence of a mesenteric nodule. The patient underwent surgical treatment. Careful exploration during the excision of herniated sac revealed a solitary nodule of the mesentery. Local excision was performed. On gross, it was a well-demarcated nodule. Microscopically, the tumor consisted of an abundant paucicellular hyalinized collagen with calcifications; associated to a sparse mononuclear inflammatory infiltrate.

Conclusions:

Calcifying fibrous tumor is a benign lesion. The diagnosis is based on histology, because clinical and radiological features are nonspecific. Awareness of this entity is crucial to distinguish it from other mesenchymal tumors especially in the gastrointestinal tract.

Calcifying fibrous tumor originating from the gastrohepatic ligament that mimicked a gastric submucosal tumor: A case report

BACKGROUND

Calcifying fibrous tumor (CFT) is a rare, benign soft tissue tumor usually occurring in children or young adults. Gastrohepatic ligament CFT with adhesion to the stomach is very rare. We present a case here.

CASE SUMMARY

A 25-year-old woman visited our hospital with abdominal pain. Computed tomography and endoscopy were performed, and a gastric submucosal tumor (SMT) with a size of 6.7 cm × 2.7 cm was detected, so endoscopic ultrasonography-guided fine needle biopsy was performed. The tumor was not diagnosed histologically, so surgical resection was planned and performed. The histopathologically confirmed mass size was 6.5 cm × 4.0 cm × 1.0 cm, and a calcified fibrous tumor that originated at the gastrohepatic ligament and adhered to the lesser curvature of the gastric antrum was identified.

CONCLUSION

Gastrohepatic ligament CFT is a very rare benign tumor. Since this disease may be confused with gastric SMT, the possibility of CFT should be kept in mind during clinical assessment of this disease.

Clinicopathologic Study of Calcifying Fibrous Tumor Emphasizing Different Anatomical Distribution and Favorable Prognosis

Aims

Calcifying fibrous tumor (CFT) is a very rare begin fibroblastic tumor featuring a widely anatomical distribution and may mimic various spindle cell tumors. Misdiagnosis and hence mistreatment are likely caused due to unfamiliarity to clinicians or junior pathologists. We collected a relatively large series of CFTs in our institution aiming at further summarizing their clinicopathologic features in Chinese patients and discussing the diagnosis and differential diagnosis in clinical practice.

Methods

Clinicopathologic data of 22 CFTs were retrospectively reviewed. Histologic features were reevaluated and summarized. Immunostaining markers include CD34, SMA, Desmin, keratin, S100, ALK1, CD117, IgG, IgG4, and Ki-67. Follow-up of all cases was performed.

Results

22 CFTs include gastric (n=8), pulmonary (n=2), hepatic (n=2), cervical (n=1), appendiceal (n=1), esophageal (n=1), retroperitoneal (n=1), intra-abdominal (n=1), diaphragmatic (n=1), spermatic cord and scrotum (n=1), anconeal (n=1), mesenteric (n=1), and omental (n=1) lesions. Coexisting hepatocellular carcinoma, pancreatic carcinoma, pheochromocytoma, Castleman disease, and leiomyoma of the uterus and other metabolic or functional disorders were also appreciated. CFT histologically features spindle cells embedded dense hyalinized stroma with scattered psammomatous calcifications and lymphoplasmacytic infiltration and immunohistochemically for CD34. None of any individuals die of CFT per se.

Conclusion

Our study discloses that CFT is a bona fide benign fibroblastic lesion, regardless of its developing location. Involvement of digestive tract seems much more common in the Chinese population. Awareness of the clinicopathologic characteristics of this rare entity and its mimickers contribute to avoiding misdiagnosis and mistreatment in clinical practice.

Calcifying fibrous tumor and inflammatory myofibroblastic tumor are epigenetically related: A comparative genome-wide methylation study

Based on histological findings, calcifying fibrous tumor (CFT) may be a late (burned out) stage of inflammatory myofibroblastic tumor (IMT). This concept, however, has not been proven by molecular means. Five CFTs were analyzed for IMT-related rearrangements in ALK, ROS1 and RET using fluorescence in situ hybridization (FISH). Additionally, genome-wide methylation patterns were investigated and compared with IMT (n = 7), leiomyoma (n = 7), angioleiomyoma (n = 9), myopericytoma (n = 7) and reactive soft tissue lesions (n = 10) using unsupervised hierarchical cluster analysis and t distributed stochastic neighbor embedding. CFT patients, 4 females and 1 male, had a median age of 20 years ranging from 7 to 43 years. Two patients were younger than 18 years old. The tumors originated in the abdomen (n = 4) and axilla (n = 1). Histologically, all lesions were (multi) nodular and hypocellular consisting of bland looking (myo)fibroblasts embedded in a collagenous matrix with calcifications. FISH analysis brought up negative results for ALK, RET and ROS1 rearrangements. However, genome-wide methylation analysis revealed overlapping methylation patterns of CFT and IMT forming a distinct homogeneous methylation cluster with exception of one case clustering with myopericytoma/angioleiomyoma. In conclusion, DNA methylation profiling supports the concept that CFT and IMT represent both ends of a spectrum of one entity with CFT being the burn out stage of IMT.

Sclerosing Tumors of the Gastrointestinal Tract: A Systematic Approach

Some lesions in the gastrointestinal tract have a propensity for sclerosis such that it may mask the actual true nature of the lesion. The purpose of this review is to highlight those lesions of the gastrointestinal tract that can be attended by sclerosis. The sclerosis can mask the cellularity of the lesion; hence, knowledge of the key lesions that are known to have sclerosis will be aid the diagnostic pathologist.

Whole-exome sequencing identifies unique mutations and copy number losses in calcifying fibrous tumor of the pleura: report of 3 cases and review of the literature

Calcifying fibrous tumor of the pleura (CFTP) is a rare mesenchymal tumor of unknown pathogenesis. The diagnosis often requires exclusion of other common entities. Our aim was to determine if genomic changes were associated with CFTP that could contribute to mechanisms underlying tumorigenesis. Three cases of CFTP with their corresponding uninvolved control lung tissue were identified. Two patients were male, and 1 was female (age range, 21-32 years). Tumors were multifocal in 2 cases and solitary in 1. Immunohistochemistry for STAT6, BCL-2, CD34, cytokeratin AE1/AE3, calretinin, desmin, S100, ALK, and β-catenin was used. All immunohistochemistries were negative in CFTPs. DNA was isolated from all 3 pairs of CFTPs and matching normal lungs for whole-exome sequencing. Damaging, tumor-specific, coding variants were identified in 3 genes including multiple heterozygotic, de novo mutations in the Zinc Finger Protein 717 (ZNF717), fascioscapulohumeral muscular dystrophy-1 (FRG1) and cell division cycle 27 (CDC27) genes. Whole-exome sequencing revealed statistically significant, focal, tumor-specific copy number losses among all CFTPs including a large (302 kb) loss at 6p22.2 comprising 32 genes of the histone cluster 1 family and the hemochromatosis (HFE) gene. This is the first study to evaluate the molecular pathogenesis of CFTP and to identify novel deleterious mutations in ZN717, FRG1, and CDC27 genes as well as significant copy number losses on 8 chromosomes with a large loss common to all samples on chromosome 6. These mutations deleteriously altered coding domains in a manner predicted to be damaging to protein function and may contribute to CFTP tumorigenesis.

An Extremely Rare Case of Lower Urinary Tract Symptoms: Floating Benign Mesenchymal Mass in Abdomen

A 48-year-old man admitted to the urology outpatient clinic with major symptoms of right-side pain and intermittent lower urinary tract symptoms (LUTSs) such as low urine flow rate, dysuria, and frequency. Uroflowmetry showed low urine flow, and laboratory tests revealed no pathology. Ultrasound (US) showed a 7 cm calcific mass above the bladder and a kidney cyst with a diameter of 5.3 cm in the upper pole of the right kidney. Enhanced computed tomography confirmed the US findings. Laparoscopic transperitoneal renal cyst decortication was performed. There was no sign of additional tumors. An independent mass in the abdomen was diagnosed, and the mass was removed. Based on the pathology, the diagnosis was a benign mesenchymal calcific mass. This is the first report of LUTSs due to a free benign mesenchymal mass in the published literature.