Case Report

Malignant Fibrous Histiocytoma of

Chest Wall

Dr. Nugroho Sigit H. SpRad

INTRODUCTION
• Malignant Fibrous Histiositoma (MFH) is a
mesenchymal tumor with differentiation toward
fibroblast-like cells and histiocytes
• One of the most frequent location of MFH is a
soft tissue, with a higher incidence in the lower
extremities followed by upper extremities and
retroperitoneum
• MFH can be found in various organs
• MFH in the chest wall is a rare condition
INTRODUCTION
• The most common chest wall mass with rib
destruction is metastasis, followed by multiple
myeloma
• This report describes and illustrates the clinical,
radiologic and pathologic features of a case of
primary MFH of the chest wall affecting a 33-
year old man
• We also discuss the differential diagnosis of
chest wall mass with rib destruction
CASE REPORT
• A 33-year-old man developed intermittent
upper left chest wall pain, without cough and
dyspneu
• He had no prior history of smoking or asbestos
exposure. He had no known underlying
systemic disease
• Radiologic studies included a posteroanterior
and lateral chest radiograph and computerized
tomography (CT)
 CHEST RADIOGRAPH

A round mass lesion in the left lateral chest, rounded,

well defined, obtuse angle (+), calsifications (+)
COMPUTERIZED TOMOGRAPHY (CT)
COMPUTERIZED TOMOGRAPHY (CT)

• CT demonstrated the presence

of relatively well defined,
ovoid shaped mass at the
latero sinistra chest wall.
• Bony destruction third rib
• There was no periosteal
raction
• The interface between the
mass and the lung was
smooth.
• There was no mass and
nodule in the lung
 Microscopic findings
A. Few cartilage tissues and bone tissue with
cellular tumors are partly impressed in the
beams, which can be part of giant cells with
more than one nucleus. Cells are composed of
spindle, atipi, polymorphic, cytoplasmic cells of
many round, oval, hyperchromatic nuclei
B. Compact bone tissue with bone marrow and
cartilage tissue with tumors such as A.
No sign of malignancy
Impression: The left third rib: Malignant Fibrous
Histiocytoma grade I
DISCUSSION
• Radiography MFH is seen as an osteolytic area with
bone destruction and extensive transition zone

• The location of the lesion is usually eccentric close to

the end of the bone or inside the intra-articular

• In most cases it shows a little or no sclerotic reaction,

no periosteal reaction, and sometimes appears as a
soft-tissue mass
DISCUSSION
• MFH radiographic findings are not specific and can
be observed similar to other disease features

• Chest X-rays are often performed on initial evaluation

in patients who are clinically suspected of being
malignant chest wall tumors
DISCUSSION
• CT and magnetic resonance (MR) imaging are useful
for the radiological evaluation of the soft tissue
component
• CT can provide more accurate detection of cortical
bone destruction. The mass usually shows intense
enhancement on CT with a clear margin separating it
from the surrounding tissue
• The mass often shows decreased central attenuation
due to necrosis, hemorrhage and mucoid material
DISCUSSION
• In this case, a 33-year-old man, with histology results
in a diagnosis of MFH grade I, at the left third rib
• Epidemiologically the peak incidence of MFH often
occurs in the fifth and sixth decades.
• Although rare in children, angiomatoid subtypes often
occur in patients under 20 years of age
 DISCUSSION
• In plain chest radiographs were suggested as mesothelioma
• Clinically mesothelioma : chest pain, shortness of breath,
cough, tiredness and lethargic lethargy, sometimes affects
the production of antidiuretic hormones and gynecomastia
and is often associated with asbestos exposure
• Clinical anamnesis patients: upper left chest pain without
exposure to asbestos and no hormonal or gynecomastia
disorders
• So that clinical diagnosis towards mesothelioma can be
removed
Radiograph
Mesothelioma images are unilateral, concentric,
plaquelike, there is thickening of the nodular
pleura. Generally there is pleural effusion and
pleural calcification is seen in 20% of patients
with mesothelioma
MFH: no pleural effusion and rarely any
calcification
CT
• CT demonstrated the presence of relatively
well defined, ovoid shaped mass at the latero
sinistra chest wall, bony destruction costa III
(+), periosteal reaction (-), suggested mass
from bone
 Differential diagnosis of Malignant Fibrosa Histiocytoma,
Sarcomatoid mesothelioma and Osteosarcoma
Malignant Fibrosa Histiocytoma Sarcomatoid Osteosarcoma
mesothelioma
Demography Oder adults Seventh decade - Osseus tumor : Third
Man = Woman >85 % laki-laki and fourth decades
- Ekstraosseus tumor :
fifth decade
- Predominant man
Symptoms - Associated with radiation - Chest pain - Chest wall mass with
and causes therapy and previous bone - Dyspnea chest pain
lesions - Hormone production - Associated with
- Chest wall tumor, lung tumor disorders radiation therapy and
- Cough, dyspnea - Associated with previous bone lesions
- Hemoptoe paparan asbestos - Local recurrent
Radiograph - Muscle origin or bone origin - Diffuse and noduler - The mass arising of
- Rare calsification pleural thickening costae, scapula or
- Non specific - Focal mass clavicula
- Rare or no periosteal - Matrix osteoid
calsifications
- Metastasis to the
lung and lymph
nodes
Histo- Variabel Storiform-pleomorphic Predominan dari spindle Visible osteoid in a
pathology and myxoid subtype cell. malignant stroma
 Differential diagnosis of Malignant Fibrosa Histiocytoma,
Sarcomatoid mesothelioma and Osteosarcoma
Malignant Fibrosa Sarcomatoid
Criteria Osteosarcoma Kasus
Histiocytoma mesothelioma
Location Lower limb 49% Knee (55%) pleura The left third rib
Upper limb 19% Flat bones (20%)
Retroperitoneum (16%) and
Peritoneal cavity (5%-10%)

Epiphysis or diaphysis, Metaphysis (80%)

diaphysis (10%)
Eccentric or intraarticullar Costo chondral Intramedullary
junction
Ragiograph Intramedulary lytic lesions, Sclerotic mass, Pleural massa, Homogenous
geographic bone destruction, intramedularry, ill lobulated, opacity, obtuse
permeative and mouth eaten defined, extend to the Pleural effusion angle (+),
cortex, bone Ipsilateral ballooning in the
destruction (mouth left third rib
eaten)
Matrix (CT) Matrix condroid (-), density Osteoid matrix without Calsifications (+) Density equals
equals muscle, decreased chondroid matrix muscle
central attenuation due to Rib destruction
necrosis Well defined,
Irregular borders
Calsifications (-)
Cortical layer Cortical disruption Destruction expansive
Periosteal reaction (+) rare (+) aggressive  (-) (-)
∆ Codman, sunburst
CONCLUSION
In this case, a 33-year-old man, with histology results in
a diagnosis of MFH grade I, at third rib

Chest radiograph, appear a round mass lesion in the

left lateral chest, rounded, well defined, balonning,
obtuse angle (+), calsifications (+)

CT demonstrated the presence of relatively well defined,

ovoid shaped mass at the latero sinistra chest wall,
relative expansive, irregular borders with destruction
in the lateral and posterior third rib and no periosteal
reaction
CONCLUSION
The radiological imaging of MFH in this case is different
from that of mesothelioma in the absence of pleural
thickening, pleural effusion and calcification is rare and
differs from the osteosarcoma image in the absence of
periosteal reactions and calcification
Thank you