Difference between revisions of "Fibroblastic/myofibroblastic tumours"

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(→‎General: +hypoglycemia)
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DDx:
DDx:
*[[DFSP]] - t(17;22).
*[[Dermatofibrosarcoma protuberans]] (DFSP) - t(17;22) COLA1/PDGFB.
*Congenital-infantile fibrosarcoma - t(12;15) ETV6/NTRK3.  
*[[Congenital-infantile fibrosarcoma]] - t(12;15) ETV6/NTRK3.  
*[[Solitary fibrous tumour]].
*[[Solitary fibrous tumour]].
*[[Synovial sarcoma]] - t(X;18) SYT/SSX.
*[[Synovial sarcoma]] - t(X;18) SYT/SSX.

Revision as of 16:15, 20 August 2012

This article covers fibroblastic/myofibroblastic tumours. These tumours fit into the larger category of soft tissue lesions.

List of tumours

Benign

WHO classification:[1]

  • Fibrous hamartoma of infancy.
  • Juvenile hyaline fibromatosis.
  • Desmoplastic fibroblastoma.
  • Mammary-type myofibroblastoma.

Locally aggressive

WHO classification:[1]

Occasionally metastasizing

WHO classification:[2]

Malignant

WHO classification:[2]

Inflammatory myofibroblastic tumour

  • AKA inflammatory pseudotumour, AKA inflammatory fibrosarcoma,[3] AKA plasma cell granuloma.[4][5]

General

  • Mostly benign.
  • Children & young adults.
  • Classically located in mesentery of ileocolic region or small bowel.[3]

Microscopic

Features:[3]

  • Inflammation:
  • Spindle cells without atypia.
  • +/-Fasciular architecture.
  • Mitoses -- though none atypical.
  • +/-Necrosis.
  • +/-Hemorrhage.
  • Calcifications.

DDx:

Notes:

  • Some consider this a wastebasket diagnosis... for benign appearing spindle cell lesions.[7]

Images:

IHC

Features - dependent on site:

  • SMA +ve.[8]
  • Vimentin +ve.

Variable staining with:

  • CD34, AE1/AE3, calretin.[9][8]

Negative:[8]

  • S100, CD117, CD68.

Molecular

  • ALK rearrangements.[6]

Proliferative fasciitis

General

  • Benign.
  • May mimic a sarcoma.[10]

Clinical:

  • Solid subcutaneous nodule.
  • Rapid growth.
  • May be painful.

Gross

  • Classically upper and lower extremities.[10]
  • Poorly demarcated.

Microscopic

Features:[11]

  • Large polygonal (ganglion-like) and/or spindled cells with:
    • Vesicular (clear) nuclei.
    • Prominent nucleoli.
  • +/-Binucleation.
  • Loose myxoid stroma.
  • Frequent typical mitoses.
    • No atypical mitoses.

DDx:

Images:

Proliferative myositis

General

  • Benign.
  • Possible arise from pericytes.[13]

Microscopic

Features:[13][14]

  • Large ganglion-like cells.
    • Cells have single prominent nucleolus.
  • Spindle cells.
  • +/-Binucleation.
  • Mitotic activity.
    • No atypical mitoses.

Image:

IHC

Features:[13]

  • Vimentin +ve.
  • SMA +ve.
  • Desmin +ve/-ve.

Others:[13]

  • Factor XIIIa -ve.
  • S100 -ve.
  • CAM5.2 -ve.
  • NSE -ve.

Elastofibroma

General

  • Benign.
  • Classically, subscapular in elderly women.[15][16]

Gross

Features:

  • Yellow-white, moderate demarcation to surrounding tissue.[17]

Microscopic

Features:

  • Thick bundles of collagen.
  • Elastin fibres.

Image:

Nodular fasciitis

Not to be confused with necrotizing fasciitis.

General

  • Benign.
  • All age groups.
  • Associated with trauma.

Microscopic

Features:[18][19]

  • Usu. well-circumscribed.
  • Clusters of (non-pleomorphic) spindle cells.
  • Inflammation (lymphocytes).
  • Microcysts in cellular regions - uncommon - discriminatory.
  • Mitoses - common.
  • Extravasated RBCs.

The BD feature list:[20][21]

  • Tissue culture-like/CNS-like morphology.
  • Thick (keloid-like) collagen bundles - key feature.
  • Extravasated RBCs.
  • Inflammation.
  • +/-Giant cells.

Notes:

  • No significant nuclear atypia.
  • No atypical mitoses.
  • May be cellular.

DDx:[22]

Images:

IHC

Routine spindle cell panel:

  • CD34 -ve.
  • Desmin -ve.
  • SMA -ve.
  • S100 -ve.
  • AE1/AE3 -ve.

Others:

  • H-caldesmon -ve.
  • EMA -ve.
  • Vimentin +ve.

Molecular

  • Evolving - case reports.
    • t(15;15)(q13;q25).[23]

Desmoid-type fibromatosis

  • AKA desmoid tumour.
  • AKA desmoid fibromatosis.

General

Microscopic

Features:[25][26]

  • "Sweeping fascicles"/bundles.
  • Spindle cells with:
    • Small slender nuclei.
    • Solid dark eosinophilic cytoplasm.
  • +/-Mitoses - may be abundant.
  • Long thin-walled vessels - parallel to one another - important feature.

Notes:

Images:

IHC

Features:[25]

  • Beta-catenin +ve - important.
  • SMA +ve ~50% of lesions.

Low-grade myofibroblastic sarcoma

General

  • Rare ~ 100 cases in the literature.
  • Usu. oral cavity or extremities.[28]

Microscopic

Features:

  • Spindle cells in the storiform pattern[28] or in fasicles.
  • Rare mitoses.

Images:

DDx:

IHC

  • SMA +ve.
  • CD34 -ve.
  • CD117 -ve.[28]
  • H-caldesmon -ve.[28]

Lipofibromatosis

  • AKA infantile subcutaneous fibromatosis.

General

  • Childhood.

Microscopic

Features:[25]

  • Fibroblastic cells surrounding adipocytes.

Image:

IHC

Features:[25]

  • CD34 +ve.
  • BCL2 +ve.
  • S100 +ve.
  • CD99 +ve.
  • Actin +ve.
  • EMA +ve.

Solitary fibrous tumour

  • Abbreviated SFT.

General

  • Grouped with hemangiopericytoma in the WHO classification - as it is thought to be the same tumour.[25]
  • May be benign or malignant; more commonly benign.[29][30]
  • May be associated with hypoglycemia.
    • Known as Doege-Potter syndrome.[31]

Gross

Microscopic

Features - benign:

  • Spindle cells in a patternless pattern.
  • Hemangiopericytoma-like area (staghorn vessels).
  • Keloid-like collagen bundles - key feature.
  • Usually well-circumscribed.

Criteria for malignancy:[25]

  • Necrosis.
  • Mitoses >4/10 HPF -- definition suffers from HPFitis.
  • Increased cellularity.
  • Marked nuclear atypia.
  • Infiltrative margin.

Images:

IHC

  • CD34 ~90% +ve.
  • CD99 ~70% +ve.
  • BCL2 ~50% +ve.

Hemangiopericytoma

General

  • Grouped with solitary fibrous tumour in the WHO classification; possibly the same tumour (?).[25]
  • Arises from the pericyte, a connective tissue cell of small vessels that is thought to be involved in flow regulation.
  • Hematologic spread most common - to lungs.[32]
  • Oncogenic osteomalacia - assoc. with hemangiopericytoma.[32]

Presentation

  • Usually painless mass, slow enlargement.

Radiology

  • Intramedullary lytic mass.
  • May be well-circumscribed.
  • +/-Periosteal reaction.
  • +/-Sclerotic border.

May be worked-up with angiography to distinguish from a vascular malformation.[33]

Location

  • Usually extremities - femur or proximal tibial.[32]

Microscopic

Features:[33]

  • Hypervascular lesion - key diagnostic feature.[34]
    • Abundant thin-walled branching small vessels of variable size.
      • May be described as "staghorn vessels" or "antler-like" vasculature.
      • Cells may "onion-skin" around thin blood vessels.
  • Spindle or ovoid shaped cells in nests or sheets.

DDx:

IHC

Features:[25][34]

  • Vimentin +ve (usually).
  • Desmin -ve (typical).
  • Factor VIII -ve (marks endothelium).
  • CD34 +ve.
    • CD34 usu. -ve in synovial sarcoma.
  • CD31 -ve (marks benign endothelium).
  • vWF (von Willebrand factor) -ve.

May be in the DDx for meningioma:[35]

  • EMA -ve.
  • S100 -ve.

Desmoplastic fibroblastoma

General

  • Benign lesion.
  • Classically found in shoulder region.

Epidemiology:

  • May be on the lip.

Microscopic

Features:[37][38]

  • Acellular stroma with abundant collagen.

Notes:

  • No nuclear atypia.

IHC

Low-grade fibromyxoid sarcoma

  • AKA hyalinizing spindle cell tumour.
  • Should not be confused with myxofibrosarcoma.
  • Abbreviated LGFMS.

General

  • Deep soft tissue.

Microscopic

Features:[40]

  • Myxoid stroma alternating with fibrogenic areas - key feature.
  • Low cellularity.
  • Spindle cells.
  • +/-Rosette of collagen with central hyaline core.[41]

Notes:

  • Few/absent mitoses.

DDx:

Images:

IHC

Features:[41]

  • EMA +ve.
  • CD99 +ve.
  • BCL2 +ve.

Others:[41]

  • SMA -ve.
  • S100 -ve.
  • Desmin -ve.

Molecular pathology

Calcifying fibrous tumour

General

  • Rare.
  • Benign.

Microscopic

Features:[43]

  • Submucosal circumscribed fibrocollagenous nodule.
  • Psammomatous calcifications.
  • Focal plasma cells at the periphery.

Adult fibrosarcoma

General

  • Malignant.
  • Older adults.
  • Locations: head & neck, extremities.

Microscopic

Feature:[41]

  • Spindle cell lesion.
  • Herring bone pattern - key feature.
  • Mitoses.

DDx (herring bone):

  • MPNST.
  • Synovial sarcoma.
  • Fibrosarcoma.

DDx:

Images:

IHC

Features:[41]

  • Vimentin.
  • SMA.

Congenital-infantile fibrosarcoma

Should not be confused with adult fibrosarcoma.

General

  • Locally aggressive.

Microscopic

Features:[44]

  • Spindle cell lesion.

Molecular

Characteristic translocation:[45]

Myxofibrosarcoma

General

  • Malignant.
  • Usu. older people, superficial (skin/dermis) and extremities (arm, legs).[47][48]

Microscopic

Features:[47]

  • Discontinuous fibrous septae.
  • Myxoid background.
  • Variable cellularity and nuclear pleomorphism.
  • Spindle cells or epithelioid cells.[48]
  • Curvilinear vessels.[48]

DDx:

Image:

IHC

  • Vimentin +ve -- otherwise non-distinctive.[47]

See also

References

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