Correspondence
4 Dummer R, Heald PW, Nestle FO et al. Sezary syndrome T-cell clones display T-helper 2 cytokines and express the accessory factor-1 (interferon-gamma receptor betachain). Blood 1996; 88: 1383–9. 5 Sugaya M, Miyagaki T, Ohmatsu H et al. Association of the numbers of CD163(+) cells in lesional skin and serum levels of soluble CD163 with disease progression of cutaneous T cell lymphoma. J Dermatol Sci 2012; 68: 45–51.
Ultrasound B-mode and elastographic findings of angiomatoid fibrous histiocytoma doi: 10.1111/ced.12314 Angiomatoid fibrous histiocytoma (AFH) is a rare softtissue tumour of low- to intermediate-grade malignancy.1 The first case of this tumour was described in 1979, and the tumour was called ‘angiomatoid malignant fibrous
(a)
(d)
(b)
(e)
(c)
(f)
Figure 1 (a) a subcutaneous nodule, 10 mm in diameter, on the scalp. (b) Ultrasonography (B-mode) showed a cystic hypoechoic area
on the scalp (arrows), while colour Doppler ultrasonography revealed hypervascularity at the periphery of the cystic area (inset). (c) Ultrasound elastography showed a butterfly-shaped area with high elasticity, appearing as red at the centre of the cystic lesion (arrowheads). (d) Haemorrhagic and cystic spaces were visible in the lesion; (e) the periphery of the lesion was partly hyalinized, forming a pseudocapsule, and the haemorrhagic cystic spaces were lined with flattened tumour cells; (f) the tumour cells with nuclear atypia were composed of spindle-shape to ovoid-shaped cells arranged in sheets, whorls and short fascicle patterns Haematoxylin and eosin; original magnification (a) 920; (b) 9100; (c) 9400.
538
Clinical and Experimental Dermatology (2014) 39, pp533–541
ª 2014 British Association of Dermatologists
Correspondence
histiocytoma’.2 Later, the nomenclature was corrected to ‘angiomatoid fibrous histiocytoma’ because of the slow growth and the low metastasis rate.3 Ultrasonography has been utilized as a noninvasive diagnostic tool for skin tumours. We report a case of AFH and describe the ultrasound B-mode, colour Doppler and elastographic findings of AFH, which clearly correlate with the histological characteristics of the tumour. A 77-year-old woman presented with a 4-month history of a tumour on her left temporal region. On physical examination, a slightly brownish subcutaneous tumour, 10 mm in diameter, was seen (Fig. 1a). The patient underwent ultrasonography scanning (HI VISION 900; (Hitachi Medical Corporation, Tokyo, Japan). A conventional linear probe with a 5 MHz to 13 MHz transducer was used for all scans, including B-mode, colour Doppler test and elastography. B-mode revealed an irregular-shaped, cystic low-echoic area (Fig. 1b, arrows), and colour Doppler scans showed some vascular involvement at the periphery of the tumour (Fig. 1b, inset). Ultrasound elastography revealed a demarcated lesion with high elasticity at the centre of the cystic low-echoic area (Fig. 1c, arrowheads). Histopathology specimens revealed a subcutaneous tumour with haemorrhagic and cystic spaces (Fig. 1d). The demarcated elastic lesion seen by elastography corresponded histologically to the haemorrhagic and cystic spaces (pseudovascular structure of the tumour). Inflammatory infiltrates, mostly lymphocytes, were observed at the periphery of the tumour, where partly hyalinized tissue formed a pseudocapsule (Fig. 1e). The tumour cells were spindle-shaped to ovoid-shaped, and were arranged in various growth patterns, including sheets, whorls and short fascicles (Fig. 1f). Foci of nuclear pleomorphism and atypia were identified, and mitotic activity was seen in 12 cells per 10 high-power fields. Immunohistochemical results showed the tumour cells to be positive for desmin and CD68, and negative for S100, CD34 and CD31. From these findings, a diagnosis of AFH was made. The tumour was completely removed. No recurrence or metastasis was seen at follow-up 3 years after surgery. Although histological characteristics including (i) solid arrays or nests of histiocyte-like cells, (ii) haemorrhagic cyst-like spaces and (iii) aggregates of chronic inflammatory cells are germane in making the final diagnosis of AFH,3 non-invasive methods of investigating for tumours are essential because the misdiagnosis of AFH as other more malignant tumours can lead to unnecessarily aggressive treatment. The elastography and B-mode ultrasonography used in this study revealed the pseudovascular structure, the hallmark of AFH, in this case, whereas the colour Doppler test failed to detect that structure. This is consistent with the fact that pseudovascular areas are not functionally vessels but are simply spaces filled with haemorrhages. In addition, previous authors reported
ª 2014 British Association of Dermatologists
that elastography can delineate the nature of cystic areas within neck masses (e.g. second-arch branchial cleft cysts)4 and breast lesions.5 In conclusion, we report a case of AFH in which imaging methods were essential for diagnosis. Noninvasive examination helps make a precise clinical diagnosis and allows correct treatment. H. Hata, K. Natsuga, S. Aoyagi, E. Homma, and H. Shimizu Department of Dermatology, Hokkaido University Graduate School of Medicine, North 15 West 7, Sapporo 060-8638, Japan E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 14 December 2013
References 1 Weiss SW, Goldblum JR. Enzinger and Weiss’s Soft Tissue Tumors, 5th edn. Philadelphia, MO: Mosby, 2008; 390–4. 2 Enzinger FM. Angiomatoid malignant fibrous histiocytoma: a distinct fibrohistiocytic tumor of children and young adults simulating a vascular neoplasm. Cancer 1979; 44: 2147–57. 3 Fanburg-Smith JC, Miettinen M. Angiomatoid, “malignant” fibrous histiocytoma: a clinicopathologic study of 158 cases and further exploration of the myoid phenotype. Hum Pathol 1999; 30: 1336–43. 4 Bhatia KS, Rasalkar DD, Lee YP et al. Real-time qualitative ultrasound elastography of miscellaneous non-nodal neck masses: applications and limitations. UltrasounMed Biol 2010; 36: 1644–52. 5 Ginat DT, Destounis SV, Barr RG et al. US elastography of breast and prostate lesions. Radiographics 2009; 29: 2007–16.
Solitary fibrous tumour of the scalp doi: 10.1111/ced.12309 Solitary fibrous tumour (SFT) is an uncommon mesenchymal tumour that typically arises in the pleural cavity. Extrapleural sites such as the skin have been increasingly reported. However, SFT occurring in the scalp is rare, and to our knowledge, only five cases have been reported previously.1–5 We describe an additional case of SFT of the scalp. A 64-year-old Japanese man presented with a domeshaped, skin-coloured, slightly soft and elastic subcutaneous nodule, measuring about 50 mm in diameter, on his posterior scalp. The nodule was not painful or tender, and it had enlarged during the course of 1 week. T2-weighted magnetic resonance imaging disclosed a well-defined, solid subcutaneous mass measuring 45 9 22 mm in diameter, which showed irregularly mixed hyposignal and hypersignal intensities (Fig. 1a). There was no history of trauma to the
Clinical and Experimental Dermatology (2014) 39, pp533–541
539
4 Dummer R, Heald PW, Nestle FO et al. Sezary syndrome T-cell clones display T-helper 2 cytokines and express the accessory factor-1 (interferon-gamma receptor betachain). Blood 1996; 88: 1383–9. 5 Sugaya M, Miyagaki T, Ohmatsu H et al. Association of the numbers of CD163(+) cells in lesional skin and serum levels of soluble CD163 with disease progression of cutaneous T cell lymphoma. J Dermatol Sci 2012; 68: 45–51.
Ultrasound B-mode and elastographic findings of angiomatoid fibrous histiocytoma doi: 10.1111/ced.12314 Angiomatoid fibrous histiocytoma (AFH) is a rare softtissue tumour of low- to intermediate-grade malignancy.1 The first case of this tumour was described in 1979, and the tumour was called ‘angiomatoid malignant fibrous
(a)
(d)
(b)
(e)
(c)
(f)
Figure 1 (a) a subcutaneous nodule, 10 mm in diameter, on the scalp. (b) Ultrasonography (B-mode) showed a cystic hypoechoic area
on the scalp (arrows), while colour Doppler ultrasonography revealed hypervascularity at the periphery of the cystic area (inset). (c) Ultrasound elastography showed a butterfly-shaped area with high elasticity, appearing as red at the centre of the cystic lesion (arrowheads). (d) Haemorrhagic and cystic spaces were visible in the lesion; (e) the periphery of the lesion was partly hyalinized, forming a pseudocapsule, and the haemorrhagic cystic spaces were lined with flattened tumour cells; (f) the tumour cells with nuclear atypia were composed of spindle-shape to ovoid-shaped cells arranged in sheets, whorls and short fascicle patterns Haematoxylin and eosin; original magnification (a) 920; (b) 9100; (c) 9400.
538
Clinical and Experimental Dermatology (2014) 39, pp533–541
ª 2014 British Association of Dermatologists
Correspondence
histiocytoma’.2 Later, the nomenclature was corrected to ‘angiomatoid fibrous histiocytoma’ because of the slow growth and the low metastasis rate.3 Ultrasonography has been utilized as a noninvasive diagnostic tool for skin tumours. We report a case of AFH and describe the ultrasound B-mode, colour Doppler and elastographic findings of AFH, which clearly correlate with the histological characteristics of the tumour. A 77-year-old woman presented with a 4-month history of a tumour on her left temporal region. On physical examination, a slightly brownish subcutaneous tumour, 10 mm in diameter, was seen (Fig. 1a). The patient underwent ultrasonography scanning (HI VISION 900; (Hitachi Medical Corporation, Tokyo, Japan). A conventional linear probe with a 5 MHz to 13 MHz transducer was used for all scans, including B-mode, colour Doppler test and elastography. B-mode revealed an irregular-shaped, cystic low-echoic area (Fig. 1b, arrows), and colour Doppler scans showed some vascular involvement at the periphery of the tumour (Fig. 1b, inset). Ultrasound elastography revealed a demarcated lesion with high elasticity at the centre of the cystic low-echoic area (Fig. 1c, arrowheads). Histopathology specimens revealed a subcutaneous tumour with haemorrhagic and cystic spaces (Fig. 1d). The demarcated elastic lesion seen by elastography corresponded histologically to the haemorrhagic and cystic spaces (pseudovascular structure of the tumour). Inflammatory infiltrates, mostly lymphocytes, were observed at the periphery of the tumour, where partly hyalinized tissue formed a pseudocapsule (Fig. 1e). The tumour cells were spindle-shaped to ovoid-shaped, and were arranged in various growth patterns, including sheets, whorls and short fascicles (Fig. 1f). Foci of nuclear pleomorphism and atypia were identified, and mitotic activity was seen in 12 cells per 10 high-power fields. Immunohistochemical results showed the tumour cells to be positive for desmin and CD68, and negative for S100, CD34 and CD31. From these findings, a diagnosis of AFH was made. The tumour was completely removed. No recurrence or metastasis was seen at follow-up 3 years after surgery. Although histological characteristics including (i) solid arrays or nests of histiocyte-like cells, (ii) haemorrhagic cyst-like spaces and (iii) aggregates of chronic inflammatory cells are germane in making the final diagnosis of AFH,3 non-invasive methods of investigating for tumours are essential because the misdiagnosis of AFH as other more malignant tumours can lead to unnecessarily aggressive treatment. The elastography and B-mode ultrasonography used in this study revealed the pseudovascular structure, the hallmark of AFH, in this case, whereas the colour Doppler test failed to detect that structure. This is consistent with the fact that pseudovascular areas are not functionally vessels but are simply spaces filled with haemorrhages. In addition, previous authors reported
ª 2014 British Association of Dermatologists
that elastography can delineate the nature of cystic areas within neck masses (e.g. second-arch branchial cleft cysts)4 and breast lesions.5 In conclusion, we report a case of AFH in which imaging methods were essential for diagnosis. Noninvasive examination helps make a precise clinical diagnosis and allows correct treatment. H. Hata, K. Natsuga, S. Aoyagi, E. Homma, and H. Shimizu Department of Dermatology, Hokkaido University Graduate School of Medicine, North 15 West 7, Sapporo 060-8638, Japan E-mail: [email protected] Conflict of interest: the authors declare that they have no conflicts of interest. Accepted for publication 14 December 2013
References 1 Weiss SW, Goldblum JR. Enzinger and Weiss’s Soft Tissue Tumors, 5th edn. Philadelphia, MO: Mosby, 2008; 390–4. 2 Enzinger FM. Angiomatoid malignant fibrous histiocytoma: a distinct fibrohistiocytic tumor of children and young adults simulating a vascular neoplasm. Cancer 1979; 44: 2147–57. 3 Fanburg-Smith JC, Miettinen M. Angiomatoid, “malignant” fibrous histiocytoma: a clinicopathologic study of 158 cases and further exploration of the myoid phenotype. Hum Pathol 1999; 30: 1336–43. 4 Bhatia KS, Rasalkar DD, Lee YP et al. Real-time qualitative ultrasound elastography of miscellaneous non-nodal neck masses: applications and limitations. UltrasounMed Biol 2010; 36: 1644–52. 5 Ginat DT, Destounis SV, Barr RG et al. US elastography of breast and prostate lesions. Radiographics 2009; 29: 2007–16.
Solitary fibrous tumour of the scalp doi: 10.1111/ced.12309 Solitary fibrous tumour (SFT) is an uncommon mesenchymal tumour that typically arises in the pleural cavity. Extrapleural sites such as the skin have been increasingly reported. However, SFT occurring in the scalp is rare, and to our knowledge, only five cases have been reported previously.1–5 We describe an additional case of SFT of the scalp. A 64-year-old Japanese man presented with a domeshaped, skin-coloured, slightly soft and elastic subcutaneous nodule, measuring about 50 mm in diameter, on his posterior scalp. The nodule was not painful or tender, and it had enlarged during the course of 1 week. T2-weighted magnetic resonance imaging disclosed a well-defined, solid subcutaneous mass measuring 45 9 22 mm in diameter, which showed irregularly mixed hyposignal and hypersignal intensities (Fig. 1a). There was no history of trauma to the
Clinical and Experimental Dermatology (2014) 39, pp533–541
539
