937770

case-report2020
IJSXXX10.1177/1066896920937770International Journal of Surgical PathologyPineda-Díaz et al

Case Report
International Journal of Surgical Pathology

Intraarticular Inflammatory
1­–7
© The Author(s) 2020
Article reuse guidelines:
Myofibroblastic Tumor of the Left Knee sagepub.com/journals-permissions
DOI: 10.1177/1066896920937770
https://doi.org/10.1177/1066896920937770

With ALK-CARS Fusion Detected With journals.sagepub.com/home/ijs

Archer Fusionplex Sarcoma NGS Panel:

Case Report and Literature Review

Janet Pineda-Díaz, MD1, Irit Solar, PhD, MHA2, Dov Hershkovitz, MD, PhD2,3,
Ido Drukman, MD2, and Osnat Sher, MD2

Abstract
Inflammatory myofibroblastic tumor (IMT) is a lesion of intermediate biological potential with local recurrences and
rare metastases found in multiple anatomical locations. We present a case of a pure intraarticular IMT of the knee, a
location that has not been previously documented, with genetic confirmation of ALK-CARS fusion detected with next-
generation sequencing. A 20-year-old healthy male was admitted to the orthopedic oncology department due to several
months of pain and restriction in movement of his left knee. On magnetic resonance imaging, multiple intraarticular
nodular lesions were seen. The patient underwent 2 synovectomies within the course of 1 year. The initial biopsy was
interpreted as nodular fasciitis. The second biopsy revealed exuberant tissue displaying compact fascicles of spindle
cells intermixed with myxoid areas in a background of inflammatory cells, highly suggestive for IMT. Due to the unusual
intraarticular location, equivocal ALK immunostaining and the differential diagnosis with nodular fasciitis, we performed
targeted next-generation sequencing using Archer FusionPlex Sarcoma panel, which can identify multiple fusions in a
single assay. An ALK-CARS fusion was found, supporting the diagnosis of IMT. This report emphasizes the added value
of broad molecular analysis in cases with unusual clinical presentation, equivocal immunohistochemistry, and a wide
differential diagnosis.

Keywords
ALK-CARS, inflammatory myofibroblastic tumor, next-generation sequencing, Archer FusionPlex

Introduction Clinical Summary

Inflammatory myofibroblastic tumor (IMT) is considered
a neoplasm of intermediate biological potential that often
recurs locally and rarely metastasizes. Histologically, it is
composed of myofibroblastic and fibroblastic spindle cells
with a mixed inflammatory infiltrate.1,2
Approximately 50% of IMTs are positive for ALK
(anaplastic lymphoma kinase) immunohistochemistry and
harbor ALK gene rearrangements with several different
fusion partners reported.3-6
Although this tumor may potentially appear in every
location and commonly involves soft tissue of the limbs,7
to the best of our knowledge, a pure primary intraarticular
location has not yet been reported in the literature. In this
article, we report a case of intraarticular IMT of the knee
with ALK-CARS fusion detected by next-generation
sequencing (NGS).
A 20-year-old healthy male was admitted to the orthopedic
oncology department due to several months of pain and
movement restriction in his left knee without a history of
trauma. On magnetic resonance imaging (MRI), multiple
intraarticular nodular lesions were seen with an intermedi-
ate signal on T2 showing heterogeneous enhancement
(Figure 1A). The findings were interpreted as compatible
1
Centro Médico ABC, Ciudad de México, Mexico
2
Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
3
Tel-Aviv University, Tel-Aviv, Israel
Corresponding Author:
Osnat Sher, Bone and Soft Tissue Pathology Service, Institute of
Pathology, Tel Aviv Sourasky Medical Center, Dafna 5, Tel Aviv
6492601, Israel.
Email: Osnats@tlvmc.gov.il
2 International Journal of Surgical Pathology 00(0)

Figure 1.  (A) Initial magnetic resonance imaging (MRI) showed a diffuse enhancing intra-articular mass in the anterior and
posterior aspects of the knee. (B) MRI 1.5 years later after surgery showing enlargement of residual/recurrent masses with diffuse
erosive changes in the tibia and femur that were not previously present.

with pigmented villonodular synovitis. The patient was
referred to arthroscopy and underwent a synovectomy.
Pathological Findings
The histopathological examination of the first biopsy
showed fragments of fibrous tissue composed of bland
spindle cells set in a loose fibromyxoid stroma. Focal
chronic inflammatory infiltrate was present. Mononuclear
cell proliferation, giant cells, or hemosiderin pigment were
not seen. Immunostains for caldesmon, β-catenin, desmin,
actin, S100, and ERG were negative. The diagnosis of a
benign lesion was made, suggestive for intraarticular nod-
ular fasciitis (Figure 2A).
The patient was therefore referred to physical therapy
and follow-up. Due to persistent pain, swollen knee, and
restriction in movement after several months, an MRI was
repeated, showing recurrent diffuse intraarticular nodules,
especially in the suprapatellar recess, causing multifocal
bone erosions (Figure 1B). He underwent a second sur-
gery, in which abundant tissue was excised.
The second biopsy yielded more tissue for histological
evaluation and contained features that were not present in
the original biopsy. It showed plump myofibroblasts
admixed with few plasma cells and lymphocytes set in a
collagenous stroma with fascicular arrangement.
Occasional ganglion-like cells and giant cells were also
seen. Areas of myxoid stroma were focally present. No
significant atypia, atypical mitotic figures, or necrosis
were identified. The more collagenous fascicular areas that
were not present in the original biopsy raised the differen-
tial diagnosis of IMT (Figure 2A-F).
Immunohistochemistry showed that tumor cells were
focally positive for CD68 and SMA, and negative for
panCK, CD23, CD21, EMA, SOX10, MUC4, ERG,
CD34, desmin, caldesmon, and S100. Ki67 was positive
in about 5% of the cells. Immunostain for ALK was weak
and therefore equivocal (Figure 2F). Due to the unusual
location, equivocal ALK immunostain, and differential
diagnosis with nodular fasciitis, molecular confirmation
of ALK rearrangement was necessary. Molecular studies
were carried out using the FusionPlex Sarcoma NGS
Panel (Archer Dx), a targeted NGS-based assay, that
simultaneously detects and identifies fusions of 26 genes
associated with soft tissue tumors from formalin-fixed
paraffin-embedded tissues. The assay is based on a modi-
fied amplicon approach, referred to as anchored multi-
plex polymerase chain reaction (PCR). An ALK-CARS
fusion (chr11:3033425, chr2:29446394) was identified
(Figure 3). This fusion was previously reported in the lit-
erature8,9 supporting the diagnosis of IMT.
Follow-up
A positron emission tomography-computed tomogra-
phy performed 1 month after surgery showed an
Pineda-Díaz et al 3

Figure 2.  (A) The first biopsy was composed almost entirely of bland spindle cells in a loose fibromyxoid stroma (hematoxylin
and eosin [H&E], 40×). (B) The second biopsy showed fascicles of spindle cells and a chronic inflammatory infiltrate (H&E, 40×).
(C) Area of plump myofibroblasts with mild atypia and ganglion-like cells in collagenous stroma (H&E, 40×). (D) Same area in
higher magnification (H&E, 100×). (E) Ganglion-like cells in myxoid stroma (H&E, 100×). (F) Immunostain for ALK was weak
and equivocal.

increased uptake in a diffuse heterogeneous synovial
lesion involving all compartments of the knee. No
metastatic disease was seen. After a multidisciplinary
discussion, the patient was offered treatment with
crizotinib prior to surgical treatment. The patient
declined this treatment and underwent 2 subsequent
extensive debulking procedures in another institution.
Due to some radiological and clinical improvement in
the ensuing months, a drastic procedure such as an
extra-articular resection was postponed, and as of now,
the patient remains on follow-up and is scheduled for
a repeat MRI in the future.
4 International Journal of Surgical Pathology 00(0)
Figure 3.  (A) CARS-ALK fusion (chr11:3033425, chr2:29446394) was identified using the FusionPlex Sarcoma NGS Panel (Archer Dx).
Discussion
Inflammatory myofibroblastic tumor is considered a neo-
plasm of intermediate biological potential with frequent
recurrence and a small risk for aggressive behavior and
metastasis. Local recurrence rate of about 10% to 25% is
reported after excision and there is a small (<5%) risk of
metastatic disease. IMT shows a predilection for children
and adolescents, but more recent data suggest a broader
age range. These tumors were initially described in the
lungs; however, they can appear in virtually any anatomi-
cal location. Some of the more common extrapulmonary
sites are the soft tissues of the limbs and head and neck and
mesentery/peritoneum, but cases of IMT in abdominal vis-
cera, bone, larynx, central nervous system, and skin,
among others, have also been described. Clinical findings
depend on the site of tumor involvement but up to one
third of patients (mainly children) present with a systemic
syndrome of fever, weight loss, anemia, hypergammaglob-
ulinemia, and elevated erythrocyte sedimentation rate.1,2,7
Entities named earlier as inflammatory pseudotumor,
plasma cell granuloma, omental-mesenteric myxoid
hamartoma, and inflammatory fibrosarcoma are now
collectively termed IMT due to morphological, clinical,
and genetic similarities. Grossly, these tumors are nodu-
lar or multinodular circumscribed masses. Multiple nod-
ules are generally restricted to the same anatomical
location and are found in almost one third of cases. Areas
of hemorrhage, necrosis, and calcifications may be pres-
ent. Tumor size ranges from 1 cm to 25 cm with an aver-
age of 6.5 cm.2,7
Microscopically, 3 basic histopathological patterns are
described and may coexist in the same tumor.1,2 The first
pattern is composed of loosely arranged myofibroblasts in
an edematous or myxoid stroma with abundant blood ves-
sels, lymphocytes, plasma cells, and eosinophils that can
be easily confused with a reactive process. The second pat-
tern is characterized by compact spindle cells arranged in
a storiform pattern with collagenized stroma and a charac-
teristic inflammatory infiltrate. This feature helps distin-
guish it from fibromatosis. The third pattern consists of
scar-like proliferation of collagen with lower cellularity,
dystrophic calcifications, and osseous metaplasia. Some
tumors have pronounced cytological atypia, with cells
containing large nuclei with distinct nucleoli and large his-
tiocytoid cells resembling ganglion cells or Reed-Sternberg
cells. In the soft tissues, nodular fasciitis, fibromatosis,
and even myofibroblastic sarcoma can show similar fea-
tures. In abdominal locations, gastrointestinal stromal
tumor and dedifferentiated liposarcoma should be
considered.5
IMTs may be positive for muscle-related markers,
CD68, and keratin.2 About 50% of IMTs show cytoplas-
mic positivity for ALK, reflecting the ALK protein over-
expression that results from ALK gene rearrangement
found in about 50% to 70% of IMTs.10
Over the years, variable ALK fusion partners have been
identified such as ATIC, CARS, TPM3, TPM4, CLTC,
RANBP2, EML4, and SEC3IL.6,11 They have been
described in various anatomical locations, wide age range,
and varying morphological features.
We found only 2 previous reports of IMT with this
fusion in the literature.8,12 Both were males, a neonate and
a 10-year-old with a paraspinal lumbar and a paraspinal
cervical mass, respectively9,12 (Table 1). It is interesting to
note that these 2 cases as well as ours were found in soft
tissue/skeletal locations. Another common feature is the
relatively sparse inflammatory infiltrate. Our case also
showed a focal patchy infiltrate and that was not extensive
throughout the lesion. In some areas, it was completely
absent. The predominant histological features of all the
cases was the fascicular arrangement of the cells in col-
lagenous stroma. All cases had absent to low mitotic rate
and no necrosis.
Our case was different in regard to its intraarticular
location and multinodularity. The 2 other described cases
Pineda-Díaz et al 5

were solitary lesions. Histologically, our case also showed

Excised after chemo’ positive

Management and prognosis
myxoid areas that were not described in the other 2 cases,

pulmonary metastases.
leading to the initial confusion with nodular fasciitis in the

Excised. Prognosis N/A

margins. Developed
original biopsy.

Excised with local

The ALK gene, located on the short arm of chromo-
some 2, encodes for a receptor tyrosine kinase, which

recurrence
belongs to the insulin receptor subfamily. The CARS gene,
located on chromosome 11, encodes the cysteinyl-tRNA
synthetase enzyme, and it is believed that when CARS
dimerizes it activates ALK, as reported for other ALK
fusions.8,12
equivocal
ALK stain
Negative

The gene CARS is located at a chromosomal region

Positive

Weak

that contains the imprinted domain and tumor suppressor

genes lost in Wilms tumor and rhabdomyosarcoma. The
chromosomal rearrangement resulting in ALK-CARS
Compact fascicles of spindle cells in collagenous stroma
Compact proliferation of large spindle cells in fascicular

and areas of plump myofibroblasts in myxoid stroma.

fusion may affect genes in the proximity of the breakpoint,

pattern. No atypia, mitotic figures, or necrosis seen.
stroma, low mitotic index, and sparse inflammation

which may contribute to aggressive behavior.12 This may

Inflammatory infiltrate present but not extensive.
Fascicles of spindle cells in abundant collagenous

be the explanation for the in utero growth and metastases

seen in the 2 previously described cases. Our case is cur-
Scant but notable inflammatory infiltrate.

rently free of metastatic disease but had a recurrence and

persistent tumor, which may eventually lead to knee
Rare mitotic figures. No necrosis.

replacement in the future.

Histology

Up to date, there is no clear cut association between the

morphology and behavior of IMT with a specific fusion
except for perhaps the ALK-RANBP2 fusion.6 Reported
cases were all intraabdominal, showed epithelioid round
cell morphology, nuclear membrane staining of ALK, and
a more aggressive clinical course. Perhaps it could be pru-
dently suggested that the soft tissue location and predomi-
nantly fascicular morphology in the 3 ALK-CARS cases
Abbreviations: IMT, inflammatory myofibroblastic tumor; ALK, anaplastic lymphoma kinase.

may be related to this specific fusion; however, additional

cases should be evaluated before such a conclusion can be
reached.
piecemeal

The recent advances in targeted therapy, especially in

Received
10.5 cm
Size

the field of ALK inhibitors, make confirmation of ALK

5 cm

rearrangement necessary and important, especially in non-

resectable or metastatic cases. The European Organization
Table 1.  Comparison of 3 IMTs With ALK-CARS Fusion.

for Research and Treatment of Cancer, 90101 CREATE,

intraarticular
cervical area
lumbar area

reported 50% of participants with ALK-positive IMTs

Location
Paraspinal

Paraspinal

achieving an objective response, and concluded that crizo-

Knee,

tinib could be considered as the standard of care for

patients with locally advanced or metastatic ALK-positive
IMTs who do not qualify for curative surgery.11 There is no
(congenital) male

targeted therapy reported for the CARS gene to date.

20-year-old male
10-year-old male

Other gene rearrangements have also been reported in

Age/sex

IMTs that were “fusion negative” in regard to ALK. These

Neonatal

include ROS1, NTRK3, RET, and PDGFRB.13,14

Interestingly, 90% of “fusion negative” IMTs were seen in
adults. The involvement of these genes further expands the
possibility of targeted therapy.
Case 1, Cools

In recent years, high throughput technologies such as

Debelenko

Present case

NGS have enabled the discovery of new fusion genes

et al12
Case 2,
et al8

allowing for more accurate classification, prognostication,

Cases

and therapeutics in mesenchymal tumors and soft tissue

6 International Journal of Surgical Pathology 00(0)
sarcomas.15 As stated, we detected the ALK-CARS fusion
using the Archer FusionPlex Sarcoma panel (ArcherDx).
This panel for gene fusion identification in formalin-fixed
paraffin-embedded tissues of bone and soft tissue tumors
was validated in our laboratory by comparing the fusions
obtained with previous results found by traditional molec-
ular techniques such as fluorescence in situ hybridization
and RT-PCR. The sensitivity and specificity of the Archer
FusionPlex Sarcoma panel was found to be 97% and
100%, respectively. Furthermore, the ALK-CARS fusion
in this case was also validated in our laboratory with a
novel comprehensive NGS panel, based on a different
NGS technology approach, the Trusight Oncology 500
(Illumina).
The advantage of NGS and specifically targeted NGS
panels in comparison with conventional assays such as
fluorescence in situ hybridization and RT-PCR is the abil-
ity to provide a comprehensive highly sensitive and spe-
cific tool within a relatively short turnaround time for
ruling out several differential diagnoses simultaneously as
well as detecting rearrangement of genes that may be ther-
apeutically targeted. Furthermore, the anchored multiplex
special chemistry of the FusionPlex Sarcoma technology
makes novel fusion detection possible as it utilizes open-
ended, unidirectional gene-specific primers, and molecu-
lar barcode adaptors.
A disadvantage may be that in the presence of a nega-
tive result, a reevaluation of RNA and library quality is
mandatory as highly degraded RNA and poor quality
libraries may affect the sensitivity of the assay although
fusions may still be detected even on low-quality sam-
ples. Also, as the assay is designed to target the most
common breakpoint regions, unusual breakpoints may
be a source of “false negative” results.16 It is important
to remember that because several genes are analyzed in
one single test, it is possible that an “unexpected” fusion
may be found. Such a result should be interpreted with
caution taking into account the histological and clinical
features, as the same fusions may occur in morphologi-
cally different tumors.
In summary, we report a case of an intraarticular
IMT, a location not previously reported in the literature,
with ALK-CARS fusion identified by NGS using the
Archer FusionPlex Sarcoma panel. IMT can mimic
reactive, inflammatory, benign, and malignant tumors,
and therefore, molecular analysis can aid in the diagno-
sis, especially in cases with small biopsies or equivocal
immunohistochemical staining. The advantage of NGS
and specifically the targeted Archer FusionPlex Sarcoma
panel is the ability to rule out several differential diag-
noses in one single test as well as detect novel fusion
partners that may have prognostic and therapeutic
implications.
Author Contributions
Conception and design of the study: JPD, DH, OS
Acquisition and analysis of data: JPD, IS, DH, ID, OS
Drafting the manuscript or figures: JPD, IS, DH, ID, OS
Approval of final manuscript: JPD, IS, DH, OS
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Ethical Approval
Not applicable, because this article does not contain any studies
with human or animal subjects.
Informed Consent
Not applicable, because this article does not contain any studies
with human or animal subjects.
Trial Registration
Not applicable, because this article does not contain any clinical
trials.
ORCID iD
Osnat Sher https://orcid.org/0000-0003-0280-8102
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