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Background
This is a rare sarcoma but is important from the standpoint that under the microscope, it can mimic many benign and malignant conditions. As the name also suggests, it has microscopic features that can sometimes resemble a carcinoma. Unlike most sarcomas, it has a propensity to spread to lymph nodes.
OUTLINE
GROSS APPEARANCE/
CLINICAL VARIANTSCHARACTERIZATION General VARIANTS ANGIOMATOID FEATURES
Department of Dermatology, University of Graz, Graz, Austria.
Epithelioid sarcoma (ES) is a rare, aggressive soft tissue tumor with a characteristic predilection for adolescents and young adults, and a tendency to occur on distal extremities.
We report a case of ES arising in an 80-year-old woman within a burn scar that histopathologically showed unusual 'angiomatoid' features. The patient presented initially with a solitary nodule on her right wrist arising at the site of a burn scar.
Histopathologically, the tumor was composed of a proliferation of relatively bland, epithelioid and spindle cells focally arranged in a nodular pattern around areas of 'geographic' necrosis. In addition, there were prominent foci of hemorrhage and blood-filled spaces as well as tumor cells with intracytoplasmic vacuoles, features suggestive of an angiomatous process.
Immunohistochemistry showed positivity of tumor cells for cytokeratins and epithelial membrane antigen (EMA) whereas all vascular markers tested were negative. The overall histopathologic features were consistent with a diagnosis of ES. Follow up showed multiple recurrences arising proximally along the right upper extremity.
Our case underlines the clinical and histopathological heterogeneity of ES, emphasizing the unusual occurrence of ES with 'angiomatoid' features in the elderly. In this uncommon setting, this tumor should be especially distinguished from epithelioid hemangioendothelioma and epithelioid angiosarcoma.
The significance of development of ES on a healed burn scar is uncertain, but may suggest a possible causal relationship.PROXIMAL TYPE Proximal-type epithelioid sarcoma: case report and result of comparative genomic hybridization.
Lee MW, Jee KJ, Ro JY, Lee DP, Choi JH, Moon KC, Koh JK.
Department of Dermatology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea Department of Medical Genetics, Haartman Institute, Helsinki University Central Hospital, University of Helsinki, Finland, and Department of Pathology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea.
J Cutan Pathol. 2004 Jan;31(1):67-71 Abstract quote.
BACKGROUND: Epithelioid sarcoma is a rare mesenchymal neoplasm. Recently, a more aggressive, so-called 'proximal type' epithelioid sarcoma has been described.
CLINICAL CASE: A 40-year-old-woman presented with 5 x 4 cm, erythematous, indurated, non-movable, painful mass on the pubic area. Histopathology demonstrated diffuse tumor-cell infiltration into the subcutaneous and fascia, which was consisted of prominent epithelioid cells and scattered rhabdoid cells. A multinodular growth pattern or granulomatous appearance with central necrosis was not observed. The tumor cells showed positive reactions for vimentin, cytokeratin (AE1/AE3), and CD34. Despite the surgery, left inguinal mass with lymphadenopathy occurred one month later. We also carried out comparative genomic hybridization (CGH) with tumor cells. CGH revealed chromosomal gain of 5q32-qter, 12q24-qter, and 22q.
CONCLUSION: We report a case of proximal-type of epithelioid sarcoma, which showed the chromosomal gains of 5q32-qter, 12q24-qter, and 22q by CGH.Proximal-Type Epithelioid Sarcoma: A Clinicopathologic Study of 20 Cases
Tadashi Hasegawa, M.D., Yoshihiro Matsuno, M.D., Tadakazu Shimoda, M.D., Toru Umeda, M.D., Ryohei Yokoyama, M.D. and Setsuo Hirohashi, M.D.
Pathology (THSH), Clinical Laboratory (YM, TS), and Orthopedic (TU, RY) Divisions, National Cancer Center Research Institute and Hospital, Tokyo, Japan
Mod Pathol 2001;14:655-663 Abstract quote
We studied the clinicopathologic and immunohistochemical features of 20 cases of proximal-type epithelioid sarcoma to identify prognostic factors.
The 20 patients ranged in age from 13 to 80 years (mean, 40 y); 12 patients were male and 8 were female. The tumors presented as deep soft-tissue or subcutaneous masses on the inguinal region in five, the thigh in four, the vulva in three, the axilla in three, and one each in the flank, chest wall, back, hip and perineum. The tumors ranged from 2 to 16 cm at their greatest diameter (mean: 7.8 cm).
Histologically, 12 tumors (60%) were classified as the large-cell subtype, characterized by sheets of large cells with prominent nucleoli resembling poorly differentiated carcinoma, and a frequent rhabdoid phenotype, six (30%) were classified as the conventional subtype, and two (10%) as the angiomatoid subtype. The numbers of tumors exhibiting immunoreactivity for various markers were: vimentin (20 cytokeratin (20 [100%]); epithelial membrane antigen (17 [85%]); CD34 (9 [45%]); CD99 (5 [25%]); muscle markers, either desmin or [{alpha}] -smooth muscle actin (3 [15%]), other markers such as S-100 protein, neurofilament, neuron-specific enolase, synaptophysin and CD56 (12 [60%]); and p53 (16 [80%]). Fourteen lesions (70%) exhibited an MIB-1 index of 30% or more and, by a system of histologic grading using the MIB-1 score, 16 tumors (80%) were classified as high-grade (Grade 3). Thirteen patients (65%) developed local recurrence and 15 (75%) had metastases, primarily to the lymph nodes. At the last follow-up, 13 patients (65%) had died of their disease. A large tumor size and early metastasis were independently associated with a poor outcome.
We conclude that proximal-type epithelioid sarcomas are rare, undifferentiated soft-tissue sarcomas of adults, with epithelioid features and a frequent rhabdoid phenotype. These tumors, when arising in proximal locations, have a much worse prognosis than those arising in distal locations
SPECIAL STAINS/
IMMUNO-
HISTOCHEMISTRYCHARACTERIZATION GENERAL
Epithelioid sarcoma: new insights based on an extended immunohistochemical analysis.
Laskin WB, Miettinen M.
Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Ill, USA.
Arch Pathol Lab Med. 2003 Sep;127(9):1161-8. Abstract quote
CONTEXT: Epithelioid sarcoma has a distinctive epithelioid phenotype and characteristically exhibits immunohistochemical reactivity for epithelial markers (keratins and epithelial membrane antigen) and mesenchymal markers (most notably vimentin and CD34). Antibodies to certain keratin subunits and other novel antigens now available to surgical pathologists have not been tested on a large number of cases.
OBJECTIVE: To assist in the differential diagnosis of epithelioid sarcoma and to help elucidate its histogenesis through an expanded immunohistochemical profile.
DESIGN: Immunohistochemical testing with diverse antibodies was performed on 95 archived epithelioid sarcomas including 73 classic and 22 histologically variant subtypes retrieved from the files of the Armed Forces Institute of Pathology.
RESULTS: Immunohistochemical reactivity (number positive/number of cases tested [percent positive], frequency of staining) included keratin 14 (31/64 [48%], variable), gamma-catenin (35/74 [47%], variable), keratin 5/6 (10/33 [30%], focal), calretinin (8/40 [20%], focal), keratin 20 (11/71 [15%], focal), p63 (3/20 [15%], focal), whereas 9 invasive cutaneous squamous cell carcinomas showed strong p63 positivity, epithelial-specific antigen (10/74 [14%], variable), CD117/Kit (5/37 [14%], focal), keratin 15 (3/23 [13%], rare cell), mesothelin (2/64 [3%], rare cell), and CD10 (1/41 [2%], rare cell). No reactivity was observed for keratins 2, 5, and 10.
CONCLUSIONS: Diagnostically, p63 and keratin 5/6 distinguish cutaneous squamous cell carcinoma (positive) from epithelioid sarcoma (usually negative). No single immunomarker was able to distinguish the main 4 histologic subtypes of epithelioid sarcoma, indicating that they are all histogenetically related lesions. The limited expression of specific keratin subtypes used in our study supports the notion that epithelioid sarcoma is a mesenchymal neoplasm capable of partial epithelial transformation.CYTOKERATIN
Cytokeratin 7 and 20 expression in epithelioid sarcoma.Humble SD, Prieto VG, Horenstein MG.
Departments of Pathology, University of South Alabama Medical Center, Mobile, Alabama, and University of Texas MD Anderson Cancer Center, Houston, Texas.
J Cutan Pathol 2003 Apr;30(4):242-6 Abstract quote BACKGROUND: Epithelioid sarcoma (ES) is a rare malignant soft tissue tumor of uncertain histogenesis that arises predominantly in the extremities of young adults. Immunohistochemically, the neoplastic cells are typically positive for vimentin, low molecular weight cytokeratin (CAM5.2) and epithelial membrane antigen (EMA).
METHOD: We examined eight cases of ES from seven different patients. All cases were studied with immunohistochemistry for EMA, CAM5.2 (keratin 8 and 18), 34BE12 (keratins 1, 5, 10 and 14/15), cytokeratins 7 and 20 (CK7, CK20), and CD34.
RESULTS: The average patient age was 53 (range 43-76) and the male:female ratio was 5:2. The location was the upper extremity in five tumors, the lower extremity, the perineum, and the paraspinal soft tissue in one tumor each. All cases contained predominantly epithelioid cells, but spindle cells were also present in three cases. All cases contained areas of geographic necrosis. CAM5.2 was strongly positive in seven tumors and focally positive in one (8/8). EMA was diffusely positive in two cases and focally positive in five cases (7/8). CD34 was diffusely positive in 3/8 cases. 34BE12 was diffusely positive in one case and focally positive in two others (3/8). CK7 was diffusely positive in one case and focally positive in another (2/8). CK20 was negative in all cases (0/8). All cases tested were positive for vimentin (6/6), 2 cases were focally positive for HHF35 (2/5), and all cases tested were negative for S-100 protein (0/7).
CONCLUSIONS: In addition to the known immunoreactivity for CAM5.2 and EMA, there is positivity for CK7 and 34BE12 in a small proportion of cases. None of the cases expressed CK20. This immunophenotypic profile suggests that ES is more similar to carcinoma and synovial sarcoma than to other soft tissue tumors, and may be of diagnostic utility.
Epithelioid sarcoma: an immunohistochemical analysis evaluating the utility of cytokeratin 5/6 in distinguishing superficial epithelioid sarcoma from spindled squamous cell carcinoma.Lin L, Skacel M, Sigel JE, Bergfeld WF, Montgomery E, Fisher C, Goldblum JR.
Cleveland Clinic Foundation, Cleveland, Ohio USA; Johns Hopkins Hospital, Baltimore, Maryland, USA; and Royal Marsden NHS Trust, London, England UK.
J Cutan Pathol 2003 Feb;30(2):114-7 Abstract quote BACKGROUND: Epithelioid sarcoma (ES) is a rare, aggressive soft tissue tumor characterized by nodular aggregates of epithelioid and/or spindled cells that are immunoreactive to cytokeratins (CKs) and epithelial membrane antigen. ES that arises in the dermis may cause epidermal ulceration and can resemble, clinically, morphologically and immunohistochemically, cutaneous squamous cell carcinoma. CK 5/6 has recently been found to be an excellent marker of squamous cell carcinoma, including spindled variants, but it is not known if this marker can be utilized to distinguish superficial ES from cutaneous spindled squamous cell carcinoma (SSCC).
METHODS: Twenty-four cases of ES with typical histologic features and 10 cases of SSCC with ultrastructural evidence of epithelial differentiation were studied. Immunohistochemical analysis using an antibody to CK 5/6 was performed. The extent of immunoreactivity was evaluated in a semiquantitative manner using the following scale: 0, < 5% of cells staining; 1+, 6-25% of cells staining; 2+, 26-50% of cells staining; 3+, 51-75% of cells staining; 4+, > 75% of cells staining.
RESULTS: CK 5/6 was expressed in all 10 cases of SSCC, including one case with 3+ staining and six cases with 4+ staining. In contrast, CK 5/6 staining was found only in rare tumor cells (1+ staining) in one of 24 (4%) cases of ES.
CONCLUSIONS: CK 5/6 staining is useful in distinguishing superficial ES from cutaneous SSCC.
DYSADHERIN
Prognostic significance of dysadherin expression in epithelioid sarcoma and its diagnostic utility in distinguishing epithelioid sarcoma from malignant rhabdoid tumor.
Izumi T, Oda Y, Hasegawa T, Nakanishi Y, Iwasaki H, Sonobe H, Goto H, Kusakabe H, Takahira T, Kobayashi C, Kawaguchi K, Saito T, Yamamoto H, Tamiya S, Iwamoto Y, Tsuneyoshi M.
1Department of Anatomic Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
Mod Pathol. 2006 Jun;19(6):820-31. Abstract quote
Dysadherin is a cancer-associated cell membrane glycoprotein, which downregulates E-cadherin and promotes metastasis.
We studied the clinicopathological features in 72 cases of epithelioid sarcoma and in six cases of malignant rhabdoid tumor, and also assessed the immunohistochemical expression of dysadherin, E-cadherin and MIB-1 in epithelioid sarcoma and malignant rhabdoid tumor cases. In addition, we compared dysadherin mRNA expression between epithelioid sarcoma and malignant rhabdoid tumor cell lines, using RT-PCR and real-time quantitative RT-PCR analysis.
Immunohistochemical dysadherin expression was more frequently observed in proximal-type epithelioid sarcoma (71%) in comparison with distal-type epithelioid sarcoma (36%) (P=0.037). Furthermore, seven proximal-type epithelioid sarcoma cases mimicking malignant rhabdoid tumor (histologically classified as the large cell type, accompanied by frequent rhabdoid cells and located in deep soft tissue) were all positive for dysadherin (100%), whereas dysadherin expression was not detected at all in any of the true six malignant rhabdoid tumors (0%). Cell lines established from proximal-type epithelioid sarcoma revealed significantly higher levels of dysadherin mRNA expression, compared with the levels seen in malignant rhabdoid tumor cell lines by real-time quantitative RT-PCR (P=0.0433). Epithelioid sarcoma patients with dysadherin expression survived for a significantly shorter time than those without dysadherin expression (P=0.001). In multivariate analysis, dysadherin immunopositivity (P=0.0004) was one of the two independent adverse prognostic factors.
We conclude that dysadherin expression in epithelioid sarcoma is a significant poor prognostic factor and that it is a powerful diagnostic marker for distinguishing epithelioid sarcoma, including the proximal-type epithelioid sarcoma, from malignant rhabdoid tumor. In epithelioid sarcoma, especially in proximal-type epithelioid sarcoma, increased cell disadhesion and motility by dysadherin plays an important role to acquire aggressive biological behavior. However, in malignant rhabdoid tumor, cell growth cycle that is regulated by hSNF5/INI1 gene seems to be critical to lethal biological behavior rather than dysadherin.VIMENTIN NEGATIVE Vimentin-negative epithelioid sarcoma. The value of an immunohistochemical panel that includes CD34.
Arber DA, Kandalaft PL, Mehta P, Battifora H.
Division of Pathology, City of Hope National Medical Center, Duarte, California 91010.
Am J Surg Pathol 1993 Mar;17(3):302-7 Abstract quote
Virtually all reported cases of epithelioid sarcoma have been vimentin rich, and the coexpression of vimentin and keratin is considered a characteristic immunophenotype in these tumors.
We report three cases of soft tissue tumors with histologic and clinical features consistent with epithelioid sarcoma, all of which failed to immunoreact by standard immunohistochemistry for vimentin using two different monoclonal antibodies. Antigen retrieval demonstrated focal vimentin staining in one case, whereas the other two remained negative. An extensive panel of immunohistochemical stains revealed strong diffuse staining with keratin and epithelial membrane antigen in all three cases as well as patchy membrane staining with an antibody to CD34. CD34 positivity is commonly seen in epithelioid sarcoma, but it is very rarely found in carcinomas.
We conclude that these cases represent a unique immunophenotypic variant of epithelioid sarcoma that can be immunohistochemically confirmed, despite the lack of identifiable vimentin, by their immunoreactivity for keratin and CD34.
DIFFERENTIAL DIAGNOSIS KEY DIFFERENTIATING FEATURES HEMANGIO-ENDOTHELIOMA
Epithelioid sarcoma-like hemangioendothelioma.Billings SD, Folpe AL, Weiss SW.
Am J Surg Pathol 2003 Jan;27(1):48-57 Abstract quote We are reporting seven histologically identical cases of a distinctive, low-grade vascular tumor that closely mimics an epithelioid sarcoma because of growth in solid sheets and nests, the eosinophilia of the rounded to slightly spindled neoplastic cells, and the diffuse, strong cytokeratin expression.
Termed epithelioid sarcoma-like hemangioendothelioma, all were diagnosed by the submitting pathologist or another expert consultant as epithelioid sarcoma. Although none displayed architectural evidence of vascular differentiation in the form of multicellular vascular channels, some displayed subtle cytologic features of vascular differentiation and all displayed immunohistochemical evidence of endothelial differentiation.
The patients (four male; three female) ranged in age from 17 to 54 years (median 23 years). Ranging in size from 1 to 3.5 cm, they occurred in the extremities (n = 5), scalp (n = 1), and chest wall (n = 1), both in deep (n = 3) and superficial (n = 3) soft tissue or both (n = 1). The tumors were characterized by sheets, ill-defined nodules, or fascicles of deeply eosinophilic cells set within a desmoplastic stroma. Multicellular vascular channel formation and/or hemorrhage were absent in all cases. In four cases intracytoplasmic vacuolization suggestive of intracytoplasmic vascular lumen formation was noted. The typical neoplastic cell was large and rounded in shape but modulated in areas to a spindled or multipolar shape. Mitotic activity was low (<5 mitotic figures/50 high power fields), nuclear pleomorphism was mild to moderate, and necrosis was absent. The tumors were positive for cytokeratin (6 of 6), vimentin (6 of 6), CD31 (5 of 6), FLI-1 (6 of 6), but negative for CD34 (0 of 6).
Within a follow-up period of 3-72 months (median 39 months), two patients experienced a local recurrence and one patient regional soft tissue metastases, but no distant ones. Two patients presented with multifocal lesions suggestive of regional metastases. Currently, two patients are alive with disease and five are disease free.
Epithelioid sarcoma-like hemangioendothelioma appears to be a largely unrecognized epithelioid vascular tumor with an indolent course. Despite its similar clinical and histologic features, it differs from epithelioid sarcoma by the presence of endothelial markers and the absence to date of distant metastases. Its distinction from other epithelioid vascular lesions is discussed. We think this tumor fits best into the family of "hemangioendothelioma" or vascular lesions of intermediate malignancy.
PROGNOSIS AND TREATMENT CHARACTERIZATION PROGNOSIS GENERAL Epithelioid sarcoma: the clinicopathological complexities of this rare soft tissue sarcoma.
Spillane AJ, Thomas JM, Fisher C. Sarcoma Unit, Royal Marsden Hospital, London, England, UK.
Ann Surg Oncol 2000 Apr;7(3):218-25 Abstract quote
BACKGROUND: Epithelioid sarcoma is a rare high grade soft tissue sarcoma with a known propensity for locoregional recurrence. The literature is limited on other characteristics such as frequency of multifocal disease at presentation, the relationship of presenting size of the primary lesion to prognosis, and the ability of current staging systems to predict prognosis.
METHODS: Review of the Royal Marsden National Health Service Trust (RMH) experience of 37 cases over 21 years.
RESULTS: The mean age was 29 years, with male predominance (2.7:1), and distal limb locations were most common (56%). Five patients presented with multifocal local disease. Median follow-up was 88 months in the 19 patients still alive. The 5- and 10-year actuarial overall survival was 70% and 42%, respectively. Tumors deep to the investing fascia had a worse prognosis than superficial tumors. Regional metastasis events were also associated with significantly worse overall survival. Local recurrence, size of 5 cm or larger, and regional metastasis events were predictive of worse distant metastasis-free survival. Tumor size (<5 cm vs. > or =5 cm), local recurrence events, sex, and site were not significant predictors of survival. The American Joint Committee on Cancer/International Union Against Cancer staging systems and the recently proposed RMH staging system of the Royal Marsden National Health Service Trust provided poor differentiation of prognosis in epithelioid sarcoma. The 5-year actuarial local recurrence rate was 35%. The 5-year actuarial regional nodal metastasis rate was 23%. The actuarial 5-year distant metastasis rate was 40%, with pleuropulmonary metastases the most common site of metastatic disease, and 35% of pleuropulmonary metastases presented with pleural effusion. Median post-distant metastasis survival was 8 months.
CONCLUSIONS: Epithelioid sarcoma has unusual clinical behavior compared with other high grade soft tissue sarcoma. It has a propensity for multifocal disease at presentation, local recurrence, regional metastasis, and particularly poor prognosis after regional or distant metastatic disease. Size and stage according to the American Joint Committee on Cancer/International Union Against Cancer are unreliable predictors of prognosis.
METASTASIS
Epithelioid sarcoma metastatic to the tongue: a rare entity.
Ozdemir E, Kocyigit P, Bostanci S, Okcu-Heper A, Aksu D, Gurgey E.
Ankara University, School of Medicine, Departments of Dermatology and Pathology, Ankara, Turkey.
J Cutan Pathol. 2004 May;31(5):401-5. Abstract quote
Epithelioid sarcoma (ES) typically arises as a firm nodule on the extremities of young men.
The tumor is remarkable for diagnostic difficulties both clinically and histopathologically resulting in a high frequency of initial misdiagnosis. ES is also known to have a high rate of recurrence and high rate of metastasis predominantly to the lymph nodes, lungs, and scalp.
Herein, the second case of ES with metastasis to the tongue is reported.
Metastatic epithelioid sarcoma to the brain: Palisaded necrosis mimicking glioblastoma multiforme.Prayson RA, Chahlavi A.
Departments of Anatomic Pathology and Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH.
Ann Diagn Pathol 2002 Oct;6(5):302-6 Abstract quote Epithelioid sarcomas are rare, morphologically distinct tumors that have a propensity to arise in the extremities. Brain metastasis from epithelioid sarcoma are a relatively rare occurrence.
We report a case of brain metastasis in a 50-year-old man who was previously diagnosed with an epithelioid sarcoma arising in the elbow. Before the diagnosis of brain metastasis, he had developed an axillary lymph node metastasis. He presented with neurologic symptoms of progressively worsening headache and loss of vision on the right side. He underwent gross total resection of an occipital lobe mass.
Histologically, the tumor was focally characterized by prominent perinecrotic pseudopalisading and demonstrated immunoreactivity with antibodies to cytokeratin AE1/3 and CAM5.2; the tumor did not stain with glial fibrillary acidic protein antibody. The literature is reviewed and the morphologic distinction between metastatic epithelioid sarcoma and other central nervous system neoplasms is discussed.
TREATMENT Excision Macpherson and Pincus. Clinical Diagnosis and Management by Laboratory Methods. Twentyfirst Edition. WB Saunders. 2006.
Rosai J. Ackerman's Surgical Pathology. Ninth Edition. Mosby 2004.
Sternberg S. Diagnostic Surgical Pathology. Fourth Edition. Lipincott Williams and Wilkins 2004.
Robbins Pathologic Basis of Disease. Seventh Edition. WB Saunders 2005.
DeMay RM. The Art and Science of Cytopathology. Volume 1 and 2. ASCP Press. 1996.
Weedon D. Weedon's Skin Pathology Second Edition. Churchill Livingstone. 2002
Fitzpatrick's Dermatology in General Medicine. 6th Edition. McGraw-Hill. 2003.
Weiss SW and Goldblum JR. Enzinger and Weiss's Soft Tissue Tumors. Fifth Edition. Mosby Elesevier 2008
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