Pleomorphic Sarcoma (Malignant Fibrous Histiocytoma) of Soft Tissue Imaging 

Pleomorphic Sarcoma (Malignant Fibrous Histiocytoma) of Soft Tissue Imaging 

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Undifferentiated pleomorphic sarcoma (UPS), previously called malignant fibrous histiocytoma (MFH), is a soft tissue sarcoma (STS) that can occur anywhere in the body, but it usually occurs in the extremities (especially the thighs) or back of the abdomen (see the image below).  Approximately 15% of undifferentiated pleomorphic sarcomas arise in the abdomen and pelvis. [1] UPS often grows quickly and spreads to other parts of the body, including the lungs.

Undifferentiated pleomorphic sarcoma usually occurs in older adults, and men account for two thirds of cases. UPS is the most common sarcoma to develop at sites of prior irradiation. Investigators have shown that most patients have received a radiation dose of 50 Gy or more, and the median time interval between radiation exposure and the development of a radiation-associated sarcoma is approximately 10 years. Undifferentiated pleomorphic sarcoma may also arise at sites of chronic ulceration. [1]

The World Health Organization (WHO) has published a classification system for tumors of the soft tissue and bone, which includes detailed cytogenetic and molecular data. Undifferentiated/unclassified sarcomas include the following subtypes [2] :

Historically, the term malignant fibrous histiocytoma (MFH) was applied to pleomorphic spindle cell neoplasms with fibroblastic and histiocytic differentiation. However, the majority of tumors within this classification did not show any evidence of histiocytotic differentiation, and many were found to be other types of poorly differentiated tumors. The small minority of tumors for which the term MFH was most representative are now classified as undifferentiated high-grade pleomorphic sarcoma. 

Tumors are further classified by WHO as benign, intermediate, or malignant, and intermediate tumors are designated as either locally aggressive or rarely metastasizing. [2]

UPS has been reported to occur in the lungs, liver, kidneys, bladder, scrotum, vas deferens, heart, aorta, stomach, small intestine, orbit, CNS, paraspinal area, dura mater, facial sinuses, nasal cavity, oral cavity, nasopharynx, and soft tissues of the neck. [3]  

The most common clinical presentation is an enlarging painless soft-tissue mass in the thigh, typically 5-10 cm in diameter. The majority of tumors are intramuscular. At gross pathologic examination, the lesion is multilobulated, with necrosis, degeneration, or hemorrhage on the cut surface. In some tumors, extensive hemorrhage can be present. Although the border of the tumor may appear well defined at gross pathologic examination, microscopic spread along muscle fibers and fascial planes is often present. Microscopically, tumor cells with variably pleomorphic nuclei are characteristic. There is no characteristic immunohistochemical profile. Immunohistochemical analysis is used to help exclude other tumors that may have a pleomorphic appearance. [1]

Rare signs and symptoms include episodic hypoglycemia and rapid tumor enlargement during pregnancy. Additionally, UPS has been associated with hematopoietic diseases such as non-Hodgkin lymphoma, Hodgkin lymphoma, multiple myeloma, and malignant histiocytosis.

Retroperitoneal tumors may present with constitutional symptoms, including fever, malaise, and weight loss. The tumor is often large at presentation and may cause displacement of the bowel, kidney, ureter, and/or bladder.

UPS may also occur secondary to radiation exposure and shrapnel injury and may be seen adjacent to metallic fixation devices, including total joint prostheses. Early and complete surgical removal using wide or radical resection is indicated because of the aggressive nature of the tumor.

The National Comprehensive Cancer Network (NCCN) clinical practice guidelines for STS of the extremities, superficial trunk, or head and neck include the following imaging recommendations [4] :

In concurrence with NCCN, the ESMO–EURACAN (European Society for Medical Oncology–European Reference Network for rare adult solid cancers) clinical practice guidelines on STSs recommend MRI as the main imaging modality in the extremities, pelvis, and trunk. Standard radiographs may be useful to rule out a bone tumor, to detect bone erosion with a risk of fracture, and to show calcifications. CT is used in calcified lesions to rule out a myositis ossificans and in retroperitoneal tumors, where the performance is identical to MRI. Ultrasound may be the first exam, but it should be followed by CT or MRI. [5]

Sarcoma specialists from the United Kingdom, including members of the British Sarcoma Group and NHS England Sarcoma Clinical Reference Group, also issued guidelines on management of STS.  Imaging recommendations include [6] :

The Trans-Atlantic Retroperitoneal Sarcoma Working Group was established to address challenging management issues encountered when caring for patients with retroperitoneal soft tissue sarcomas (RPS). Their imaging recommendations include the following [7] :

The American College of Radiology (ACR) Appropriateness Criteria for soft-tissue masses include the following recommendations [8] :

For a full summary of guidelines recommendations, see Soft Tissue Sarcoma Guidelines.

As with other soft-tissue tumors, MRI is the imaging method of choice because of its ability to provide superior contrast between tumor and muscle, excellent definition of surrounding anatomy, and ease of imaging in multiple planes. [9, 10]  

(UPSs are displayed in the images below.)

 Although MRI is typically best suited for defining the anatomy of the tumor and its surrounding structures, the signal characteristics of pleomorphic sarcoma, as well as the true histologic nature of the tumor or other soft-tissue masses, often cannot be ascertained by imaging alone, with few exceptions (eg, lipoma). Furthermore, patients with claustrophobia or cardiac pacemakers and aneurysm clips may not be able to undergo examination with MRI. In these patients, axial CT scanning may be performed. CT scanning can provide adequate information regarding the location and gross extent of the mass, although the contrast between tumor and muscle is often less than that seen with MRI. CT scanning is also useful for evaluation of calcifications. [11, 12]

No single imaging technique can provide a specific histologic diagnosis of pleomorphic sarcoma, and biopsy is usually necessary. If the radiologist is asked to perform a biopsy on a potentially malignant soft-tissue mass, the orthopedic surgeon resecting the mass must be consulted first. With certain tumors, the biopsy tract must be removed with the mass; a presurgical image-guided biopsy performed without appropriate orthopedic consultation may result in more extensive surgery (including amputation) than would have been necessary otherwise.

See Soft-Tissue Sarcomas: What You Need to Know, a Critical Images slideshow, to help identify and treat some of these malignant tumors of mesenchymal origin.

Radiographs may reveal a nonspecific soft-tissue mass (see the image below), often greater than 5 cm in diameter. Deep intramuscular tumors often lie adjacent to the diaphysis of a long bone.

Secondary osseous involvement, including periosteal reaction, cortical erosion, and pathologic fracture, is uncommon but suggestive of a malignant soft-tissue sarcoma.

Calcification or ossification can be detected in 5-20% of patients. Calcifications within the tumor may be punctate, curvilinear, and/or poorly defined.

Heterotopic bone formation may be present in the periphery of the mass.

On CT images, UPS lesions are well-circumscribed, multinodular, or infiltrating masses of soft-tissue attenuation. Undifferentiated pleomorphic sarcomas are often large at the time of diagnosis and invade adjacent anatomic structures. Centrally within the tumor, areas of low-attenuation necrosis, hemorrhage, or myxoid change can be seen. The tumor may appear cystic with a rim of peripheral enhancement when marked intralesional hemorrhage is present. [1]

Calcification from osseous or chondroid metaplasia occurs in approximately 16% of cases. Calcifications may be small and punctate in a speckled pattern or coarse and chunky. After administration of intravenous contrast material, the enhancement pattern is variable, although regions of marked contrast enhancement and large intratumoral vessels may be seen. Hemoperitoneum from tumoral hemorrhage has been reported. [1]  

Fat attenuation is not observed in the tumors; this fact can be useful in distinguishing undifferentiated pleomorphic sarcoma from some well-differentiated liposarcomas. [13]

Retroperitoneal tumors manifest as heterogeneous masses with areas of hemorrhage and/or necrosis and occasionally focal or diffuse coarse calcifications (approximately 10%); the tumors may invade the abdominal musculature but do not invade the renal veins or inferior vena cava. [12, 14, 15]

(See the images below.)

MRI typically reveals an intramuscular mass with heterogeneous signal intensity on all pulse sequences (see the images below). As with other soft-tissue neoplasms, the signal intensity pattern is nonspecific, usually low to intermediate on T1-weighted images and intermediate to high on T2-weighted images; low signal intensity of T1-weighted images and prominent high signal intensity on T2-weighted images may be a feature of myxofibrosarcoma/myxoid MFH, reflecting the high water content of these lesions. Other findings include the following:

Regions of prominent fibrous tissue (high collagen content) may demonstrate low signal intensity on both T1-weighted and T2-weighted images.

Calcification may present as foci of low signal on both T1-weighted and T2-weighted sequences.

Subacute hemorrhage should be considered when regions of high signal are noted on both T1-weighted and T2-weighted images.

Areas of necrosis demonstrate a signal pattern similar to that of fluid.

As with CT, solid components of MFH typically reveal nodular and peripheral enhancement.

Tumor margins appear relatively well defined on MRI; a low signal intensity margin may be observed, representing a pseudocapsule.

Gadolinium-based contrast agents have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness.

The radiologist should keep in mind that the diagnosis of UPS is made using histopathology, not imaging; however, MRI remains invaluable for delineating tumor extent.

Sonography typically reveals a well-defined heterogeneous mass that contains hyperechoic areas of cellularity and hypoechoic regions of necrosis. The appearance of tumors on ultrasound is nonspecific; however, sonography may be used to evaluate tumor volume. Retroperitoneal tumors tend to appear as hypoechoic solid masses with scattered regions of heterogeneity. [16]

(See the images below.)

Technetium-99m bone scintigraphy often shows increased uptake by tumor, regardless of the presence of calcium within the tumor or invasion of adjacent bone. Hypervascular lesions show increased radionuclide uptake on both dynamic and blood pool images. The mildly increased uptake observed on static images is also probably related to hypervascularity and may be more prominent with internal calcification. Bone scans usually are not ordered to evaluate the primary tumor but may be obtained if osseous metastases are suggested. Gallium-67 scans may also demonstrate increased activity.

(See the images below.)

Angiographic findings are nonspecific. The tumor may be hypovascular or, more commonly, hypervascular with early venous return (see the image below). Similarly, retroperitoneal tumors may be either hypovascular or hypervascular, with blood supply from the lumbar, celiac, iliac, renal, renal capsular, and/or inferior adrenal arteries.

Overview

What is pleomorphic sarcoma (malignant fibrous histiocytoma) of soft tissue?

What is the WHO classification of pleomorphic sarcoma (malignant fibrous histiocytoma) of soft tissue?

Where in the body do pleomorphic sarcoma (malignant fibrous histiocytoma) of soft tissue occur?

What are the signs and symptoms of pleomorphic sarcoma (malignant fibrous histiocytoma) of soft tissue?

What are the NCCN imaging guidelines for pleomorphic sarcoma (malignant fibrous histiocytoma) of soft tissue?

What are the UK imaging guidelines for pleomorphic sarcoma (malignant fibrous histiocytoma) of soft tissue?

What are the Trans-Atlantic Retroperitoneal Sarcoma Working Group imaging guidelines for pleomorphic sarcoma (malignant fibrous histiocytoma) of soft tissue?

What are the ACR Appropriateness Criteria for imaging of pleomorphic sarcoma (malignant fibrous histiocytoma) of soft tissue?

What is the role of imaging in the workup of pleomorphic sarcoma (malignant fibrous histiocytoma) of soft tissue?

What is the role of radiography in the workup of pleomorphic sarcoma (malignant fibrous histiocytoma) of soft tissue?

What is the role of CT in the workup of pleomorphic sarcoma (malignant fibrous histiocytoma) of soft tissue?

What is the role of MRI in the workup of pleomorphic sarcoma (malignant fibrous histiocytoma) of soft tissue?

What is the role of ultrasonography in the workup of pleomorphic sarcoma (malignant fibrous histiocytoma) of soft tissue?

What is the role of nuclear imaging in the workup of pleomorphic sarcoma (malignant fibrous histiocytoma) of soft tissue?

What is the role of angiography in the workup of pleomorphic sarcoma (malignant fibrous histiocytoma) of soft tissue?

Levy AD, Manning MA, Miettinen MM. Soft-Tissue Sarcomas of the Abdomen and Pelvis: Radiologic-Pathologic Features, Part 2-Uncommon Sarcomas. Radiographics. 2017 May-Jun. 37 (3):797-812. [Medline]. [Full Text].

Fletcher CDM, Bridge JA, Hogendoorn P, Mertens F. World Health Organization Classification of Tumours of Soft Tissue and Bone. 4th Edition. Lyon, France: IARC; 2013.

Cong Z, Gong J. Primary malignant fibrous histiocytoma of the liver: CT findings in five histopathological proven patients. Abdom Imaging. 2011 Oct. 36(5):552-6. [Medline].

[Guideline] von Mehren M, Randall RL, Benjamin RS, et al. NCCN Clinical Practice Guidelines in Oncology: Soft Tissue Sarcoma, Version 2.2018. National Comprehensive Cancer Network. Available at https://www.nccn.org/professionals/physician_gls/pdf/sarcoma.pdf. March 27, 2018; Accessed: November 1, 2018.

[Guideline] Casali PG, Abecassis N, Bauer S, et al, ESMO Guidelines Committee and EURACAN. Soft tissue and visceral sarcomas: ESMO-EURACAN Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2018 Oct 1. 29 (Supplement_4):iv51-iv67. [Medline]. [Full Text].

[Guideline] Dangoor A, Seddon B, Gerrand C, Grimer R, Whelan J, Judson I. UK guidelines for the management of soft tissue sarcomas. Clin Sarcoma Res. 2016. 6:20. [Medline]. [Full Text].

[Guideline] Trans-Atlantic RPS Working Group. Management of Recurrent Retroperitoneal Sarcoma (RPS) in the Adult: A Consensus Approach from the Trans-Atlantic RPS Working Group. Ann Surg Oncol. 2016 Oct. 23 (11):3531-3540. [Medline]. [Full Text].

[Guideline] Expert Panel on Musculoskeletal Imaging:., Kransdorf MJ, Murphey MD, Wessell DE, Cassidy RC, Czuczman GJ, et al. ACR Appropriateness Criteria® Soft-Tissue Masses. J Am Coll Radiol. 2018 May. 15 (5S):S189-S197. [Medline]. [Full Text].

Faizi NA, Thulkar S, Sharma R, et al. Magnetic resonance imaging and positron emission tomography-computed tomography evaluation of soft tissue sarcoma with surgical and histopathological correlation. Indian J Nucl Med. 2012 Oct. 27(4):213-20. [Medline]. [Full Text].

Amit P, Patro DK, Basu D, Elangovan S, Parathasarathy V. Role of Dynamic MRI and Clinical Assessment in Predicting Histologic Response to Neoadjuvant Chemotherapy in Bone Sarcomas. Am J Clin Oncol. 2013 Feb 5. [Medline].

Tan Y, Xiao EH. Rare hepatic malignant tumors: dynamic CT, MRI, and clinicopathologic features: with analysis of 54 cases and review of the literature. Abdom Imaging. 2013 Jun. 38(3):511-26. [Medline].

Shi F, Zhang F, Gao F, Wu K, Maharjan R, Li C. Refractory malignant fibrous histiocytoma: CT-guided treatment with a multidisciplinary, minimally invasive approach. Technol Cancer Res Treat. 2015 Feb. 14 (1):3-9. [Medline].

Levy AD, Manning MA, Al-Refaie WB, Miettinen MM. Soft-Tissue Sarcomas of the Abdomen and Pelvis: Radiologic-Pathologic Features, Part 1-Common Sarcomas: From the Radiologic Pathology Archives. Radiographics. 2017 Mar-Apr. 37 (2):462-483. [Medline]. [Full Text].

Fang N, Wang YL, Zeng L, Wu ZJ, Cui XJ. Metastatic Malignant Fibrous Histiocytoma in the Stomach: Imaging With 18F-FDG PET/CT. Clin Nucl Med. 2015 Jun 6. [Medline].

Zheng W, Chen J, Liu J, Zuo C, Zhou Z. FDG PET/CT findings of malignant fibrous histiocytoma of the stomach. Clin Nucl Med. 2015 May. 40 (5):413-4. [Medline].

Gok G, Elsayed M, Thind M, Uygur B, Abtahi F, Chahwala JR, et al. Incremental value of live/real time three-dimensional transesophageal echocardiography over the two-dimensional technique in the assessment of primary cardiac malignant fibrous histiocytoma. Echocardiography. 2015 Jul. 32 (7):1164-70. [Medline].

Gregory Scott Stacy, MD Professor, Department of Radiology, University of Chicago Hospitals

Gregory Scott Stacy, MD is a member of the following medical societies: American College of Radiology, American Medical Association, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America, Society of Skeletal Radiology

Disclosure: Received grant/research funds from Biomet for research agreement. for: Biomet.

Doris Yip, MD Staff Physician, Department of Radiology, University of Chicago Hospitals

Doris Yip, MD is a member of the following medical societies: American College of Radiology

Disclosure: Nothing to disclose.

Murali Sundaram, MBBS, FRCR, FACR Professor of Radiology and Consulting Staff, Cleveland Clinic Lerner College of Medicine of CWRU

Murali Sundaram, MBBS, FRCR, FACR is a member of the following medical societies: American College of Radiology, American Medical Association, American Roentgen Ray Society, Association of University Radiologists, International Skeletal Society, Radiological Society of North America, Society of Skeletal Radiology

Disclosure: Nothing to disclose.

Felix S Chew, MD, MBA, MEd Professor, Department of Radiology, Vice Chairman for Academic Innovation, Section Head of Musculoskeletal Radiology, University of Washington School of Medicine

Felix S Chew, MD, MBA, MEd is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America

Disclosure: Nothing to disclose.

Michael A Bruno, MD, MS, FACR Professor of Radiology and Medicine, Pennsylvania State University College of Medicine; Director, Radiology Quality Management Services, The Penn State Milton S Hershey Medical Center

Michael A Bruno, MD, MS, FACR is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America, Society of Nuclear Medicine and Molecular Imaging, Society of Skeletal Radiology

Disclosure: Received royalty from Oxford Press for book author/editor & reviewer; Received royalty from Elsevier Press for book author / editor.

Pleomorphic Sarcoma (Malignant Fibrous Histiocytoma) of Soft Tissue Imaging 

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