Granular cell tumor of the extremity: magnetic resonance imaging characteristics with pathologic correlation

Granular cell tumor of soft tissues: MR findings

Granular cell tumors (GrCT) are histologically unique neoplasms that often manifest as painless solitary nodules located in the dermis or submucosal tissue. In this article we analyze the radiologic features of this type of tumor in five patients by magnetic resonance imaging (MRI), analyzing morphologic and signal characteristics. MR imaging findings were similar to other publications and we demonstrate low ADC values in our series.

Case report: Giant atypical granular cell tumor of the median nerve

Granular cell tumors are extremely uncommon soft tissue neoplasms that mostly occur in the head and neck regions. Granular cell tumors are generally benign, asymptomatic, and rarely involve the median nerve. Due to the lack of awareness about granular cell tumors, they are easily misdiagnosed and mistreated in primary hospitals. Here, we report a giant atypical granular cell tumor located on the median nerve, approximately 12 cm in size, with unusual symptoms of median nerve damage. Magnetic resonance imaging revealed a fusiform mass that was hyperintense on T2-weighted images and iso-hypointense on T1-weighted images. The mass was subsequently biopsied and found to be a granular cell tumor. The tumor was resected, and a pathological examination was performed. Pathological examination revealed necrotic foci, abundant eosinophilic granules, pustular ovoid bodies, and multiple mitoses. Immunohistochemical staining revealed that the tumor cells were positive for S-100, CD68, SMA, SOX-10, Calretinin, and TFE3. The integrated diagnosis was an atypical granular cell tumor. To the best of our knowledge, this is the first report of an atypical granular cell tumor involving the median nerve. Furthermore, we comprehensively reviewed the existing literature to provide a concise summary of the diagnostic criteria, imaging findings, and pathological features of granular cell tumors. Given the high recurrence and metastasis rates of this disease, granular cell tumors of the median nerve should be considered when a patient presents with symptoms of median nerve impairment. The diagnosis of atypical granular cell tumors relies on pathological examination. In addition, extensive resection and long-term follow-up are necessary to improve prognosis.

Intramuscular granular cell tumor in the sternocleidomastoid muscle: A case report and literature review

Granular cell tumor (GCT) is a rare soft-tissue neoplasm that originates from Schwann cells. Most cases occur in the subcutaneous or submucosal regions, and intramuscular GCT is even more uncommon. Herein, we describe an atypical GCT growing in the sternocleidomastoid muscle. A 41-year-old Chinese man was admitted to our hospital for a right neck mass. In magnetic resonance images, the mass showed higher signal intensity than the adjacent normal muscle on T2-weighted images and intermediate signal intensity on T1-weighted images. Slightly enhanced and higher signal intensity was observed in the peripheral rim on contrast-enhanced fat-sat T1-weighted images, and the "stripe sign" was evident. The tumor was completely resected, and pathological examination indicated an atypical GCT. The patient tolerated the procedure well. This is a rare case report of an intramuscular GCT from diagnosis to treatment. Magnetic resonance imaging might help diagnose such tumors, and we review different magnetic resonance imaging characteristics of intramuscular GCTs at other sites.

An Update on Cutaneous Granular Cell tumours for Dermatologists and Dermatopathologists

Granular cell tumours are rare soft tissue neoplasms which occur at a wide variety of sites and commonly involve the skin. Distinction between benign and malignant granular cell tumours is important because benign tumours are commonly cured by complete excision and malignant tumours commonly recur and cause fatal metastatic disease. Communication between the dermatologist and pathologist is also important, as the pathologist may provide false reassurance by evaluating a benign appearing part of a clinically malignant tumour. The following review summarises the current literature on the epidemiology, clinical presentation, pathology, radiology, treatment and prognosis of cutaneous granular cell tumours, with a focus on improving diagnosis and management for dermatologists and dermatopathologists.

Malignant granular cell tumor of the multifidus muscle: Case report and review of the literature

Granular cell tumors (GCTs) are uncommon soft tissue tumors characterized by cytoplasmic granular appearance of the neoplastic cells. Malignant GCTs comprise less than 2% of GCTs and are mostly found in the subcutaneous soft tissues of the lower extremities, especially the thighs. This report presents a case of malignant granular cell tumor in the right multifidus muscle. A 69-year-old woman presented to the surgeon with a 3 month history of light pain in the lumbar area and hip joint, with no particular history. CT and MRI revealed a soft tissue tumor with a maximum diameter of 7.5 cm. There is patchy unenhanced hypointense shadow in the mass. Widely excision was performed for the primary tumor, which was interpreted as an malignant GCTs. GCTs should be considered in the differential diagnosis in a rapidly growing intramuscular tumors. We investigated the CT and MRI findings of malignant granular cell tumor.

Malignant Granular Cell Tumor of the Lower Extremity in an Adolescent Male

Granular cell tumors (GCTs) are extremely rare soft tissue tumors, with only 2% of tumors being malignant. Malignant GCTs are more often seen in women between the ages 40 and 60. There has been no case reported of a malignant GCT in a pediatric patient. We present a case of a 14-year-old male who presented with a large mass in his left lower extremity. After being biopsied, the mass was diagnosed as a malignant GCT. The tumor was completely excised with wide margins and close follow-up with the patient continued.

Hypointense head and neck lesions on T2-weighted images: correlation with histopathologic findings

PURPOSE

On T2-weighted images, most solid lesions exhibit nonspecific intermediate signal intensity, whereas most cystic lesions exhibit marked hyperintensity. In contrast, on T2-weighted images, a relatively small number of lesions exhibit hypointensity. This review aimed to differentiate, according to the histopathologic findings, head and neck lesions showing hypointensity on T2-weighted images.

METHODS

In this review article, hypointense head and neck lesions on T2-weighted images are classified into the following nine categories: calcified or osseous lesions, granulomatous lesions, fibrous lesions, mucous- or proteincontaining lesions, hemosiderin-containing lesions, melanin-containing lesions, thyroglobulin-containing lesions, rapid blood flow, and air-filled spaces.

CONCLUSION

Knowledge regarding hypointense head and neck lesions on T2-weighted images allows radiologists to make accurate differential diagnoses. Key points • Hypointense head and neck lesions on T2-weighted images include calcified or osseous lesions, granulomatous lesions, fibrous lesions, mucous- or protein-containing lesions, hemosiderin-containing lesions, melanin-containing lesions, thyroglobulin-containing lesions, rapid blood flow, and air-filled spaces. • Radiologists should recognize the hypointense head and neck lesions on T2-weighted images for the final correct diagnosis, resulting in appropriate patient management.

Malignant granular cell tumor of the median nerve: a case report with a literature review of 157 cases

Malignant granular cell tumors are an extremely rare, high-grade sarcoma with a schwannian phenotype and are composed of malignant granular cells with cytoplasmic lysosomal inclusion. To date, 157 cases of malignant granular cell tumors have been reported. We report the first case of a malignant granular cell tumor arising from the digital nerve to the median nerve in the palm, and we review the 157 previously reported cases and summarize the clinical profile, treatment, and outcome of this tumor. The median age, tumor size, and follow-up periods were 51 years, 6 cm, and 24 months respectively. With respect to the oncological result, 53 patients (33.8%) had no evidence for disease, 31 (19.7%) were alive with the disease, and 51 (32.5%) died because of the disease. Our case report indicates that rare malignant tumors can arise from the digital nerve to the median nerve in the palm, an anatomical site that is usually affected by benign lesions. Exhaustive discussions between surgeons and pathologists are necessary for the treatment of this rare malignant tumor.

Isolated limb infusion as a treatment option for malignant granular cell tumour

A 54-year-old man presented with a painful lesion on the right posterior calf with MRI identifying a 5 cm lesion in the medial head of the gastrocnemius. He underwent wide local excision of the tumour, and the final pathology was consistent with atypical granular cell tumour. Three years later, he developed a recurrent right popliteal mass. Complete staging workup also identified multiple lung nodules and a caecal polyp that were consistent with metastatic granular cell tumour. He was started on pazopanib and deemed a poor candidate for palliative resection due to encasement of the popliteal vessels. The patient refused above-the-knee amputation (AKA) at that point and was evaluated for isolated limb infusion as an alternative. He received three cycles of isolated limb infusion within a 2-year period and achieved good response from the first two cycles. He underwent AKA 4 years after his diagnosis of malignant granular cell tumours and is currently doing well.

Synchronous gastric leiomyoma and intramuscular abdominal wall granular cell tumor with similar imaging features: A case report

INTRODUCTION

Gastric leiomyomas are benign mesenchymal tumors, comprising about 2.5% of gastric neoplasms, which can be difficult to differentiate from gastrointestinal stromal tumors which have malignant potential. Granular cell tumors in the abdominal wall are also rare. Since mesenchymal tumors are difficult to diagnose by imaging, further studies are needed to establish the diagnosis.

PRESENTATION OF CASE

A 60-year-old asymptomatic woman underwent routine upper endoscopy and was found to have a gastric submucosal lesion. Computed tomography scan also showed an abdominal wall mass. The appearance of both lesions on imaging studies were similar, but it was unclear if the two lesions had the same origin. Endoscopic ultrasound-guided fine needle aspiration biopsy of the gastric lesion was insufficient to establish the diagnosis. Laparoscopic-endoscopic cooperative resection of the gastric lesion and ultrasound-guided core-needle biopsy of the abdominal wall mass enabled pathological diagnosis of both lesions.

DISCUSSION

Diagnostic imaging findings of these two lesions were similar. Histologic and immunohistochemical studies are essential to establish a definitive diagnosis. Laparoscopic-endoscopic cooperative surgery may be an effective minimally invasive approach, allowing both pathological diagnosis and complete resection of a gastric submucosal tumor, especially when endoscopic-ultrasound guided fine needle aspiration or biopsy fails to make the diagnosis.

CONCLUSION

Laparoscopic-endoscopic cooperative surgery can be an effective minimally invasive approach to resect some lesions. This is first report of the patient with a synchronous gastric leiomyoma and an intramuscular granular cell tumor in the abdominal wall.

Epidemiology of malignant cutaneous granular cell tumors: A US population-based cohort analysis using the Surveillance, Epidemiology, and End Results (SEER) database

BACKGROUND

Malignant cutaneous granular cell tumors (mcGCTs) are rare and associated with substantial morbidity and mortality. The literature includes single-institution studies.

OBJECTIVE

To examine the incidence, secondary malignancies, treatment, overall survival, and disease-specific survival (DSS) of patients with mcGCT.

METHODS

A population-based cohort analysis was conducted in the Surveillance, Epidemiology, and End Results database from 1973 to 2013 for patients with a diagnosis of mcGCT. Risk-adjusted associations between overall survival/DSS and patient characteristics and treatment modalities were assessed by Cox proportional hazard regression. Quantile regression was used to determine median survival times.

RESULTS

The 5-year DSS rate was 62.8%. Patients demonstrated an increased risk for renal and pancreatic cancers. In risk-adjusted models, male sex (hazard ratio [HR], 0.21; 95% confidence interval [CI], 0.06-0.82; P = .02), advanced cancer stage (HR, 2.29; 95% CI, 1.40-3.72; P < .01), and surgical resection (HR, 0.06; 95% CI, 0.01-0.59; P = .02) predicted DSS. Median survival time in years increased for males (1.39), earlier stage (0.60), and surgical intervention (5.34).

LIMITATIONS

Absent or incorrect reporting in retrospective Surveillance, Epidemiology, and End Results data is possible. The database is more likely to include academic centers. Some subanalyses may be underpowered because of the limited sample size for a rare cancer.

CONCLUSIONS

Our study presents an in-depth assessment of factors that identify high-risk patients. Residency in a nonmetro area, black race, female sex, and no surgical resection were each associated with poorer DSS.

The magnetic resonance appearance of surfers' knots: a case report

Athletes are at increased risk of developing soft-tissue lesions of the lower limbs. Although the majority of these will be benign, the differential diagnosis is broad and increasingly, doctors are turning to magnetic resonance imaging (MRI) as a first-line investigation when presented with these sorts of lesions, both to narrow the differential diagnosis and exclude malignancy. We report the case of a 28-year-old Caucasian man who presented with 2 soft-tissue lesions of the right foot. History and examination of the nodules fitted with a diagnosis of surfers' knots, an unusual form of acquired, benign, connective tissue nodule that may appear over the tibial tuberosities, dorsum of the feet, and occasionally on the chest of surfers in association with repetitive microtrauma during surfing. MRI findings were consistent with this diagnosis with both lesions exhibiting T1 hypointensity and speckled T2 hypointensity with no significant blooming artifact on gradient echo imaging. When imaged with gadolinium, they demonstrated only mild contrast enhancement. MRI is a valuable tool when investigating athletes with soft-tissue lesions over the lower limbs where the possibility of malignancy must be addressed. In selected cases, MRI may be sufficient to permit a conservative approach to the management of these patients.

Granular cell tumour: malignant or benign?

INTRODUCTION

Granular cell tumours (GrCTs) are uncommon soft tissue tumours that are usually benign (approximately 0.5%-2.0% have been reported as malignant). They are very rarely found at the extremities. Differentiating a malignant GrCT from a benign one is important as the former is aggressive and has a poor prognosis, whereas the latter, after surgical resection, has excellent outcomes. A malignant lesion can be suspected on clinical presentation and confirmed via histopathological examination using the Fanburg-Smith criteria.

METHODS

This was a retrospective review of all cases of GrCT of the extremities that presented to the Orthopaedic Oncology Unit of University Malaya Medical Centre, Malaysia, from September 2006 to March 2013.

RESULTS

There were a total of five cases, all of which involved female patients aged 13-40 (mean age 24) years. Three cases involved the upper limbs and two involved the lower limbs. Using the Fanburg-Smith criteria, three cases were classified as benign, one as atypical and one as malignant. Wide local excision was performed in all five cases and the outcomes were excellent except for the patient with a malignant tumour. That patient presented with lung metastasis about three months after surgery.

CONCLUSION

Malignant and benign GrCTs can be differentiated on clinical presentation and by using the Fanburg-Smith criteria. We believe that wide local excision is the best treatment for both benign and malignant tumours. The role of adjuvant chemotherapy and radiotherapy in malignant GrCTs should be studied. All patients with GrCTs should receive follow-up to check for recurrence and metastasis.

Intramuscular granular cell tumor: emphasizing the stripe sign

We present a case of an intramuscular granular cell tumor in the thigh manifesting a 'stripe sign' on magnetic resonance imaging (MRI). This MR finding may correspond with the entrapped muscle fibers within the tumor, which demonstrated parallel arrangement on histopathologic examination. In addition, other disease entities characterized by the presence of this sign such as proliferative myositis, heterotopic ossification, and muscular sarcoidosis will be reviewed.

A case report of a rare intramuscular granular cell tumor

Background

Granular cell tumors (GCTs) were firstly described by Weber in 1854 and 70 years later by Abrikossoff and classified as benign tumors. Originally considered muscle tumors, they have been identified as neural lesions, due to their close association with nerve and to their immunohystochemical characteristics.

GCTs are uncommon tumors and they may arise in any part of the body; they have been mainly observed in tongue, chest wall and upper extremities; less frequent sites are larynx, gastrointestinal tract, breast, pituitary stalk and the female anogenital region.

Here we report a case of GCT showing an uncommon localization such as the upper third of the right rectus muscle of the abdominal wall.

Case presentation

A 45 year-old woman of Caucasian origin presented to the surgeon with a 6-month history of light pain in the upper third of the abdominal wall.

Radiological exams (Ultrasonography, Computed Tomography and Contrast magnetic resonance imaging) showed a localized in the right rectus abdominis muscle.

After excision, histological and immunohystochemical analysis, with the support of electron microscopy, allowed making diagnosis of granular cell tumor.

Discussion

After fist description by Abrikosoff in 1926 of GCT like mesenchymal tumor of unknown origin, in recent years immunohystochemical techniques definitely demonstrated the histogenetic derivation of GCT from Schwann cells.

Granular cell tumors are rare, small, slow-growing, solitary and painless subcutaneous nodules which behave in a benign fashion, but can have a tendency to recur; in rare cases they can metastasize, when they became malignant; there are some clinical and histological criteria to suspect the malignance of this tumor.

Conclusion

It is important that clinicians, radiologists and pathologists are aware of the clinical presentation and histopathology of GCT for appropriate management, counselling and follow-up. In our case we had a complete radiological, morphological and immunohystochemical characterization of the lesion and a definitive diagnosis of benignity confirmed by electron microscopy.

Granular cell tumor of the ulnar nerve: MR neurography characterization

The authors report an unusual case of ulnar neuropathy caused by granular cell tumor. The report describes the anatomic 3 Tesla MR Neurography and functional diffusion tensor findings of the case, which was subsequently confirmed on surgical excision and histopathology.

A malignant granular cell tumor excised with mohs micrographic surgery

Malignant granular cell tumors are extremely rare, aggressive neoplasms displaying rapid growth and frequent associated metastatic disease. Excision and evaluation for metastatic disease are mandatory. We present a 54-year-old patient with a malignant granular cell tumor, treated with Mohs micrographic surgery. Cutaneous granular cell tumors are uncommon neoplasms, likely of perineural origin. Most follow a benign and uneventful course, with wide local excision being the treatment of choice (Enzinger, 1988). The malignant granular cell tumor is an extremely rare, aggressive variant, which provides a diagnostic challenge and management dilemma, especially with early presentation when it may be mistaken for other entities. There is also controversy regarding surgical management and follow-up of both benign and malignant granular cell tumors.

Granular cell tumor of the male breast: two case descriptions and brief review of the literature

A granular cell tumor of breast is a rare and usually benign tumor originating from Schwann cells. The mammographic and sonographic appearances of a granular cell tumor pose a diagnostic dilemma because of its similarity to breast malignancy. We describe 2 cases of breast granular cell tumors in male patients, which were confirmed after surgical excision and histologic examination.

Malignant granular cell tumor of the thigh

Malignant granular cell tumor is a rare neural tumor characterized by abundant granular-appearing tumor cells. These tumors account for <2% of all granular cell tumors. Unlike its benign counterpart, a malignant granular cell tumor presents primarily in the lower limb and is notably larger. Both the uncommon occurrence of malignant granular cell tumors and its similarities in feature with their benign counterparts make diagnosis of this particular malignancy difficult. By 1998, Fanburg-Smith et al developed a diagnostic criteria in which granular cell tumors were divided into 3 categories-benign, atypical, and malignant-based on 6 histological characteristics of the tumor: necrosis, spindling, vesicular nuclei with large nucleoli, increased mitotic activity, high nuclear-to-cytoplasmic ratio, and pleomorphism. This article presents a case of a large malignant granular cell tumor in the right thigh of a 69-year-old woman. Gross examination of the mass showed the well-demarcated, tan, white tumor measuring 18.2 cm long and 7.6 cm wide at its largest width. Histological examination of the mass, performed by an oncological pathologist, demonstrated foci of tumor necrosis, scattered apoptotic cells, prominent nucleoli, increased nuclear-to-cytoplasmic ratio, increased mitotic activity, and areas of spindling with significant atypia. To our knowledge, this is the largest reported case of malignant granular cell tumor in the lower limb diagnosed using the histological criteria established by Fanburg-Smith et al. This case stresses the importance of thorough evaluation in instances of atypical granular cell tumor presentations.

Intramuscular granular cell tumor in the lower extremities

Granular cell tumors are uncommon but typically histologically benign neoplasms that occasionally behave as malignant tumors. Differentiation of benign granular cell tumors from malignant counterparts with radiographic and/or histologic analysis is crucial for physicians. We retrospectively studied five cases of intramuscular granular cell tumors arising in the lower extremities. All tumors had been histologically diagnosed as benign and were resected with a wide surgical margin. The minimum followup was 1 year (mean, 45 months; range, 12-119 months) after surgery. Four patients had no local recurrence or distant metastasis (at a minimum of 18 months followup), whereas one patient with lymph node metastasis had a recurrence and distant metastasis 3 months after surgery resulting in death. Intramuscular granular cell tumors can be diagnosed based on their characteristic MRI features, such as peripheral high intensity on T2-weighed images, and histologic evaluation. The histologic criteria described by Fanburg-Smith et al. can differentiate malignant granular cell tumors from benign tumors. A wide resection seems suitable for most granular cell tumors in the extremities.

LEVEL OF EVIDENCE

Level IV, diagnostic study. See the Guidelines for Authors for a complete description of evidence.

Granular cell tumours: a rare entity in the musculoskeletal system.Sarcoma. 2009;2009:765927. [PMID: 20169099 DOI: 10.1155/2009/765927]

Granular Cell Tumours are rare mesenchymal soft tissue tumours that arise throughout the body and are believed to be of neural origin. They often present as asymptomatic, slow-growing, benign, solitary lesions but may be multifocal. 1-2% of cases are malignant and can metastasise. Described series in the literature are sparse. We identified eleven cases in ten patients treated surgically and followed-up for a period of over 6 years in our regional bone and soft tissue tumour centre. Five tumours were located in the lower limb, four in the upper limb, and two in the trunk. Mean patient age was 31.2 years (range 8–55 years). Excision was complete in one case, marginal in five cases and intralesional in five cases. No patients required postoperative adjuvant treatment. Mean follow-up was 19.3 months (range 1–37 months). One case was multifocal, but there were no cases of local recurrence or malignancy. Histopathological and immunohistochemical analysis revealed the classical granular cell tumour features in all cases. We believe this case series to be the largest of its type in patients presenting to an orthopaedic soft tissue tumour unit. We present our findings and correlate them with findings of other series in the literature.

Granular cell tumor of the toe: a case report

The authors present a case of a granular cell tumor of the second digit that was treated with a partial digit amputation. A 49-year-old male presented with an atypical hyperkeratotic lesion at the distal aspect of the second toe with adjacent dystrophy of the nail plate. Radiographs, magnetic resonance images, and, finally, ultrasound images were used to confirm the presence of an underlying mass, and biopsy confirmed the diagnosis of granular cell tumor. Partial digital amputation was eventually undertaken. We feel that it is important for surgeons to maintain a high index of suspicion, particularly when a seemingly benign lesion, such as a hyperkeratosis, fails to respond as expected to treatment.

LEVEL OF CLINICAL EVIDENCE

4.

Granular cell tumour of the breast: MRI findings and review of the literature

Granular cell tumours (GCTs) are uncommon, usually benign neoplasms that can mimic malignancy on breast imaging. GCTs can originate anywhere in the body but are most frequently found in the head and neck area, particularly in the oral cavity. When occurring in the breast, as occurs in 5-8% of all cases of GCT, the clinical presentation is similar to that of a primary breast carcinoma. We report a case of granular cell tumour of the breast presenting as a suspicious lesion on breast imaging, and review the MRI features of GCTs.

Case report. Granular cell tumors of extremities: comparison of benign and malignant variants

Granular cell tumors are uncommon soft tissue neoplasms that arise from cells of neural origin. We present three patients with this rare tumor: one with a benign tumor, one with a malignant tumor, and one with a histologically benign tumor that later metastasized to the lung. We studied the difficulty in differentiating between the benign and malignant variants using only histology. We also compared the clinical, radiographic, and pathologic features and the criteria for malignancy, natural history, and prognosis.

Superficial soft-tissue masses of the extremities

Superficial soft-tissue masses are among the most common indications for imaging of the extremities. A broad array of benign and malignant processes may be manifested in palpable cutaneous or subcutaneous masses or nodules. Most such lesions are treated with surgical excision, but some may be conservatively managed. The lesions can be differentiated according to their location in one or more skin layers (epidermis, dermis, and subcutis), their histologic composition, and the associated anatomic abnormality or disease process. Because the imaging characteristics of many benign soft-tissue lesions overlap with those of malignant ones, knowledge of the patient's clinical history (including any laboratory test results) and direct visual examination of the lesion often are important for differentiation. Histologic analysis may be necessary to achieve a definitive diagnosis.