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Recurrent cutaneous malignant fibrous histiocytoma

European Journal of Dermatology. Volume 19, Number 2, 187-8, March-April 2009, Correspondence

DOI : 10.1684/ejd.2008.0609

Author(s) : Wei-Min Shi, Wan-Qing Liao, Zhou-Wei Wu, Prajwal Pandey, Xing-Yu Mei, Hai-Hong Qin, Jin-Hua Xu, Liangliang Shen , Dermatology Department, Tong Ji Hospital, Tong Ji University, Shanghai 200065, China, Dermatology Department, Chang Zheng Hospital, Secondary Military Medical University, Shanghai 200003, China, Dermatology Department, Hua Shan Hospital, Fu Dan University, Shanghai 200040, China.

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ARTICLE

Auteur(s) : Wei-Min Shi¹, Wan-Qing Liao², Zhou-Wei Wu¹, Prajwal Pandey¹, Xing-Yu Mei¹, Hai-Hong Qin¹, Jin-Hua Xu³, Liangliang Shen¹

¹Dermatology Department, Tong Ji Hospital, Tong Ji University, Shanghai 200065, China
²Dermatology Department, Chang Zheng Hospital, Secondary Military Medical University, Shanghai 200003, China
³Dermatology Department, Hua Shan Hospital, Fu Dan University, Shanghai 200040, China

Malignant fibrous histiocytoma (MFH) is a common soft tissue sarcoma occurring on the extremities and has a high recurrence rate even after wide complete excision. Its presentation as a destructive cutaneous lesion is very rare. We report a cutaneous MFH that recurred locally 14 years after primary resection.

Case report

A 62-year-old Chinese male presented with a 3-month swelling on the skin of his right shin. The swelling was insidious on onset and increased in size progressively. The lesion manifested as a single eruption (1.5 cm in diameter) at the same location as its original MFH, which had been excised. It grew rapidly in size (> 10 cm in diameter) and formed a substantive and protuberating tumor. The patient had a history of a similar lesion at the same site that had been diagnosed as MFH pathologically and excised 14 years previously. The tumor had not recurred from the time of operation until the current onset. On physical examination, a huge non-tender, soft, immobile mass was found on the lateral aspect of the right shin (figure 1A). Its surface was ulcerating with a bloody discharge (figure 1B) and numerous eczematous patches arose peripherally. No regional lymphadenopathy was found. Routine investigations including x-ray of the chest and the right lower leg were normal. A biopsy revealed that the tumor was composed of myxoid stroma and some highly pleomorphic spindle-shaped cells, arranged in sheets and irregular fascicles in a focal storiform pattern (figure 1D). Frequent abnormal mitoses (figure 1E) and numerous bizarre multinucleated giant cells (figure 1F) were found. The tumor was primarily diagnosed as local recurrent MFH and surgically excised. Within a few weeks after the incision healed, six new papules of unknown characteristics were observed near the operation site (figure 1C), but further biopsy was refused.

Discussion

MFH was recognized by O’Brien JE in 1964 [1]. It is one of the most common soft tissue sarcomas that is more likely to appear in the muscular plane of the extremities or in the retroperitoneum. The tumor contains two cell types (fibroblast-like and histiocyte-like) and varying proportions of both cells pathologically classify the MFH into 5 subtypes: storiform-pleomorphic (65%), myxoid (15%), giant cell (10%), inflammatory (8%), and angiomatoid (2%) [2]. The pathological finding of this case is more inclined to myxoid type. Mentzel et al. classified myxoid type into two groups: superficial and deep [3]. They believed that the superficial group tends to spread extensively in a longitudinal manner to the deep fascia. However, the growth pattern of this case was more horizontal and extroversive without deep infiltration and remote metastasis. There is controversy in the differentiation grade of myxoid type. Weiss and Enzinger believed storiform-pleomorphic and myxoid types tend to be high-grade neoplasms [4], whereas Morris found most myxoid types behave as low grade neoplasms and pursue a less aggressive course [5]. In this case, relatively scanty tumor cells and inflammatory cell infiltration may contribute to its less aggressiveness. We also propose that primary MFH on the skin may have a prognosis superior to homologous tumors that proceed from deeper soft tissue [6]. In summary, the prognosis of MFH is closely related with its pathological type, growth pattern, differentiation and its location.

Acknowledgements

Thanks for the kind financial aids from The Foundation of Shanghai Science and Technology Committee (No. 064119529) and there is no conflict of interest to disclose in the paper.

References

1 O’Brien JE, Stout AP. Malignant fibrous xanthomas. Cancer 1964; 17: 1445-55.

2 Weiss SW. Malignant fibrous histiocytoma. A reaffirmation. Am J Surg Pathol 1982; 6: 773-84.

3 Mentzel T, Calonje E, Wadden C, et al. Myxofibrosarcoma. Clinicopathologic analysis of 75 cases with emphasis on the low-grade variant. Am J Surg Pathol 1996; 20: 391-405.

4 Weiss SW, Enzinger FM. Myxoid variant of malignant fibrous histiocytoma. Cancer 1977; 39: 1672-85.

5 http://liddyshriversarcomainitiative.org/Newsletters/V02N02/MFH/mfh.htm.

6 Headington JT, Niederhuber JE, Repola DA. Primary malignant fibrous histiocytoma of skin. J Cutan Pathol 1978; 5: 329-38.