Sclerosing epithelioid fibrosarcoma is a clinicopathologically distinct tumour of the soft tissue first described by Meis-Kindblom et al
The tumour occurs mostly in the deep musculature and is frequently associated with the adjacent fascia or periosteum. It is characterised histologically by a proliferation of uniform, small, slightly angulated, round to oval epithelioid cells with sparse, often clear cytoplasm arranged in nests and cords, associated with prominent hyaline sclerosis of the stroma. There may be myxoid areas with cyst formation, foci of hyaline cartilage, calcification, and metaplastic bone. Most of the tumours show positive staining for vimentin, but variable staining for EMA, S100 protein, CAM5.2, and AE1/AE3. Ultrastructurally, the tumour cells contain a network of intermediate cytofilaments and moderate numbers of mitochondria intimately associated with rough endoplasmic reticulum. The features are consistent with those of fibroblastic/myofibroblastic differentiation.
In their series of 25 patients, information regarding survival was available in 16 cases, and six patients showed no evidence of disease at a follow up period of 13 to 204 months. Eight of 15 patients suffered from local recurrences, the time of first recurrences from initial diagnosis ranged from 28 to 132 months. Six of 14 patients developed distant metastases at an interval of 56 to 168 months. Four of these 16 patients died of the disease 37 to 164 months after presentation. They concluded that sclerosing epithelioid fibrosarcoma is a distinctive soft tissue sarcoma that behaves in a relatively low grade manner.
Their findings were largely validated by subsequent reports by others.2–12
In particular, in the recent series of 16 patients by Antonescu et al
the authors concluded that sclerosing epithelioid fibrosarcoma is a clinicopathologically distinct low grade fibrosarcoma that is closely related to low grade fibromyxoid sarcoma13–15
and hyalinising spindle cell tumour with giant rosettes.16–20
These three tumours belong to the same family of so called “fibrosing fibrosarcomas”, which are sarcomas that exhibit fibroblastic differentiation and show prominent widespread fibrosis readily evident both grossly and microscopically.
Even though the incidence of persistent disease and local recurrences in the series of Antonescu et al
(57%) is similar to that of Meis-Kindblom et al
(50%), Antonescu et al
observed a shorter mean interval to first local recurrence (22.6 v
71.5 months). Furthermore, the metastasis and mortality rates in the series of Antonescu et al
(86% and 57%) are also significantly higher than those of Meis-Kindblom et al
(43% and 25%). One of the possible explanations for this difference is that the tumours in three of the 16 cases of Antonescu et al
involved the cranium, and it has been speculated that sclerosing epithelioid fibrosarcomas of the neuraxis may behave more aggressively than those arising in the deep skeletal muscles.7
Indeed, two of the three patients with involvement of the cranium in the series of Antonescu et al
died of their disease.9
“Sclerosing epithelioid fibrosarcoma, despite its low grade, is a clinicopathologically distinct soft tissue tumour with full malignant potential, with the recurrence, metastasis, and mortality rates being 48%, 60%, and 35%, respectively”
Another point of interest is that histological evidence of tumour necrosis was noted in six of the 16 cases reported by Antonescu et al
. In two of these six patients, the necrosis was also detected macroscopically; the patient with 50% necrosis died of the disease at 86 months, and the other with 30% necrosis had a follow up period of only two months. In contrast, none of the tumours in the series of Meis-Kindblom et al
involved the cranium or showed necrosis. In this regard, it is also of interest to note that in a recently reported case of sclerosing epithelioid fibrosarcoma by Hanson et al
not only did the tumour exhibit large areas of necrosis (45%), but there were also areas of high grade nuclear anaplasia and active mitosis. The tumour recurred 10 months after surgery and there was disseminated metastasis to the lumbar spine, liver, and peritoneum. High grade areas were also seen in the recurrent tumour and peritoneal metastasis. The patient died 12 months after initial presentation. Accordingly, the prognostic implication of the various clinicopathological parameters, notably the location and histomorphology of the tumour, deserves further detailed analysis.
Review of the English literature shows that a total number of 57 cases of sclerosing epithelioid fibrosarcoma have been reported (table 1). Follow up information was available in 44 patients. The cumulative data fully support the notion that sclerosing epithelioid fibrosarcoma, despite its low grade, is a clinicopathologically distinct soft tissue tumour with full malignant potential, with the recurrence, metastasis, and mortality rates being 48%, 60%, and 35%, respectively (table 2).
Summary of the clinical presentation of the cases of sclerosing epithelioid fibrosarcoma reported in the literature
Summary of the clinical outcomes of the cases of sclerosing epithelioid fibrosarcoma reported in the literature
In addition to the usual occurrence in the deep muscular compartment, Bilsky and colleagues7
and Antonescu and colleagues9
identified a group of patients with tumour principally involving the cranium and intracranial contents. Antonescu et al
also noted bone invasion by sclerosing epithelioid fibrosarcoma in six of their 16 patients. However, primary sclerosing epithelioid fibrosarcoma affecting the bone is distinctly rare and only one recent report12
is found in the English literature. The case concerns a 42 year old woman with a 13 year history of a “stable lesion” in the left iliac bone. Biopsy of the lesion at that time was interpreted as necrosis with fibrosis and reactive changes. Unfortunately, the lesion assumed an aggressive radiological appearance three years later, and a tumour of the scalp was also detected. Biopsy of the bone lesion and resection of the scalp tumour showed histological features of sclerosing epithelioid fibrosarcoma. The patient remained alive with lung metastasis two years after the diagnosis.
The radiological appearances of the tumour in our patient fully document that it primarily originates from and involves the sacrum, an opinion endorsed by JM Mirra (personal communication, 1996). The gross morphology, histology, immunohistochemical staining pattern, and ultrastructural appearances of the tumour are highly characteristic of sclerosing epithelioid fibrosarcoma. Accordingly, our patient is the second reported case of primary sclerosing epithelioid fibrosarcoma of the bone. The patient remained well and free of disease five years after complete surgical removal of the tumour. However, she presented with metastasis involving the scalp and lung six years after surgery. She finally died of disseminated disease with metastasis to the lung, liver, scalp, and retroperitoneum eight years after initial presentation.
It is of interest that both our case of primary osseous sclerosing epithelioid fibrosarcoma and that reported by Abdulkader et al affected the iliac bone, and occurred in middle aged female patients. Furthermore, the tumours in both patients pursued an indolent but aggressive clinical course, with metastasis to the lung and scalp. Our patient finally succumbed eight years after initial presentation.
The spectrum of differential diagnosis of sclerosing epithelioid fibrosarcoma is broad, as reflected in the diagnoses offered by the referring pathologists in the series of patients reported by Meis-Kindblom et al
The bland cytology of the tumour cells and the hyalinised stroma raise the possibility of benign lesions such as desmoid tumour, fibrous histiocytoma, and hyalinised leiomyoma. However, the epithelioid appearance of the tumour cells in our case, together with their pale eosinophilic or clear cytoplasm, and arrangement in infiltrative cords or strands, are typical of sclerosing epithelioid fibrosarcoma and allow its ready differentiation from desmoid and fibrous histiocytoma. The negative staining for desmin distinguishes sclerosing epithelioid fibrosarcoma from a hyalinised leiomyoma. The malignant diagnostic considerations include infiltrating carcinoma, monophasic synovial sarcoma, clear cell sarcoma (malignant melanoma of soft part), myxoid chondrosarcoma, and sclerosing lymphoma. The negative staining of the tumour cells in our case for CAM5.2, AE1/AE3, EMA, S100, HMB45, and LCA argues against the aforementioned diagnoses. In fact, the histological pattern of our case, in combination with the sole positive staining for vimentin and electron microscopic features of fibroblastic differentiation, fulfil the strict diagnostic criteria of sclerosing epithelioid fibrosarcoma proposed by Eyden et al
In conclusion, sclerosing epithelioid fibrosarcoma can occur as a primary tumour in the bone, and from the clinical course of our patient and the patient reported by Abdulkader et al, we speculate that its behaviour is similar to its soft tissue counterpart. Whenever possible, wide local resection should be carried out because there is no clear evidence to support the use of adjuvant treatment alone in this rare tumour.
Take home messages
- We report the second case of primary osseous sclerosing epithelioid fibrosarcoma
- The clinical behaviour of this rare tumour appears to be similar to its soft tissue counterpart
- The tumour pursued an indolent but aggressive clinical course, with metastasis to the lung and scalp
- Whenever possible, wide local resection should be carried out because there is no clear evidence to support the use of adjuvant treatment alone