PMC7809524_01
Imaging assessments. (a) CT abdomen/pelvis w/o contrast demonstrating hernia. (b) Left sided inguinal fluid collection. (c and d) Right and left sided fluid collection shown in CT abdomen/pelvis with contrast. (e) CT abdomen/pelvis with contrast 13 months after original surgery. (f) CT abdomen/pelvis with contrast 21 months after original surgery. (g) CT abdomen/pelvis with contrast 27 months after original surgery.
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The patient is a 54-year-old Caucasian male with a past medical history significant for chronic lower back pain for 15 years and basal cell carcinoma, who initially presented with a left sided inguinal mass associated with mild discomfort (Figure 1(a)). At 4.5 months postoperatively, the patient returned with a left sided groin fluid collection (Figure 1(b)). A follow up CT scan of the abdomen/pelvis with contrast demonstrated a large left sided retroperitoneal seroma with fluid that extended into the left inguinal canal in addition to a new retroperitoneal fluid collection (Figure 1(c) and (d)). Colorado. CT scans of the abdomen/pelvis were reviewed by a urologist with experience in sarcomas, and interpreted as being suspicious for a malignant cystic mass (Figure 1(e)-(g)). He underwent a third laparotomy, and intraoperatively, multiple cystic, hemorrhagic masses were removed along with the left testicle which was completely surrounded by the mass (Figure 1(e)-(g)).
Immunohistochemistry analysis. (a-c) 100X, 200X, and 400X, respectively of most atypical areas with histologic and IHC results consistent with undifferentiated pleomorphic sarcoma (UPS). Less than 5% of the reviewed tumor looked like UPS. These areas feature scattered large, bizarre, frankly malignant pleomorphic cells, present in a background of moderately atypical spindled to epithelioid sarcoma cells, with some admixed collagen deposition. (d) Besides the areas of UPS (a-c), other areas were also compatible with sarcoma; these areas were often present along the apparent "surfaces" of the tissue, where it presumably bordered cystic spaces. These areas consisted of hypercellular proliferations of mildly to moderately atypical spindle cells with a "streaming" growth pattern. The results of IHC studies of these areas also showed no definite line of differentiation (undifferentiated). These areas accounted for 5-10% of reviewed tumor area. As these areas were usually located along the apparent surfaces of cystic spaces, which were often bloody spaces, they often had admixed hemorrhage and hemosiderin deposition. (e) The majority of the solid tissue within the specimen appeared benign and reactive - as shown in this picture. These areas often consisted of reactive-appearing collagenous fibrosis, with some focal entrapped fat, and with foci of chronic inflammation. (f) Similar to (d), showing the second (spindled) pattern of malignant cells along an apparent surface of a hemorrhagic cystic space. (g) The majority of the solid areas of this specimen showed reactive-appearing collagenous fibrosis, with hemosiderin deposition, with foci of chronic inflammation, and with foci of entrapped fat. (h) Also present within the specimen, admixed with the benign-appearing fibrotic areas and the few areas appearing consistent with sarcoma, were areas of organized hemorrhage/hematoma.
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Some foci demonstrated frankly malignant cells that were compatible with pleomorphic sarcoma (Figure 2(a)-(c)). Figure 2 shows different sections of the mass for comparison.