Fine needle aspiration (FNA) cytology in the diagnosis of recurrent soft tissue sarcoma

Adult Soft-Tissue Sarcomas of the Extremities

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Soft-tissue sarcomas (STS) in adults comprise a heterogeneous group of tumors of mesenchymal origin that share similar biological patterns of local tumor growth and metastatic dissemination.

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The judicious use of imaging studies, biopsy techniques, and pathological evaluations is essential for accurate diagnosis and for planning treatment strategy.

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Wide local resection and radiation therapy form the cornerstone of management of high-grade STS. The role of adjuvant radiation therapy is questionable in the management of small (≤5 cm) superficial lesions that can be resected with negative margins. Chemotherapy given to patients who have nonmetastatic, high-grade STS results in varying benefit in terms of local tumor control and overall survival.

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Coordinated care by a multidisciplinary team of trained surgeons, medical oncologists, radiologists, radiation oncologists, and pathologists has been documented to improve local tumor control and the overall survival of patients with STS.

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Although considerable progress in tumor diagnostics and targeted therapies has been made over the past 2 decades, recommendations and controversies relating to tumor imaging and margins of resection have not changed.

Large Undifferentiated Pleomorphic Sarcoma of the Posterior Thigh

Patient: Female, 62

Final Diagnosis: Undifferentiated pleomorphic sarcoma

Symptoms: Pain in the leg

Medication: —

Clinical Procedure: Surgical excision

Specialty: Oncology

Doppler ultrasound for diagnosis of soft tissue sarcoma: efficacy of ultrasound-based screening score

BACKGROUND

The utility of ultrasound imaging in the screening of soft-part tumours (SPTs) has been reported. We classified SPTs according to their blood flow pattern on Doppler ultrasound and re-evaluated the efficacy of this imaging modality as a screening method. Additionally, we combined Doppler ultrasound with several values to improve the diagnostic efficacy and to establish a new diagnostic tool.

PATIENTS AND METHODS

This study included 189 cases of pathologically confirmed SPTs (122 cases of benign disease including SPTs and tumour-like lesions and 67 cases of malignant SPTs). Ultrasound imaging included evaluation of vascularity by colour Doppler. We established a scoring system to more effectively differentiate malignant from benign SPTs (ultrasound-based sarcoma screening [USS] score).

RESULTS

The mean scores in the benign and malignant groups were 1.47 ± 0.93 and 3.42 ± 1.30, respectively. Patients with malignant masses showed significantly higher USS scores than did those with benign masses (p < 1 × 10(-10)). The area under the curve was 0.88 by receiver operating characteristic (ROC) analysis. Based on the cut-off value (3 points) calculated by ROC curve analysis, the sensitivity and specificity for a diagnosis of malignant SPT was 85.1% and 86.9%, respectively.

CONCLUSIONS

Assessment of vascularity by Doppler ultrasound alone is insufficient for differentiation between benign and malignant SPTs. Preoperative diagnosis of most SPTs is possible by combining our USS score with characteristic clinical and magnetic resonance imaging findings.

[Giant fibrolipoma of the mediastinum]

The authors discuss the management of an enormous fibrolipoma which rarely occurs in the mediastinum. A 54-year-old patient underwent an extended posterolateral thoracotomy and resection of a mass which was preoperatively diagnosed as liposarcoma. The size of the removed specimen was 42×35×23 cm and weight was 5200 g. Final histology revealed a primary mediastinal fibrolipoma. Following a long-standing lung compression, the lung has fully expanded after a temporary postoperative failure of expansion. Postoperative serial chest x-rays confirmed that the marked mediastinal midline shift gradually resolved, and the patient's complaints improved considerably, too.

DISCUSSION

the vast majority of tumors located in the mediastinum needs to be operated on. Surgical techniques available involve open or videothoracoscopic methods. The latter is limited though by the patient's general condition and the size of the mass needs to be resected. In cases when the tumour is deemed to be irresectable, surgical debulking and oncological adjuvant treatment can be justified to improve quality of life.

Fine needle aspiration for clinical triage of extremity soft tissue masses

BACKGROUND

Fine needle aspiration cytology (FNAC) is a rapid and low-morbid alternative to open biopsy or needle core biopsy for soft tissue masses. Numerous reports describe its use with metastatic or recurrent lesions, but FNAC is less accepted for primary lesions.

QUESTIONS/PURPOSES

We wished (1) to estimate the sensitivity, specificity, and positive and negative predictive values of FNAC for diagnosing malignancy; (2) to estimate the accuracy of subtyping and grading.

METHODS

We retrospectively examined the diagnostic accuracy and clinical effectiveness of office-based FNAC performed by a trained pathologist on 213 females and 219 males (mean age, 51.8 years) who presented with a palpable soft tissue mass to one musculoskeletal oncology clinic between 2002 and 2008.

RESULTS

The FNAC was reported as benign in 62.0%, indeterminate in 8.1%, and malignant in 29.9%. A second technique, such as needle core biopsy or open biopsy, was performed for 24.8% of lesions before a definitive treatment plan was rendered. Final tissue confirmation by open biopsy or resection was available for 52.2% of benign FNAC and 78.3% of malignant FNAC. Sensitivity, specificity, and positive and negative predictive values for detecting malignancy with either histopathologic confirmation or clinical followup were 89.2%, 89.8%, 96.1%, and 98.1%. There were seven sampling and nine interpretation FNAC errors in determining the nature of the lesion. Subtyping and grading for malignant lesions were 77.2% and 95.2% accurate, respectively.

CONCLUSIONS

FNAC is effective for initial triage and treatment selection at tertiary referral centers with close collaboration among the surgeon, pathologist, and radiologist.

LEVEL OF EVIDENCE

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

Scope of FNAC in the diagnosis of soft tissue tumors--a study from a tertiary cancer referral center in India

BACKGROUND

Fine needle aspiration cytology (FNAC) forms one of the first diagnostic tools in the evaluation of tumors. Its role in diagnosing soft tissue tumors (STT) has been fairly documented, as well as debated. Present study was aimed at evaluating its scope in diagnosing 127 cases of soft tissue tumors.

METHODS

Conventional Pap and MGG staining was available in all the cases. Immunocytochemistry (ICC) was performed in 15 cases. Histopathological details were available in 115 cases.

RESULTS

50% cases were referred for a primary diagnosis, while 26.8% & 22.8% cases were evaluated for recurrent and metastatic lesions, respectively. Extremities were the commonest sites. On FNAC, 101 cases (79.5%) were labeled as malignant, whereas 10 cases (7.9%) were labeled as benign. The remaining 16 cases (11%) were not categorized and were labeled as 'unsure/not specified'. Histopathological confirmation in 115 cases, gave a diagnostic accuracy of 98%, with a positive predictive value of 98% in malignant cases and a negative predictive value of 100% in benign cases. Two cases were false positive. Among the various cytological categories, 60 cases (47.2%) were of spindle cell type, followed by 32 (25.2%) of round cell type and 14 cases (11%) of lipomatous type. Other 12 cases (9.4%) were of pleomorphic type; 7 (5.5%) cases of epithelioid type and remaining 2 cases were of myxoid type. All the round cell, pleomorphic and myxoid type of tumors were sarcomas, whereas 73.3% cases of spindle cell type were labeled as 'malignant'. Exact cytological sub typing was offered in 58 cases, with rhabdomyosarcoma (RMS) as the most frequently sub typed tumor. The two false positive malignant cases were of fibromatosis and a pigmented schwannoma, on biopsy. Out of 28 metastatic lesions, lymph nodes were the commonest site for metastasis, with epithelioid tumors that formed highest percentage of metastatic cases.

CONCLUSION

FNAC is fairly specific and sensitive in STT diagnoses for primary, recurrent and metastatic lesions. The cytological types, especially round cell and pleomorphic sarcomas, can be quickly identified. Clinicopathological correlation with ICC as an adjunct, are valuable in exact sub typing.

Cytomorphological study of soft tissue neoplasms: role of fluorescent immunocytochemistry in diagnosis

OBJECTIVES

Exact categorization of soft tissue tumours (STTs) on smears requires application of various ancillary techniques. This study was aimed at evaluating the role of fluorescent immunocytochemistry (FICC) in cyto-diagnosis of 30 STT cases.

METHODS

Thirty cases of soft tissue tumours were included in the present study. All cases were subjected to routine Giemsa and Papanicolaou stain. Extra smears were made and kept for fluorescent immunostaining. A panel of cytoskeletal antibodies, tagged with FITC (Fluorescein isothyocynate), was employed in all these cases. Fluorescent immunostained smears were examined under Zeiss Confocal Laser scanning microscope, using double immunofluorescence (red-green). Finally, all cases were subjected to biopsy and again immunoperoxidase staining.

RESULTS

Among the 30 cases in the present study, unaided cytological diagnoses ranged from 'spindle cell' tumour in four (13.3%) cases, benign and malignant spindle cell tumour in 17 (56.6%) cases, to malignant mesenchymal tumour in nine (30%) cases. FICC helped in further correct categorization of 25/30 (83.3%) cases viz. leiomyoma (three), benign neurogenic tumour (six), schwannoma (one), dermatofibrosarcoma protuberans (three), synovial sarcoma (two), rhabdomyosarcoma (two), malignant fibrous histiocytoma (five) and malignant peripheral nerve sheath tumour (three). Aggressive fibromatosis was found to be a missed diagnosis in two cases. Overall concordance between cyto-diagnosis with FICC, and histopathology results was 83.3% (P < 0.05).

CONCLUSION

Fluorescent immunocytochemistry is a significant ancillary technique for making a rapid and specific diagnosis of STT, as required for their timely management. Incorporation of a wide panel of antibody markers with clinico-cytological correlation is recommended in forming an exact diagnosis in these cases.

Fine-needle aspiration of primary and recurrent dermatofibrosarcoma protuberans

Dermatofibrosarcoma protuberans (DFSP) is a nodular cutaneous mesenchymal tumor of intermediate malignancy. Studies on fine-needle aspiration of DFSP are extremely rare; to our knowledge, only 33 cases have been reported. We have reviewed 14 examples of DFSP in 13 patients. Ten primary tumors were aspirated before surgical biopsy and four recurrent lesions (all from superficial lesions) were also investigated by fine-needle aspiration. All smears were surprisingly homogeneous and composed of isolated spindle cells in all cases (one unsatisfactory smear is excluded). Tissue fragments with a stroriform pattern were seen in 11 cases, fibrillary stromal fragments in 10 cases, naked nuclei in 8 cases, slight to moderate cytonuclear atypia in 5 cases. Mitotic figures, myxoid background, mast cells, and dispersed adipocytes were rare. Giant cells, necrosis, or marked cytonuclear atypia were not seen. DFSP shares morphological characteristics of some low-grade spindle-cell neoplasms. It should be differentiated from other benign low- and intermediate-grade spindle neoplasm such as low-grade fibrosarcoma, fibromyxosarcoma, low-grade malignant peripheral nerve sheath tumor, benign peripheral nerve sheath tumor, nodular fasciitis, and fibrous histiocytoma.

Comparative fine-needle aspiration and pathologic study of malignant fibrous histiocytoma: Cytodiagnostic features of 95 tumors in 71 patients

To determine diagnostic cytomorphologic features of malignant fibrous histiocytoma (MFH) on fine-needle aspiration (FNA) materials, we reviewed the cytologic material and corresponding histologic slides of 95 tumors in 71 patients. Forty-four (46%) tumors were primary, 38 (40%) were recurrent, and 13 (14%) were metastatic. Histological variants of MFH were as follows: 52 (54.7%, 43 patients) were of the storiform/pleomorphic, seven (7.4%, five patients) were giant cells, four (4.2%, four patients) were inflammatory, and 31 (33.7%, 19 patients) were myxoid type. Review of original cytology reports showed that only 23 (24.2%) tumors were diagnosed as MFH and 68 (71.6%) as other types of malignancies. Four (4.2%) cases were reported as unsatisfactory/suspicious. Our findings showed that spindle-shaped, round, giant cells, osteoclastic-like giant, and inflammatory cells were the most consistent features that allow identification of the storiform/pleomorphic, giant cell, and inflammatory variants of MFH. The myxoid tumors had marked myxoid background matrix with spindle-shaped cells and, less frequently, round and giant cells. Pleomorphic leiomyosarcoma and dedifferentiated liposarcoma should be considered in the differential diagnosis of stroriphorm/pleomorphic, giant cells, and inflammatory variants of MFH. However, myxoid MFH may resemble their leiomyosarcoma and liposarcoma counterparts.

Cytologic findings of myxoid neurothekeoma: case report based on fine-needle aspiration cytology, immunohistochemistry, and correlating histopathology

Myxoid neurothekeomas (nerve sheath myxomas) are rare benign cutaneous neoplasms that may morphologically mimic other myxoid neoplasms of skin and soft tissue. The cytologic and histopathologic features of this lesion may resemble various myxoid sarcomas, chordoma, myxoid neurofibroma, dermal cutaneous mucinosis, and cutaneous myxoma as well as other myxoid or chondroid neoplasms. In this study, a myxoid neurothekeoma was analyzed using multiple techniques. We found that myxoid neurothekeomas reveal a nonspecific pattern by fine-needle aspiration, including stellate cells embedded within an abundant metachromatic myxoid stromal matrix. These are cytologic features shared by various other subcutaneous neoplasms and thus may not be helpful in forming a definitive diagnosis. Histopathologically, the tumor is composed of nodules of myxoid stroma containing interspersed bland spindled and stellate cells. Immunohistochemical studies show tumor cell positivity for S-100 protein and vimentin, a profile shared by other neoplasms with similar cytologic features and therefore of little diagnostic value. The histologic and cytologic differential of subcutaneous and soft tissue myxomatous lesions is broad and, therefore, is of unique value to the cytopathologist to consider myxoid neurothekeomas among the differential of other myxomatous neoplasms.

Cytohistologic correlations in 56 synovial sarcomas in 36 patients: the Institut Curie experience

Synovial sarcoma (SS) is a high-grade malignant soft tissue tumor that manifests different phenotypic subtypes that may render their cytologic evaluation challenging. Although several cytologic studies of SS have been published, correlative studies of cytologic and corresponding histologic features are limited. To better define the cytological features of various SS forms, we reviewed the cytologic and the corresponding histologic material of 56 tumors from 36 patients. Classical patterns were defined as dispersed or small clusters of cells with bland chromatin, inconspicuous nucleoli, oval to spindle-shaped cytoplasm and branching tumor tissue fragments, vessel stalks, acinar structures in scant mucin background, seen in all 53 (94.7%) cellular cases. Epithelial, squamous, round cells, mast cells, necrosis, comma-like nuclei, marked nuclear atypia, secretory mucin, and rosette-like structures were also occasionally observed. Comparing the histological subtype we noted that epithelial cells and secretory mucin were restricted to biphasic SS, round cells to poorly differentiated SS, and comma-like nuclei to monophasic fibrous SS. We conclude that the classical pattern is highly suggestive of SS of all three monophasic, biphasic, or poorly differentiated subtypes. These characteristics, along with molecular genetic studies, may improve the cytologic diagnosis of SS.

A single-institutional, multidisciplinary approach to primary sarcomas involving the chest wall requiring full-thickness resections

OBJECTIVE

Primary sarcomas involving the chest wall requiring full-thickness excision are rare. We reviewed our experience with these lesions in a tertiary referral cancer center by using multidisciplinary approaches.

METHODS

A 10-year retrospective study identified 51 patients referred with primary sarcomas of the chest wall: 40 for initial treatment and 11 after previous unsuccessful surgical excisions elsewhere (secondary referral). Presenting symptoms were pain alone in 23 (45%) of 51 patients, pain with an associated mass in 8 (16%) patients, and an asymptomatic mass alone in 13 (25%) patients. Median symptom duration was 241 days in the primary group and 225 days in the recurrent group. Tumor locations were the sternum (n = 11), the rib alone (n = 36), and the posterior rib with extension into vertebral bodies (n = 4). Histologic types included the following: chondrosarcomas (n = 15), malignant fibrous histiocytomas (n = 9), osteosarcomas (n = 4), Ewing sarcomas (n = 3), desmoid tumors (n = 7), and other types (n = 13). The median tumor volume of those referred initially was 311 cm(3) compared with 84 cm(3) in patients with recurrent lesions.

RESULTS

Twenty-six (51%) of 51 patients received treatment before resection, including chemotherapy alone (n = 22), radiation alone (n = 3), and combined chemotherapy and radiation therapy (n = 1). The complete sternum was removed in 6 of 11 patients, and the average number of ribs requiring resection was 3.8. Four patients had vertebral body resections. Prosthetic meshes alone were required in 16 of 51 patients, and meshes with methylmethacrylate were required in 18 of 51 patients. Muscle flap reconstructions by plastic surgery were required in 24 patients. Negative margins were obtained in 47 of 51 patients. There were no perioperative deaths with morbidities occurring in 12 (24%) of 51 patients (wound [n = 3], prolonged air leak [n = 1], prolonged ventilator requirement [n = 1], arrhythmias [n = 3], doxorubicin (Adriamycin)-induced cardiomyopathy [n = 1], and other [n = 3]). Postoperative treatment was administered to 13 patients (chemotherapy alone, n = 9; chemotherapy with radiation therapy, n = 4). The cumulative 5-year survival of all patients was 64% (initial referral, 61.3%; secondary referral, 72.7%). The average follow-up is 44.7 months.

CONCLUSIONS

A combined aggressive multidisciplinary approach to primary sarcomas of the chest wall resulted in no treatment-related deaths and a cumulative 5-year survival of 64% in patients referred to our tertiary care cancer center.

Fine-needle aspiration cytology and immunocytochemistry of soft-tissue tumors and osteo/chondrosarcomas of the head and neck

The purpose of the study was to present the clinical and cytological findings of 28 cases of malignant or borderline mesenchymal tumors of the head and neck, of which 22 originated from soft tissue and 6 were found in bone or cartilage. The basic procedures employed involved a cytologic review and subclassification of fine-needle aspiration (FNA) smears from the tumors, which were diagnosed as: pleomorphic sarcomas (5 poorly differentiated, 1 angiosarcoma, and 1 epithelioid sarcoma), spindle-cell sarcomas (2 leiomyosarcomas, 2 malignant mesenchymal tumors, and 1 malignant schwannoma), myxoid sarcomas (2 liposarcomas and 1 high-grade tumor), round-cell tumors (1 malignant histiocytic tumor and 1 chloroma), osteosarcomas (3), chondrosarcomas (3), and borderline tumors (2 pleomorphic lipoma, 1 myxolipoma, 1 cranial fasciitis, and 1 fibromatosis). Histological correlation and problems in subtyping on both cytologic and histological material are discussed. It is concluded that FNA cytology can be used with high accuracy to diagnose musculoskeletal tumors in rare sites such as the head and neck.