fatty tumours - pathkids.compathkids.com/trainingdays/fatty_tumours.pdf · 2011. 10. 20. ·...
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FATTY TUMOURS
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LIPOMA
• Age
• Distribution
• Macroscopic
• Microscopic
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LIPOMA
• Middle-aged / elderly
• M = F
• Mostly superficial (subcutis), occasionally
deep
• Mostly central (rare on face, hands and feet)
• Macroscopic (many show fibrosis, necrosis,
myxoid change etc)
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DEEP LIPOMAS
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INTRAMUSCULAR LIPOMA
• Mostly adults
• M > F
• Large muscles of thigh, shoulder,
upper arm.
• Infiltrative growth pattern.
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INTRAMUSCULAR LIPOMA
• Differential diagnosis
– Intramuscular haemangioma
– Angiomatosis
– Lipomatosis
– Atypical lipomatous tumour.
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NEURAL FIBROLIPOMA
• Fatty mass in forearm / wrist / hand of
young person
• Diffuse infiltration of major nerve, often
median nerve.
• One third have macrodactyly.
• Do not excise – peripheral nerve defect.
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JOINT LIPOMA
(lipoma arborescens)
• Mostly adults (M > F)
• Most often knee (usually unilateral)
• Occasionally other joints (shoulder, hip,
elbow)
• Associated with degenerative joint
pathology
• Probably reactive rather than neoplastic
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ANGIOLIPOMA
• Age
• Symptoms
• Distribution
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ANGIOLIPOMA
• Young adults
• Forearm (trunk, upper arm)
• Painful / tender
• Multiple
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LIPOMATOSIS
• Not a discrete fatty mass
• Diffuse overgrowth of mature fat
• May involve subcutis and muscle
• Many subtypes: Diffuse (extremity or trunk)
Symmetric (neck, Madelung disease)
Pelvic
Steroid
HIV lipodystrophy (protease inhibitors)
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SPINDLE CELL / PLEOMORPHIC
LIPOMA
• Age
• Gender
• Distribution
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SPINDLE CELL / PLEOMORPHIC
LIPOMA
• Middle-aged / elderly
• M >> F
• Shoulders / posterior neck
• Mostly subcutis
• Occasional dermal or odd site
(e.g. oral cavity)
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PLEOMORPHIC LIPOMA
• May show features of spindle cell lipoma
• Also shows degenerative nuclear features
• Multinucleated tumour giant cells (floret cells)
• Lipoblasts present
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HIBERNOMA
A benign tumour of brown fat
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BROWN FAT
• Brown fat – multiple cytoplasmic lipid vacuoles.
• Mainly found in infants / children.
• Disappears / diminishes in adults.
• In children – extensive including interscapular, neck, mediastinum, intra-abdominal, retroperitoneum.
• In adults – around kidneys / aorta, mediastinum, neck.
• Function – heat production.
• Brown – because of increased vascularity and increased mitochondria.
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HIBERNOMA
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HIBERNOMA
• Mostly adults
• Most commonly thigh
• Mostly subcutaneous
• 10% intramuscular
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HIBERNOMA
Differential Diagnosis
• Granular cell tumour
(both S100 positive)
• Rhabdomyoma
(desmin / myogenin positive)
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LIPOBLASTOMA
• Paediatric form of lipoma
(i.e. is benign).
• Mimics liposarcoma.
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LIPOSARCOMA and LIPOBLASTS
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LIPOBLAST
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LIPOBLAST
• Enlarged hyperchromatic nucleus indented by a well-defined cytoplasmic vacuole.
• May be unilocular or multilocular.
• Correct histological context.
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LIPOBLAST Mimics
• Fat atrophy
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LIPOBLAST Mimics
• Fat atrophy
• Vacuolated macrophages (e.g.
silicone)
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LIPOBLAST Mimics
• Fat atrophy
• Vacuolated macrophages
(e.g. silicone)
• Tumours
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LIPOBLASTS
• Liposarcoma
• Pleomorphic lipoma
• Chondroid lipoma
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LIPOSARCOMA
LG • Well differentiated / atypical
lipomatous tumour
LG • Myxoid liposarcoma
HG • Pleomorphic liposarcoma
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LIPOSARCOMA
LG • Well differentiated / atypical
lipomatous tumour
HG
De-differentiated
LG
• Myxoid liposarcoma
HG
Round cell liposarcoma
HG
• Pleomorphic liposarcoma
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ALT/WDLS
• Locally aggressive
• Non-metastasising
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ALT / WDLS
• Atypical fat (+ lipoblasts)
• Sclerosis + bizarre stromal cells
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ALT / WDLS
• Lipoma-like (fat predominant)
• Sclerosing (sclerosis predominant)
• Inflammatory (lymphocytes + plasma
cells)
• Spindle cell (spindle cells predominant)
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ALT / WDLS
• Deep - retroperitoneal
- Intramuscular
• Superficial, subcutis
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PROGNOSIS
• Retroperitoneum – Poor (recurrence,
high-grade transformation)
• Extremities (subcutaneous, IM) - Good
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HIGH-GRADE TRANSFORMATION
in ALT / WDLS
• De-differentiation
• Non-lipogenic sarcoma (pleomorphic, low-grade, inflammatory MFH-like, myxofibrosarcoma-like, whorling pattern)
• High-grade or low-grade
• Heterologous differentiation (smooth muscle, rhabdomyoblasts)
• Distant metastases (15 to 20%)
• Mortality (25 to 30%)
• Extremity ALT (<2% de-differentiation risk)
• Retroperitoneal ALT / WDLS (>20% risk)
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MYXOID LIPOSARCOMA
• Low-grade sarcoma
• Bland oval / short spindle
cells
• Lipoblasts
• Vasculature
– thin-walled capillary
– plexiform (chicken-wire)
• Myxoid ground substance
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ROUND CELL LIPOSARCOMA
• High-grade transformation of MLS
• >5% round cell, worse prognosis
• Increased cellularity
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MYXOID LS / ROUND CELL LS
• 2nd most common LS (1/3)
• Young adults (peak in 4th and 5th decades)
• Deep soft tissue
• 2/3 in thigh musculature
• T (12;16) translocations (CHOP; FUS fusion)
• Metastasis in 30-40% of cases (e.g. to retroperitoneum
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DIFFERENTIAL DIAGNOSIS
• Myxoid LS
– other myxoid tumours especially
myxofibrosarcoma
– Extraskeletal myxoid chondrosarcoma
– Lipoblastoma
• Round cell LS
– Other round cell malignancies.
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ROUND CELL MALIGNANCY
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PLEOMORPHIC LS
• High-grade LS
• Rarest LS subtype (5%)
• Elderly (>50 years)
• Deep soft tissue
• Extremities
• Approximately 40% metastasis, 40%
mortality
• Worse prognosis than de-differentiated LS
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PLEOMORPHIC LS
• Many pleomorphic lipoblasts
• Pleomorphic spindle cells +
occasional lipoblasts
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DIFFERENTIAL DIAGNOSIS of
PLEOMORPHIC LS
• Pleomorphic spindle cell
sarcoma
• De-differentiated LS
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LIPOBLASTOMA
• A benign fatty tumour of infants (1st 3 years)
• Superficial or deep
• Lobules – fibrous septa
• In lobules – variable fatty differentiation
• Myxoid sarcoma LS-like areas
• Mature to mature fat
• No 12;16 translocation
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DIFFERENTIAL DIAGNOSIS OF
LIPOBLASTOMA
• Myxoid LS
• Lipoma