British Journal of Radiology 74 (2001),651-653 © 2001 The British Institute of Radiology
Cystic malignant fibrous histiocytoma of the gastrocolic ligament
C-C Huang, MD1,
S-F Ko, MD1,
S-H Ng, MD1,
T-Y Lee, MD1,
Y-L Wan, MD1,
J-W Lin, MD2 and
W-J Chen, MD2
Departments of 1Radiology and 2Pathology, Chang Gung University, Chang Gung Memorial Hospitals at Kaohsiung and Linkou, 123 Ta-Pei Road, Niao-Sung Hsiang, Kaohsiung Hsien 833, Taiwan
Correspondence: S-F Ko MD
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Abstract
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A case of malignant fibrous histiocytoma (MFH) of the gastrocolic ligament is presented. It appeared as a huge, thin walled cystic tumour in the upper abdominal cavity on CT. Barium studies showed splaying of the stomach and transverse colon by the mass. 1 year after resection of the cystic tumour, recurrence occurred at the greater curvature of the stomach and in the liver, with a cystic appearance similar to the primary tumour. To our knowledge, the CT appearance of primary cystic MFH of the gastrocolic ligament has not been previously documented.
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Introduction
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Malignant fibrous histiocytoma (MFH) is one of the most common sarcomas appearing in late adult life. It frequently occurs in the soft tissue of the extremities, the retroperitoneum and in bone. MFH may arise from the supporting structures of various organs [1–5]. Despite this ubiquity, involvement of the peritoneal cavity is uncommon. Most examples of MFH appear on imaging studies as heterogeneous solid masses with areas of necrosis [4–7]. The gastrocolic ligament extends inferiorly from the greater curvature of the stomach to suspend the transverse colon. It can act as a "two-way street" through which carcinoma of the stomach can extend downward to invade the colon or vice versa [8]. Primary gastrocolic ligament tumour is rare [8, 9]. We report the CT findings in a case of primary cystic MFH of the gastrocolic ligament.
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Case report
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A 55-year-old woman was admitted with a 5-year history of progressive enlargement of a palpable abdominal mass. Physical examination demonstrated a soft, non-tender mass in the left upper abdomen. CT showed an oval, thin walled, septated, intra-abdominal cystic mass in the upper abdominal cavity, 18 cm in size (Figure 1a
). The attenuation value of the cystic content ranged from 10 HU to 30 HU. Barium meal and small bowel follow-through studies showed elevation of the stomach and downward displacement of the transverse colon (Figure 1b). The cystic tumour was seen at surgery to bulge out from the gastrocolic ligament. The stomach and transverse colon were displaced but not invaded. The mass did not involve the pancreas. Aspiration of the cystic mass yielded dark red bloody fluid. Only the cystic mass was resected because the initial pathological diagnosis of the frozen section of the biopsy specimen taken during surgery was a benign cyst with an inflammatory wall. The mass was grayish red and smooth. Slightly thickened and uneven walls, a few septa and large central cystic spaces with bloody content were found on sectioning of the tumour.
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Figure 1. (a) Enhanced CT shows a thin walled cystic tumour in the upper abdominal cavity with a slightly thickened septum (arrowheads). Note the haemorrhagic content with slightly higher density (arrow) in one of the cystic spaces. (b) Barium meal and small bowel follow-through studies show downward displacement of the transverse colon (arrowheads) and upward displacement of the stomach (arrow). (c) Enhanced CT 21 months after surgery shows a multisepated metastatic cystic tumour in the liver (black arrow) and a locally recurrent cystic tumour with an irregular solid component (white arrow). Note a small amount of ascites in the right subphrenic region.
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Histopathological examination showed extensive haemorrhage in the cystic spaces and pleomorphic MFH in the cyst wall, with histiocytic and fibroblastic elements arranged in a vague storiform pattern. Most of the tumour cells possessed moderate pleomorphic nuclei. Scattered bizarre cells and giant cells were noted. There was no vascular neoplastic component, thus excluding angiomatoid MFH. The resection margins were free of tumour cells. The final diagnosis was a storiform–pleomorphic MFH with haemorrhagic and cystic degeneration. Follow-up CT 21 months later revealed a recurrent cystic tumour with an irregular solid component along the gastrocolic ligament. In addition, a new multiseptated cystic liver, metastasis was also present (Figure 1c
). The patient died from sepsis 2 months later.
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Discussion
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Great interest and controversy have been generated in the pathological and oncological aspects of MFH since the early description by O'Brien and Stout [1–3]. MFH is typically manifested as a broad range of histopathological appearances and is currently classified into four subtypes: storiform–pleomorphic, myxoid, giant cell and inflammatory. MFH is characterized microscopically by areas of spindle cells arranged in a storiform pattern, and pleomorphic areas with haphazardly arranged sheets of fibroblasts and histiocytes [2, 3]. Typically appearing in the fifth and sixth decades of life, MFH generally affects the extremities and retroperitoneum [1–5]. Uncommon locations include the head and neck region, dura mater, brain, lung, heart, aorta, pancreas, liver, spleen, breast, intestine and mesentery [4–7, 10, 11]. To our knowledge, this is the first report of primary cystic MFH in the gastrocolic ligament.
Radiographic findings for MFH are non-specific and usually show as a soft tissue mass. Calcification has been reported in 7–20% of cases [4–7]. Barium studies can demonstrate extrinsic compression in cases of peritoneal involvement [5,6] and are helpful in tumour localization. A variety of patterns have been reported on ultrasound, including hypoechoic, mixed (due to tumour necrosis) or predominately anechoic with thick septa. MFH generally presents as a hypoechoic or heteroechoic solid mass [5, 6].
On CT, MFH typically presents as a poorly marginated or well circumscribed mass, with a density similar to or slightly less than that of normal muscle and with hypodense areas due to necrosis [4–7]. Eccentrically located lumpy and ring-like calcifications due to osteoid and chondroid metaplasia have been reported on CT in 16% of abdominal MFH [7]. Tumour invasion of contiguous viscera, especially the kidney, was observed in 33–44% of retroperitoneal MFH cases, with resultant poor prognosis [4]. In contrast, mesenteric and peri-rectal MFH, presenting as non-invasive, homogeneously enhanced masses with better prognoses, have been described [7]. Occasionally MFH with extensive necrosis may be manifested as a cystic tumour [10, 11]. Panicek et al [12] have described three cases of MFH of the lower extremity with considerable intratumoral haemorrhage during pre-operative chemotherapy simulating tumour growth. Approximately 5% of MFH cases demonstrate extensive haemorrhage, creating a cyst-like space that may be confused with haematoma [3].
Although tumour necrosis in MFH may finally progress to such an extent that it may resemble a cystic mass or abscess on imaging studies [10, 11], the serial CT images for our case demonstrated that some MFH may exhibit an inherent propensity for intratumoral bleeding, even without chemotherapy or tumour necrosis, mimicking a benign cystic lesion on CT.
The differential diagnoses for intraperitoneal cystic lesions include duplication, pancreatic pseudocyst, cystic leiomyoma or leiomyosarcoma, teratoma, cystic mesothelioma, lymphangioma, haematoma, abscess and synovial sarcoma [8, 9]. Despite the protean manifestations of MFH making pre-operative diagnosis difficult, it should be considered as a rare differential diagnosis of an abdominal cystic mass in older adults.
Received for publication October 2, 2000.
Revision received February 22, 2001.
Accepted for publication April 4, 2001.
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References
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Abstract
Introduction
