Pseudosarcomatous lesions of the soft tissues reported as sarcoma during a 6-year period (1958-1963)

Pseudosarcomatous lesion of the soft tissues is a term used in the present study for various soft tissue lesions and tumours easily clinically or histologically, or both, misinterpreted as sarcoma. Eighty-one cases, that is to say 10 per cent of all tumours classified and reported to the Swedish Cancer Registry as malignant soft tissue tumours during the 6-year period studied (1958-1963), were reclassified as pseudosarcomatous lesions of the soft tissues. Forty-seven cases were classified as pseudoarcomatous proliferative lesions of the soft tissue with or without bone formation; 38 cases of nodular fasciitis, 1 of proliferative fasciitis and 8 of proliferative myositis. In 3 of these cases there were mixed forms of proliferative fasciitis and proliferative myositis with areas compatible with the diagnosis of nodular fasciitis evident in all cases. Twenty-two cases of atypical fibroxanthomas of the skin were next in frequency, followed by 7 ancient neurilemmomas, 2 spindle cell lipomas, 1 pseudomalignant osseous tumour of the soft tissues, 1 pigmented villonodular synovitis and 1 juvenile xanthogranuloma. An attempt is made to explain the reasons for these erroneous diagnoses of sarcoma and it is stressed that for these lesions the conventional histological criteria for malignancy are not valid. The awareness and knowledge of the existence of these particular entities are therefore considered mandatory for an accurate diagnosis.     

Nodular fasciitis: Spontaneous resolution following diagnosis by fine-needle aspiration

Nodular fasciitis can be histologically mistaken for a sarcoma. Typical cases are less than 5 cm and enlarge rapidly over days or weeks before diagnosis. The natural history of nodular fasciitis is unknown, since the diagnosis is usually based on excised lesions. Fine-needle aspiration of nodular fasciitis has been described, and features benign-appearing spindle cells (singly and in groups), collagen, and myxoid material. We describe 11 cases in which nonsurgical observation led spontaneously to complete resolution. Our study includes 7 males and 4 females (24 to 73 years of age; median = 42). Lesions were located in the arm (4), thigh (3), temporal area (2), breast (1) and the parotid (1) and ranged from 0.5 to 5.0 cm. (median = 1.5). They had been present for from less than 1 to 4 weeks (median = 2). In 9 cases, spontaneous resolution occurred in from 3 to 8 weeks (median = 4). Two other patients were lost to follow-up for up to 11 months, after which resolution was noted. Small palpable masses in the subcutaneous soft tissues which evolve over a short period of time and show the cytologic features of nodular fasciitis should be managed nonsurgically. If resolution does not occur within a few weeks, surgery can then be performed. Diagn Cytopathol 1993;9:322-324.     

假肉瘤性软组织病变的细针吸取细胞学

目的：总结假肉瘤性软组织病变细针吸取细胞学（ＦＮＡＣ）特点,寻求在针吸细胞学基础上与肉瘤鉴别的要点。方法：总结１０例结节性筋膜炎,１例增生性筋膜炎,１例增生性肌炎的针吸细胞学改变及临床经过。结果：假肉瘤性软组织病变的ＦＮＡＣ特点是细胞的种类、大小较多样化及多数会出现节细胞样细胞。细胞核大,核仁明显,但核的恶性特征不明显。有６例结节性筋膜炎及１例增生性肌炎临床自行消退。结论：可凭ＦＮＡＣ特点将假肉瘤     

Fine-needle aspiration biopsy: Pitfalls in the diagnosis of spindle-cell lesions

Seven cases of spindle-cell proliferations in which fine-needle aspiration biopsy (FNAB) did not correlate with subsequent histology are presented. Three cases were considered low-grade sarcoma, one a dermatofibrosarcoma protuberans (DFSP), one a spindle-cell tumor with malignancy not excluded, and one a rhab-domyosarcoma vs. a fibrosarcoma. Two of the these three were histologically nodular fasciitis and one an inflammatory pseudotumor. Two cases were diagnosed cytologically as fibromatosis or nodular fasciitis (NF). One of these histologically was an intramuscular hemangioma, the other a DESP. The last two cases were diagnosed by FNAB as spindle-cell lesion, undetermined if benign or malignant, and malignant fibrous histiocytoma (MFH). Histologically both of these case were leiomyosarcoma. The cyto-logic features of each case, differential diagnosis, and potential pitfalls are discussed. In the evaluation of FNAB smears dominated by spindle cells, cellullarity, individual cells and cell patterns,and background stromal features coupled with a precise clinical history may allow a narrow differential diagnosis with a focus on whether the lesion is benign or malignant. Caution is warranted in the exact classification of spindle-cell tumors from FNAB as this may have a major impact on patient management. © 1994 Wiley-Liss, Inc.     

Intratumoural lymphatics in benign and malignant soft tissue tumours

Soft tissue sarcomas do not generally metastasise via lymphatics, and the presence or absence of lymphatic vessels within sarcomas and benign soft tissue tumours is not known. In this study, we determined whether lymphatic vessels were present in a wide range of benign and malignant soft tissue lesions by examining intratumoural expression of the lymphatic endothelial cell markers, Lyve-1 and podoplanin. Intratumoural Lyve-1+/podoplanin+ lymphatics were not identified in sarcomas apart from all cases of epithelioid sarcoma (a tumour which is known to metastasise to lymph nodes) and a few cases of leiomyosarcoma, rhabdomyosarcoma and synovial sarcoma. Intratumoural lymphatics were also absent in most benign soft tissue tumours. Reparative and inflammatory soft tissue lesions contained lymphatics, as did all (pseudosarcomatous) proliferative myofibroblastic lesions including nodular, proliferative and ischaemic fasciitis, elastofibroma, nuchal fibroma and deep fibromatosis. Our results show that most soft tissue sarcomas do not contain intratumoural lymphatics, a finding which is consistent with the infrequent finding of sarcoma metastasis to lymph nodes. In contrast to fibrosarcoma and a number of other malignant spindle cell tumours, proliferative fibroblastic/myofibroblastic lesions of soft tissue contain intralesional lymphatic vessels.     

Nodular fasciitis or pseudosarcoma]

Nodular fasciitis is a benign neoplastic and reactive proliferation of fibroblasts of soft tissues, which is often mistaken for a sarcoma because of its rapid growth, rich cellularity and mitotic activity. A case is reported that provides the opportunity to discuss the specific clinical and pathological features of nodular fasciitis.     

Metachronous soft-tissue masses in children and young adults with cancer: correlation of histology and aspiration cytology

We describe a series of 28 fine needle aspiration biopsies (FNAB) of soft tissue from 22 patients. Four patients had two separate FNABs, and one had three aspiration procedures. The patient population was limited to children and young adults (age range, 2 months to 29 years; mean, 16 years) who were known to have diverse forms of cancer, and who subsequently developed a mass in the peripheral soft tissues (including breast). The interval between the time of diagnosis of the primary malignant neoplasm and FNAB ranged from 1 day to 17 years (mean, 39 months). All FNAB diagnoses were confirmed by subsequent surgical open biopsy or clinical follow-up greater than 1 year. No complications occurred from the procedure. The cytomorphology is presented in selected cases and correlated with the patient's original tissue histopathology. Twenty aspirates were diagnosed as cytologically malignant, one as suspicious for malignancy. Seven were considered benign. None were unsatisfactory. One false-positive and no false-negative cytologic diagnoses were obtained. The overall accuracy of FNAB diagnoses was 96%, while sensitivity was 100% and specificity 88%. Sites of aspiration included soft tissues of the head and neck (seven cases), trunk (eight cases), breast (four cases), and extremities (nine cases). Malignant cytologic diagnoses included sarcoma (thirteen), seminoma (two), lymphoma/leukemia (two), melanoma (one), undifferentiated neoplasm (one), and neuroblastoma (one). Electron microscopy of aspirated cells was used to confirm the diagnosis in two cases. Fine needle aspiration biopsy of soft tissue masses from children and young adults with cancer demonstrates a high diagnostic accuracy, and its use is justified in this population.     

Is fine-needle aspiration biopsy a practical alternative to open biopsy for the primary diagnosis of sarcoma? Experience with 140 patients

We reviewed the clinicopathologic features of 145 consecutive fine-needle aspiration biopsy (FNAB) specimens from 140 patients without a previous diagnosis of sarcoma. Among 138 adequate specimens, 42 bone sarcomas and 80 soft tissue sarcomas were recognized as sarcomas; histologic subtyping was easier in bone than in soft tissue sarcomas and in pediatric than in adult cases. There was no correlation in accuracy of subtyping in low- vs high-grade sarcomas. FNAB was most accurate for subtyping of skeletal osteosarcoma, pediatric small round cell bone/soft tissue sarcomas, synovial sarcoma, skeletal chondrosarcoma, and adult myxoid soft tissue sarcomas. Although almost always recognized as sarcoma, subtyping of adult pleomorphic soft tissue sarcomas generally was not possible but did not influence therapy; all were considered high-grade sarcomas for treatment purposes. There were 4 misinterpretations of subtype in soft tissue sarcomas; none resulted in a change in therapy. Cytogenetic analysis on aspirated material confirmed t(11;22) in 2 Ewing and t(X;18) in 3 synovial sarcomas. No procedure-related complications occurred. Among bone and soft tissue sarcomas, FNAB was sufficient for initiation of definitive therapy in 87% and 83% of patients, respectively. Most FNAB specimens from bone and soft tissue sarcomas are recognized easily as sarcoma, but subtyping seems more accurate in bone sarcomas. Although histologic subtyping of adult soft tissue sarcomas is often impossible, no influence on initial therapy is usually observed. In contrast, subtyping of pediatric sarcomas by FNAB seems highly accurate and is necessary for appropriate therapy.     

Intramuskuläre Fasciitis nodularis

Nodular fasciitis is a frequently occurring pseudosarcomatous fibrous proliferation which usually affects the subcutaneous tissue. In the present study, we investigated tissue specimens from 26 patients with intramuscular nodular fasciitis. The median age of patients was 31 years, with the tumors occurring mainly in the extremities (11 patients) and the trunk (11 patients). These had an average size of 2.6 cm. Males predominated (male:female 9:4). Histological examination revealed a proliferation of myofibroblasts (positive for smooth muscle-actin) embedded in a myxoid or fibrous stroma. In 25/26 cases, myogenic giant cells were observed (positive for desmin, negative for smooth-muscle actin and CD 68). Less frequently (11/26 patients), osteoclastic giant cells were found (positive for CD 68, negative for desmin and smooth-muscle actin). In intramuscular nodular fasciitis, myogenic giant cells are encountered more often than previously described. They are relevant for the differential diagnosis of sarcoma and fibromatoses, since they can be misinterpreted as neoplastic giant cells. However, the uniformity of the myofibroblastic proliferate and the myogenic phenotype of the giant cells without proliferative activity (no mitoses, negativity for Ki-67) lead to a correct diagnosis.     

Cytological findings in nodular fasciitis

Nodular fasciitis, proliferative fasciitis, and proliferative myositis are tumorous proliferative soft tissue changes which on histological examination are quite often erroneously diagnosed as malignant neoplasms. Reported are cytological and histological findings recorded from nodular fasciitis in a man aged 34 years. The cytomorphology of nodular fasciitis is sufficiently characteristic, so that the lesion can be differentiated with certainty from malignant processes, since the cells have no features of malignancy, and the admixture of granulocytes and histiocytes in smears suggests a proliferative inflammatory process.     

Fine-needle aspiration biopsy of gouty tophi: Lessons in cost-effective patient management

Gout, a disease resulting from the effects of hyperuricemia and a crystal-induced arthropathy, may produce soft tissue masses (tophi), which mimick neoplasia clinically and radiographically. We have recently diagnosed three cases of gouty tophus, two of which were clinically suspected to represent sarcomas, by fine-needle aspiration biopsy (FNAB) after extensive radiologic and clinical evaluation. There were two women and one man, aged 71, 73, and 50 yr, with palpable soft tissue masses that involved the right forearm, right hand, and right foot, respectively. Biopsies were obtained by using 25-gauge needles without the aid of general anesthesia. Morphologically, aggregates and disassociated slender, needle-shaped crystals were abundant and easily recognized on both Diff-Quik and Papanicolaou stains. By using a polarizing microscope with a first-order red compensator, the crystals showed negative birefringence, characteristic of sodium urate. Benign-appearing histiocytes, foreign-body-type giant cells, neutrophils, and amorphous debris were scattered among the diagnostic crystals. The diagnosis of gouty tophus can be easily established with FNAB in conjunction with compensated polarizing microscopy. Application of FNAB in the initial evaluation of appropriate soft-tissue masses provides a cost-effective diagnostic method, preventing more costly and often unnecessary clinical and radiologic tests. Diagn. Cytopathol. 17:30–35, 1997. © 1997 Wiley-Liss, Inc.     

Pseudosarcomas of soft tissue

One of the most common and important pitfalls in soft tissue pathology are the so-called pseudosarcomas. These lesions are nonneoplastic; however, their rapid growth, hypercellularity, cytologic atypia, and mitotic activity makes them prone to be misinterpreted as sarcoma. The most common of these lesions are fibroblastic/myofibroblastic and matrix-forming proliferations, including nodular fasciitis, proliferative fasciitis and myositis, ischemic fasciitis, massive localized edema, myositis ossificans, and bizarre parosteal osteochondromatous proliferation and related entities. Most of these lesions rarely recur following simple excision; therefore, their accurate recognition helps prevent excessive therapy.     

Fine needle aspiration biopsy of soft tissue sarcomas: utility and diagnostic challenges

The role of fine needle aspiration biopsy (FNAB) as the primary modality for the initial diagnosis of previously undiagnosed soft tissue sarcomas presents several important challenges. Most practicing pathologists are inexperienced with the wide array of soft tissue neoplasms and their morphologic heterogeneity, making them susceptible to misdiagnosis. However, in the hands of experienced cytopathologists, FNAB in conjunction with ancillary techniques has a diagnostic accuracy approaching 95% for the diagnosis of malignancy. FNAB has been shown to have a diagnostic yield nearly identical with core needle biopsy while avoiding significant clinical complications. Nevertheless, FNAB has certain limitations related to the accurate histologic grading and subtyping of certain subgroups of sarcomas. It may also be difficult to accurately distinguish between low-grade sarcomas and benign or borderline cellular lesions, especially in the spindle cell sarcoma subgroup. The aim of this review is to highlight the utility and limitations of FNAB in the primary diagnosis of soft tissue sarcomas, highlight diagnostically challenging lesions, and comment on the limitations of FNAB in providing a "definitive" diagnosis.     

Diagnosis of Kaposi's sarcoma by fine-needle aspiration biopsy

Fifteen cases of Kaposi's sarcoma diagnosed by fine-needle aspiration biopsy were reviewed. The diagnosis was confirmed by tissue biopsy in eight of the cases. All of the patients were homosexual males, and 13 had a previous diagnosis of AIDS. The aspirates were obtained from enlarged lymph nodes (five cases), soft-tissue masses (two cases), oral cavity lesions (seven cases), and an abdominal mass. The most characteristic cytologic features were intact tissue fragments composed of overlapping spindle cells with nuclear distortion and ill-defined cytoplasmic borders. Smaller groups of loosely cohesive spindle-shaped cells and individual spindle cells with cytoplasm were also helpful features. In the appropriate clinical setting, these cytologic features on FNAB are felt to be diagnostic of Kaposi's sarcoma.     

Cytologic features of clear cell sarcoma (malignant melanoma) of soft parts: a study of fine-needle aspirates and exfoliative specimens

We describe the cytologic features of clear cell sarcoma of soft tissue (CCS) in 11 fine-needle aspiration biopsy (FNAB) specimens and 6 exfoliative specimens from 11 patients. In 3 patients, FNAB was the initial method of tumor evaluation. In 6 of 11 cases, immunostaining with S-100 or HMB-45 was evaluated. Electron microscopic evaluation was performed in 1 case. Both the FNAB and exfoliative specimens varied in overall cellularity, although reproducible cytologic features were identified. A significant diagnostic pitfall, namely the potential of CCS to form microacinar structures mimicking adenocarcinoma, is described with particular reference to CCS metastatic to regional lymph nodes. A rare case of the granular cell variant of CCS is illustrated as well. Owing to the rarity of CCS, the diagnosis on cytologic smears is extremely difficult and is aided substantially by pertinent clinical data. The diagnosis can be made conclusively by     

Nodular fasciitis of parotid region: a pitfall in the diagnosis of pleomorphic adenomas on fine-needle aspiration cytology

Fine-needle aspiration cytology (FNAC) is routinely employed for the preoperative diagnosis of salivary gland lesions. Although most cases show morphologic features characteristic of specific entities, some lesions can be diagnostically challenging. We report two parotid aspirates, initially diagnosed as pleomorphic adenoma on FNA. The patients, a 33-yr-old white man, and a 24-yr-old white woman, presented with indurated lesions arising in the parotid gland region. The aspirates from both patients were markedly hypercellular. Smears showed a mixture of spindle cells with a well-demarcated cytoplasm showing occasional long cytoplasmic process; and cells with abundant cytoplasm with round to oval eccentric nuclei, giving the impression of plasmacytoid cells of pleomorphic adenoma. The nuclear chromatin was evenly distributed and finely granular with one or two occasional small nucleoli. Intermingled with the tumor cells were scattered neutrophils, eosinophils, and macrophages. Aggregates of spindle cells were also seen embedded in a mucoid background with occasional small tufts of a fibrillar mucoid stroma. These fibrillar tufts were magenta red in the Diff-Quik stain, giving the impression of matrix of pleomorphic adenoma. Both cases were later diagnosed on histologic examination as nodular fasciitis. Nodular fasciitis should be considered in the differential diagnosis of a mass arising in association with the parotid gland.     

p53 Immunohistochemistry in malignant fibrous histiocytomas and other mesenchymal tumours

In this study we analysed by immunohistochemistry the expression of p53 protein in 14 malignant fibrous histiocytomas (MFHs), 22 other types of sarcoma (eight leiomyosarcomas, four rhabdomyosarcomas, four liposarcomas, two fibrosarcomas, two chondrosarcomas, one malignant schwannoma, and one dermatofibrosarcoma protuberans), and 25 non-malignant mesenchymal lesions (eight dermatofibromas, four cases of nodular fasciitis, three leiomyomas, three fibromatoses, two epithelioid leiomyomas, two neurofibromas, one schwannoma, one myositis ossificans, and one giant cell tumour of tendon sheath). Four MFHs and nine other types of sarcoma (four leiomyosarcomas, two chondrosarcomas, one liposarcoma, one fibrosarcoma, and one dermatofibrosarcoma protuberans) showed nuclear positivity for p53. Of the benign soft tissue lesions, p53 positivity was observed in two fibromatoses, one nodular fasciitis, and one dermatofibroma. The number of p53-positive cells in these benign lesions was considerably smaller than that in most of the p53-positive sarcomas. The p53 positivity in MFHs and other types of sarcoma indicates that p53 gene alterations may play a part in the neoplastic transformation of these tumours. The occurrence of p53 positivity in benign mesenchymal lesions suggests that sometimes p53 protein may accumulate in cells without an associated malignancy. Because of this, p53 immunoreactivity cannot, by itself, be used as a criterion of malignancy According to our results, p53 positivity in over 1 per cent of tumour cells in mesenchymal lesions favours malignancy.     

前列腺非上皮性肿瘤及瘤样病变的病理观察

目的：探讨前列腺非上皮性肿瘤的诊断和鉴别诊断并观察其预后,方法：收集临床及病理资料,应用HE,免疫组织化学LSAB法及电镜等方法,对16例前列腺非上皮性肿瘤的临床和形态特点进行了观察,并进行了随访,结果：16例中诊断前列腺间质结节6例,前列腺恶性分叶状肿瘤1例,前列腺间质肉瘤3例,前列腺平滑肌肉瘤3例,纤维肉瘤1例,前列腺非霍奇金恶性淋巴瘤2例。结论：伴发生前列腺良性增生过去诊断为前列腺平滑肌瘤的病变为前列腺的间质结节,在穿刺的标本中,前列腺叶状囊肉瘤易与前列腺间质肉瘤混淆,前列腺间质肉瘤以无特定结构的小梭形细胞为特点,前列腺平滑肌肉瘤、纤维肉瘤、前列腺非霍奇金恶性淋巴瘤与软组织同类肿瘤的诊断标准相同。前列腺非上皮性恶性肿瘤预后差。     

Diagnostic value of fine needle aspiration biopsy in non-thyroidal head and neck lesions: a retrospective study of 866 aspiration materials

Aim: We aimed to investigate the diagnostic value of fine needle aspiration biopsy (FNAB) and compared our FNAB results of non-thyroidal head and neck lesions with excisional biopsy results. Materials and methods: A total of 866 aspiration material taken from different parts of head and neck region out of thyroid were evaluated at Haydarpasa Numune Training and Research Hospital Pathology Laboratory, between January 2002 and May 2013 and 248 of which has histopathologic response were included in the study. Patients depending on origin of the masses were divided into three categories as; salivary gland, lymph nodes and soft tissue/cystic lesions. The sensitivity, specificity, diagnostic accuracy values of fine needle aspiration biopsies have been investigated for all the series and individually for each category. Findings: Diagnostic sensitivity, specificity, accuracy, positive predictive value and negative predictive values of non-thyroidal head and neck masses were respectively; For all of the series; 94.6%, 97.9%, 96.7%, 95.9%, 97.2%, Salivary gland: 88.9%, 100%, 98.8%, 100%, 98.7%, Lymph nodes: 94.7%, 89.3%, 92.9%, 94.7%, 89.2%, Soft tissue/cystic lesions: 100%, 100%, 100%, 100%, 100%. For all of the series; there were 4 false negative (FN) cases; and 3 false positive (FP) cases. Conclusion: FNAB in the diagnosis of head and neck masses; it is an easy, cheap and usefull procedure.