Steven D.

Billings 1

Cutaneous Soft Tissue Tumors: Morphology to Molecular

Introduction
Cutaneous soft tissue tumors remain a very challenging area in dermatopathology.
There is significant overlap in both histologic features and immunophenotype.
Furthermore, the clinical presentation is often relatively nondescript and frequently
devoid of clinical clues that so often aid in the diagnosis of inflammatory diseases and
other neoplasms.
There are a number of soft tissue tumors that do have signature, recurring
cytogenetic findings that are increasingly being used in the diagnosis of these tumors.
Chromosomal translocations account for the single most common type of cytogenetic
abnormality in sarcomas. Approximately one third of sarcomas belong to a group of soft
tissue tumors that harbor specific chromosomal translocations, and detection of these
translocations has become an important part of the diagnostic evaluation. There are two
methods that are routinely used diagnostically to confirm the presence of specific
translocations: fluorescence in situ hybridization (FISH) and RT-PCR.
For FISH, the most common diagnostic approach is the dual color break-apart
probe. In this situation the probes are targeted to one of the loci involved in the
translocation. The probes are targeted to sequences that flank the opposite side of the
breakpoint. In non-rearranged chromosomes, the fluorescent red and green probes
combine to yield a yellow signal. If the targeted area of the chromosome is disrupted the
fluorescent signals will be separated (broken apart) yielding a distinct red and green
signal.
RT-PCR relies on detecting mRNA and amplification of that product. It is
usually not feasible to use this method for genomic DNA because of the presence of large
introns between the sequences of interest. RT-PCR is theoretically more sensitive than
FISH, but RNA integrity may be a limiting factor in paraffin embedded tissue. That said,
RT-PCR can sometimes detect cryptic translocation that are not identified with FISH.
This talk will focus soft tissue tumors that may present in the skin that have
defining cytogenetic abnormalities.

Angiomatoid fibrous histiocytoma (AFH)

AFH is fibrohistiocytic tumor of intermediate malignancy. It typically presents in
children and young adults as cutaneous/subcutaneous nodules, usually on the extremities.
There may be systemic symptoms such as weight loss and night sweats. The tumor has a
high rate of local recurrence (~20-40%) but metastasis is rare (<5%).
Microscopically AFH has a fibrous pseudocapsule with lymphoid aggregates.
The tumor is composed of histiocytic cells with a sheet-like to swirling growth pattern.
Intratumoral hemorrhage and pseudovascular spaces are common. There can be
considerable histologic variation in AFH. Some cases have significant cytologic atypia
causing confusion with high grade sarcomas. I have also encountered cases with
numerous associated eosinophils. Immunohistochemistry can be helpful but is largely
supportive rather than definitively diagnostic. Roughly 50% of cases are positive for
desmin, EMA, CD68, and/or CD99. Immunoreactivity for desmin can cause diagnostic
confusion with rhabdomyosarcoma.
 Steven D. Billings 2

Cytogenetically AFH has one of three different recurring translocations:

t(12;16)(q13;p11) resulting in a FUS/ATF1 fusion gene, t(12;22)(q13;q12) resulting in a
EWSR1/ATF1 fusion, and t(2;22)(q33;q12) resulting in a EWSR1/CREB1 fusion. The last
appears to be the most common translocation variant. Given the sometimes confusing
morphologic pattern and inconsistent immunophenotype, FISH to detect evidence of a
translocation has become invaluable in the diagnosis of this tumor. FISH using
breakapart probes for either EWSR1 or FUS is positive in about 80% of cases. We
routinely perform FISH for EWS and reserve FISH for FUS in EWSR1 negative cases, as
about 75% of AFH have a translocation involving EWSR1. It should be pointed out that
in about 15-20% of AFH, FISH studies will be negative. This could be the result of a
cryptic translocation not detectable by FISH or the tumor may harbor an as yet
unidentified translocation.

Clear cell sarcoma (CCS)

CCS, formerly called melanoma of soft parts, is an unusual sarcoma with
melanocytic differentiation. It is most common in young adults but cases have been
described in young children and elderly patients as well. It usually presents in deeper soft
tissue of the distal extremities associated with aponeurosis or tendon, but it may present
in a variety of locations. CCS may also present as a primary cutaneous neoplasm, arising
primarily in the dermis.
Microscopically the tumor is composed of nests and fascicles of spindled to
epithelioid cells with clear to lightly eosinophilic cytoplasm. Multinucleated wreath-like
cells are often present but may be focal in nature. By immunohistochemistry the tumor
cells are positive for S100 protein and melanocytes specific markers such as HMB45 or
Melan-A.
The growth pattern can resemble melanoma and the immunophenotype is
identical. Therefore, patients can be mistakenly diagnosed with a metastatic melanoma
of unknown primary or intradermal melanoma in cutaneous cases.
CCS, however, has specific cytogenetic abnormalities: either a t(12;22) involving
EWS and ATF (~90% of cases) and t(2;22)(q33;q12) resulting in a EWSR1/CREB1 fusion.
The latter translocation is preferentially found in CCS involving the gastrointestinal tract.
The EWS-ATF chimeric protein activates MITF, a transcription factor that activates c-
Met, an oncogenic tyrosine kinase. There is experimental evidence inhibition of this
tyrosine kinase may inhibit CCS and in the future may potentially offer an effective and
rational chemotherapeutic option for this aggressive sarcoma.
It is interesting that the same identical translocations are found in AFH,
highlighting the fact that the translocation, while fundamental to the tumor biology, can
be found in tumors with significantly different morphologies and behavior. Unlike AFH,
CCS is an aggressive sarcoma with frequent recurrence and metastasis.

Ewing Sarcoma
Ewing sarcoma/primitive neuroectodermal tumor is a rare sarcoma that usually
presents in bone or deep soft tissue. Rarely, Ewing sarcoma may present in the skin as a
result of metastasis or as a primary cutaneous neoplasm. Primary cutaneous Ewing
sarcoma usually presents in young adult women but a wide age range may be affected
from children to elderly patients. The proximal lower extremity is the most common site
 Steven D. Billings 3

followed by the trunk, but any site may be affected. They typically present as small (<3
cm) often painful nodules. The lesions are frequently polypoid.
Microscopically, Ewing sarcoma is characterized by uniform round to oval tumor
cells with a stippled chromatin pattern and little clear to eosinophilic cytoplasm. PAS
stains will demonstrate glycogen deposits in the cytoplasm. By immunohistochemistry,
Ewing sarcoma is diffusely immunoreactive for CD99 and Fli-1. Rarely,
immunoreactivity for neuron specific enolase, synaptophysin, S100 protein, cytokeratin,
and desmin may be seen; when present, immunoreactivity for these markers is usually
focal. Greater than 90% of conventional Ewing sarcomas harbor a detectable t(11;22)
usually involving EWS and Fli1. The translocation has been detected in just over 50% of
primary cutaneous Ewing sarcomas tested. This discrepancy may reflect bias inherent in
small series, technical issues with archival tissue, or perhaps some primary cutaneous
Ewing sarcomas may harbor different cytogenetic abnormalities.
Primary cutaneous Ewing sarcoma is not as aggressive as its deep counterparts.
Likely this reflects the fact that the cutaneous tumors present as superficial, small lesions.
As a caveat, there is one documented death from metastatic disease from a primary
cutaneous Ewing sarcoma.

Low grade fibromyxoid sarcoma (LGFMS)

Low-grade fibromyxoid sarcoma (LGFMS) is an uncommon sarcoma. It was
originally described in 1987 by Harry Evans who described two cases of a deceptively
bland sarcoma with paradoxically aggressive behavior. This initial description was
followed a report of 12 additional cases that seem to confirm this unusually aggressively
behavior despite relatively low-grade histologic features. In this report, 7 out of 12
patients developed metastases and 4 died of their disease. Also described in the late
1990s was the hyalinizing spindle cell tumor with giant collagen rosettes. It was noted
that this tumor has similar clinical and histologic features to LGFMS and suggested that it
was possibly a variant of LGFMS. This relationship was confirmed with a identification
of a novel translocation t(7;16) involving effusion of the FUS/CREB3L2 genes shared by
both tumors, supporting that the concept that they were ends of a spectrum within the
same tumor.
LGFMS usually occurs in young to middle-aged adults. It predominantly presents
as a deep soft tissue mass most commonly in the lower extremity, but they may be seen in
almost any location. Although most commonly presenting as a deep soft tissue mass, up
to 20% of LGFMS present as superficial neoplasms of the subcutis or dermis. Superficial
LGFMS appears to present in pediatric patients in a disproportionate number. Normally,
pediatric cases account for roughly 10-20% of all cases of LGFMS. In a large series of
superficial LGFMS, almost 40% of the cases were seen in pediatric patients.
LGFMS has subtle somewhat protean histologic features. It is characterized by a
proliferation of hyperchromatic spindled to stellate tumor cells embedded in a variably
collagenous and myxoid stroma. The tumor usually shows transitions from fibrous to
myxoid zones that may be gradual or quite abrupt with distinct myxoid nodules. In the
majority of cases, the tumor cells are arranged in a subtle swirling growth pattern. Focal
areas with a fascicular growth pattern may be seen in fibrous zones. In the myxoid zones
a prominent curvilinear vasculature is often seen. The tumor cells usually demonstrate
subtle nuclear atypia. Mitotic figures are usually rare. Collagen rosettes, characterized by
 Steven D. Billings 4

variably sized mats of collagen surrounded by oval to somewhat round tumor cells, are
present in some cases and may occasionally be prominent. Areas of intermediate grade
sarcoma may be focally present in a minority of cases.
Immunohistochemical stains for superficial LGFMS are generally of little use in
the diagnosis of LGFMS. LGFMS is immunoreactive for vimentin and may occasionally
show focal immunoreactivity for EMA, CD34 and actin. LGFMS is typically negative
for S100 protein, desmin and cytokeratin. FISH utilizing breakaway probes for FUS are
a useful adjunct to the diagnosis of LGFMS, positive in 70-90% of cases.

Dermatofibrosarcoma protuberans (DFSP)

DFSP is the prototypical fibrohistiocytic tumor of intermediate malignancy.
Clinically it typically presents in young adults as nodules of the trunk. The clinical
presentation can be quite broad, however, with cases occurring in children to elderly
patients in almost any location in the skin.
Microscopically conventional DFSP is composed of a storiform proliferation of
uniform slender spindled cells with an infiltrative growth pattern. The tumor typically
infiltrates and surrounds adipocytes in the subcutis. In combination with the storiform
pattern and uniform nature of the tumor cells, diagnosis is rarely difficult. When faced
with small biopsies, an immunohistochemical stain for CD34 can be useful, as DFSP is
diffusely positive for this marker.
Variants of DFSP can be more challenging. Myxoid DFSP can be especially
difficult to diagnose. In myxoid DFSP, the characteristic storiform growth pattern is
absent or present in only a limited amount. The prominent myxoid stroma results in the
loss of the recognizable storiform pattern and the accentuation of the underlying
vasculature that is relatively inapparent in conventional DFSP. The vasculature can show
hyalinized vessels or delicate branching capillaries that can resemble the vasculature of
myxoid liposarcoma. The tumor cells frequently take on a more stellate morphology.
The edge of the tumor often has a blunter interface with surrounding tissue with a more
nodular growth pattern. Close inspection will usually reveal at least focal areas of fat
infiltration, but it may not be apparent in biopsy specimens. Myxoid DFSP retains
immunoreactivity for CD34 but it may be patchy and less intense than conventional
DFSP. Furthermore rare cases may focally express EMA causing confusion with
perineurioma.
Fibrosarcomatous DFSP demonstrates areas of herringbone fascicles of more
atypical spindled cells rather than the typical storiform growth pattern. Usually the
transition from conventional DFSP is abrupt. The fibrosarcomatous areas often lose or
have diminished CD34 expression. Recognition of this variant is important as it is
potentially more aggressive with a significantly increased risk of metastasis compared
with conventional DFSP.
Giant cell fibroblastoma (GCF) is a juvenile form of DFSP. It typically occurs in
pediatric patients. The tumor cells are more randomly arranged with spindled and stellate
cells and multinucleated cells that often line pseudovascular spaces. Areas of
conventional DFSP are sometimes present.
All of these variants may show areas of conventional DFSP underscoring the
relationship between the subtypes. Further cementing the relationship is the fact that they
all share a common cytogenetic abnormality. All have a conventional translocation or
 Steven D. Billings 5

supernumerary ring chromosome that contains a t(17;22). The translocation results in the
type 1A collagen promoter being connected to PDGF-β, resulting in autocrine growth
stimulation. PCR or FISH assays can detect this translocation in cases where
conventional histologic or immunohistochemistry modalities are not conclusive. This
translocation also has significant clinical implications. PDGF-β is a tyrosine kinase that
can be inhibited by imantinib mesylate (Gleevec). Although there have been no large
scale trials, patients with advanced/non-resectable disease have had objective responses
in roughly 50% of cases treated with this drug, with some patients having complete
responses. These results hold promise for the development of selected targeted
chemotherapeutic agents aimed at disrupting the effect of the oncogenic translocations in
a large number of sarcomas.

Selected References:
1. Ladanyi M, Antonescu CR, Dal Cin P. Cytogenetic and molecular genetic
pathology of soft tissue tumors, In: SW Weiss and JR Goldblum, eds. Enzinger
and Weiss’s Soft Tissue Tumors, Mosby Elesevier, 2008.

2. Billings SD, Folpe AL. Cutaneous and subcutaneous fibrohistiocytic tumors of

intermediate malignancy: an update. American Journal of
Dermatopathology.;26:141-155, 2004.

3. Tanas MR, Rubin BP, Montgomery EA, Turner SL, Cook JR, Tubbs RR, Billings
SD, Goldblum JR. Utility of FISH in the diagnosis of angiomatoid fibrous
histiocytoma: a series of 18 cases. Modern Pathology. 23:93-97, 2010.

4. Weinreb I, Rubin BP, Goldblum JR. Pleomorphic angiomatoid fibrous

histiocytoma: a case confirmed by fluorescence in situ hybridization analysis for
EWSR1 rearrangement. Journal of Cutaneous Pathology. 35: 855-860, 2008
5. Tanas MR, Goldblum JR. Fluorescence In Situ Hybridization in the Diagnosis of
Soft Tissue Neoplasms: A Review. Advances in Anatomic Pathology. 16:383–
391, 2009.
6. Hantschke M. Mentzel T. Rutten A. Palmedo G. Calonje E. Lazar AJ. Kutzner H.
Cutaneous clear cell sarcoma: a clinicopathologic, immunohistochemical, and
molecular analysis of 12 cases emphasizing its distinction from dermal
melanoma. American Journal of Surgical Pathology. 34:216-22, 2010.
7. Davis IJ. McFadden AW. Zhang Y. Coxon A. Burgess TL. Wagner AJ. Fisher
DE. Identification of the receptor tyrosine kinase c-Met and its ligand, hepatocyte
growth factor, as therapeutic targets in clear cell sarcoma. Cancer Research.
70:639-45, 2010.
8. Wang WL. Mayordomo E. Zhang W. Hernandez VS. Tuvin D. Garcia L. Lev DC.
Lazar AJ. Lopez-Terrada D. Detection and characterization of EWSR1/ATF1 and
EWSR1/CREB1 chimeric transcripts in clear cell sarcoma (melanoma of soft
parts). Modern Pathology. 22:1201-9, 2009.
 Steven D. Billings 6

9. Lee CS, Southey MC, Slater H, Auldist AW, Chow CW, Venter DJ. Primary
cutaneous Ewing's sarcoma/peripheral primitive neuroectodermal tumors in
childhood. A molecular, cytogenetic, and immunohistochemical study.
Diagn Mol Pathol. 4:174-81, 1995.

10. Hasegawa SL, Davison JM, Rutten A, Fletcher JA, Fletcher CD. Primary
cutaneous Ewing's sarcoma: immunophenotypic and molecular cytogenetic
evaluation of five cases. Am J Surg Pathol.;22:310-8, 1998.

11. Ehrig T, Billings SD, Fanburg-Smith JC. Superficial primitive neuroectodermal

tumor/Ewing sarcoma (PN/ES): same tumor as deep PN/ES or new entity? Ann
Diagn Pathol.;11:153-9, 2007.

12. Ozdemirli M, Fanburg-Smith JC, Hartmann DP, Azumi N, Miettinen M.

Differentiating lymphoblastic lymphoma and Ewing's sarcoma: lymphocyte
markers and gene rearrangement. Mod Pathol.;14:1175-82, 2001.

13. Evans HL. Low-grade fibromyxoid sarcoma. A report of 12 cases. American

Journal of Surgical Pathology. 17:595-600, 1993.

14. Lane et al. Hyalinizing spindle cell tumor with giant rosettes: a distinctive tumor
closely resembling low-grade fibromyxoid sarcoma. American Journal of Surgical
Pathology. 21:1481-8, 1997.

15. Storlazzi et al. Fusion of the FUS and BBF2H7 genes in low grade fibromyxoid
sarcoma. Human Molecular Genetics. 12:2349-58, 2003.

16. Reid et al. Low-grade fibromyxoid sarcoma and hyalinizing spindle cell tumor
with giant rosettes share a common t(7;16)(q34;p11) translocation. American
Journal of Surgical Pathology. 27:1229-36, 2003.

17. Panagopoulos et al. The chimeric FUS/CREB3l2 gene is specific for low-grade
fibromyxoid sarcoma. Genes, Chromosomes & Cancer. 40:218-28, 2004.

18. Billings, et al. Superficial low-grade fibromyxoid sarcoma (Evans tumor): a

clinicopathologic analysis of 19 cases with a unique observation in the pediatric
population. American Journal of Surgical Pathology. 29:204-10, 2005.

19. Patel RM, Downs-Kelly E, Dandekar MN, Fanburg-Smith J, Billings SD, Tubbs
RR, Goldblum JR. Frequency of FUS (16p11) Gene Rearrangement as Detected
by Fluorescence In-Situ Hybridization in Cutaneous Low-Grade Fibromyxoid
Sarcoma: A Potential Diagnostic Tool. American Journal of Dermatopathology.
In press.

20. Patel KU. Szabo SS. Hernandez VS. Prieto VG. Abruzzo LV. Lazar AJ. Lopez-
Terrada D. Dermatofibrosarcoma protuberans COL1A1-PDGFB fusion is
 Steven D. Billings 7

identified in virtually all dermatofibrosarcoma protuberans cases when

investigated by newly developed multiplex reverse transcription polymerase chain
reaction and fluorescence in situ hybridization assays. Human Pathology. 39:184-
93, 2008.

21. Reimann JD. Fletcher CD. Myxoid dermatofibrosarcoma protuberans: a rare

variant analyzed in a series of 23 cases. American Journal of Surgical Pathology.
31:1371-7, 2007.

22. Mentzel T. Scharer L. Kazakov DV. Michal M. Myxoid dermatofibrosarcoma

protuberans: clinicopathologic, immunohistochemical, and molecular analysis of
eight cases. American Journal of Dermatopathology. 29:443-8, 2007.

23. Sandberg AA. Bridge JA. Updates on the cytogenetics and molecular genetics of
bone and soft tissue tumors. Dermatofibrosarcoma protuberans and giant cell
fibroblastoma. Cancer Genetics & Cytogenetics. 140:1-12, 2003.

24. Rutkowski P. Van Glabbeke M. Rankin CJ. Ruka W. Rubin BP. Debiec-Rychter
M. Lazar A. Gelderblom H. Sciot R. Lopez-Terrada D. Hohenberger P. van
Oosterom AT. Schuetze SM. European Organisation for Research and Treatment
of Cancer Soft Tissue/Bone Sarcoma Group. Southwest Oncology Group.
Imatinib mesylate in advanced dermatofibrosarcoma protuberans: pooled analysis
of two phase II clinical trials. Journal of Clinical Oncology. 28:1772-9, 2010.