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Pleural based mass in 50 years old female.

Stephen Berns, MD

Pathology Department
Orlando Regional Healthcare

Estados Unidos
Comentado en:
 Historia Clínica
50 year old woman with an incidental pleural based mass discovered by chest x-ray.
Imagen de Pleural based mass in 50 years old female.
Imagen de Pleural based mass in 50 years old female.
Imagen de Pleural based mass in 50 years old female.
Imagen de Pleural based mass in 50 years old female.


El 22/11/2004 2:24, Daniel Scharifker dijo:

Aunque no es facil discernir el grado de atipias o la presencia de mitosis, me inclino por un Fibroma pleural submesotelial


El 22/11/2004 2:38, Gustavo Sales Barbosa dijo:



El 22/11/2004 2:51, Iván Gallegos Méndez. Universidad de Chile. dijo:

Me parece un tumor fibroso solitario de la pleura. Realizaría cd-34.


El 22/11/2004 2:52, Dr. Reynaldo Falcón-Escobedo dijo:

Solitary fibrous tumor of the pleura.

CD34 and Bcl-2 must be positive and cytokeratin negative.


El 22/11/2004 4:13, Shashidhar dijo:

Benign appearance both clinical and microscopic supports,

Localized fibrous tumor of pleura/Pleural fibroma.


El 22/11/2004 5:33, Sandro Casavilca dijo:

Proliferación mesenquimal fusocelular compatible con tumor fibroso solitario. Coincido en solicitar bcl2, cd 34 y actina musculo específica.


El 22/11/2004 12:59, Clelia Miracco dijo:

I think it could be a Solitary fibrous tumor of the pleura.

I'm not completely sure about the histological benign appearance of the lesion.

Is there a necrotic area depicted in Fig. 3 and mitotic figures in Fig. 4?

Besides markers such as CD34 and Bcl-2 it perhaps could be helpful to search for other features, such as p53 expression and assess the proliferative rate.

Clelia Miracco

Department of Human Pathology and Oncology




El 22/11/2004 13:20, Nora Maison dijo:

Solitary fibrous tumor of pleura


El 22/11/2004 14:23, Romualdo Correia Lins Filho dijo:

Estimados Dr. Stephen Berns e demais colegas do foro

Embora eu considere o diagnóstico de tumor fibroso solitário uma boa hipótese, acho que, em algumas imagens, a celularidade que se observa é grande demais. Alguns focos são praticamente sólidos. Na figura 2 observei o que parece ser material mucinoso no interior de alguns agregados celulares.

Minha primeira hipótese diagnóstica é de um SARCOMA SINOVIAL PLEURAL. Acrescentaria EMA e queratina ao painel imunoistoquímico que, certamente, deverá incluir o CD34.

Abraços a todos


Caruaru - Brasil


El 22/11/2004 15:11, vincenzo polizzi dijo:

Solitary fibrous tumor of pleura.

Cari saluti a tutti

Vincenzo Polizzi


El 22/11/2004 15:14, Leon Fábio Campos dos Santos dijo:

Acrescentaria ao diagnóstico diferencial Fasciite nodular.



El 22/11/2004 18:55, Patricia Fonseca Pereira dijo:

Tumor fibroso solitário.

Hospital Geral de Bonsucesso

Rio de Janeiro Brasil


El 22/11/2004 18:59, MYRIAM dijo:



El 22/11/2004 21:17, Túlio Souza dijo:

Vejo uma neoplasia de células fusiformes, raras delas com discreta anaplasia. A avaliação de mitoses é difícil nestas imagens, mas acho que há algumas.

A minha principal hipótese diagnóstica como muitos colegas já falaram é um tumor fibroso solitário pleural, porém não dá para afastar outras neoplasias de células fusiformes.


El 23/11/2004 1:57, Hernan Molina Kirsch dijo:

Tumor fibroso solitario


El 24/11/2004 6:31, Giorgio Gherardi dijo:

Ciao a tutti da Milano

I am not sure that this is a solitary fibrous tumor of the pleura because of the high cellularity in some microscopic fields, the lack of at least focal hemangiopericytoma-like pattern, the presence of necrosis, the presence of abundant newly formed small vessels. In addition, the clinical history of the patient is important (previous excision of a soft tissue tumor?) as well the radiologic features of the lesion (size of the lesion? is it an infiltrative growth? is there any involvement of the lung?). The hypothesis of pleuropulmonary synovial sarcoma is interesting but this latter is supposed to be a mitotically active tumor. In conclusion, I wish to add another hypothesis: spindle-cell hemangioendothelioma.


El 26/11/2004 2:12, Dr Gonzalo De Toro Residente Anatomia Patologica Universidad de la F dijo:


England et al5 reviewed 223 cases of localized fibrous tumor of the pleura and developed histologic criteria to separate malignantlesions from their benign counter-parts.Criteria for malignancy include high cellularity, high mitotic rate (more than 4 mitoses per 10high-power fields), pleomorphism,hemorrhage, and necrosis. Our case exhibited malignant histologic features including areas of high cellularity, mitoses,cellular pleomorphism,and focal necrosis.

Histologic differential diagnoses of pleural-based malignant spindle cell tumors include malignant localized fibrous tumor, spindle cell carcinoma,Sarcomatoid malignant mesothelioma, and various sarcomas. Immunohisto-chemical studies are usually helpful in separating these entities.

Localized fibrous tumors of thepleura are negative for keratin and are frequently reactive for CD34.Both spindle cell carcinomas and sarcomatoid malignant mesotheliomas are positive for keratin.Additionally, malignant mesothe-liomas may also be positive for mesothelial marker calretinin.Sarcomas are typically negative for both keratin and CD34, although positive staining for either markermay occur in rare cases.

England DM,Hochholzer L,McCarthy MJ. Localized benign and malig-nant fibrous tumors of the pleura: a clinico-pathologic review of 223 cases. Am J SurgPathol. 1989;13:640-658.

Urschel JD,Brooks JS,Werness BA,etal. Metachronous benign solitary fibroustumours of the pleura (localized “mesothe-liomas”): a case report. Can J Surg. 1998;41:467-469.

Yousem SA, Flynn SD. Intrapulmonary localized fibrous tumor: intra-parenchymal so-called localized fibrousmesothelioma. Am J Clin Pathol. 1988;89:365-369.

Carter D, Otis CN. Three types ofspindle cell tumors of the pleura: fibroma,sarcoma, and sarcomatoid mesothelioma.Am J Surg Pathol. 1988;12:747-753.

Crotty TB, Myers JL, Katzenstein AL,et al. Localized malignant mesothelioma: aclinicopathologic and flow cytometricstudy. Am J Surg Pathol. 1994;18:357-363.

Ali SZ,Hoon V,Hoda S,et al. Solitaryfibrous tumor: a cytologic-histologic studywith clinical, radiologic, and immunohisto-chemical correlations. Cancer. 1997;81:116-121.

Attanoos RL,Dojcinov SD,Webb R,etal. Anti-mesothelial markers in sarcomatoidmesothelioma and other spindle cell neo-plasms. Histopathology. 2000;37:224-231.

Fisher C. Synovial sarcoma. AnnDiagn Pathol. 1998;2:401-421.

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 Comentario del Autor
This tumor has highly cellular areas of atypical cells with a high mitotic rate (21 per 10 hpf) and sheets of necrotic cells. These malignant areas merge with a more benign area of lower cellularity arranged in a patternless pattern with intermixed collagen fibers and a hemangiopericytoma-like staghorn vasculature. Included in the H+E histologic differential diagnosis is malignant fibrous histiocytoma, malignant peripheral nerve sheath tumor, sarcomatoid mesothelioma, monophasic synovial sarcoma, fibrosarcoma, leiomyosarcoma, and spindle cell carcinoma 1.

The tumor is positive for vimentin, CD34, and BCL-2. It is negative for synaptophysin, chromogranin A, calretinin, s100, cd45, cd99, cam 5.2, ae 1/3, desmin, and smooth muscle actin. These findings support a diagnosis of a tumor of solitary fibrous tumor origin, which are reported to be vimentin positive, CD34 positive, cytokeratin rarely focally positive, and negative for CD31, desmin, s100 negative, and neuroendocrine marker negative 2.

Histologic criteria for mailignancy of a solitary fibrous tumor by England et al. 3 are increased mitotic activity (>4 mitosis per 10 hpf), high cellularity, pleomorphism, hemorrhage and necrosis. This tumor has these features.

A case of malignant solitary fibrous tumor was reported to have a recurrent supernumerary chromosome 8 clone (48 xy; +8; +8; del(9)). 4. Another case with liposarcomatous differentiation was reported 1.

Resectability has been reported as the single most important predictor of clinical outcome 3. Some authors have suggested that even benign tumors can recur and that all patients should be followed on a long term
clinical basis 5.

I have included a list of references that are the most accessible to me. However, many pathology lumenaries, including Dr. Juan Rosai, have published on this subject and the literature is fairly extensive.
1 Bai H, Aswad BI, Gaissert H, Gnepp DR
Malignant solitary fibrous tumor of the pleura with liposarcomatous differentiation.
Arch Pathol Lab Med. 2001 Mar;125(3):406-9.

2 Hanau CA, Miettinen M
Solitary fibrous tumor: histological and immunohistochemical spectrum of benign and malignant variants presenting at different sites.
Hum Pathol. 1995 Apr;26(4):440-9.

3 England DM, Hochholzer L, McCarthy MJ
Localized benign and malignant fibrous tumors of the pleura. A clinicopathologic review of 223 cases.
Am J Surg Pathol. 1989 Aug;13(8):640-58.

4 de Leval L, Defraigne JO, Hermans G, Dome F, Boniver J, Herens C
Malignant solitary fibrous tumor of the pleura: report of a case with cytogenetic analysis.
Virchows Arch. 2003 Apr;442(4):388-92.

5 Kanthan R, Torkian B
Related Articles, Links Recurrent solitary fibrous tumor of the pleura with malignant transformation.
Arch Pathol Lab Med. 2004 Apr;128(4):460-2.
NOTA: Esto es un foro médico profesional, que no tiene como objetivo ofrecer consejo médico o de salud. Los mensajes enviados a este foro solicitando estos consejos, no serán atendidos. La información científica ofrecida está refrendada por las referencias y bibliografía correspondientes y de su veracidad son responsables sus autores. La participación en este Foro es gratuita.

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