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Histomorphological Pattern of Radiologically Detected Osteolytic Lesions of Bone – A Study of Eighty Cases

Histomorphological Pattern of Radiologically Detected Osteolytic Lesions of Bone – A Study of Eighty Cases

*Runa NJ,1 Khan JB,2 Kaizer N,3 Dewan MR,4 Sharmin S,5 Ahmed SS,6 Hasan AM,7 Haque N,8 Hussain M9

 

Abstract:

To determine the spectrum of lesions and to correlate them with age, sex of patients and also anatomical site a histomorphological study of radiologically detected osteolytic lesions of bone was done. Eighty cases of radiologically detected lytic lesions of bone were studied over a period of two years from January 2014 to December 2015. Out of 80 cases of lytic lesion of bone, 18 cases were of inflammatory, 32 cases were of benign tumors, 20 cases of primary malignant bone tumors and 10 cases of metastatic lytic lesions were found. Most of the patients belonged to the middle age group with the age incidence varying with the type of lesion. Out of the 80 cases, 46 were males and 34 were females. Most of the bone diseases occurred more commonly around the knee joint and in the males within the age group of 11-20 years. Conclusion: Benign tumors are more common amongst all lytic lesions with giant cell tumor ranking first. Tuberculous osteomyelitis is more common in this study than pyogenic osteomyelitis. Osteosarcoma and secondary metastasis were more common among malignant bone tumors.

 [Journal of Histopathology and Cytopathology, 2017 Jul; 1 (2):83-90]

Key words: Bone, Osteolytic lesions, Histopathology, Radiology

 

 

 

  1. *Dr. Nusrat Jahan Runa, Assistant Professor, Department of Pathology, Dhaka Central International Medical College, Dhaka. njruna03@gmail.com
  2. Zubaida Bahroon Khan, Lecturer, Department of Pathology, Dhaka Medical College, Dhaka.
  3. Nahid Kaizer, Assistant Professor of Pathology, MH Samorita Medical College, Dhaka.
  4. Md. Rezaul Karim Dewan, Professor of Pathology, Dhaka Medical College, Dhaka.
  5. Shegufta Sharmin, Resident of Pathology, Dhaka Medical College, Dhaka.
  6. Syed Salauddin Ahmed, Associate Professor of Pathology, National Institute of Traumatic and Orthopedic Rehabilitation, Dhaka.
  7. AZ Mahmudul Hasan, Assistant Registrar, Department of Orthopedic Surgery, Dhaka Medical College Hospital, Dhaka
  8. Nazmul Haque, Associate Professor, Department of Pathology, Dhaka Medical College, Dhaka.
  9. Maleeha Hussain, Professor and Head, Department of Pathology, Dhaka Medical College, Dhaka.

 

*For correspondence

Introduction
 Lesion of bone is a frequently found radiological presentation of patients seen in orthopedic practice. Osteolytic lesions are evident radiologically where the destructive processes outstrip the laying down of new bone. The spectrum of pathological conditions causing osteolytic changes can be inflammatory to neoplastic lesions.1-3 Within benign lesions, the common differential diagnosis of lytic lesion includes simple bone cyst, aneurysmal bone cyst, osteochondroma (exostosis), enchondroma, non-ossifying fibroma and brown tumor of the bone. Among the malignant tumors the most common are Ewing sarcoma, osteosarcoma and multiple myeloma.4 Primary bone cancer is much rarer than bone metastasis.5,6 Bone is the third most common site of metastatic disease. Metastatic tumor that produces osteolytic lesions, detected in X-ray when the lesion is greater than 1.0 cm and 30% – 50% of the bone density have beendestroyed.4 As far as secondary tumors are concerned primary sites like lung, kidney, thyroid, breast, gastrointestinal and melanomas produce mainly lytic lesion while others elicit mixed lytic and sclerotic reaction.7 Carcinomas are much more likely to metastasize to bone than sarcomas.

It is difficult to determine radiologically with plain film imaging whether a lytic lesion is benign or malignant. It is important to remember, however that some benign processes such as osteomyelitis can mimic malignant tumors and some malignant lesions such as metastases or myeloma can mimic benign. The osteolytic lesions of tuberculosis may closely mimic those due to multiple myeloma or secondary malignant deposits.8 The histopathologist is the final person to guide an orthopedic surgeon for the treatment of patients with lytic lesions.

 Methods

This study was conducted at the Department of Pathology, Dhaka Medical College, Dhaka from January 2014 to December 2015. The criterion for the selection of the patient was radiologically detected osteolytic lesions of bone. Total 80 cases were selected. Detailed history was taken. Biopsy for histopathology was performed in all patients for the diagnosis of lytic lesions of bone. Biopsy was taken mainly by incision and excision method.

In laboratory soft tissue were fixed in 10 % formalin while for bone 3 to 5 mm thick sections were made and adequately fixed in 10% buffered formalin and then decalcification was achieved by placing the specimens in 5% nitric acid for 2 days. After that all tissue were processed by increasing concentrations of alcohol and paraffin blocks were prepared. Sectioned were stained with haematoxylin and eosin. After that all slides were examined under microscope, the final diagnosis was made into inflammatory, benign and malignant lesion accordingly.

 Results

In this study 18 cases of inflammatory, 32 cases of benign, 20 cases of primary malignant and 10 cases of secondary malignant lytic lesions were found out of total 80 cases. Benign neoplastic lesions of bone comprises the highest number (32 cases, Table I).

Table I: Distribution of frequency of study patients by histological diagnosis (n=80)

Lesions Number %
             Inflammatory 18 22.5
Neoplasm
Benign 32 22.5
Malignant primary 20 25.0
Malignant Secondary 10 12.5
Total 80 100%

From different age group, the most common age group was 11-20 years, in which total 32 cases of lytic lesion were found. Benign neoplastic lesions (18 cases) were most common in this group. In age group 21-40 years, total 25 cases of lytic lesion were found, of which benign lesion (12 cases) was most common. In age group of above 40 years, total 19 cases of lytic lesion were found, in which 12 malignant lesions were found. In below 10 year group only 4 cases were found, which were of malignant type (Table II).

Table II: Showing distribution of the study patients by age

 

 

Lesions

 Age groups (in years)
0-10 11-20 21-40 Above 40
Inflammatory Pyogenic Osteomyelitis 0 4 2 2
Tuberculous osteomyelitis 0 1 6 3
Neoplasm Benign 0 18 12 2
Malignant primary 4 9 3 4
Malignant secondary 0 0 2 8
         Total 4 32 25 19

 

Out of 80 patients, 46 (57.50%) were male and 34 (42.50%) were female. In male patients 19 cases were of benign neoplastic lesion, 8 cases were inflammatory lesion and 19 cases were malignant lesion. Where as in female, 13 cases were benign lesion, 10 cases were inflammatory lesion and 11 cases were malignant lesion. So, benign neoplastic lesions were the most common among both the sex (Table- III).

 

Table III: Types of leions with sex distribution of the study patients

 

               Lesions                    Male                Female
        Inflammatory Pyogenic osteomyelitis                     02 (2.5%)                   06 (7.5%)
Tuberculous osteomyelitis                     06 (7.5%)                   04 (5.0%)
 

 

Benign

 Giant cell tumor                     06 (7.5%)                   09 (11.25%)
Enchondroma                     04 (3.75%)                   01 (1.25%)
Simple bone cyst                     02 (2.5%)                   01 (1.25%)
Fibrous dysplasia                     02 (2.5%)                   01 (1.25%)
Aneurymal bone cyst                     03 (3.75%)                   01 (1.25%)
Hemangioma                     02 (1.25%)                   —
 

 

Malignant

      Primary
Osteosarcoma                     05 (6.25%)                  03 (3.75%)
Ewing sarcoma                     03 (3.75%)                  04 (5.0%)
Chondrosarcoma                     02 (2.5%)                  01 (1.25%)
Multiple myeloma                     01 (1.25%)                  —
          MFH                     01 (1.25%)                  —
    Secondary                     07 (8.75%)                 03 (3.75%)
                                           Total                    46 (57.50%)                 34 (42.50%)

Out of 80 cases, 24 patients had osteolytic lesion in the tibia. Among them 17 lesions were in the upper end. The second most common site of lesion was femur [Table IV].

 

Table IV: Distribution of the study patients according to anatomical site (n=80)

 

Diagnosis Femur
Upper		 Femur

Lower

 Tibia

Upper

 Tibia

Lower

 Fibula Humerus Radius Meta-carpal Phalanges Total
Tubercular osteomyelitis – 2 3 3 – – – 1 1 10
Pyogenic osteomyelitis – 2 2 2 – 1 1 – – 8
Giant cell tumour of bone – 6 3 2 1 1 1 – – 15
Enchondroma – – – – – – – 1 4 5
Hemangioma – – – – 1 1 – – – 2
Benign cystic lesion – – – – 1 1 1 – – 3
Aneurysmal bone cyst – – 1 1 – 2 – – – 4
Fibrous dysplasia – – 2 1 – – – – – 3
Ewing sarcoma 1 2 1 – 1 1 1 – – 7
Osteosarcoma 3 5 – – – – – – 8
Chondrosarcoma 1 – – – – 2 – – – 3
Multiple myeloma 1 – – – – – – – – 1
MFH – 1 – – – – – – 1
Metastatic adenocarcinoma – – 1 – 2 – – – 3
Metastatic squamous cell carcinoma 1 – – – – – – – – 1
Metastatic renal cell carcinoma 2 – – – – – – – – 2
Metastatic follicular variant of papillary carcinoma – – – – 2 1 – – 3
Metastatic Prostatic carcinoma 1 – – – – – – – – 1
Total 6 15 18 10 4 14 5 2 5 80

 

MFH – Malignant fibrous histiocytoma

Out of total 18 inflammatory lytic lesions, 8 cases were of pyogenic osteomyelitis and 10 cases were of tuberculous osteomyelitis (fig 1 and 2). So, tuberculous osteomyelitis was slightly more common than pyogenic osteomyelitis in inflammatory lytic lesions (Table V). From total 32 benign neoplastic lytic lesions, 15 cases were of giant cell tumor, 5 cases were of enchondroma. Giant cell tumour shows a higher incidence than other benign lytic lesion (Table VI).

Table V: Distribution of inflammatory lesion

 

Histologically diagnosed Inflammatory lesion   Number %
Pyogenic osteomyelitis          08 10
Tuberculous osteomyelitis          10 12.5

 

Table VI: Distribution of frequency of benign lesion by histopathological diagnosis

 

Histologically diagnosed Benign lesion No of cases %
   Giant cell tumor       15 18.75
   Enchondroma       05   6.25
   Simple bone cyst       03   3.75
   Fibrous dysplasia       03   3.75
  Aneurysmal bone cyst       04   5.0
  Hemangioma       02   2.5
            Total       32 40.0

While in 30 malignant lesions, 20 cases were primary and 10 cases were secondary malignant lesions. Primary malignant lesions were more common than metastatic lytic lesions in the present series  (Table VII).

 

Table VII: Distribution of frequency malignant lytic lesion by histological diagnosis

 

          Malignant lesion No of cases Percentage (%)
Primary Osteosarcoma 08 10
Ewing sarcoma 07 8.75
Chondrosarcoma 03 3.75
Multiple myeloma 01 1.25
Malignant fibrous histiocytoma 01 1.25
Secondary Metastatic follicular variant of papillary
carcinoma of thyroid in bone		 03 3.75
Metastatic adenocarcinoma of lung in bone 03 3.75
Metastatic renal cell carcinoma in bone 02 2.5
Metastatic adenocarcinoma of prostate in bone 01 1.25
Metastatic squamous cell carcinoma of lung in bone 01 1.25
                    Total 30 37.5

 

Osteosarcoma and metastatic tumours from lung were common in the primary and secondary malignant tumour groups (fig 3 and 4).

 

 

 

 

 

 

Fig 1. X-Ray photograph showing lytic area in the right upper tibia. Subsequent biopsy revealed tubercular osteomyelitis (case no 16)

 

 

 

 

 

 

 

Fig 2. Photomicrograph of the case in fig 1 showing epithelioid cells, lymphocytes, a giant cell and bone, consistent with tubercular osteomyelitis (ase No: 16, H & E stain ´200)

 

 

 

 

 

 

Fig 3. X-ray photograph showing lytic lesion with destruction of the overlying cortical bone with ‘sunburst’ appearance in lower end of femur (Case no. 42)

 

 

 

 

 

 

Fig 4. Photomicrograph showing Osteosarcoma (Case No: 42, H&E stain ´400)

 

 

 

 

 

Fig 5. X-ray photograph showing a lytic lesion in upper end of femur (Case no. 17)

 

 

 

 

 

 

Fig 6. Photomicrograph showing metastatic squamous cell carcinoma (Case No: 17, H&E stain´400)

Discussion

This study was carried out to determine various histomorphologic pattern of lytic lesions of bone. Of total 80 cases, 18 cases of inflammatory, 32 cases of benign neoplastic lesion, 20 cases of primary malignant bone tumors and  10 cases of secondary tumors were found. One of the important point to be considered is the age of the patient. Some of the lytic lesions are most probably confined to certain age groups such as: metastatic neuroblastoma in the infant and young child, metastasis and multiple myeloma in the middle-aged and elderly, lymphomas affecting only bone usually occur during adult life. Ewing sarcoma mostly affecting children and young teenagers while giant cell tumor in the young to middle aged adults.9,10 In our study, the most common age group of bone lesions was in second decade. Among 32 cases of benign osteolytic lesion, 18 cases were belonging to age group 11-20 years. In age group 21-40 years, total 25 cases of lytic lesion were found, in which benign (12 cases) were the commonest. In age group above 40
years, a total of 19 cases were found, in which malignant lesion was the most common diagnosis. In below 10 years age group only 4 cases were found to be Ewing’s sarcoma (Table II).In our study, osteomyelitis was found in all age groups above ten years. The diagnosis of chronic recurrent multifocal osteomyelitis is essentially one of exclusion. Infective osteomyelitis and malignancy are the main differential diagnoses.11 The osteolytic lesions of tuberculosis at multiple sites need to be differentiated from multiple myeloma, secondary metastasis and bacterial osteomyelitis.

 

In this study, more than half (57.50%) of the patients were male and  42.50% were female; male to female ratio was 1.4:1, which indicates that osteolytic lesion are predominant in male subjects, which closely agrees with available literature.12,13

 

The bone around the knee joint that is, the distal end of the femur and the proximal end of the tibia, were found to be the commonest sites for osteolytic lesions comprising 38.7% in this series. The lower end of the femur was affected in 17.5% of cases and the upper end of the tibia in 21.2% of cases that has matched with other literature.14

In our study, out of 80 cases of lytic bone lesions, most common were benign neoplastic lesions making 32 cases. Among them, 15 cases were giant cell tumour of bone having female predominance (Table III).  In present study, the most common site of giant cell tumor was lower end of femur and upper end of tibia [Table IV]. Characteristic radiologic findings demonstrate the lesion is most often eccentrically placed lytic lesion with no periosteal reaction to the long axis of the bone. Total 5 cases of enchondroma has been reported with an incidence of 6.26% of total cases and an incidence of 15% of all benign tumors, mostly seen in patients younger than age 20 years (3/5 cases) in the current study.

Osteosarcoma is the most common primary bone tumor in young and adolescents. It occurs most frequently in the second decade, occurring in the metaphysis, mostly in lower end of femur followed by upper end of tibia.15,16 In the present study, we observed a similar finding. Ewing sarcoma is a highly malignant, undifferentiated, peripheral primitive neuro-ectodermal tumor occurring most commonly at the diaphysis of long bones, in the 0-20 years age group, with female predominance.15,16 Our study has matched with the available literature. Pain, pathological fractures and hypercalcemia are the major sources of morbidity with bone metastasis. Pain is the most common symptom found in 70% patients with bone metastases.17 Pain is caused by stretching of the periosteum by the tumor as well as nerve stimulation in the endosteum. Pathological fractures are most common in breast cancer due to the lytic nature of the lesions.18 In our study ten cases of metastatic lytic lesion were found, which included Follicular Variant Of Papillary Carcinoma of thyroid metastasize to upper end of the humerus, Carcinoma of kidney with metastasis to upper end of femur, Squamous Cell Carcinoma and adenocarcinoma of Lung metastasize to upper end of femur and humerus.  In case of follicular variant of papillary carcinoma of thyroid lytic lesion over humerus was the first noticeable sign and even the patient & clinician were unaware of thyroid malignancy.

Among the various diagnoses, benign tumors form the largest group (40%) of patients presenting with a lytic lesion on radiological findings. There is a male preponderance with 57.5% of the patients being males. Also, majority of the patients fall into the second decade with 40% of the patients in the age group of 11- 20 years. The common diagnoses among the benign lesions were giant cell tumors, while there were a slightly higher number of cases of tuberculous osteomyelitis as against bacterial osteomyelitis in the inflammatory conditions. Among the malignant lesions, primary tumors were a commoner diagnosis as opposed to the secondaries. The metastatic tumors tend to occur more commonly in the elderly population. The commonest primary malignant lesion that showed up was osteosarcoma. Overall, giant cell tumor is the commonest diagnosis presenting with a lytic lesion on radiological finding. Occult malignancy can be presented as lytic lesion of bone in the form of secondary. All lyticlesions may have osteoclastic giant cells and they should not be misinterpreted as Giant cell tumor.

 Conclusion

Lytic lesion of bone is a very used to radiological finding for orthopedic surgeon in many patients. Even an orthopedic surgeon and radiologist together won’t be able to reach to the precise conclusion and further treatment. Histopathology is the gold standard for the precise diagnosis from a very large number of conditions leading to lytic lesion.

 References

  1. Bommer KK, Ramzy I & Mody D. Fine needle aspiration biopsy in the diagnosis and management of bone lesions: A study of 450 cases. Cancer, 1997; 81:148-156.
  2. Kreicbergs A, Henrik C, Bauer F, Brosjo O, Lindholm J & Skoog L. Cytological Diagnosis of Bone Tumors. The Journal of Bone and Joint Surgery, 1996; 78(2):258-263.
  3. Ackerman LV & Del Regato JA 1954, Cancer: Diagnosis, Treatment, and prognosis. 2nd edition, Louis, Mosby, p. 1028.
  4. Popat V, Sata V, Vora D, Bhanvadia V, Shah M & Kanara L. Role of Histopathology In Lytic Lesions of Bone. The Internet Journal of Orothopedic surgery, 2010; 19(1):1-7.
  5. Bhattacharya P, Chowdhury AR, Bhaskar M & Biswanath P. Clinico pathological correlation of Primary Malignant Bone Tumors. Open Journal of Orthopedics, 2015; 5:100-108.
  6. Wedin R, Henrik C, Bauer F, Skoog L, Soderlund V & Tani E. Cytological diagnosis of skeletal lesions. The Journal of Bone and Joint Surgery, 2000; 82(5):673-678.
  7. Adler O & Rosenberger A. Fine Needle Aspiration Biopsy of Osteolytic Metastatic Lesions. AJR, 1979; 33:15-18.
  8. Chawla KP, Pandit, AA, Jaiswal PK & Ahuja A. 1990, ‘Ostearticular tuberculosis with involvement of multiple sites (a case report)’, J Postgrad Med,1990;36:171-72.
  9. Manaster BJ. Tumors. In: Manaster BJ, Disler DG, May DA, eds. Musculoskeletal
    Imaging: The Requisites.2nd ed. St. Louis, MO: Mosby; 2002:1-104.
  10. Resnick D. Tumors and tumor-like lesions of bone: Imaging and pathology of specific lesions. In: Resnick D, ed. Bone and Joint Imaging.2nd ed. Philadelphia, PA: W.B. Saunders; 1996:991-1063.
  11. L P Robertson, P Hickling. Chronic recurrent multifocal osteomyelitis is a differential diagnosis of juvenile idiopathic arthritis. Ann Rheum Dis 2001; 60:828-831.
  12. Chakrabarti S, Datta AS & Hira M. Critical Evaluation of Fine Needle Aspiration Cytology as a Diagnostic Tecnique in Bone Tumors and Tumor-like lesions. Asian Pac J Cancer Prev, 2012; 13: 3031-4
  13. Wahane R. Fine Needle Aspiration Cytology of Bone Tumors. ACTA, 2007; 51(%):711-720.
  14. Mahajan S, Saoji AA & Agarwal A. Utility of Fine Needle Aspiration Cytology in Diagnosis Bone Tumors. Cancer Transl Med, 2015; 1(5):166-169.
  15. Bone RJ. Ackerman’s Surgical Pathology. In: Rosai J, editor. St. Louis: Mosby; 1996. pp. 1917–2020.
  16. Rosenberg AE. Bones, joints and soft tissue tumors. In: Kumar V, Abbas AK, Fausto N, Aster JC, editors. Robbins and cotran; Pathologic Basis of disease. 8th ed. Gurgaon: Elsevier Reed Elsevier India private limited; 2010. pp. 1205–56.
  17. Vinholes J et al., Effects of Bone Metastases on Bone Metabolism: Implications for Diagnosis, Imaging and Assessment of Response to Cancer Treatment, Cancer Treatment Reviews, 1996; 22:289-331.
  18. Stoll B and Parbhoo S, Bone Metastasis, Raven Press Books, Ltd.: New York NY, 1983, p. 14. 3 Vinholes, et al. 1/14/98 8:46 AM 1.

 

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Pathology-Based Cancer Registry in Bangladesh: The Need of Our Time


Editorial
Pathology-Based Cancer Registry in Bangladesh:  The Need of Our Time

 Kamal M*

 *Professor Mohammed Kamal, Professor, Department of Pathology, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh. kamalzsr@yahoo.com

Cancer is a public health concern both in the developed and developing countries and is among the leading causes of death worldwide. In 2012, there were 14 million new cases and 8.2 million cancer-related deaths worldwide. The number of new cancer cases estimated to rise to 22 million within the next two decades.  More than 60% of the world’s new cancer cases occur in developing and resource constrained countries of Asia, Africa, and Central and South America.  70% of the world’s cancer deaths also occur in these regions.1  Bangladesh is not spared from this problem. Cancer is the sixth leading cause of death in Bangladesh. The magnitude of cancer in Bangladesh is getting alarming because of abundance of environmental carcinogens, malnutrition, lack of awareness and screening facilities. Poverty, ignorance and illiteracy have compounded the problem. The magnitude of the problem from cancer is often unrecognized by health and general policy makers alike due to other overwhelming and more visible competing health problems and natural calamities. Therefore, appropriate prevention and surveillance of cancer deserves urgent attention.2

Tumour registries are systems for collection, storage, analysis and interpretation of data from cancer patients.  It involves recording of personal particulars of cancer patients and the clinical and pathological characteristics of the cancers, collected continuously and systematically from various data sources.  Ideally the key source of information on cancers in any country is through a population-based cancer registry. About 200 population-based cancer registries exist in various parts of the world.3   However, because of the costs for maintaining a population-based cancer registry and lack of necessary infrastructure, Bangladesh, like many other developing countries, has not been able to establish any such registry to date. In spite of having high morbidity and mortality from many cancers (e.g., lung, head and neck, cervix, liver, colon, stomach etc.), there are no reliable data for the incidence, prognosis, morbidity and mortality from cancers in Bangladesh. Data sources and methods used for Bangladesh statistics are estimated from national incidence estimates using modeled survival and mortality based on reports from a few tertiary care hospitals and from neighboring countries.4

To overcome this, an effective alternative is ‘Pathology Based Cancer Registry’ which is efficiently going on in many parts of the world. The basis of this approach is documentation of cancers through hospital and/or pathology laboratories where the cancer patients attend for their diagnosis and follow-up. Although not perfect, this method is proving to be an effective in some developing countries.5.6,7  Though an accurate picture of cancer situation depends on the establishment of a population based cancer registry, data derived from pathology based cancer registry would be able to measure levels of cancer burden in the community by recording all cases of cancers (and non- cancer) in given laboratories  with emphasis on pathological diagnosis and clinical Information of the patients. In the absence of population based cancer registry, pathology based cancer data can be utilized as a reflection of the patterns of cancer in the population.

To establish a pathology based cancer registry in Bangladesh, the practical approach will be to start a collaborative network of all pathologists based at academic institutions, hospitals, and private clinics and laboratories. It can be done phase wise, starting from the Dhaka city and gradually expanding throughout the country. The collected data can provide estimation of cancer incidence and prevalence, patterns, epidemiology and other valuable information. Collaborative between government and non-government institutions, pathologists, epidemiologists, practitioners and relevant national and international policy makers is needed for smooth functioning.

References

  1. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C et al. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC Cancer Base No. 11
  2. Lyon, France: International Agency for Research on Cancer; 2013.
  3. Rahman A, Zaman M, Hossain A and Karim ABMF. National Cancer Control Strategy and Plan of Action 2009-2015, Directorate General of Health Services. Ministry of Health and Family Welfare Dhaka, Bangladesh. 2008; 1-37.
  4. Wagner G. History of cancer registration. In Jensen OM, Parkin DM, MacLennan R, Muir CS, and R.G. Skeet RG, editors. Cancer Registration: Principles and Methods. IARC Scientific Publications No. 95. Lyon, France.IARC.1991. p. 3-6.
  5. Kalam MA and Ahmed T. Cancer, Cancer Control and Bangladesh, Editorial. Bangladesh Journal of Plastic Surgery. 2012; 3(1): 1-2.
  6. Jensen OM, Whelan SL. Planning a cancer registry. . In Jensen OM, Parkin DM, MacLennan R, Muir CS, and R.G. Skeet RG, editors. Cancer Registration: Principles and Methods. IARC Scientific Publications No. 95. Lyon, France.IARC.1991.p. 22-28.
  7. Bhurgri Y. The role of cancer registration in national cancer control, Pakistan. J Pak Med Assoc. 2004 Aug; 54(8). P. 402-404.
  8. Etemadi AI, Sadjadi A, Semnani S, Nouraie SM, Khademi H, Bahadori M. Cancer registry in Iran: a brief overview. Arch Iran Med. 2008 Sep;11(5):577-80.

 

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Angiolipoma of Stomach: A Case Report


Angiolipoma of Stomach: A Case Report

 *Jahan JA,1 Akhter S,2  Kamal M,3 Karim SS4

 Abstract

Angiolipoma is a variant of benign lipomatous tumors and generally found in subcutaneous tissues. The tumor is rarely found in gastrointestinal tract. We present a case of a 55-year-old male who presented with melena. Endoscopy of upper gastrointestinal tract showed a polypoid mass, while abdominal CT scan suggested a submucosal lipoma. After partial gastrectomy,  histological examination of the tumor revealed an encapsulated nodule composed of mature fatty tissue, fibrous tissue and small blood vessels, and accordingly the lesion was diagnosed as angiolipoma.

  [Journal of Histopathology and Cytopathology, 2018 Jan; 2 (1):63-67]

Key words:  Angiolipoma, Stomach

 

  1. *Dr. Jasmine Akhter Jahan, Resident,  Department of  Pathology, Bangabandhu Sheikh Mujib Medical University, Dhaka. drjasmine30@gmail.com
  2. Shabnam Akhter, Associate Professor, Department of  Pathology, Bangabandhu Sheikh Mujib Medical University, Dhaka.
  3. Professor Mohammed Kamal, Professor, Department of Pathology, Bangabandhu Sheikh Mujib Medical University, Dhaka.
  4. Syed Sirajul Karim, Department of Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka.

 

* For correspondence.

 Introduction

Angiolipoma is one of the benign adipocytic tumors that usually occur in subcutaneous tissues.1  The tumor is composed of adipose tissue and proliferating blood vessels. It is commonly found in subcutaneous tissues of the trunk and extremities.2  Although endoscopic and radiologic examination may provide helpful information, the final diagnosis of angiolipoma relies on histopathological features of excised specimen.3

Case report

A 55-year-old male patient was admitted in a private hospital in  Dhaka with the complaints of gastric mass, melena and generalized weakness. His symptoms had begun 20 days back and he experienced bloody stool with foul smell, which had lasted for seven days. Initially he visited an outside hospital, where he was diagnosed as a severely anaemic patient. His laboratory test results were as follows: hemoglobin level 7.8 g/dl, red blood cell count  2.78 × 1012/L, white blood cell count 13× 109/L, neutrophil count 74% and erythrocyte sedimentation rate (ESR) 82 mm in first hour. He was admitted in that hospital for blood transfusion because of his severe anemia and 2 units of fresh whole blood were transfused. Further investigation including complete metabolic panel, liver function tests, serum ferritin,  urinalysis and stool culture were all found within normal limit. Ultrasound of whole abdomen was also performed, which showed fatty infiltration in the liver (Grade-1). Endoscopy of upper gastro-intestinal tract revealed a polypoid mass in the gastric antrum with smooth surface and evidence of recent bleeding (Fig. 1).

The esophagus and duodenum appeared normal. Biopsy of the lesion showed massive necrosis and fibrinous exudate. After the blood transfusions when the patient became hemodynamically stable, he was discharged on request. Later the patient got admitted into Bangabandhu Sheikh Mujib Medical University with melena, cough and fever for definitive treatment. On arrival his abdomen was soft and non-distended. The patient’s past medical history was occasional dyspepsia for one year which was relieved by antacids. The family history was unremarkable. Repeat laboratory tests showed haemoglobin level of 11.6 g/dl, red blood cell count of 4.15 × 1012/L, white blood cell count of 9.0× 109/L,  neutrophil count of 67% and erythrocyte sedimentation rate (ESR) of 60 mm in 1st hour. A complete biochemical panel, serum albumin, fasting blood sugar, complete urine analysis, chest X-ray, electrocardiography (ECG) and echocardiography were all normal. An abdominal CT scan with contrast showed a well defined almost rounded fat density area measuring about 4.1 cm x 3.9 cm in the lumen of pyloric and antral part of stomach appeared to be arising from posterior wall, suggestive of submucosal lipoma at pyloric and antral part of stomach (Fig. 2). Tiny calcification is seen in hepatic parenchyma. Accordingly the patient was operated. A large antral growth was found and distal partial gastrectomy with gastrojejunostomy was performed. The patient recovered from surgery without complication. The specimen was sent to the department of pathology where gross examination showed a 5 × 5 × 3 cm polypoid tumor on the lesser curvature and posterior surface in the antrum  (Fig. 3). Three lymph nodes ranging from 02 mm to 04 mm were identified. Histologic examination revealed a tumor composed of lobules of fatty tissue with intervening fibrous tissue and small thin walled blood vessels  (Fig. 4 and 5). Mucosal ulceration was present. Lymph nodes showed reactive changes with no evidence of tumor. The final pathologic diagnosis was angiolipoma of the stomach. During follow-up, this patient showed no recurrence.

 

 

 

 

 

 

 

Fig 1.  Endoscopic appearance of the gastric polypoid mass.

 

 

 

 

 

 

Fig 2.   CT scan of abdomen showing gastric mass with low intensity in the centre (arrow)

 

 

 

 

 

Fig 3. Specimen of stomach showing mass with yellow fatty core (P) and normal mucosa (M).

 

 

 

 

 

Fig 4.  Histological section of stomach showing angiolipoma (T) and normal mucosa (M) (H&E x120)

 

 

 

 

 

 

Fig 5.   Histological section  showing adepocytes (A), blood vessels (BV) and fibrous tissue (F) (Masson Trichrome x220)

Discussion

Angiolipoma is a benign adipocytic tumour, usually arising in subcutaneous tissue. It is composed of adipose tissue and proliferating blood vessels.2 Most common site of angiolipoma are the extremities. It also involves subcutaneous tissue of trunk. Angiolipomas usually appear in the late teens or early twenties and has a male predominance.1

Angiolipoma was first defined in 1912  by Bowen (cited by Howard).4 The histopathological features of angiolipomas were differentiated from those of lipomas by Howard (1960).5 Clinically angiolipomas usually present with multiple subcutaneous, tender, small nodules in arms and trunk. They are most often less than 2 cm in diameter.1,6 Cytogenetic analysis detected chromosomal aberrations, such as rearrangements of 12q14-15, rearrangements of 6p21-22, or deletions of 13q12-14 and 13q22. The gene involved in 12q14-15 is HMG A2 and in 6p21-22 is HMG A1.7 These aberrant expressions suggest that the pathogenesis of angiolipomas may be different from other lipomas. The tumor in some cases show familial incidence, which is rare (5% of all cases) and have autosomal dominant inheritance.1,8

Grossly, the tumour is well defined, encapsulated and have cut surface which is yellowish to reddish according to the prevalence of fat or vascular component. Morphologically, it is comprised of mature adipose tissue with an interspersed vascular proliferation.1,2  Occasional fibrin thrombi are seen. The tumor can be classified as lipomatous or angiomatous type. This classification is based on the ratio of presence of adipose tissue or vascular tissue (8). The tumor is typically diagnosed with hemotoxylin & eosin stain. The immunohistochemical examination is rarely needed. Angiolipoma shows focal to diffuse positivity for S100 protein in the adipocytes. Also endothelial markers e.g. CD34 and CD31 are positive in the vascular component.2

Angiolipoma in the gastrointestinal tract is very rare and  seen mostly in the colon.9, 10  Twenty two cases of angiolipoma involving the gastrointestinal tract have been reported in the literature up to 2013. Among them, four cases were in the stomach. The antrum is the common site for gastric angiolipoma. Other involved areas are oesophagus, duodenum, small intestine, colon and rectum.9, 2

Patients with angiolipoma in the gastrointestinal tract are usually asymptomatic. Some may present with indigestion, abdominal discomfort, abdominal pain, GI bleeding and anaemia, symptoms of intussusceptions or obstruction with increasing size of the tumor .2, 9, 10 Submucosal polypoid mass lesion is typically found in upper GI endoscopy. Histologically, angiolipoma in the stomach is composed of mature fatty tissue and proliferating blood vessels. Fibrin thrombus is rarely seen in gastric angiolipoma and other nonsubcutaneous angiolipomas, in contrast to cutaneous angiolipomas.2, 10

Diagnosis of angiolipomas in the gastrointestinal tract can be made by radiological examination via barium radiograph, abdominal ultrasound, abdominal computed tomography (CT) or magnetic resonance imaging (MRI) before polypectomy or resection. A filling-defect in lumen by barium enema and a hyperechoic lesion on transabdominal ultrasound. Abdominal computed tomography (CT) image may show variable findings depending on tissue components of the lesion. This has an appearance from high-density mass due to lipomatous component to heterogeneous lesion with mixed fatty and soft tissue density.2, 9 The final diagnosis is confirmed by histopathological examination.2,8,9

The pre-operative diagnostic accuracy for gastric angiolipomas is quite low. So the correct diagnosis is usually made intraoperatively and confirmed by histopathology.9 The treatment options depend on the type of the lesion. It varies from polypectomy of small pedunculated lesions to surgical excision of large mass. After complete excision, the tumor typically does not recur.2

The angiolipoma in our case presented with melena and anaemia requiring whole blood  transfusion. Endoscopy revealed polypoid mass with recent bleeding. As the lesion was submucosal, endoscopic biopsy failed to diagnose the tumour. A well circumscribed submucosal lipoma was identified on abdominal CT scan. After distal partial gastrectomy, final diagnosis  of gastric angiolipoma was made by histopathological examination by its typical morphological features.

Conclusion

Angiolipoma is a benign tumor, commonly occurring in subcutaneous tissue but rare in gastrointestinal tract. It is important to remember that submucosal polypoid lesions in GI tract with or without symptoms can be an angiolipoma, although it is quite rare.

 References

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  6. Rogy MA, Mirza D, Berlakovich G, Winkelbauer F, Rauhs R. Submucous large-bowel lipomas: presentation and management. An 18-year study. Eur J Surg, 1991; 157(1): 51-55.
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