Primary intra-abdominal malignant fibrous histiocytoma presenting as pyrexia of unknown origin – report of a case with review of literature
© Qureshi et al; licensee BioMed Central Ltd. 2006
Received: 10 March 2006
Accepted: 22 June 2006
Published: 22 June 2006
Primary intra-abdominal malignant mesenchymal tumours are very rare and there are not many cases of visceral malignant fibrous histiocytoma in the English literature. We report a new case of abdominal malignant fibrous histiocytoma presenting as abdominal pain and pyrexia of unknown origin in a 54 year old female followed by a brief review of literature. Presentation with pyrexia of unknown origin is extremely rare in this condition.
The term Malignant Fibrous Histiocytoma (MFH) was originally described by O'Brien and Stout in 1964  to cover a variety of pleomorphic soft tissue sarcomas derived from histiocytes capable of fibroblastic transformation. MFH is a common sarcoma of mesenchymal origin affecting soft tissues of the body, especially the extremities and retroperitoneum. Primary intra-abdominal MFH is a rare disease and few cases are reported in the English literature. Its presentation as high-grade pyrexia of unknown origin (PUO) is extremely unusual. We report a case of malignant fibrous histiocytoma affecting colon, spleen, left hemi diaphragm and distal pancreas in a 54 year old female, who presented with abdominal pain and pyrexia of unknown origin.
A 54 year old female presented to our surgical outpatient clinic with abdominal pain and pyrexia. Abdominal pain was of recent onset and mainly in the left upper abdomen but she had fever for at least 6 months. Her pyrexia was high grade (39.5–40 C0), intermittent, and most common in the early morning. Clinical examination revealed a firm, vaguely defined, tender mass in the left upper quadrant of the abdomen. Blood results showed persistently high ESR (>100), high CRP (>240), leukocytosis, mildly raised Alkaline Phosphatase and anaemia (normochromic, normocytic). There was no overt source of infection that could account for the fever. Repeated blood cultures did not yield any bacterial growth. NM Leukocyte HMPAO scan showed no convincing abnormality to help localise an infective focus. There was no improvement in pyrexia after treating the patient with broad-spectrum antibiotics.
The patient was consented for surgery and distal pancreatectomy, splenectomy, left adrenalectomy and resection of part of colon was undertaken to remove the tumour via a left thoracoabdominal approach. The patient had an uneventful post-operative recovery and her pyrexia resolved completely following surgery.
Three different specimens were submitted for histology. Specimen A had a smooth external surface, measured 180 × 140 × 130 mm and comprised of a multi-nodular mass with spleen and a loop of large bowel. The cut surface of the tumour was grey with large areas of necrosis up to 80%. The bowel segment appeared to be entrapped and focally infiltrated by the tumour up to the mucosa; however, both cut ends margins were free of tumour. Specimen B comprised of lobulated mass with fatty tissue and measured 140 × 60 × 30 mm. Some adrenal tissue was identified which was not involved by the tumour. Specimen C consisted of four pieces of haemorrhagic tissue.
Malignant Fibrous Histiocytoma is a sarcoma of mesenchymal origin affecting soft tissues of the body, particularly the extremities and retroperitoneum. Rarely, it may affect intra-peritoneal organs. Its occurrence has been reported in almost all parts of the body including head and neck , intracranial [3, 4], intra-abdominal organs [5, 6] and heart muscle . It is considered as the most common soft tissue sarcoma of the adults , but may occur in children as well as infants .
The mode of presentation of MFH depends on the primary site of the body affected by the tumour, for example, dyspnoea and arrhythmias can be caused by cardiac lesions. In addition, symptoms of systemic illness caused by the tumour may also be the presenting complaint. Reporting our patient, intra-abdominal MFH presented as pyrexia of unknown origin, caused likely by tumour necrosis and release of inflammatory and pyrogenic factors.
2. myxoid (myxofibrosarcoma)
3. Giant cell (malignant giant cell tumor of soft parts and has the worst prognosis)
4. Inflammatory (xanthosarcoma and malignant xanthogranuloma)
Investigations for the diagnosis of MFH include routine haematological, biochemical and radiological tests. A CT scan of the abdomen should be performed early in a patient who presents with abdominal pain and pyrexia of unknown origin but no obvious source of symptoms. This can help identify and localise tumours, if and define extent of growth and presence of metastatic disease. The final diagnosis of MFH is based primarily on the histopathological examination and immunohistochemical reactivity. These diagnostic procedures rely on several criteria, which include the presence of typical spindle and polygonal (strap-like) cells that are filled with an abundant eosinophilic cytoplasm, cells with cross-striations, and, particularly, desmin- and myoglobin-positive immunoreactivity [12, 13]. However, the presence of cytoplasmic filaments is not always found in MFH and makes it harder to establish a reliable differential diagnosis.
MFH is an aggressive tumour with a high potential of metastasis to other parts of the body. The Liver is the most commonly involved site of metastatic sarcomas, occurring in 64%–70% of patients [15, 16]. The current treatment of choice for primary malignant fibrous histiocytomas is surgical resection [14, 15], which involves wide excision of the tumour with an aim for tumour free margins. Recurrence of the tumour is not uncommon even when resection margins are tumour free. Metastasis may present months or years after resection of the primary lesion. Treatment for metastatic disease is surgical where possible; palliative surgery may be carried out if complete resection is not possible. The role of adjuvant radiotherapy and chemotherapy is not clear in the case of retroperitoneal and visceral sarcomas. There are studies that suggest no improvement in overall survival after systemic chemotherapy [16–18]. Some advocate the use of chemoembolization for unresectable metastatic sarcomas, which can provide durable tumour response .
In order to improve survival in patients with MFH, complete resection of the primary tumour as well as isolated peritoneal or hepatic metastases should be attempted where possible. An early multidisciplinary approach is important to improve clinical outcome. Our case report shows that primary intra-abdominal MFH can present in unusual ways including high-grade fever of unknown origin. Clinicians must remember this while establishing differential diagnosis for patients with PUO and abdominal pain.
Many thanks to Dr Deshmukh for providing histopatholgy image.
Written consent was obtained from patient's next of kin.
- O'Brien JE, Stout AP: Malignant fibrous xanthomas. Cancer. 1964, 17: 1445-55.View ArticlePubMedGoogle Scholar
- Sadati KS, Haber M, Sataloff RT: Malignant fibrous histiocytoma of the head and neck after radiation for squamous cell carcinoma. Ear Nose Throat J. 2004, 83 (4): 280-1.Google Scholar
- Ozhan S, Tali ET, Isik S, Saygili MR, Baykaner K: Haematoma-like primary intracranial malignant fibrous histiocytoma in a 5-year-old girl. Neuroradiology. 1999, 41 (7): 523-5. 10.1007/s002340050797.View ArticlePubMedGoogle Scholar
- Fujimoura N, Sugita Y, Hirohata M, Naohisa M, Terasaki M, Tokutmi T, Shigemori M: Primary Intracerebral Malignant Fibrous Histiocytoma in a Child. Paediatric Neurosurgery Basel. 2002, 37 (5): 271-5. 10.1159/000066211.View ArticleGoogle Scholar
- Kotan C, Kosem M, Alici S, Ilhan M, Tuncer I, Harman M: Primary malignant fibrous histiocytoma of the small intestine presenting as an intussusception: report of a case. Surg Today. 2002, 32 (12): 1091-5. 10.1007/s005950200221.View ArticlePubMedGoogle Scholar
- Gruttadauria S, Doria C, Minervini MI, Doyle HR, Mandala L, Foglieni CS, et al: Malignant fibrous histiocytoma of the gallbladder: case report and review of the literature. Am Surg. 2001, 67 (7): 714-7.PubMedGoogle Scholar
- Donsbeck AV, Ranchere D, Coindre JM, Le Gall F, Cordier JF, Loire R: Primary cardiac sarcomas: an immunohistochemical and grading study with long-term follow-up of 24 cases. Histopathology. 1999, 34 (4): 295-304. 10.1046/j.1365-2559.1999.00636.x.View ArticlePubMedGoogle Scholar
- Singh B, Shaha A, Har-El G: Malignant fibrous histiocytoma of the head and neck. J Craniomaxillofac Surg. 1993, 21: 262-5.View ArticlePubMedGoogle Scholar
- Kim OH, Lee KY: Malignant fibrous histiocytoma of primary omental origin in an infant. Pediatr Radiol. 1994, 24 (4): 285-7. 10.1007/BF02015460.View ArticlePubMedGoogle Scholar
- Enzinger F: Recent developments in the classification of soft tissue sarcomas. Management of Primary Bone and Soft Tissue Sarcomas. 1977, Chicago: Year Book of Medical Publishers, IncGoogle Scholar
- Enzinger FM, Weiss SW: Soft Tissue Tumors. 1983, St. Louis: CV Mosby, 166-198.Google Scholar
- Miettinen M: Rhabdomyosarcoma in patients older than 40 years of age. Cancer. 1988, 62: 2060-2065. 10.1002/1097-0142(19881101)62:9<2060::AID-CNCR2820620932>3.0.CO;2-Y.View ArticlePubMedGoogle Scholar
- De Jong ASH, Van Kessel-Van Mark M, Albus Lutter CE: Pleomorphic rhabdomyosarcoma in adults: immunohistochemistry as a tool for its diagnosis. Hum Pathol. 1987, 18: 298-303.View ArticlePubMedGoogle Scholar
- Ng EH, Pollack RE, Romsdahl M: Prognostic implications of patterns of failure for gastrointestinal leiomyo- sarcomas. Cancer. 1992, 69: 1334-1341.View ArticlePubMedGoogle Scholar
- Lee YTN: Leiomyosarcomas of the gastrointestinal tract: general pattern of metastasis and recurrence. Cancer Treat Rev. 1984, 10: 91-101. 10.1016/0305-7372(83)90007-5.View ArticleGoogle Scholar
- Edmonson JH, Ryan LM, Blum RH, Brooks JS, Shiraki M, Frytak S, et al: Randomized comparison of doxorubicin alone versus ifosfamide plus doxorubicin or mitomycin, doxorubicin and cisplatin against advanced soft tissue sarcomas. J Clin Oncol. 1993, 11: 1269-1275.PubMedGoogle Scholar
- Casper ES, Christman KL, Schwartz GK, Johnson B, Brennan MF, Bertino JR: Edatrexate in patients with soft tissue sarcoma. Cancer. 1993, 72: 766-770. 10.1002/1097-0142(19930801)72:3<766::AID-CNCR2820720321>3.0.CO;2-Z.View ArticlePubMedGoogle Scholar
- Wilson RE, Wood WC, Lerner HL, Antman K, Amato D, Corson JM, et al: Doxorubicin chemotherapy in the treatment of soft-tissue sarcoma – combined results of two randomized trials. Arch Surg. 1986, 121: 1354-1359. 10.1001/archsurg.121.11.1354.View ArticlePubMedGoogle Scholar
- Rajan DK, Soulen MC, Clark TW, Baum RA, Haskal ZJ, Shlansky-Goldberg RD, et al: Sarcomas metastatic to the Liver: Response and Survival after Cisplatin, Doxorubicin, Mitomycin-C, Ethiodol, and Polyvinyl Alcohol Chemoembolization Journal of Vascular and Interventional Radiology. 2001, 12: 187-193.Google Scholar
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