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Year : 2018  |  Volume : 14  |  Issue : 2  |  Page : 444-446

Giant cells in soft tissue tumors! Is it a clue to diagnosis or cytologists mystery??? An unusual case report


1 Department of Pathology, KS Hegde Medical Academy, Nitte University, Mangalore, Karnataka, India
2 Department of General Surgery, KS Hegde Medical Academy, KS Hegde Medical Academy, Nitte University, Mangalore, Karnataka, India

Date of Web Publication8-Mar-2018

Correspondence Address:
Dr. H L Kishanprasad
Department of Pathology, KS Hegde Medical Academy, Nitte University, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.199433

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 > Abstract 


Giant cells in soft tissue (ST) tumors are rare, pose great challenges to treating clinicians, and diagnosing pathologists. Common lesion with giant cells includes benign conditions such as nodular fasciitis to highly malignant lesions such as giant cell variant of malignant fibrous histiocytoma and extraskeletal osteosarcoma. Giant cell tumors of ST, extension of bony lesion to the ST are also rare possibilities. Recently, giant cell fibroblastoma and dermatofibrosarcoma protuberans have also been added to this list. These tumors show unpredictable behavior; some patients are cured by simple surgical excision whereas others develop metastasis. Diagnosing these in cytology is still more challenging. We report here a rare case of a giant cell-rich dermatofibrosarcoma protuberans in a 23-year-old male who presented with ST lesion in left forearm since 6 months. The lesion was predicted in fine-needle aspiration cytology and confirmed later with histopathology. When evaluated along with clinical features, the cytological features are very useful to distinguish between these tumors with giant cell morphology.

Keywords: Cytology, dermatofibrosarcoma, multinucleated giant cell, soft tissue tumor


How to cite this article:
Kishanprasad H L, Lobo L, Shetty JK, Impana B D. Giant cells in soft tissue tumors! Is it a clue to diagnosis or cytologists mystery??? An unusual case report. J Can Res Ther 2018;14:444-6

How to cite this URL:
Kishanprasad H L, Lobo L, Shetty JK, Impana B D. Giant cells in soft tissue tumors! Is it a clue to diagnosis or cytologists mystery??? An unusual case report. J Can Res Ther [serial online] 2018 [cited 2020 Jun 1];14:444-6. Available from: http://www.cancerjournal.net/text.asp?2018/14/2/444/199433




 > Introduction Top


Giant cells in soft tissue (ST) tumors are rare, pose great challenges to treating clinicians and diagnosing pathologists. Common differential diagnosis includes benign conditions like nodular fasciitis to highly malignant lesions like giant cell variant of malignant fibrous histiocytoma and extraskeletal osteosarcoma.[1],[2],[3],[4] Giant cell tumor of ST (GCT-ST) and extension of the bony lesion to the ST are also rare possibilities. Recently, giant cell fibroblastoma and dermatofibrosarcoma protuberans (DFSP) have also been added to the above list. These tumors show unpredictable behavior with some patients are cured by simple surgical excision whereas others develop metastasis.[1],[2] We encountered such a rare lesion, which produced diagnostic dilemma in fine-needle aspiration cytology (FNAC) of the ST mass in a 23-year-old male due to interspersed giant cells.


 > Case Report Top


A 23-year-old male presented with ST mass in the left forearm for 6 months. The lesion was firm to hard subcutaneous mass, measuring 2 cm × 1 cm. Underlying bone and overlying skin was unremarkable. FNAC showed few clusters of atypical spindly cells with pleomorphism and dispersed osteoclast giant cells [Figure 1]a,[Figure 1]b,[Figure 1]c Background has hemorrhage and necrosis. Based on these, possibility of GCT of the soft part was considered. Hence, excision biopsy showed partially capsulated lesion measuring 2 cm × 1 cm with gray white and hemorrhagic cut surface [Figure 1]d. Histopathology of the same showed spindly cells arranged in hypercellular and hypocellular areas with focal storiform pattern [Figure 2]a and [Figure 2]b. Cells were pleomorphic with hyperchromatic nuclei. Increased atypical mitosis (1–2/10 HPF) was noted. Many osteoclast giant cells were seen admixed with these tumor cells [Figure 2]c and [Figure 2]d. Foci of necrosis and proliferating blood vessels were also seen. Correlating clinical, cytological, and above histopathology finding, final diagnosis of giant cell-rich DFSP was given. The patient was closely followed up and he is symptomatically better with no recurrence or metastasis after 2 years of follow-up.
Figure 1: (a and b) Fine-needle aspiration cytology showing spindly tumors cells with interspersed osteoclast giant cells within necrotic background (Pap, ×100). (c) Spindly tumor cells in clusters (MGG, ×100). (d) Partially capsulated mass with hemorrhagic areas

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Figure 2: (a and b) Histopathology showing spindly tumor cells arranged in sheets and vague storiform pattern (H and E, ×100). (c and d) Histopathology showing interspersed osteoclast giant cells and necrosis changes

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 > Discussion Top


Giant cells in cytology of ST tumors are very rare. Most of the giant cells in ST aspirate are osteoclast-type giant cells. Many times, giant cells in cytology will assist in diagnosis.[3],[4],[5] However, many lesions will have giant cells in aspiration will pose diagnostic difficulty for cytopathologists. Giant cell fibroblastoma is a rare childhood ST tumor of intermediate malignancy which shares many features of DFSP. Dermatofibrosarcoma is known to be a rare, slow-growing malignant tumor. It has been shown that giant cell fibroblastoma has a close histogenic relationship to DFSP, and it has been reported that giant cell fibroblastoma can transform into DFSP.[1],[2]

The differential diagnosis includes GCT-ST is a tumor whose cytomorphology closely resembles that of a GCT of the bone. Many consider malignant GCT-ST as histological variants of malignant fibrous histiocytomas. These GCT-STs occur in patients in all age groups ranging from 1 to 87 years. Approximately, 80–90% of all GCTs are located in the extremities. Other tumor locations include the face, abdominal wall, shoulders, neck, and retroperitoneum. Low- and high-grade forms have been separated from each other on the basis of the atypia, pleomorphism, and mitotic activity of the mononuclear neoplastic component. Malignant forms of GCT-ST show a mixture of osteoclast-like, multinucleated giant cells, cytoplasm-rich histiocytes, and fibroblasts. The latter two cell types exhibit varying degrees of cellular and nuclear pleomorphism.[1],[2],[3],[4]

Other differential diagnosis includes GCT of tendon sheath, which is encapsulated, shows characteristic, nodular growth patterns, lacks the typical spindle stromal cells of a conventional GCT, and contains scattered giant cells, lymphocytes, foamy macrophages, and large amount of fibrous tissue. The benign tumors include pigmented, villonodular synovitis, which affects synovial lined joints, bursae, and tendon sheaths. Nodular fasciitis with osteoclast-like giant cells is composed of immature fibroblasts in sheets and irregular bundles. Giant cells surround the area of hemorrhage and myxoid degeneration. Giant cell malignant fibrous histiocytoma, giant cell rich leiomyosarcoma, and extraskeletal osteosarcoma are usually large, deep-seated lesions with obvious cellular atypia.[1],[5],[6] Our case was giant cell-rich DFSP in a 23-year-old male who presented as ST mass in the left forearm. The lesion was predicted in FNAC and confirmed later with histopathology. Treatment for these is with surgical excision having tumor-free surgical margin.[3],[4],[5] Our case was treated with surgical excision with tumor-free margin.


 > Conclusion Top


Encountering giant cells in FNAC many a times gives clue to the diagnosis. However, in few cases as described in our case, it will pose diagnostic and treatment challenges. In such scenarios, it has to be evaluated with clinical and the cytological features along with histological correlation is very useful to distinguish between these tumors with giant cell morphology.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Softah A. Recurrence of dermatofibrosarcoma protuberans: A case report and a review of literature. Indian J Chest Dis Allied Sci 2003;45:261-3.  Back to cited text no. 1
    
2.
Hassan MJ, Ahmad SS, Hassan M, Basha M, Kurram MF. Giant cell fibroblastoma – A case report. Oman Med J 2012;27.  Back to cited text no. 2
    
3.
Harvell JD, Kilpatrick SE, White WL. Histogenetic relations between giant cell fibroblastoma and dermatofibrosarcoma protuberans. CD34 staining showing the spectrum and a simulator. Am J Dermatopathol 1998;20:339-45.  Back to cited text no. 3
    
4.
Terrier-Lacombe MJ, Guillou L, Maire G, Terrier P, Vince DR, de Saint Aubain Somerhausen N, et al. Dermatofibrosarcoma protuberans, giant cell fibroblastoma, and hybrid lesions in children: Clinicopathologic comparative analysis of 28 cases with molecular data – a study from the French Federation of Cancer Centers Sarcoma Group. Am J Surg Pathol 2003;27:27-39.  Back to cited text no. 4
    
5.
Maeda T, Hirose T, Furuya K, Shirakawa K, Kobayashi K. Giant cell fibroblastoma associated with dermatofibrosarcoma protuberans: A case report. Mod Pathol 1998;11:491-5.  Back to cited text no. 5
    
6.
Gupta K, Dey P, Goldsmith R, Vasishta RK. Comparison of cytologic features of giant-cell tumor and giant-cell tumor of tendon sheath. Diagn Cytopathol 2004;30:14-8.  Back to cited text no. 6
    


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  [Figure 1], [Figure 2]



 

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