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case_images: (A) At low power, the original biopsy sample showed reactive skin and dermal scar (upper right) overlying the superficial aspect of a hemorrhagic lesion with myxoid stroma in the superficial subcutis at lower left. While broadly transected at the base, the mixed inflammatory infiltrate and extravasated erythrocytes likely contributed to the original case contributor's favoring nodular fasciitis as the diagnosis (H&E, photographed at 40X). (B) Computed tomography (CT) of the patient's left calf taken after the initial excision and before the secondary excision. Sagittal section with a hyperdense lesion located within the soft tissue of the posterior aspect of the calf. Consistent with a local recurrence of the tumor after the initial surgery.. Abbreviation: H&E, hematoxylin and eosin.
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case_images: Histologic review (Figure 1A) at our institution for treatment purposes, acknowledging the possibility of myxoid nodular fasciitis, considered a number of additional myxoid neoplasms and demonstrated no rearrangement of the EWSR1 locus by break-apart fluorescence in situ hybridization. A computed tomography (CT) scan was ordered, which displayed a nonspecific appearance (Figure 1B).
case_images: Gross image of resected tumor at the completion of the re-excision of the tumor. Wide local excision with resection of the fascia overlying the muscle belly of the gastrocnemius and Achilles tendon. Ruler displayed for scale is slightly larger than 6 inches and 15 cm in length.
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case_images: Based on the positive margins and rapid regrowth, the decision was made for the patient to undergo a wide local excision of the skin and subcutaneous fat of the left calf down to the level of the gastrocnemius (Figure 2).
case_images: (A) Upon resection, a distinctly nodular tumor with myxoid stroma and interstitial hemorrhage is seen in the subcutis (H&E, photographed at 12.5X). (B) At higher power, the tumor's inflammatory and myxoid stroma is apparent, as are the atypical plump epithelioid to spindled lesional cells. A characteristic "Reed-Sternberg-like" cell with bilobed nucleus and prominent nucleoli is apparent at center (H&E, 200X). (C) At high power, the nuclear atypia apparent is marked, as is a cell with engulfed inflammatory cells (neutrophils), representing the emperipolesis characteristic of this tumor type (H&E, 400X). (D) In the patient's re-resections, higher grade features were apparent, including very dense cellular areas with marked cellular and nuclear pleomorphism (left) as well as coagulative necrosis (right; H&E, 200X).. Abbreviation: H&E, hematoxylin and eosin.
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case_images: Histologically, this tumor showed a nodular lesion (Figure 3A) based in the subcutis. It was variably but moderately cellular, with nodules of spindled to atypical epithelioid ganglion-like cells scattered in a myxoid background, some with the bilobed "Reed-Sternberg-like cell" nuclear morphology; emperipolesis was present (Figure 3B-C). An updated biopsy displayed recurrent, high-grade sarcoma (Figure 3D).
case_images: Gross image of the patient's left calf approximately 1 year after her second excision. The wound displays local recurrence with ulceration of the calf.
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case_images: Twelve months after her secondary excision, the patient's left calf developed an area of skin ulceration, indicating further progression of her locally recurrent tumor (Figure 4).
case_images: (A) CT-scan of the patient's thorax consistent with a 1500 mL malignant pleural effusion of the right thorax. (B) A representative field from the cell block preparation from the patient's pleural effusion demonstrated an atypical cellular population comprising epithelioid and spindle cells and myxoid stroma, again with admixed inflammatory cells, documenting distant metastatic thoracic recurrence for this tumor (H&E, 200X).. Abbreviation: CT, computed tomography; H&E, hematoxylin and eosin.
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case_images: She was admitted for acute hypoxic respiratory failure with a large right pleural effusion (Figure 5A). An aspirate smear was positive for metastatic myxoid sarcoma (Figure 5B), consistent with the patient's previous high-grade sarcoma.