Correspondence
histiocytoma’.2 Later, the nomenclature was corrected to ‘angiomatoid fibrous histiocytoma’ because of the slow growth and the low metastasis rate.3 Ultrasonography has been utilized as a noninvasive diagnostic tool for skin tumours. We report a case of AFH and describe the ultrasound B-mode, colour Doppler and elastographic findings of AFH, which clearly correlate with the histological characteristics of the tumour. A 77-year-old woman presented with a 4-month history of a tumour on her left temporal region. On physical examination, a slightly brownish subcutaneous tumour, 10 mm in diameter, was seen (Fig. 1a). The patient underwent ultrasonography scanning (HI VISION 900; (Hitachi Medical Corporation, Tokyo, Japan). A conventional linear probe with a 5 MHz to 13 MHz transducer was used for all scans, including B-mode, colour Doppler test and elastography. B-mode revealed an irregular-shaped, cystic low-echoic area (Fig. 1b, arrows), and colour Doppler scans showed some vascular involvement at the periphery of the tumour (Fig. 1b, inset). Ultrasound elastography revealed a demarcated lesion with high elasticity at the centre of the cystic low-echoic area (Fig. 1c, arrowheads). Histopathology specimens revealed a subcutaneous tumour with haemorrhagic and cystic spaces (Fig. 1d). The demarcated elastic lesion seen by elastography corresponded histologically to the haemorrhagic and cystic spaces (pseudovascular structure of the tumour). Inflammatory infiltrates, mostly lymphocytes, were observed at the periphery of the tumour, where partly hyalinized tissue formed a pseudocapsule (Fig. 1e). The tumour cells were spindle-shaped to ovoid-shaped, and were arranged in various growth patterns, including sheets, whorls and short fascicles (Fig. 1f). Foci of nuclear pleomorphism and atypia were identified, and mitotic activity was seen in 12 cells per 10 high-power fields. Immunohistochemical results showed the tumour cells to be positive for desmin and CD68, and negative for S100, CD34 and CD31. From these findings, a diagnosis of AFH was made. The tumour was completely removed. No recurrence or metastasis was seen at follow-up 3 years after surgery. Although histological characteristics including (i) solid arrays or nests of histiocyte-like cells, (ii) haemorrhagic cyst-like spaces and (iii) aggregates of chronic inflammatory cells are germane in making the final diagnosis of AFH,3 non-invasive methods of investigating for tumours are essential because the misdiagnosis of AFH as other more malignant tumours can lead to unnecessarily aggressive treatment. The elastography and B-mode ultrasonography used in this study revealed the pseudovascular structure, the hallmark of AFH, in this case, whereas the colour Doppler test failed to detect that structure. This is consistent with the fact that pseudovascular areas are not functionally vessels but are simply spaces filled with haemorrhages. In addition, previous authors reported
ª 2014 British Association of Dermatologists
that elastography can delineate the nature of cystic areas within neck masses (e.g. second-arch branchial cleft cysts)4 and breast lesions.5 In conclusion, we report a case of AFH in which imaging methods were essential for diagnosis. Noninvasive examination helps make a precise clinical diagnosis and allows correct treatment. H. Hata, K. Natsuga, S. Aoyagi, E. Homma, and H. Shimizu Department of Dermatology, Hokkaido University Graduate School of Medicine, North 15 West 7, Sapporo 060-8638, Japan E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 14 December 2013
References 1 Weiss SW, Goldblum JR. Enzinger and Weiss’s Soft Tissue Tumors, 5th edn. Philadelphia, MO: Mosby, 2008; 390–4. 2 Enzinger FM. Angiomatoid malignant fibrous histiocytoma: a distinct fibrohistiocytic tumor of children and young adults simulating a vascular neoplasm. Cancer 1979; 44: 2147–57. 3 Fanburg-Smith JC, Miettinen M. Angiomatoid, “malignant” fibrous histiocytoma: a clinicopathologic study of 158 cases and further exploration of the myoid phenotype. Hum Pathol 1999; 30: 1336–43. 4 Bhatia KS, Rasalkar DD, Lee YP et al. Real-time qualitative ultrasound elastography of miscellaneous non-nodal neck masses: applications and limitations. UltrasounMed Biol 2010; 36: 1644–52. 5 Ginat DT, Destounis SV, Barr RG et al. US elastography of breast and prostate lesions. Radiographics 2009; 29: 2007–16.
Solitary fibrous tumour of the scalp doi: 10.1111/ced.12309 Solitary fibrous tumour (SFT) is an uncommon mesenchymal tumour that typically arises in the pleural cavity. Extrapleural sites such as the skin have been increasingly reported. However, SFT occurring in the scalp is rare, and to our knowledge, only five cases have been reported previously.1–5 We describe an additional case of SFT of the scalp. A 64-year-old Japanese man presented with a domeshaped, skin-coloured, slightly soft and elastic subcutaneous nodule, measuring about 50 mm in diameter, on his posterior scalp. The nodule was not painful or tender, and it had enlarged during the course of 1 week. T2-weighted magnetic resonance imaging disclosed a well-defined, solid subcutaneous mass measuring 45 9 22 mm in diameter, which showed irregularly mixed hyposignal and hypersignal intensities (Fig. 1a). There was no history of trauma to the
Clinical and Experimental Dermatology (2014) 39, pp533–541
539
Correspondence
(a)
(b)
(c)
(d)
Figure 1 (a) Magnetic resonance image disclosed a well-defined, solid subcutaneous mass (arrow). (b) Subcutaneous tumour on the
posterior scalp, which (c) was encapsulated and easily detached from the surrounding tissue. (d) The tumour was 47 9 32 9 20 mm in size, and when cut, showed a whitish soft-tissue mass.
involved area, but a haematoma was suspected because of the sudden enlargement of the mass. When the mass was punctured, a small amount of blood was aspirated. Because the mass did not greatly change over the following 2 months, a biopsy was taken from it. Based on the histological findings described later we suspected an SFT, and under general anaesthesia, the mass was excised completely with a rim of normal tissue (Fig. 1b). The subcutaneous tumour was encapsulated and easily detached from the surrounding tissue (Fig. 1c). The tumour was 47 9 32 9 20 mm in size, with the cut section showing a whitish soft-tissue mass (Fig. 1d). Microscopically, a spheroid, well-circumscribed tumour composed of alternating hypercellular and fibrous hypocellular areas was observed in the subcutis (Fig. 2a). In the highly cellular areas, spindle-shaped cells without atypical nuclei were present in short interlacing fascicles, mixed with small vessels and interstitial fibrous tissue (Fig. 2b). Immunohistochemically, spindle cells were positive for CD34 (Fig. 2c),
540
Clinical and Experimental Dermatology (2014) 39, pp533–541
bcl-2 (Fig. 2d) and CD99, but negative for epithelial membrane antigen, a-smooth muscle actin, desmin and S-100 protein. We diagnosed this case as an SFT of the scalp, and there has been no recurrence during a follow-up of 3 months. A characteristic histological feature of SFT is the presence of alternating hypercellular and hypocellular areas. Cutaneous CD34-positive spindle cell tumours include spindle cell lipoma (SCL) and dermatofibrosarcoma protuberans (DFSP), in addition to SFT. We excluded SCL because of the lack of an adipocytic component, and DFSP because of the absence of diffuse infiltration of the subcutaneous adipose tissue. As far as we are aware, there have previously been only five reported cases of SFT of the scalp. Including the present case, four men and two women have been reported, and the mean age was 34 years (range 2–64), including two 2year-old children.3,5 Ramdial and Madaree documented an aggressive CD34-positive fibrous scalp lesion measuring
ª 2014 British Association of Dermatologists
Correspondence
(a)
(c)
(b)
(d)
Figure 2 (a) A spheroid, well-circumscribed tumour composed of alternating hypercellular and hypocellular areas in the subcutis; (b) in
the highly cellular areas, spindle-shaped cells without atypical nuclei were present in short interlacing fascicles. Haematoxylin and eosin, original magnification (a) 94; (b) 9400. (c,d) The spindle cells were positive for (c) CD34 and (d) bcl-2. Original magnification (c,d) 9400.
150 mm in a 2-year-old girl, and categorized it as a malignant SFT.3 Apprroximately 10–15% of extrapleural SFTs show local recurrence, sometimes repeatedly.4 Although most SFTs behave in a benign manner, the course of SFT is unpredictable, and long-term follow-up is necessary. Y. Omori,1 H. Saeki,1 K. Ito,1 H. Matsuzaki,1 M. Tokita,1 M. Itoh,1 K. Tanito,1 T. Ishiji,1 M. Fukunaga2 and H. Nakagawa1 Departments of 1Dermatology and 2Pathology, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 1058461, Japan. E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 17 December 2013
ª 2014 British Association of Dermatologists
References 1 Okamura JM, Barr RJ, Battifora H. Solitary fibrous tumor of the skin. Am J Dermatopathol 1997; 19: 515–18. 2 Cowper SE, Kilpatrick T, Proper S, Morgan MB. Solitary fibrous tumor of the skin. Am J Dermatopathol 1999; 21: 213–19. 3 Ramdial PK, Madaree A. Aggressive CD34-positive fibrous scalp lesion of childhood: extrapulmonary solitary fibrous tumor. Pediatr Dev Pathol 2001; 4: 267–75. 4 Erdag G, Qureshi HS, Patterson JW, Wick MR. Solitary fibrous tumor of the skin: a clinicopathologic study in 10 cases and review of the literature. J Cutan Pathol 2007; 34: 844–50. 5 Rizk T, Awada A, Sebaaly A, Hourani R. Solitary fibrous tumor of the scalp in a child. J Neurosurg Pediatr 2013; 11: 79–81.
Clinical and Experimental Dermatology (2014) 39, pp533–541
541
histiocytoma’.2 Later, the nomenclature was corrected to ‘angiomatoid fibrous histiocytoma’ because of the slow growth and the low metastasis rate.3 Ultrasonography has been utilized as a noninvasive diagnostic tool for skin tumours. We report a case of AFH and describe the ultrasound B-mode, colour Doppler and elastographic findings of AFH, which clearly correlate with the histological characteristics of the tumour. A 77-year-old woman presented with a 4-month history of a tumour on her left temporal region. On physical examination, a slightly brownish subcutaneous tumour, 10 mm in diameter, was seen (Fig. 1a). The patient underwent ultrasonography scanning (HI VISION 900; (Hitachi Medical Corporation, Tokyo, Japan). A conventional linear probe with a 5 MHz to 13 MHz transducer was used for all scans, including B-mode, colour Doppler test and elastography. B-mode revealed an irregular-shaped, cystic low-echoic area (Fig. 1b, arrows), and colour Doppler scans showed some vascular involvement at the periphery of the tumour (Fig. 1b, inset). Ultrasound elastography revealed a demarcated lesion with high elasticity at the centre of the cystic low-echoic area (Fig. 1c, arrowheads). Histopathology specimens revealed a subcutaneous tumour with haemorrhagic and cystic spaces (Fig. 1d). The demarcated elastic lesion seen by elastography corresponded histologically to the haemorrhagic and cystic spaces (pseudovascular structure of the tumour). Inflammatory infiltrates, mostly lymphocytes, were observed at the periphery of the tumour, where partly hyalinized tissue formed a pseudocapsule (Fig. 1e). The tumour cells were spindle-shaped to ovoid-shaped, and were arranged in various growth patterns, including sheets, whorls and short fascicles (Fig. 1f). Foci of nuclear pleomorphism and atypia were identified, and mitotic activity was seen in 12 cells per 10 high-power fields. Immunohistochemical results showed the tumour cells to be positive for desmin and CD68, and negative for S100, CD34 and CD31. From these findings, a diagnosis of AFH was made. The tumour was completely removed. No recurrence or metastasis was seen at follow-up 3 years after surgery. Although histological characteristics including (i) solid arrays or nests of histiocyte-like cells, (ii) haemorrhagic cyst-like spaces and (iii) aggregates of chronic inflammatory cells are germane in making the final diagnosis of AFH,3 non-invasive methods of investigating for tumours are essential because the misdiagnosis of AFH as other more malignant tumours can lead to unnecessarily aggressive treatment. The elastography and B-mode ultrasonography used in this study revealed the pseudovascular structure, the hallmark of AFH, in this case, whereas the colour Doppler test failed to detect that structure. This is consistent with the fact that pseudovascular areas are not functionally vessels but are simply spaces filled with haemorrhages. In addition, previous authors reported
ª 2014 British Association of Dermatologists
that elastography can delineate the nature of cystic areas within neck masses (e.g. second-arch branchial cleft cysts)4 and breast lesions.5 In conclusion, we report a case of AFH in which imaging methods were essential for diagnosis. Noninvasive examination helps make a precise clinical diagnosis and allows correct treatment. H. Hata, K. Natsuga, S. Aoyagi, E. Homma, and H. Shimizu Department of Dermatology, Hokkaido University Graduate School of Medicine, North 15 West 7, Sapporo 060-8638, Japan E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 14 December 2013
References 1 Weiss SW, Goldblum JR. Enzinger and Weiss’s Soft Tissue Tumors, 5th edn. Philadelphia, MO: Mosby, 2008; 390–4. 2 Enzinger FM. Angiomatoid malignant fibrous histiocytoma: a distinct fibrohistiocytic tumor of children and young adults simulating a vascular neoplasm. Cancer 1979; 44: 2147–57. 3 Fanburg-Smith JC, Miettinen M. Angiomatoid, “malignant” fibrous histiocytoma: a clinicopathologic study of 158 cases and further exploration of the myoid phenotype. Hum Pathol 1999; 30: 1336–43. 4 Bhatia KS, Rasalkar DD, Lee YP et al. Real-time qualitative ultrasound elastography of miscellaneous non-nodal neck masses: applications and limitations. UltrasounMed Biol 2010; 36: 1644–52. 5 Ginat DT, Destounis SV, Barr RG et al. US elastography of breast and prostate lesions. Radiographics 2009; 29: 2007–16.
Solitary fibrous tumour of the scalp doi: 10.1111/ced.12309 Solitary fibrous tumour (SFT) is an uncommon mesenchymal tumour that typically arises in the pleural cavity. Extrapleural sites such as the skin have been increasingly reported. However, SFT occurring in the scalp is rare, and to our knowledge, only five cases have been reported previously.1–5 We describe an additional case of SFT of the scalp. A 64-year-old Japanese man presented with a domeshaped, skin-coloured, slightly soft and elastic subcutaneous nodule, measuring about 50 mm in diameter, on his posterior scalp. The nodule was not painful or tender, and it had enlarged during the course of 1 week. T2-weighted magnetic resonance imaging disclosed a well-defined, solid subcutaneous mass measuring 45 9 22 mm in diameter, which showed irregularly mixed hyposignal and hypersignal intensities (Fig. 1a). There was no history of trauma to the
Clinical and Experimental Dermatology (2014) 39, pp533–541
539
Correspondence
(a)
(b)
(c)
(d)
Figure 1 (a) Magnetic resonance image disclosed a well-defined, solid subcutaneous mass (arrow). (b) Subcutaneous tumour on the
posterior scalp, which (c) was encapsulated and easily detached from the surrounding tissue. (d) The tumour was 47 9 32 9 20 mm in size, and when cut, showed a whitish soft-tissue mass.
involved area, but a haematoma was suspected because of the sudden enlargement of the mass. When the mass was punctured, a small amount of blood was aspirated. Because the mass did not greatly change over the following 2 months, a biopsy was taken from it. Based on the histological findings described later we suspected an SFT, and under general anaesthesia, the mass was excised completely with a rim of normal tissue (Fig. 1b). The subcutaneous tumour was encapsulated and easily detached from the surrounding tissue (Fig. 1c). The tumour was 47 9 32 9 20 mm in size, with the cut section showing a whitish soft-tissue mass (Fig. 1d). Microscopically, a spheroid, well-circumscribed tumour composed of alternating hypercellular and fibrous hypocellular areas was observed in the subcutis (Fig. 2a). In the highly cellular areas, spindle-shaped cells without atypical nuclei were present in short interlacing fascicles, mixed with small vessels and interstitial fibrous tissue (Fig. 2b). Immunohistochemically, spindle cells were positive for CD34 (Fig. 2c),
540
Clinical and Experimental Dermatology (2014) 39, pp533–541
bcl-2 (Fig. 2d) and CD99, but negative for epithelial membrane antigen, a-smooth muscle actin, desmin and S-100 protein. We diagnosed this case as an SFT of the scalp, and there has been no recurrence during a follow-up of 3 months. A characteristic histological feature of SFT is the presence of alternating hypercellular and hypocellular areas. Cutaneous CD34-positive spindle cell tumours include spindle cell lipoma (SCL) and dermatofibrosarcoma protuberans (DFSP), in addition to SFT. We excluded SCL because of the lack of an adipocytic component, and DFSP because of the absence of diffuse infiltration of the subcutaneous adipose tissue. As far as we are aware, there have previously been only five reported cases of SFT of the scalp. Including the present case, four men and two women have been reported, and the mean age was 34 years (range 2–64), including two 2year-old children.3,5 Ramdial and Madaree documented an aggressive CD34-positive fibrous scalp lesion measuring
ª 2014 British Association of Dermatologists
Correspondence
(a)
(c)
(b)
(d)
Figure 2 (a) A spheroid, well-circumscribed tumour composed of alternating hypercellular and hypocellular areas in the subcutis; (b) in
the highly cellular areas, spindle-shaped cells without atypical nuclei were present in short interlacing fascicles. Haematoxylin and eosin, original magnification (a) 94; (b) 9400. (c,d) The spindle cells were positive for (c) CD34 and (d) bcl-2. Original magnification (c,d) 9400.
150 mm in a 2-year-old girl, and categorized it as a malignant SFT.3 Apprroximately 10–15% of extrapleural SFTs show local recurrence, sometimes repeatedly.4 Although most SFTs behave in a benign manner, the course of SFT is unpredictable, and long-term follow-up is necessary. Y. Omori,1 H. Saeki,1 K. Ito,1 H. Matsuzaki,1 M. Tokita,1 M. Itoh,1 K. Tanito,1 T. Ishiji,1 M. Fukunaga2 and H. Nakagawa1 Departments of 1Dermatology and 2Pathology, The Jikei University School of Medicine, 3-25-8, Nishishimbashi, Minato-ku, Tokyo, 1058461, Japan. E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 17 December 2013
ª 2014 British Association of Dermatologists
References 1 Okamura JM, Barr RJ, Battifora H. Solitary fibrous tumor of the skin. Am J Dermatopathol 1997; 19: 515–18. 2 Cowper SE, Kilpatrick T, Proper S, Morgan MB. Solitary fibrous tumor of the skin. Am J Dermatopathol 1999; 21: 213–19. 3 Ramdial PK, Madaree A. Aggressive CD34-positive fibrous scalp lesion of childhood: extrapulmonary solitary fibrous tumor. Pediatr Dev Pathol 2001; 4: 267–75. 4 Erdag G, Qureshi HS, Patterson JW, Wick MR. Solitary fibrous tumor of the skin: a clinicopathologic study in 10 cases and review of the literature. J Cutan Pathol 2007; 34: 844–50. 5 Rizk T, Awada A, Sebaaly A, Hourani R. Solitary fibrous tumor of the scalp in a child. J Neurosurg Pediatr 2013; 11: 79–81.
Clinical and Experimental Dermatology (2014) 39, pp533–541
541
