PMC6098899_01
Gross imaging of the patient's mass: gross images of the area of ulceration which developed following cardiac catherization photographed in 2014 (a) show no signs of growth. In 2017, a mass (b) demonstrating outward growth and the area of the radiation injury following a year of close observation with a superimposed image of the same (c) mass was obviously exophytic and purulent measuring 5 x 3 cm at the time. The mass was photographed again prior to surgery two months later (d) in addition to MRI imaging shown with sagittal (e) and axial STIR (f) imaging demonstrating T1 signaling slightly intense to muscle and heterogeneous T2 signaling with avid contrast enhancement at the level of the posterior T10 rib. Both images fail to show evidence of muscular or bony invasion.
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During his last catheterization and stent procedure, which took over 4 hours (approx. 33 mSv), he developed a radiation-induced injury to his right back around the T10 dermatome (Figure 1(a)). Upon presentation to us, however, the physical exam demonstrated a fungating mass approximately 5 x 9 cm with central purulent necrosis and induration surrounding the periphery (Figures 1(b)-1(d)). Initial staging showed only localized disease by MRI with no evidence of metastasis by CT scan (Figures 1(e) and 1(f)).
Undifferentiated pleomorphic sarcoma on microscopic analysis: H&E section (200x magnification) showing cellular spindle cell neoplasm with fascicular growth pattern (a). H&E section (400x magnification) showing pleomorphic vesicular nuclei with irregular nuclear contours and mitotic activity (b). Immunohistochemical stain (400x magnification) for vimentin strongly positive within neoplastic cells (c).
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Marked pleomorphism was present with vesicular nuclei, irregular nuclear contours, and scattered prominent nucleoli (Figures 2(a) and 2(b)). The neoplastic cells are positive for CD68 and vimentin (Figure 2(c)).