Epithelioid inflammatory myofibroblastic sarcoma: a case report
Case Report

Epithelioid inflammatory myofibroblastic sarcoma: a case report

Daniel E. Sarmiento1, Jessica A. Clevenger2, Gregory A. Masters3, Thomas L. Bauer4, Brian T. Nam4

1Department of Surgery, 2Department of Pathology, Christiana Care Health System, Newark, DE 19718, USA; 3Department of Medical Oncology, 4Department of Thoracic Surgery, Helen F. Graham Cancer Center & Research Institute, Newark, DE 19713, USA

Correspondence to: Daniel E. Sarmiento, MD. Department of Surgery, Christiana Care Health System, 4755 Ogletown-Stanton Road, Suite 2E70-B, JHA Education Center, Newark, DE 19718, USA. Email: dsarmiento@christianacare.org.

Abstract: Inflammatory myofibroblastic tumor (IMT) of the lung is a rare malignancy with few cases reported in the literature. Histologically, it is composed by spindle cells and an infiltrate of inflammatory cells. Children and young, non-smoking adults constitute the majority of cases, the clinical behavior ranges from a benign entity to a malignant process with rapid recurrence and metastatic progression. We present a case of epithelioid inflammatory myofibroblastic sarcoma (EIMS) of the pleura, a malignant variant of IMT, which was initially treated with debulking surgical resection followed by systemic chemotherapy. The tumor was found to have an anaplastic lymphoma kinase (ALK) gene rearrangement. An ALK directed tyrosine kinase inhibitor was used with an impressive response, the patient remains in remission nearly 1 year after presentation. The pathogenesis, pathologic findings, clinical behavior and imaging of pulmonary EIMS are discussed.

Keywords: Pleura; sarcoma; gene polymorphism


Submitted Aug 18, 2015. Accepted for publication Oct 10, 2015.

doi: 10.3978/j.issn.2072-1439.2015.10.55


Introduction

Inflammatory myofibroblastic tumors (IMT) were first reported in 1905 by Birch-Hirschfield (1). IMTs are rare mesenchymal neoplasms of intermediate biologic potential (2). Histologically composed of spindle cells and an infiltrate of inflammatory cells (3) they are typically seen in children and young, non-smoking adults, both sexes are affected equally and there are no significant racial or geographical differences (4). They usually present as a solitary mass often in the lung, retroperitoneum or abdominopelvic region. Most are asymptomatic but when symptoms occur they commonly consist of fever, cough, pain, hemoptysis, or weight loss their clinical behavior ranges from a benign entity to a malignant process with rapid recurrence and metastatic progression (5,6). A variant of IMT known as epithelioid inflammatory myofibroblastic sarcoma (EIMS), as described in our case, displays a malignant behavior with a high potential for recurrence and is associated with a poor prognosis (7,8).


Case report

A 71-year-old Caucasian male presented with dyspnea on exertion and a 20-pound weight loss over a 3-month time period. A chest X-ray initially showed a pleural effusion and he underwent thoracentesis during which two liters of serosanguineous fluid was removed. Cytology was non-diagnostic. The patient had return of his symptoms and a chest computed tomography (CT) showed a recurrent effusion (Figure 1) prompting surgical evaluation. With the concern for an underlying neoplastic process, the patient agreed to undergo a diagnostic and therapeutic surgical exploration.

Figure 1 Moderate-sized left pleural effusion with compressive atelectasis of the left lower lobe.

A video-assisted thoracoscopic surgical (VATS) procedure was performed and intraoperative findings included not only a pleural effusion, but a dominant, 12.5 cm × 12 cm × 8 cm, pleural-based mass arising from the lower lobe as well as multiple, 1-4 cm tumor implants throughout the thoracic cavity. The mass as well as many of the tumor implants were removed in an R2 resection. Pathologic examination determined that this was a malignant neoplasm with features consistent with an EIMS (findings discussed below). Molecular analysis revealed an anaplastic lymphoma kinase (ALK) gene rearrangement.

The patient clinically-improved postoperatively, but developed recurrent symptoms within one month. A CT scan showed dramatic progression of disease (Figure 2). After discussion at our multidisciplinary thoracic oncology tumor board, the patient underwent treatment with crizotinib and had a significant clinical response. However, after 2 months, the patient again developed recurrent symptoms. He was switched to a second-line ALK inhibitor with near-complete, radiologic resolution of disease (Figure 3). The patient is nearly 1 year from surgery and remains in clinical remission.

Figure 2 Chest computed tomography coronal and axial views depicting numerous lobular-nodular pleural-based masses throughout left thorax, some of which demonstrate extension into the adjacent fat planes, left mediastinal borders and left hilar region.
Figure 3 Chest computed tomography coronal and axial views evidence remarkable improvement with almost total resolution of pleural masses and fluid. Small amount of fluid/thickening remains medially.

Pathological findings

Microscopic features show a hypervascular tumor with myxoid stroma, focal necrosis and cartilaginous differentiation. Signet ring cells were present. Final interpretation was consistent with a malignant epithelioid neoplasm most suggestive of an EIMS. This tumor was found to have a 2p23 ALK gene rearrangement by immunohistochemistry and fluorescence in situ hybridization (FISH).


Discussion

EIMS may present in different locations but there are common features shared by all described in table (Table 1).

Table 1
Table 1 EIMS characteristics
Full table

ALK is a tyrosine kinase receptor predominately expressed in the central nervous system (9). Rearrangements involving the ALK locus on chromosome 2p23 have been documented in approximately 36-60% of IMT’s (10). While the correlation between the expression of ALK and the prognosis of IMT remains unknown, several case reports have suggested that IMTs with fusion between ALK and ran-binding protein 2 (RANBP2), usually exhibit a more aggressive clinical course with a recurrence rate of 88% and metastasis rate of 25%. Fewer than 10 cases of IMTs with genetically confirmed RANBP2-ALK fusion protein have been reported to date and only in males and tumors arising from abdominal organs (e.g., the peritoneum, mesentery, and omentum) (2).

The treatment of choice for IMT/EIMS is complete surgical resection when possible. However, recurrence is common after resection (8). Several reports suggest prolonged disease-free survival given that EIMTs frequently contain a rearranged ALK gene. While targeted tyrosine kinase inhibitors have been shown to be effective in certain non-small cell lung cancers and gastrointestinal stromal tumors, their role in EIMTs is still under investigation (8). Our patient with an ALK gene rearrangement has had a dramatic response to ALK targeted therapy, both clinically and now radiologically.


Conclusions

Little is known about the true incidence, natural history, or preferred treatment of this rare entity. The few case reports in the literature have described a combination of surgery and systemic therapy with ALK inhibitors when an ALK mutation is present. The effectiveness of alternative treatment modalities such as radiotherapy, chemotherapy, and steroids is uncertain.


Acknowledgements

None.


Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.


References

  1. Gallego L, Santamarta TR, Blanco V, et al. Inflammatory myofibroblastic tumor of the lung and the maxillary region: a benign lesion with aggressive behavior. Case Rep Dent 2013;2013:879792.
  2. Li J, Yin WH, Takeuchi K, et al. Inflammatory myofibroblastic tumor with RANBP2 and ALK gene rearrangement: a report of two cases and literature review. Diagn Pathol 2013;8:147. [PubMed]
  3. Fisher C. Myofibroblastic malignancies. Adv Anat Pathol 2004;11:190-201. [PubMed]
  4. Gleason BC, Hornick JL. Inflammatory myofibroblastic tumours: where are we now? J Clin Pathol 2008;61:428-37. [PubMed]
  5. van den Heuvel DA, Keijsers RG, van Es HW, et al. Invasive inflammatory myofibroblastic tumor of the lung. J Thorac Oncol 2009;4:923-6. [PubMed]
  6. Ezzine-Baccari S, Bacha D, Sassi S, et al. Inflammatory myofibroblastic tumor of the lung: a benign lesion with aggressive behavior. Gen Thorac Cardiovasc Surg 2012;60:531-3. [PubMed]
  7. Kozu Y, Isaka M, Ohde Y, et al. Epithelioid inflammatory myofibroblastic sarcoma arising in the pleural cavity. Gen Thorac Cardiovasc Surg 2014;62:191-4. [PubMed]
  8. Fujiya M, Kohgo Y. ALK inhibition for the treatment of refractory epithelioid inflammatory myofibroblastic sarcoma. Intern Med 2014;53:2177-8. [PubMed]
  9. Patel AS, Murphy KM, Hawkins AL, et al. RANBP2 and CLTC are involved in ALK rearrangements in inflammatory myofibroblastic tumors. Cancer Genet Cytogenet 2007;176:107-14. [PubMed]
  10. Butrynski JE, D’Adamo DR, Hornick JL, et al. Crizotinib in ALK-rearranged inflammatory myofibroblastic tumor. N Engl J Med 2010;363:1727-33. [PubMed]
Cite this article as: Sarmiento DE, Clevenger JA, Masters GA, Bauer TL, Nam BT. Epithelioid inflammatory myofibroblastic sarcoma: a case report. J Thorac Dis 2015;7(10):E513-E516. doi: 10.3978/j.issn.2072-1439.2015.10.55