Treatment and Diagnose of Spinal Phosphaturic Mesenchymal Tumor: A Case Report and a Systematic Literature Review

BACKGROUND

Spinal phosphaturic mesenchymal tumor (PMT) is a rare disorder but can be cured once the diagnosis is clear and a complete removal by surgery is performed. To the best of our knowledge, only 22 cases in the spine have been described, and we report a case with the largest number of spinal segments (T12-L5) affected among spine PMT cases.

METHODS

A comprehensive literature search was performed until May 23, 2023, following the Preferred Reporting Items for Systematic Reviews guidelines. Studies were chosen through relevant PubMed, Web of Science, and EMBASE searches to prioritize obtaining the largest studies. The Medical Subject Headings and Boolean operators employed for this search were ("PMT" or "TIO" or "Tumor-induced osteomalacia" or "phosphaturic mesenchymal tumor") and ("spine" or "spinal"). Two researchers (L.S.Z. and D.B.C) independently reviewed and evaluated the included articles. Any differing opinions were discussed until a consensus was reached. A total of 18 studies were included. A case report is also presented.

RESULTS

We report a case of spinal PMT. The full text of the relevant articles was construed. A total of 18 studies were reviewed and consolidated. These articles are roughly divided into the following 5 subcategories: 1) clinical features and baseline distribution, 2) laboratory and imaging findings, 3) pathological manifestations, and 4) surgical methods and treatment options.

CONCLUSIONS

Spinal PMT is very rare with a high rate of misdiagnosis and debilitating complications, so it is of significance to increase awareness of the disease among spine surgeons consulted by patients with spinal PMT. 68Ga-DOTATOC-PET/CT shows very high sensitivity to the spinal PMT but there is no way to exactly determine the location of the tumor. PMT has unique immunohistochemical characteristics and malignant PMT is rare. Once diagnosed, complete surgical excision is the recommended treatment. Burosumab is one of the available options, especially in cases that are recurrent and difficult to surgically resect.

Endoscopic Ultrasonography in the Diagnosis and Treatment Strategy Choice of Esophageal Leiomyoma

OBJECTIVES:

Esophageal leiomyoma is the most common benign tumor of the esophagus, and it originates from mesenchymal tissue. This study analyzed the clinicopathological characteristics of esophageal leiomyoma and aimed to evaluate the role of endoscopic ultrasonography in the diagnosis and treatment selection for these lesions.

METHODS:

Two hundred and twenty-five patients who had suspected esophageal leiomyomas in endoscopic ultrasonography were enrolled at the Endoscopy Center of The First Affiliated Hospital, Zhejiang University from January 1st, 2009 to May 31th, 2015. The main outcomes included the demographic and morphological characteristics, symptoms, comparisons of diagnosis and treatment methods, adverse events, and prognosis.

RESULTS:

One hundred and sixty-seven patients were diagnosed as having an esophageal leiomyoma by pathological examination. The mean patient age was 50.57±9.983 years. In total, 62.9% of the lesions originated from the muscularis mucosa, and the others originated from the muscularis propria. The median distance to the incisors was 30±12 cm. The median diameter was 0.72±0.99 cm. As determined by endoscopic ultrasonography, most existing leiomyomas were homogeneous, endophytic, and spherical. The leiomyomas from the muscularis mucosa were smaller than those from the muscularis propria and much closer to the incisors (p<0.05). SMA (smooth muscle antibody) (97.2%) and desmin (94.5%) were positive in the majority of patients. In terms of treatments, patients preferred endoscopic therapies, which led to less adverse events (e.g., intraoperative bleeding, local infection, pleural effusion) than surgical operations (p<0.05). The superficial leiomyomas presented less adverse events and better recovery (p<0.05) than deep leiomyomas.

CONCLUSION:

Endoscopic ultrasonography has demonstrated high accuracy in the diagnosis of esophageal leiomyomas and provides great support in selecting treatments; however, EUS cannot completely avoid misdiagnosis, so combining it with other examinations may be a good strategy to solve this problem.

[Comparative of gastrointestinal mesenchymal tumors of CT virtual endoscopy and pathology]

OBJECTIVE

To observe the lower gastrointestinal mesenchymal tumors CT virtual endoscopy and pathology, and to explore its possible mechanism.

METHODS

Select 80 patients suspected colon gastroenterology treat in the hospital gastroenterology department, randomly divided into experimental group and control group, 40 cases in experimental group were given CT virtual endoscopy and pathological check, the control group received conventional colonoscopy and pathological check, and all the results compared with the pathological results.

RESULTS

Compared with the pathological test results, consistent rate with the experimental group reached 94.73%, the same rate was 92.85% in control group. The difference was not statistically significant (P > 0.05).

CONCLUSIONS

CT virtual endoscopy can quickly image and draw detailed information, and can improve the sensitivity and specificity of cancer diagnosis greatly. Clinically, CT virtual endoscopy have the same function as colonoscopy, can replace colonoscopy, can be important complement of electronic colonoscopy by those who cannot tolerate electronic colonoscopy or have contraindications. Its value is worth taking a step forward in-depth study.

The influence of technical factors on sonoelastographic assessment of solid breast nodules

PURPOSE

The aim of the study was to assess the influence of technical factors and/or lesion characteristics on the final elastographic score in solid breast nodules.

MATERIALS AND METHODS

Patients with solid breast masses examined between May 2007 and May 2008 in the Radiology Department of Cluj District University Hospital were included in the study. All lesions were examined with conventional ultrasound, Doppler ultrasound and sonoelastography, according to a preset protocol. The influence of the following factors on the elastographic score was evaluated: type of section (sagittal versus transverse); size of region of interest (small versus large); amplitude and frequency of movement; initial compression (light versus strong); angulation (perpendicular versus angulated transducer); characteristics of the lesion (size and location). The reference diagnosis was the histopathology diagnosis and, in twenty cases, short-term follow-up.

RESULTS

Ninety-two patients with a mean age of 48.11 years and 101 breast nodules were included in the study. The overall sensitivity and specificity for elastography were 79 % [68-88 %] and 79 % [65 - 89 %], respectively, with a negative predictive value of 74 % [60-85 %] and a positive predictive value of 84 % [72-91 %]. The following factors did not influence the elastographic score: type of section (scores on transverse and longitudinal section, Z = -0.641, p = 0.552); the amplitude and frequency of movements during the elastographic examination (Cochran's Q concordance = 0.706, p = 0.872); strong initial compression in the case of benign nodules (Z = 0.000, p = 1.000); size of the lesions. Of the elastographically benign nodules, 9 were false negative and of the 46 elastographically malignant nodules, 12 were false positive. The following factors influenced the elastographic scores: size of the region of interest (the scores were significantly different when small or large region of interest was used, Z = -0.671, p < 0.0001); transducer angulation (Z = -5.42, p < 0.0001); strong initial compression in the case of malignant nodules (Z = -6.044, p < 0.0001) and the location of the mass in the vicinity of the chest wall.

CONCLUSION

The most important factors that influence the final elastographic score, leading to false negative results, are the size of the region of interest, the initial compression and angulation of the transducer, while the frequency and amplitude of movement during the examination proved to be of no importance as long as the images were obtained within a range of assessment usefulness. Changing the scanning parameters never led to false positive results in the case of malignant breast masses.

[A comparative study of the diagnostic value of endoscopic ultrasonography with pathological features of upper gastrointestinal mesenchymal tumors]

OBJECTIVE

To study the pathological and immunohistochemical features of upper gastrointestinal mesenchymal tumors (GIMTs) and compare them with endoscopic ultrasonographic (EUS) characteristics so as to evaluate the diagnostic value of EUS in upper digestive tract GIMTs.

METHODS

Seventy-two pathological specimens of upper digestive tract GIMTs (34 surgical specimens and 38 endoscopic mucosal resection (EMR) specimens) were collected. The pathological features and the expression of CD(117), CD(34), SMA and S-100 were observed by immunohistochemical method with light microscope. The pathological types and characteristics were determined by pathologists and compared with the layer of origin and sonographic characteristics determined with preoperative EUS.

RESULTS

In the 72 cases of upper digestive tract GIMTs, 37 cases were diagnosed as stromal tumor with pathological and immunohistochemical methods (51.4%); 21 of them were malignant, accounting for 56.7% of the stromal tumors. Thirty-four cases were diagnosed as leiomyoma (47.2%) and 1 case as schwannoma (1.4%). In the 72 GIMTs cases, 40 were esophageal GIMTs. EUS showed that 38 cases were originated from the muscularis mucosae layer; 33 of them were leiomyoma and 5 stromal tumor. The 2 cases originating from the muscularis propria layer which were both stromal tumors. Thirty-two cases were gastric GIMTs, EUS showed that 2 cases originating from the muscularis mucosae layer were gastric stromal tumor. Of the 30 cases originating from the muscularis propria layer, 28 cases were stromal tumor, 1 case was leiomyoma and 1 case was schwannoma. The sensitivity and the specificity of EUS in distinguishing benign and malignant stromal tumors according to sonographic characteristics were 81.0% and 93.8% respectively.

CONCLUSION

Stromal tumor is more common in stomach mesenchymal neoplasms and is more often originated from the muscularis propria layer in EUS; leiomyoma is more common in esophagus and is more often originated from the muscularis mucosae layer. The diagnostic sensitivity and specificity of EUS are high in distinguishing benign and malignant character of upper digestive tract GIMTs. EUS plays an important role in guiding the clinical management of upper digestive tract GIMTs.

[Detection of the primary tumor site in tumor-induced osteomalacia by indium-111 octreotide scintigraphy: a case report]

We report a 31-year-old woman with tumor-induced osteomalacia suffering from slowly progressive bilateral muscle weakness predominantly in the proximal muscles and multiple bone pains for the past 2 years. She was unable to walk or raise her arms above the shoulder. We suspected tumor-induced osteomalacia due to decreased serum phosphate and 1alpha, 25 (OH),-vitamin D3 levels, low percentage of tubular reabsorption of phosphate (%TRP), adult onset, and no family history of osteomalacia. Regular imaging examinations could not detect the location of the primary tumor: however, indium-111 octreotide scintigraphy detected the causative primary mesenchymal tumor in the right sole. Pain and muscle weakness improved promptly after tumor resection, and she was able to walk 6 d postoperatively. This is the first case report in Japan describing the detection of the primary tumor site by indium-111 octreotide scintigraphy.

Left atrial malignant mesenchymoma--emergency resection and mitral replacement

Cardiac mesenchymoma is a rare malignancy with a dismal prognosis. We present a case of left atrial mesenchymoma, obstructing the mitral orifice. An emergent tumor resection with mitral valve replacement was performed. Few reports deal with emergency resection of cardiac malignancies with mitral valve replacement. Surgery is the only effective treatment modality.

Imaging of kidney cancer

Advances in molecular genetics have expanded the understanding of renal cell tumors. Now it is understood that renal cortical tumors are a family of neoplasms with distinct cytogenetics and molecular defects, unique histopathologic features, and different malignant potentials. Imaging contributes to clinical management of patients with renal tumors in providing diagnostic information for tumor detection, characterization, staging, treatment planning, and follow-up.

Glioneuronal-mesenchymal tumour with malignant transformation

We report a case of a 10-year-old girl with a tumour of the right temporoparietal region of the brain. The tumour consisted of three morphologically distinct portions: a well-differentiated one containing a mixture of a ganglioglioma with adipocytic-like cells and focal chondroid metaplasia, a separate island with neurocytic differentiation, and the malignant one, which exhibited an organoid pattern (trabecular and festooned) of primitive neuroectodemal tumour (PNET). We hypothesize that the latter component originated from the multicomponental glioneuronal tumour with mesenchymal differentiation and thus that lesion constituted an unusual example of malignant transformation of low-grade glioneuronal neoplasm.

Pediatric penile tumors of mesenchymal origin

OBJECTIVES

To describe 2 cases of mesenchymal pediatric penile tumors in a 13-year-old boy and an 11-month-old infant. Mesenchymal tumors are rare in the male external genitalia.

METHODS

Two patients, one aged 13 years and one 11 months, presented with painless penile masses at the penoscrotal junction. The evaluation included serial clinical examinations and ultrasonography. Both lesions were surgically excised after increasing in size. Because of malignancy, the first patient underwent wide reexcision of the tumor site.

RESULTS

The pathologic findings of the first case were combined dermatofibrosarcoma protuberans, giant cell fibroblastoma, and fibrosarcoma, a malignant tumor. Immunohistochemical staining showed strong and diffuse CD34 cytoplasmic positivity in the giant cell fibroblastoma and dermatofibrosarcoma protuberans components; the dedifferentiated fibrosarcoma tumor cells were negative for this antibody. The second case was myofibroma, a benign fibroblastic tumor with a prominent myofibroblastic component that is congenital and tends to occur within the first few months after birth. Neither patient had recurrence at 16 months and 3 years of follow-up. To our knowledge, this is the first reported case of combined dermatofibrosarcoma protuberans, giant cell fibroblastoma, and fibrosarcoma of the penis and the second reported case of isolated penile myofibroma.

CONCLUSIONS

Penile tumors should be included in the differential diagnosis of pediatric penile masses. Surgical resection is often curative, but patients with malignant tumors should receive careful follow-up to monitor for recurrence.

Malignant mesenchymoma arising from a uterine leiomyoma in the menopause

BACKGROUND

Malignant mesenchymoma is a rare tumor and location in the uterus is even rarer. We describe the first case of malignant mesenchymoma arising from a uterine fibroid in the menopause.

CASE REPORT

A 64-year-old woman presented with abdominal pain and underwent surgery for a large "uterine fibroid" with suspicious features on ultrasound scan. The mass had developed after the menopause. Histology showed benign leiomyomatous tissue with malignant areas consistent with malignant mesenchymoma.

CONCLUSION

We report the first case of malignant mesenchymoma arising from the uterus in menopause. Certain radiological features may be associated with this tumor. Due to its rarity, information on management of uterine malignant mesenchymoma is lacking and management options of uterine leiomyosarcomas are reviewed as a surrogate.

Chondrolipoma in the palm of a child

Chondrolipoma is a rare form of benign mesenchymoma. We report the case of a chondrolipoma in the palm of a 9-year-old boy with corresponding sonographic, magnetic resonance (MR) and pathological findings.

[Case report: Radiologic findings of retroperitoneal malignant mesenchymoma]

Malignant mesenchymomas are rare soft tissue tumors that contain two or more distinct histologic subtypes of sarcoma within the same tumor. Although experience with these tumors is limited, they are generally considered high grade neoplasms and are associated with a poor prognosis. Here we present radiologic findings of a case with malignant mesenchymoma in the retroperitoneum.

Endosonographic evaluation of c-kit-positive gastrointestinal stromal tumor

BACKGROUND

Endosonographic features of c-kit-positive gastrointestinal stromal tumors (GISTs) were compared with those of leiomyomas and schwannomas.

METHODS

Twenty-four patients with gastric mesenchymal tumors who underwent endoscopic ultrasonography (EUS) and surgical treatment were enrolled. GISTs were defined as c-kit (CD117)-positive tumors, leiomyomas as desmin-positive and c-kit-negative tumors, and schwannomas as S-100-positive and c-kit-negative tumors. Invasion to adjacent organs or more than 20 mitotic counts per 50 high power fields indicated malignancy.

RESULTS

There were 19 GISTs, three leiomyomas, and two schwannomas. All five malignant tumors were GISTs. A marginal halo was found in 12 of 19 GISTs and in both of the schwannomas, but not in any of the three leiomyomas. The echogenicities of GISTs were low but higher than that of the normal proper muscle layer, whereas those of leiomyomas and schwannomas were usually low. Lobulation of the tumor surface was documented only in GISTs, particularly in malignant ones. The tumor doubling time of a malignant GIST was 9.3 months, and that of six benign GISTs was 18.7 months (range = 10.7-28.0 months).

CONCLUSION

Marginal halo and relatively higher echogenicity on EUS might suggest GIST. Marginal lobulation and a short doubling time may be signs of a malignant GIST.

[Rare mesenchymal lesions in siblings. Two case reports]

We report on a 15-month-old boy presenting a juvenile active ossifying fibroma in the right nasal cavity and the sibling, a 9-month-old girl with a mesenchymal hamartoma of the chest wall. The two lesions showed many similarities. Both lesions are present at the time of birth or in early life with local obstructive or compressive effects. The lesions have a similar mixture of mature and immature mesenchymal tissue with areas of ossification. The entities present a tumor-like development with an abnormal mixture of tissue indigenous to the specific area of the body without notable atypical cytologic features. These features are typical criteria for hamartoma lesions.

Malignant mesenchymoma of the orbit: case report and review of the literature

OBJECTIVE

Malignant mesenchymoma are rare tumors of the orbit. From 1961 using English-language literature, we present the sixth such case and the first case with three malignant components.

DESIGN

Interventional case report.

METHODS

The clinical presentation, workup, surgical treatment, and pathology of a case of malignant mesenchymoma of the orbit are presented.

RESULTS

Although very rare, these tumors should be in the differential diagnosis of any tumor of the orbit. The prognosis is unknown because of the lack of follow-up of reported patients.

CONCLUSIONS

This malignant orbital mesenchymoma, an entity not accepted by all pathologists, was more complex than cases previously reported in the English literature in demonstrating rhabdomyosarcomatous, chondrosarcomatous, and osteogenic differentiation.

Bone and In-111 octreotide imaging in oncogenic osteomalacia: a case report

Osteoporosis associated with aging is considered the most common cause of bone mineral loss. Osteomalacia, abnormal bone loss with excess osteoid formation, is another cause. A 46-year-old man was examined for chronic hip and lower extremity pain that had not been relieved by nonsteroidal anti-inflammatory drugs or steroids. A bone scan revealed multiple foci of activity. The serum calcium level was normal, but phosphorus values were low. These results did not correspond with the indications for typical hyperparathyroid disease, so another cause was sought. An In-111 octreotide scan showed a focus in the right humeral head. At surgery, a phosphaturic tumor of mesenchymal origin was partially resected. Oncogenic osteomalacia is related to secretion of a phosphaturic material from a fibroblast growth factor.

Malignant ectomesenchymoma of the orbit in a child: Case report and review of the literature

Malignant ectomesenchymoma is a rare soft tissue tumor of childhood composed of both mesenchymal and neuroectodermal elements. Reported sites of origin are head and neck, abdomen, perineum, scrotum, and extremities. A new case of an orbital ectomesenchymoma in a 7-year-old boy is presented. The clinical picture of the tumor, radiological findings, and its histopathologic and immunohistochemical characteristics are described. The patient was successfully treated with combined surgical resection and chemotherapy. All the other reported cases of malignant ectomesenchymoma with various sites of origin are also reviewed.

Unusual primary lung tumors: a radiologic-pathologic overview

Although the great majority of lung carcinomas are histologically characterized as adenocarcinoma, squamous cell carcinoma, large cell undifferentiated carcinoma, or small cell carcinoma, a variety of rare benign and malignant lung tumors may sporadically affect the lung. Several nonneoplastic tumorlike lesions are seen infrequently but are also part of the differential diagnosis for lung masses. Conventional radiographic findings, although of limited value in the diagnosis of these entities, should be examined carefully when lung tumors are suspected. Computed tomography (CT) is well suited for making a definitive diagnosis of some disease processes. CT helps determine the location and features of the lesions and depicts associated findings to help document the extent of disease. The differential diagnosis can be narrowed when there are typical CT features (eg, the presence of fat in lipoid pneumonia). Although unusual primary lung tumors are difficult to diagnose on the basis of imaging findings alone because such findings are nonspecific in the majority of cases, cross-sectional imaging can play an important role in the diagnostic work-up of these unusual tumors by delineating their extent and directing the radiologist or bronchoscopist to the appropriate biopsy site.

Echocardiographic features of primary cardiac sarcoma

Primary cardiac sarcoma is extremely rare and seldom causes symptoms until late in its course. Discomfort may occur only when the mass causes obstruction to the intracardiac flow. Early diagnosis is vital because it allows prompt and relevant management. We describe the history and echocardiographic features in four patients with primary cardiac sarcoma and review the current literature.

Octreotide scanning in the detection of a mesenchymal tumour in the pubic symphysis causing hypophosphataemic osteomalacia

Oncogenic hypophosphataemic osteomalacia is a rare condition. The causative tumour is often difficult to locate. Primary tumours have been reported in the head and neck, skeleton, and soft tissue. Octreotide scanning was used in this case and detected a mesenchymal tumour in the pubic symphysis.

Disseminated malignant ectomesenchymoma (MEM): case report and review of the literature

Malignant ectomesenchymoma (MEM) is a rare soft tissue tumor believed to arise from a pluripotent migratory neural crest cell and composed fo both a mesenchymal element and a neuroectodermal element. The authors report the case of an 11-month-old male who presented with a local abdominal MEM and systemic metastases into lungs, liver, bones, and bone marrow. This is the first reported case of an MEM with initial bone marrow dissemination. The tumor consisted of a neuroblastoma component and a mesenchymal component with sarcomatous features. Diagnosis and therapy were complicated by the histological heterogeneity of the tumor, which also influenced the clinical appearance and course in this case. A literature search revealed 15 other evaluated cases that arose in soft tissue and had adequate clinicopathologic data. Complete surgical resection was the mainstay of treatment, and chemotherapy also appeared to be important. In all reported patients (n = 3) with initial metastases or bone marrow dissemination, as in this case, no cure could be achieved. In patients with disseminated MEM, new therapeutic approaches such as high-dose chemotherapy followed by stem cell rescue should be considered, similar to the current strategy in patients with stage VI neuroblastoma or soft tissue sarcoma.

Retroperitoneal malignant mesenchymoma: a case of mesenchymal mixed tumor with osteosarcoma, leiomyosarcoma, liposarcoma and fibrosarcoma

Malignant mesenchymoma is an interesting but very rare tumor in which malignant differentiation has occurred twice or more. We report a case of retroperitoneal malignant mesenchymoma consisting of osteosarcoma, leiomyosarcoma, liposarcoma and fibrosarcoma. Abdominal CT showed a large retroperitoneal mass with two separate and distinct parts, namely an area of prominent calcification and one of clearly enhancing solid components. The mass contained histologically distinct tumorous components with no histologic admixure at the interfaces. The densely calcified nodule corresponded to osteosarcoma, and the noncalcified clearly enhancing nodules to leiomyosarcoma, liposarcoma and fibrosarcoma.

Fibrocartilaginous mesenchymoma of the distal femur: case report and literature review

A case of a 9-year-old boy with fibrocartilaginous mesenchymoma located in the distal femur is presented. Fibrocartilaginous mesenchymoma is a rare tumor. There have been 17 cases reported since 1984. The presenting complaint was pain and local discomfort. Radiological examination showed lytic and sclerotic lesions located in the distal femur. Magnetic resonance imaging showed that there was no soft tissue expansion. Differential diagnosis included fibrocartilaginous dysplasia, dedifferentiated chondrosarcoma, desmoplastic fibroma, fibrosarcoma and low-grade osteosarcoma. The diagnosis of the tumor in a state hospital would not have been possible. Wide resection of the tumor and resection arthrodesis with an intramedullary nail has yielded good results. The patient has been disease free for 4 years. Pathological diagnosis of this very rare tumor may be challenging; the treatment should be wide resection of the tumor.

Oncogenic osteomalacia associated with mesenchymal tumour detected by indium-111 octreotide scintigraphy

In a 40-year-old man who had suffered from vague and generalized bone pains for 7 years due to oncogenic osteomalacia, the causative tumour was finally detected by Indium-111 octreotide scintigraphy. Some characteristics of the tumour associated with oncogenic osteomalacia, such as its size, growth rate, location and origin, often make the diagnosis difficult. However, the recent discovery of somatostatin receptors in mesenchymal tumours, which are the most common cause of oncogenic osteomalacia, has raised the possibility of early detection of this devastating disorder. Here, we report that radiolabelled octreotide scintigraphy has a potential role as a diagnostic tool in oncogenic osteomalacia. However, the exact role of somatostatin receptors in tumours associated with oncogenic osteomalacia still remains elusive.

Somatostatin receptor scintigraphy in the management of cerebral malignant ectomesenchymoma: a case report

A 10-year-old girl presented with a cerebral malignant ectomesenchymoma (MEM), a very unusual tumour with undifferentiated mesenchymal as well as ectodermal elements. Somatostatin receptor scintigraphy (SRS) was performed during the diagnostic workup. The recurrent residual tumour mass was exactly visualized with SRS, and was negative after successful treatment of the patient. The potential application of SRS in initial staging, follow-up and therapy planning in MEM is discussed. This is the first application of SRS in MEM.

[Histological and clinical analysis of mesenchymal malignant neoplasms (soft tissue sarcomas) of head and neck region in the data of I ENT Department of Silesian Medical Academy]

Between the years 19890-1998 in I ENT Department of Silesian Medical Academy were treated surgically 15 patients suffering from soft tissue sarcomas of head and neck region. Patomorphological examination showed: fibrosarcoma (4 cases), haemangioendothelioma malignum (2 cases), rhabdomyosarcoma (2 cases), schwannoma malignum (2 cases), fibrohistiocytoma malignum (2 cases), tumor mixtus mesenchymalis (1 case), haemangiopericytoma malignum (1 case), extrasceletal osteosarcoma (1 case). Sarcomas were localised in paranasal sinuses (7 cases), orbita (5 cases), parapharyngeal space (1 case), parotid gland (1 case) and bucca (1 case). All those patients were treated surgically and most of them were irradiated postoperatively. The authors have presented the diagnostic and methods of treatment of soft tissue sarcomas. According to our experience and data of the literature the method of choice in treatment soft tissue sarcomas should consist of surgery and radiation therapy postoperatively.

Secondary achalasia due to a mesenchymal tumour of the oesophagus

A rare case of a secondary achalasia or pseudoachalasia due to a mesenchymal tumour of the oesophagus is presented. A 67-year-old Caucasian man had symptoms including dysphagia, odynophagia, and weight loss for 8 months. Radiological examination revealed no signs of neoplasia but an exploratory laparotomy revealed the presence of a mesenchymal tumour of the oesophagus. Tucker's criteria constitute an important tool in the differential diagnosis of secondary achalasia from primary achalasia with clinical value, but in this case, exploratory laparotomy rather than non-invasive diagnostic procedures provided the final and definite diagnosis.

Use of long-term intravenous phosphate infusion in the palliative treatment of tumor-induced osteomalacia

Tumor-induced osteomalacia is characterized by paraneoplastic defects in vitamin D metabolism, proximal renal tubular functions, and phosphate transport. The resulting hypophosphatemia can cause generalized pain and muscle weakness, which significantly affect the quality of life of the patients. Palliative treatment with calcium, vitamin D, and phosphate replacement is indicated for patients in whom the causative tumor cannot be completely resected. In this report we describe a case of tumor-induced osteomalacia in whom adequate oral doses of phosphate could not be used because of gastrointestinal side-effects. Long term (3-6 months) iv phosphate infusion delivered by ambulatory infusion pumps in combination with oral calcium and vitamin D was used successfully to decrease pain and increase muscle strength. Careful monitoring of serum calcium, phosphate, and creatinine levels and reliable microinfusion technology have allowed the long term use of iv phosphate infusion without serious morbidity. This patient received repeated (three times) phosphate infusions over 8 yr, resulting in laboratory and symptomatic improvement after each course. However, this patient did suffer two episodes of central venous catheter-related infection. Because of potentially serious complications, such as severe hypocalcemia, calcified right ventricular thrombi, and nephrocalcinosis, long term iv phosphate infusion should be reserved for patients who cannot tolerate adequate doses of oral phosphate and for whom the benefits outweigh the risks.

[Fibrocartilaginous mesenchymoma of bone. A case report]

Fibrocartilaginous mesenchymoma of bone is a tumoral entity which is somewhat controversial. It has been delineated in 1984 by Dahlin and al. Fifteen cases have been reported in the literature. We report a new case which involves proximal humerus. X-ray data, microscopic findings and local recurrence indicate a low grade malignancy. Metastasis have never been reported. The main differential diagnosis are desmoplastic fibroma, fibrous dysplasia and fibrosarcoma with low grade malignancy. Treatment is surgical.

[Mesenchymal tumors of the pancreas: computed tomography patterns]

PURPOSE

To report the CT patterns of pancreatic mesenchymal lesions and to investigate the capabilities and limitations of this technique in terms of characterization.

MATERIAL AND METHODS

We selected the CT examinations of 23 patients from all CT examinations of the pancreas performed from 1986 to 1998. The patients were 10 to 85 years old and all lesions but two (1 lipoma and 1 lymphoma) had pathologic confirmation. Two lymphangiomas, 2 lipomas, 4 Schwannomas (SCH), 1 plexiform neurofibroma, 1 cystic teratoma, 1 pancreatoblastoma, 9 non-Hodgkin's lymphomas (NHL), 1 undifferentiated sarcoma and 2 leiomyosarcomas were diagnosed.

RESULTS

Lipomas had typically homogeneous negative HU values, and NHL a homogeneous hypodense pattern with mild contrast enhancement, with no necrosis or calcifications in both diffuse and nodular forms; SCH had variable appearance, with water/slightly negative HU numbers or highly enhanced patterns with a central necrotic core depending on the main Antoni A or B histology. Lymphangiomas appeared as complex cysts, with thin and regular or calcified walls and intracystic septa, while the plexiform neurofibroma had near-water homogeneous density with mild contrast enhancement and an infiltrating growth pattern. Our teratoma had multiple calcifications, mucinous and lipid components. The pancreatoblastoma, sarcomas, and leiomyosarcomas exhibited no specific findings.

CONCLUSIONS

In selected cases, CT can provide virtually diagnostic information (lipoma and teratoma), or at least highly suggestive findings (NHL, plexiform neurofibroma, lymphangioma). Moreover, knowledge of the variable morphostructural patterns of mesenchymal histotypes (SCH, sarcoma etc.) permits to include them in the differential diagnosis of pancreatic masses.

Retroperitoneal malignant mesenchymoma: imaging findings in five cases

BACKGROUND

To describe computed tomographic (CT), magnetic resonance (MR), ultrasonographic (US), and angiographic findings of retroperitoneal malignant mesenchymoma with emphasis on CT findings.

METHODS

Five CT, four US, four angiography, and two MR studies were obtained in five patients with pathologically proven retroperitoneal malignant mesenchymoma.

RESULTS

Tumors were larger than 10 cm (n = 4), well-circumscribed and heterogeneous (n = 4), and with massive intratumorous calcifications (n = 3) on plain CT or US. Tumors showed heterogeneous enhancement on contrast-enhanced CT scans (n = 4) and moderate hypervascularity with heterogeneous staining on angiography (n = 3). Tumors were essentially hypointense on T1-weighted MR images (n = 2) and heterogeneous hyperintense on T2-weighted MR images (n = 2). Plain CT showed a fat-dense structure in a tumor in one patient.

CONCLUSIONS

The radiologic findings of large expansile heterogeneous masses in the retroperitoneum, especially with massive calcifications, were considered to be typical of malignant mesenchymomas.

A primary solitary tumor of the lesser omentum with immunohistochemical features of gastrointestinal stromal tumors

We here present a primary solitary tumor of the lesser omentum that was found in a 71-yr-old woman. Differential diagnosis could not be made preoperatively; therefore, histopathological examination including immunohistochemical studies were performed to determine the nature of the tumor. The resected specimen, measuring 17 cm at the largest point, consisted of the outer solid part and the inner multiloculated cysts. Microscopically, the tumor was characterized by interlacing bundles of elongated spindle cells, with the nuclei focally showing a palisading pattern. However, skeinoid fibers were not observed anywhere. One to three mitoses per 50 high power fields were observed. Immunohistochemically, the tumor was negative for S-100 protein and smooth muscle-specific actin, but stained positive for CD34. The microscopic features were consistent with those of potentially malignant gastrointestinal stromal tumors. Stromal tumors that represent the differentiation toward neither typical leiomyomas or schwannomas rarely occur in the lesser omentum with only one such instance having been reported to date. Due to this rarity, it is difficult to make the differential diagnosis preoperatively, even with existing imaging techniques, and predicting the clinical behavior of such omental tumors is also often difficult. Therefore, complete resection should be performed when such tumors are encountered in daily practice.

[Odontogenic fibroma of the jaws. Report of a clinical case and etiopathogenic considerations]

A case of peripheral odontogenic fibroma is reported and its epidemiology, clinical aspects and etiopathogenesis are discussed. It is supposed that the epithelial component may be related to odontogenic embrionary tissue inclusions: These inclusions may stimulate a local mesenchymal reaction giving place to a proliferative lesion, as observed.