A 69-year-old man with a history of myocardial infarction, hypertension, and noninsulin-dependant diatbetes
mellitus was admitted to the hospital for a right lower quadrant mass found on physical examination. A CT
scan demonstrated an 8 x 11 cm multiloculated mixed density mass in the region of the cecum.
Prepared by Feng Tao, MD, Evan Dillon, MD, David Follet,
MD, of the Department of Radiology, and Frank Bieuei, MD, of
the Department of Pathology, Lenox Hill Hospital, New York,
A 69-year-old man with a history of myocardial infarction,
hypertension, and noninsulin-dependent diabetes mellitus was
admitted to the hospital for a right lower quadrant mass found on
physical examination. A CT scan (figure 1) demonstrated an 8 * 11
cm multiloculated mixed density mass in the region of the cecum.
This mass has irregular thick wall and internal septations. There
is no evidence of metastases in other organ systems. A subsequent
laproscopic exploration and resection of the mass and cecum with
iliocolic anastomosis was performed. Postoperatively, a right lower
quadrant abscess developed and was drained. Following radiation
therapy, patient has been disease-free for 6 months.
Malignant fibrous histiocytoma (MFH)
Gross pathology examination (figure 2) revealed a
well-circumscribed 8.7 * 7.3 * 6.5 cm tumor beneath or in the wall
of the cecum with no mucosal extension. Sectioning of the specimen
showed abundant hemorrhage, necrosis, and numerous degenerative
cystic foci, which constitute the bulk of the tumor, solid tissue
being a comparatively small component. Microscopically (figures 3
to 5), the tumor is lying predominantly beneath the colonic wall in
the subserosal/peritoneal fat. It invades the outer longitudinal
layer of the muscularis, but not the inner circular layer,
submucosa, and mucosa. The tumor is composed, in part, of spindle
cells, which are present in long fascicles, and more rounded
histolytic-like cells. A very prominent and distinctive feature is
the presence of numerous osteoclast-like giant cells. They vary
considerably from area to area. There is moderately brisk mitotic
activity, and many atypical mitoses are seen. Some fibrous bands
and several foci of more diffuse fibrosis are also present.
Infiltration into the surrounding serosal adipose tissue at the
tumor margins is seen. These findings are consistent with a
diagnosis of MFH, giant cell type (or malignant giant cell tumor of
Malignant mesenchymal tumors of the large intestine seldom occur
and the great majority of them are leiomyosarcomas
while other types of colonic sarcomas are exceedingly rare.
In the present case, the CT imaging demonstrates nonspecific
features of a large pericecal mass without evidence of local
invasion or remote metastases. The differential diagnosis includes
colonic adenocarcinoma, unknown origin metastatic focus,
leio-myosarcoma, lymphoma, inflammatory fibro-sarcoma of mesentery
sarcomatoid carcinoma, or malignant peripheral nerve sheath
A recent review reported 13 cases of colonic MFH (pleomorphic or
The mean patient age was 57 years (range 17 to 74 years), with nine
patients older than age 50. This age distribution is similar to
that of patients with soft tissue MFH, where the majority of
patients are 50 to 70 years old. The ratio of male to female is
10:3, which is consistent with the occurrence of soft tissue MFH.
Japanese men are most commonly affected. Most of the tumors are
large, with a mean diameter of 8.2 cm (median diameter 8 cm). The
gross features were categorized into two types: 1) polypoid or
pedunculated; and 2) others, such as nodular masses. Direct
involvement of the mesentery at initial operation, rather than
peritoneal involvement may be a good prognostic factor for large
It has been proposed that regional lymph node metastases of soft
tissue MFH formerly believed to be common, are quite uncommon
with an incidence of lymph node metastases being 4%,
However, the reported lymph node metastases of large intestinal MFH
is as high as 30%.
The only other metastatic site of large intestinal MFH is the
The overall mortality rate for these colorectal tumors appears
roughly parallel with that of their soft tissue counterparts.
In summary, we describe the first case of colonic MFH, giant
cell type. MFH of the large intestine is similar to soft tissue MFH
in its incidence and prognosis. However, it is possible that a high
incidence in Japanese patients and higher incidence of lymph node
metastases characterize MFH of the large bowel when compared with
soft tissue MFH.
Currently, no diagnostic imaging features of large intestine MFH
have been characterized. Future efforts should be made in finding
out the possible specific presentations of this entity on different
imaging modalities for the purpose of early diagnosis and
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