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American Journal of Medical Case Reports, 2017, Vol. 5, No. 8, 217-220
Available online at http://pubs.sciepub.com/ajmcr/5/8/4
©Science and Education Publishing
DOI:10.12691/ajmcr-5-8-4
Malignant Fibrous Histiocytoma in Lungs:
A Case Report
Yusfitaria Alvina1, Muhammad Nuralim Mallapasi2, Rosie Rosie2, Prihantono Prihantono1,*
1Department of Surgery, Faculty of Medicine Hasanuddin University, Makassar, Indonesia
2Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine Hasanuddin University, Makassar, Indonesia
*Corresponding author: prihantono.md@gmail.com
Abstract Malignant Fibrous Histiocytoma (MFH) is a mesenchymal tumor from fibroblast differentiation and
histiocyte like cells. This tumor found in 1964 and representing the biggest type of sarcoma. The Incidence of
Malignant Fibrous Histiocytoma in lung about 20-24%, with the men and women ratio 2: 1. Diagnosis of Malignant
Fibrous Histiocytoma’s hard because found in a patient without symptoms. In this case, a 62 years old patient,
professional history as a gold miner for 36 years complained chest pain particularly in the left chest. Investigated by
posteroanterior chest radiograph and thoracic CT scan obtained a picture of the left lung tumor, then performed
thoracotomy surgery and excision of tumors. Histopathological examination showed a Malignant Fibrous
Histiocytoma. Patient is repatriated from the hospital 5 days after surgery in good condition and undergoes routine
follow up every six months. Follow up 3 years after Surgery patient is in good health and no sign of residif of the
tumor.
Keywords: malignant fibrous histiocytoma, lungs, fibroblast
Cite This Article: Yusfitaria Alvina, Muhammad Nuralim Mallapasi, Rosie Rosie, and Prihantono
Prihantono, “Malignant Fibrous Histiocytoma in Lungs: A Case Report.” American Journal of Medical Case
Reports, vol. 5, no. 8 (2017): 217-220. doi: 10.12691/ajmcr-5-8-4.
1. Introduction
Malignant Fibrous Histiocytoma (MFH) is a mesenchymal
tumor with differentiation towards fibroblast and hot
histiocyte cells. The malignant origin of malignant cells
thought to be primitive multipotent mesenchymal cells,
20% -24% of soft tissue sarcomas are more common in
white patients than in Africa or Asia. The male and female
ratio is approximately 2: 1. Malignant Fibrous
Histiocytoma is most prevalent in the extremities (70% -
75%, with the lower extremity of 59% of cases), followed
by retroperitoneum [1].
2. Case Report
A man, aged 62 years, was admitted to hospital with a
chief complaint of chest pain left who felt since two years
ago, pain is intermittent, pain is radiating to the neck and
left backs, patients also complain of a cough intermittent
in 2 months latest. History undeniable coughing up blood,
no history of shoulder pain, no history of hoarseness,
difficulty swallowing no history, no history of fever,
weight loss history of more than 10 kg in the last six
months denied. History of blurred eyes, headaches and
seizures is denied. Patients have a history of working in
the field, contact with dust exposure since 36 years ago.
History of smoking for ten years with a pack of cigarettes
per day. The same family history of disease does not exist.
Table 1. Laboratory examination of patients obtained the following
results
Examination
2 June 2014
18 June 2014
HGB
14,8 g/dL
14,9 g/dL
WBC 10,4 x 103/mm3 6,3 x 103/mm3
HCT 43,9 % 43,3 %
PLT 251 x 10
3
/mm
3
286 x 10
3
/mm
3
LED
-
18/25
CT
10’’
8’’
BT 1’’ 3,30’’
Neutrofil 65,0 % 47,0 %
Lymphosit 22,3 % 34,7 %
Monosit
6,6%
8,6 %
Eosinofil
5,7 %
9,3 %
Basofil 0,4 % 0,4 %
PT 13,9 second -
APTT 38,5 second -
Glucose
99 mg/dL
113 mg/dL
Ureum
21 mg/dL
18 mg/dL
Creatinin 0,9 mg/dL 0,8 mg/dL
Albumin - 4,2 g/dL
SGOT 26 U/L 22 U/L
SGPT
20U/L
21 U/L
Sodium
-
148 mmol/L
Potassium - 4,3 mmol/L
Chloride - 103 mmol/L
HBsAg Negative Negative
218 American Journal of Medical Case Reports
Physical examination obtained generalize status:
Moderate, moderate nutrition, good conscious. The patient
weighs 68 kg, Height 159 cm. Vitalis status obtained
Blood Pressure: 120/90 mmHg. Pulse: 80 x / min,
Respiration: 20 x/min, Axillary temperature: 36.6°C.
Status localise thoracic obtained Inspections: Hemithorax
right and left symmetrical, color is equal, palpation: Vocal
Fremitus hemithorax the right and left alike, no tenderness,
no palpable tumor mass, Percussion: Hemithorax right-
resonant, hemithorax left deaf as high as ICS IV - VI and
Auscultation: Right and left hemithorax breathing sounds
are equal, no Ronchi, no wheezing, pure I / II heartbeat.
In the results of chest X-ray examination (April 29th,
2014), the results obtained as follows: The second
broncho vascular lung appears healthy, does not seem to
be active specific processes in both lungs. Appearance
opacity, firm limit, slippery outline, without calcification
or water bronchogram sign on laterobasal left hemithorax;
Cor is not enlarged. Aortic elongation; Both tapered
sinuses, normal diaphragms; Intact bones; A Costo-
Frenicus angle appears in the right hemithorax, whereas it
does not appear in the left hemithorax. Impression: lung
tumor sinister.
Figure 1. Thorax X Ray examination
Figure 2. CT Scan Thorax examination,coronal view
Then examined CT Scan Thorax (April 30th, 2014)
obtained results as follows: Looks solid mass measuring ±
8.8 x 7.43 cm density 48.45 HU, the visible border of the
slippery edge. This mass is located in the left inferior lobe
and very stinging density contrast to 72.29 HU. The mass
is not urgent to the organ, and there is no visible
destruction of the surrounding bones; Bronchovascular
abnormal left lung lesions within normal limits, no
specific features of the left lung; Trachea and carina are
good; No visible enlarged lymph nodes; Cor is not
enlarged. Hepar: no tumor metastases appear on the liver.
No visible enlargement of the suprarenal gland. The bones
are intact; Impression: T2N0M0 (IB stage) lung tumor.
Figure 3. CT Scan Thorax examination, axial view
By CT thoracic scan results, additional investigations
were performed on CT Scan Vertebra Thoracolumbar, CT
scan of the Head, abdominal ultrasound, and bronchoscopy
to determine whether or not the tumor metastases were
present. In these patients, other investigations are above
normal.
Based on history of the disease, physical examination,
and CT scan result, the patient was diagnosed with inferior
lobe lung tumor in suspicion malignancy and anterolateral
heterogeneous thoracic and lobectomy surgery on 18 June
2014 at Academic Hospital of Jaury Makassar but
intraoperative obtained tumor stemmed at inferior lobe of
the left and free of surrounding tissue (resectable), so it
was decided to do heterogeneous anterolateral thoracotomy
surgery and tumor excision.
Figure 4. Mass tissue results from the operations
American Journal of Medical Case Reports 219
Figure 5. Microscopic anatomical pathology examination
The results of anatomical pathology examination are as
follows: Macroscopic: a solid tissue of a square shape of 9
cm x 7 cm x 3 cm, reddish-white cross, chewy, 1 coupe.
Microscopic: tissue preparation coated with connective
tissue capsule, below it appears proliferation of atypical
core fibro histiocytic cells, pleomorphic, prominent
nucleolisitik, mitosis activity <9/10 small field of view,
tumor cells composed in the form of storiform and fascism,
no visible necrosis area. Grading differentiation: tumor
differentiated = 2, mitosis = 1, necrosis = 0, total score = 3.
Conclusion: Malignant Fibrous Histiocytoma, low-grade
malignancy.
After surgery, the patient is repatriated from the
hospital in good condition and undergoes routine control
every six months. The current state of the patient is good
and there is no residual tumor.
3. Discussion
The lung tumor is a neoplasm in the lung tissue that is
an abnormal new tissue growth in the lung. Benign or
Lung Tumors usually do not cause symptoms or signs,
usually found by chance on chest X-ray examination or
CT thoracic scan, but may also cause some symptoms
such as chest pain, cough, coughing, breathing, and fever
when experiencing infection. In these patients are found
symptoms of left chest pain experienced since 2 years ago
that felt lost arise and spread to the neck and back left [2].
Determination of a Tumor or an early-stage cancer is
essential because it affects the prognosis or recovery of
the sufferer. The association of risk factors with Lung
Tumors or Lung Cancer has been known from many
studies, namely 1. Tobacco smoke, the longer a person
exposed to tobacco smoke the greater the risk for lung
cancer; 2. Radon is an active radio gas formed in rocks
and certain soils. People working in mining are more
exposed to this gas; 3. Asbestos and chemicals such as
arsenic, chromium, nickel, soot, tar. Individuals who work
in construction projects or associated with these chemicals
have a high-risk of developing lung cancer; 4. Air
pollution from various gas components; 5. Hereditary
factors; 6. A person who has had Lung Cancer has a high
risk of suffering a second time; 7. Individuals with age
more than 50 years, associated with decreased immune
system. In this patient the history of his work as a field
worker in a mining company for 36 years that every day is
always in contact with nickel dust. The smoking history
lasts for 10 years by spending 1 pack of cigarettes a day [3].
Some types of benign lung tumors (benign) include
Hamartoma (most commonly found), Bronchial adenoma,
Chondroma, fibroma, or lipoma. While the kind of lung
cancer known as bronchogenic carcinoma is divided into
two types (based on microscopic), namely small cell lung
cancer, small cell lung cancers (SCLC) and non-small cell lung
cancers (NSCLC) Is a common type of lung cancer and
accounts for about 80% of lung cancer. There are five subtypes,
namely Adenocarcinomas, Squamous cell carcinomas, Large
cell carcinomas, Bronchial carcinoids and Sarcoma [4].
Sarcoma is a tumor of mesenchymal origin and is a rare
case found as a primary tumor in the lungs. Despite the
fact that pulmonary sarcomas are rare, the presence of
different sarcomas of origin must be removed before being
diagnosed with a primary tumor of the lung. These tumors
arise from the stroma of bronchial wall elements, blood
vessels, or pulmonary interstitium. Primary lung sarcoma
forms heterogeneous groups that contain different histologic
varieties. The majority are soft tissue sarcomas [5].
Prevalence Primary pulmonary sarcoma is estimated to
be less than 0.5% of all types of malignant tumors in the
lung. This type of tumor is rare and difficult to determine
the histological type. The emergence of sarcomas in
other organs should be removed before diagnosing the
tumor as a primary tumor of the lung. Malignant Fibrous
Histiocytoma is one of the largest types of sarcoma [6].
Rodriquez et al. [7] conducted a study of 7 primary
sarcoma cases in the lung and found men more affected
than women (6 men and 1 women), and in general, these
tumors can appear at any age, Average reported around
50-60 years. In another literature, it is explained that Malignant
Fibrous Histiocytoma is 20% -24% of soft tissue sarcoma
with male and female Ratio of approximately 2: 1. The
tumor peak incidence occurred in the fifth and sixth decades.
In this case, the patient was a 62-year-old man [7].
Primary lung sarcoma present in chest X-ray or CT
thoracic scan is depicted as tumor mass. This mass can
sometimes reach an enormous size and attack the
surrounding structures, and can also experience necrosis.
Primary sarcoma of the lung grows through the parenchyma
and in this way can reach a large size, once reported in
research Rodriquez [7] attained the size of 20 cm. The
nature of this tumor tends to be invasive and can spread
into the chest wall, mediastinum, or heart. In this patient, a
chest X-ray examination was done and the CT scan of
thorax, the impression of a left lung tumor. Intraoperative
obtained tumor mass size 8 cm x 8 cm x 5 cm consistency
solid chewy in hamus pulmonic inferior lobe sinus, stem
shape, and free from surrounding tissue (resectable) [8].
Malignant Fibrous Histiocytoma rarely metastasizes via
the lymphatic system, Reynard et al. have reported tumor
metastases through the lymph nodes of about 25%,
metastases are more common through the blood, and the
most commonly affected organ is the brain, liver, and
spine. Therefore, in this patient performed investigations
in the form of CT scan of the thoracolumbar vertebra,
head CT scan, abdominal ultrasound to find the presence
or absence of metastasis from the lung tumor. In this
patient, there is no metastatic description of the spine,
head or abdominal organs [9].
220 American Journal of Medical Case Reports
Table 2. AJCC GTNM Classification and Stage Grouping of Soft
Tissue Sarcomas quoted from AJCC Cancer Staging Manual 6th
edition
Stage
Grouping
Tumor
Grade
Primary
Tumor
Regional Lymph
Node Involvement
Distant
Metastasis
Stage I A
G1
T1
N0
M0
Stage I B
G1
T2
N0
M0
Stage II A
G2
T1
N0
M0
Stage II B
G2
T2
N0
M0
Stage III A
G3
T1
N0
M0
Stage III B
G3
T2
N0
M0
Stage IV A
Any G
Any T
N1
M0
Stage IV B Any G Any T Any N M1
Some literature reports that surgery with resection
methods is the best therapy. Adjuvant treatment with
radiotherapy and chemotherapy is indicated in patients
who can not complete resection, in patients who have
metastasized to lymph nodes or malignant tumor types but
the results do not lead to a significant increase in life
expectancy compared to surgical therapy alone[10].
Jeon [11] reported the use of doxorubicin chemotherapy
drugs administered to patients with Malignant Fibrous
Histiocytoma in the recurrent postoperative lung, the
patient's results were cured without frequent lung and
other organs for 36 months after surgery. Fletcher et al. [5]
reported the use of a combination of anthracycline
(epirubicin) chemotherapeutic drugs plus ifosfamide in the
Italian States was administered to patients with Malignant
Fibrous Histiocytoma in Lung who could not have a
complete resection. Mauri et al. [11] also reported patients
with Malignant Fibrous Histiocytoma in the Lung who
received chemotherapy in the form of therapeutic tyrosine
kinase inhibitor (sunitinib peroral), showed healing [11].
Based on the reporting of his research, Rodriquez [12],
all patients in his study who had Malignant Fibrous
Histiocytoma tumor type and were classified as T2 N0 M0,
and had a tumor diameter less than 12 cm, showed a long
life expectancy after only surgery. In this patient was
found Malignant Fibrous Histiocytoma T2N0M0 tumor
type (stage IB) and surgical therapy only [12].
Histological grading is an important prognostic factor
in the sarcoma. Therefore the classification of Tumor
Node Metastases (TNM) is modified into a staging system
of Grade Tumor Node Metastases (GTNM) for soft tissue
tumors. This system, which is clinically very useful, stratifies
patients into groups with a marked prognosis pattern. The
GTNM staging system is defined as follows [13]:
□ G - Tumor grade
• G1- Well differentiated.
• G2-Moderately Differentiated.
• G3-Poorly differentiated.
□ T - Tumor primer
• T1-The largest diameter of the tumor is less
than 5 cm.
• T2-The largest diameter of the tumor is more
than 5 cm.
□ N - Metastases to regional lymph nodes .
• N0-No metastases to lymph nodes.
• N1-with metastases to lymph nodes.
□ M – Length metastases
• M0 - There are no distant metastases
• M1 - There are distant metastases [14].
The prognostic factors depend on tumor size, tumor
type, age, histologic malignancy rate, metastases, and
comorbidities. Of all the sarcomas, the best prognosis is
shown by Malignant Fibrous Histiocytoma [15].
4. Conclusion
Malignant Fibrous Histiocytoma in the lungs is very
rare as a primary tumor. Preoperative diagnosis is difficult
to enforce because the tumor is rarely seen by endoscopy
and fine needle aspiration [16]. Surgical therapy is the best
and must be done radical resection to prevent recurrence.
Also, there is some literature that justifies the treatment of
adjuvant (chemotherapy or radiotherapy) after surgery [17].
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