CASE REPORT

Muir–Torre syndrome-associated pleomorphic liposarcomaarising in a previous radiation field

Masato Yozu & Pennie Symmans & Michael Dray &

Jennifer Griffin & Catherine Han & Daniel Ng &

Susan Parry & KP Wong

Received: 17 September 2012 /Revised: 29 November 2012 /Accepted: 29 December 2012 /Published online: 9 January 2013# Springer-Verlag Berlin Heidelberg 2013

Abstract Muir–Torre syndrome is a variant of Lynch syn-drome, characterised by sebaceous neoplasia and/or kera-toacanthomas associated with visceral malignancies. Muir–Torre syndrome is caused by germline mutations of one ofthe mismatch repair genes, frequently MSH2 and less fre-quently MLH1 and MSH6. Visceral malignancies associat-ed with Muir–Torre syndrome and Lynch syndrome includecolorectal, endometrial and other gastrointestinal, urologicaland gynaecological malignancies. Small numbers of Lynchsyndrome-associated soft tissue sarcomas have beenreported, but there are no reported cases of soft tissuesarcomas in Muir–Torre syndrome. In this study, we reporta 74-year-old man with known Muir–Torre syndrome withconfirmed MSH2 germline mutation, diagnosed with pleo-morphic liposarcoma of the right buttock in a previous

radiation field. The tumour showed loss of expression ofMSH2 and MSH6 on immunohistochemistry. Immunohis-tochemistry on another pleomorphic liposarcoma in a dif-ferent patient with no previous history of Muir–Torresyndrome or Lynch syndrome showed no loss of expressionof mismatch repair proteins. This is the first report of Muir–Torre syndrome-associated sarcoma and the first case ofpost-radiation sarcoma in Lynch syndrome.

Keyword Muir–Torre syndrome . Lynch syndrome .

Pleomorphic liposarcoma . Post-radiation sarcoma .

Mismatch repair gene

Introduction

Muir–Torre syndrome (MTS) is an autosomal dominant ge-netic condition, characterised by sebaceous neoplasia and/orkeratoacanthomas associated with visceral malignancies.MTS comprises a small subset (1–3 %) of Lynch syndrome(LS), with a common genetic background [1, 2]. LS is causedby germline mutations in one of four DNA mismatch repair(MMR) genes, most commonly MLH1 and MSH2, and lessfrequently MSH6 and PMS2 [3, 4]. MTS is characterised bygermline mutation ofMSH2 and less frequently ofMLH1 andMSH6 [5]. PMS2 germline mutation has not been reported inMTS. Visceral malignancies associated with MTS and LSinclude colorectal, endometrial, ovarian, gastric, small bowel,ureteric, renal pelvic, biliary tract, pancreatic and brain malig-nancies [3, 4]. Soft tissue sarcomas are not considered part ofthe LS tumour spectrum and only occasional LS-associatedsoft tissue sarcomas have been reported [6–10]. There hasbeen no reported case of soft tissue sarcoma associated withMTS. In this article, we report a pleomorphic liposarcoma ofthe right buttock in a 74-year-old man with known MTS withMSH2 germline mutation. The pleomorphic liposarcoma

M. Yozu (*) : P. Symmans : J. GriffinHistopathology Department, Middlemore Hospital, Hospital Road,Otahuhu, Auckland, New Zealande-mail: MasatoY@adhb.govt.nz

M. DrayHistology Department, Waikato Hospital, Hamilton, New Zealand

C. HanMedical Oncology Department, Auckland City Hospital,Auckland, New Zealand

D. NgIGENZ Ltd, Auckland, New Zealand

S. ParryNZ Familial GI Cancer Registry, Auckland City Hospital,Auckland, New Zealand

S. ParryGastroenterology Department, Middlemore Hospital, Auckland,New Zealand

K. WongDiagnostic Medlab, Auckland, New Zealand

Virchows Arch (2013) 462:355–360DOI 10.1007/s00428-012-1369-x

arose within the previous radiation field of therapy for a rectalcarcinoma 12 years prior. The tumour showed loss of expres-sion of MSH2 and MSH6 on immunohistochemistry. This isthe first report of MTS-associated sarcoma and also the firstreport of post-radiation sarcoma in LS.

Case report

A 74-year-old man presented with a right buttock mass. Hewas previously diagnosed with MTS with confirmed MSH2germline mutation. His past medical history included twometachronous colorectal cancers and four sebaceous neo-plasms, some demonstrating loss of expression of bothMSH2 and MSH6 on immunohistochemistry, consistent withMSH2 germline mutation (Table 1). He also had a history ofprostate cancer and multiple additional skin tumours includingtwo keratoacanthomas, seven squamous cell carcinomas, threebasal cell carcinomas, one atypical fibroxanthoma and onehidradenocarcinoma. He had received radiation therapy forrectal cancer 12 years previously. He had no significant familyhistory. Magnetic resonance imaging (MRI) revealed a 73-mmlobulated mass within the right gluteus maximus arising withinthe previous radiation field (Fig. 1a). He underwent biopsy andsubsequent resection of the right buttock mass.

Methods

Immunohistochemical analysis

Immunohistochemistry (IHC) was performed using LeicaBOND-lll, a fully automated immunohistochemistry system.The following antibodies were used [dilution, clone number,producer, heat retrieval time and incubation time]: anti-MLH1[1:200, ES05, Leica microsystems, 30 and 15 min]; anti-PMS2 [1:200, A16-4, BD Pharmingen, 40 and 60 min];

anti-MSH2 [1:500, G219-1129, BD Pharmingen, 40 and60 min]; anti-MSH6 [1:500, 44, BD Pharmingen, 40 and60 min]; anti-Vimentin [1:100, V9, DakoCytomation(Denmark), Nil, 15 min]; anti-S100 [1:4000, polyclonal rabbitanti-S100, DakoCytomation (Denmark), 10 and 15min]; anti-Desmin [1:500, D33, DakoCytomation (Denmark), 20 and15 min]; anti-smooth muscle actin (SMA) [1:1500, 1A4,DakoCytomation (Denmark), Nil, 15 min]; anti-CD34[1:100, QBEnd-10, DakoCytomation (Denmark), 20 and15 min]; anti-CD68 [1:500, PG-M1, DakoCytomation(Denmark), 10 and 15 min]; anti-cytokeratin (CK) MNF116[1:1000, MNF116, DakoCytomation (Denmark), 10 and15 min]; anti-CK AE1/AE3 [1:200, AE1/AE3, NovocastraLaboratories Ltd. (UK), 20 and 15 min]; [anti-CK7, 1:1000,OV-TL 12/30, DakoCytomation (Denmark), 10 and 15 min];anti-CK20 [1:500, Ks 20.8, DakoCytomation (Denmark), 10and 15 min] and anti-epithelial membrane antigen (EMA)[1:2,000, E29, DakoCytomation (Denmark), Nil, 15 min].For IHC for anti DNA MMR proteins, expression of MLH1,PMS2,MSH2 andMSH6was classified as ‘preserved expres-sion’ when nuclei of both lesional cells and internal positivecontrols (vascular endothelial cells, non-lesional epithelialcells, lymphocytes and stromal cells) showed positive stain-ing. The expression was classified as ‘loss of expression’when the nuclei of lesional cells failed to stain, while nucleiof internal positive controls showed positive staining.

Fluorescence in situ hybridization

Fluorescence in situ hybridization (FISH) was performed onthe pleomorphic liposarcoma tissue. Four-micrometre sec-tions were prepared from the formalin-fixed paraffin-embedded tissue blocks. The slides were deparaffinised beforehybridization. The slides were pretreated with Digestion En-zyme Solution 00-8401 (Zymed, Invitrogen, Carlsbad, CA,USA) for 20 min at 37 °C, dehydrated, co-denatured at 85 °Cwith MDM2(12q13-14)/cep12(D12Z3) probe (Zytovision)

Table 1 The case patient’s previous tumours, with results of IHC for MMR proteins

Age (years) Diagnosis MMR IHC

MLH1 PMS2 MSH2 MSH6

62 Rectal CA with radiotherapy n/a n/a n/a n/a

65 Transverse colon CA + + − −

66 Seb CA, right shoulder n/a n/a n/a n/a

69 Seb adenoma, right chest n/a n/a n/a n/a

72 Seb CA, right lower eyelid + + − −

72 Seb CA, right mid back + + − −

Others: keratoacanthoma (n=2), squamous cell carcinoma (n=7), basal cell carcinoma (n=3), atypical fibroxanthoma (n=1), hidradenocarcinoma(n=1), prostate carcinoma

CA carcinoma, Seb sebaceous, MMR mismatch repair, IHC immunohistochemistry, n/a not available, (+) positive/preserved expression, (−)negative/loss of expression

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and GLI(12q13)/CEP12(D12Z3) probe (Kreatech) for 20 minand then incubated overnight at 37 °C. Following overnighthybridization, the slides were washed in 0.4xSSC for 2 min at74 °C and mounted with Vectashield containing 4′,6-diami-dino-2-phenylindole (DAPI) (1.5 μg/ml) (Vector Laborato-ries, Inc). By using chromosome 12 centromere (CEP12) asreference, copy numbers of the MDM2 and GLI genes wereanalysed in at least 90 non-overlapping nuclei with intactmorphology. Signal ratio between MDM2 or GLI: centromere

12 ≥2.0 is defined as amplified; <2.0 is not amplified; a ratioof <2.0 with both gene and CEP12 signals >2 as polysomy[11]. FISH images were captured through an Olympus BX51(Olympus, Melville, NY, USA) fluorescence microscope us-ing CytoVision (Applied Imaging, Santa Clara, CA, USA)basic workstation with sequential DAP1, FITC and rhoda-mine filter settings under ×600 magnification. The resultingimages were reconstituted with blue, green and red pseudo-colours using CytoVision software.

Fig. 1 a Magnetic resonanceimaging on coronal short Tlinversion recovery of the rightbuttock shows a lobulated masswithin the right gluteusmaximus. b Gross image of theresection specimen. c–dHaematoxylin and eosin sectionof the tumour with arrowheadsindicating lipoblasts (c). e–h IHC for DNA mismatchrepair proteins MLH1 (e),PMS2 (f), MSH2 (g) andMSH6 (h). Scale bars: b50 mm, c–h 75 μm

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Pathologic findings and clinical follow-up

Gross examination of the right buttock mass resection spec-imen revealed an 85×80×40 mm tumour with a variablepale and yellow cut surface (Fig. 1b). Light microscopy ofboth biopsy and resection specimens revealed a pleomor-phic spindle cell malignant neoplasm in which there weremultifocal areas of readily identified lipoblasts with scal-loped nuclei and sharply punched-out cytoplasmic vacuoles(Fig. 1c, d). The pleomorphic spindle cells were diffuselypositive with vimentin and focally positive with desmin,SMA, CD34 and CD68. The pleomorphic spindle cells werenegative with CK AE1/AE3, CK MNF116, CK7, CK20 andEMA. S100 highlighted the scattered lipoblasts. FISH eval-uation revealed no evidence of MDM2 gene amplification.The malignant cells showed loss of nuclear expression ofMSH2 and MSH6 (Fig. 1g, h), with preserved expression ofMLH1 and PMS2 (Fig. 1e, f). The malignant cells showedgranular cytoplasmic staining with MSH2 (Fig. 1g).

During follow-up, the patient was diagnosed with a fur-ther sebaceous adenoma of the left upper arm, whichshowed loss of expression of MSH2 and MSH6 on IHC.The patient developed lung metastases of the pleomorphicliposarcoma 12 months after the resection of the right but-tock tumour and died from metastatic disease 8 months later.

IHC for MMR protein was also performed in anothercase of pleomorphic liposarcoma from the left thigh of an81-year-old man with no history of MTS or LS. Lightmicroscopy of the tumour was almost identical to that ofthe index case. IHC for MLH1, PMS2, MSH2 and MSH6showed preserved expression in the malignant cells. FISHevaluation showed no MDM2 gene amplification.

Discussion

We present herein a pleomorphic liposarcoma with loss ofimmunohistochemical expression of MSH2 and MSH6. Itdeveloped within a previous radiation field in a 74-year-oldman with MTS with known MSH2 germline mutation. This

study is unique in two respects; this is the first reported caseof MTS-associated sarcoma and the first reported case ofpost-radiation sarcoma in LS.

Soft tissue sarcomas, including three liposarcomas havebeen reported in association with LS [6–10] (Table 2). Inorder to exclude a coincidental sarcoma, we applied strictcriteria to define LS-associated sarcoma, which are (1) thepatient had a confirmed germline mutation in one of theDNA mismatch repair genes and (2) the sarcoma showedloss of expression of MMR proteins on IHC with a patternconsistent with the mutated gene. The pleomorphic liposar-coma in this patient showed loss of expression of MSH2 andMSH6, the pattern consistent with MSH2 germline muta-tion. Interestingly, all eight reported LS-associated soft tis-sue sarcomas occurred in patients with MSH2 germlinemutation (Table 2). MSH2 mutations are associated withhigher incidence of extracolonic tumours compared withMLH1 and MSH6 mutations [12, 13]. MSH2 mutation alsoseems to be associated with an increased risk of LS-associated soft tissue sarcomas. Interestingly, MSH2 germ-line mutation is much more common in MTS (89–93 %)than in LS (31 %) [5].

Previous studies have shown that DNA mismatch repairdeficiency characterised by microsatellite instability or loss ofexpression of MMR protein is uncommon in soft tissue sar-comas [6, 14, 15]. We performed IHC for MMR proteins in apleomorphic liposarcoma from another patient with no pasthistory of MTS or LS. The tumour showed preserved expres-sion of all MMR proteins (MLH1, PMS2,MSH2 andMSH6).These data suggest that loss of expression of DNA MMRproteins is not a common feature in pleomorphic liposarcoma.

The possibility that the sarcomas in the present case andin the previously published cases on LS are coincidentalsarcomas and that the loss of expression (LOE) of MMRproteins are unrelated to the sarcoma development cannot becompletely excluded. However, rarity of LOE of MMRproteins in general soft tissue sarcomas and the distinctassociation of LS-associated soft tissue sarcomas withMSH2 germline mutation favour genetic contribution tothe sarcoma development.

Table 2 Reported cases ofLynch syndrome (LS)-associatedsoft tissue sarcoma

MFH malignant fibrous histio-cytoma, NOS not otherwisespecified, R right, L left

Reference Diagnosis Location Germline mutation

Sijmons et al. [6] MFH R lower leg MSH2

den Bakker et al. [7] Pleomorphic rhabdomyosarcoma L upper leg MSH2

Hirata et al. [8] Well differentiated liposarcoma L thigh MSH2

Nilbert et al. [9] Liposarcoma, NOS Thigh MSH2

Liposarcoma, NOS Shoulder MSH2

Brieger et al. [10] MFH L psoas muscle MSH2

MFH R upper leg MSH2

Present study Pleomorphic liposarcoma R buttock MSH2

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The development of sarcoma is a recognised complica-tion of radiation therapy [16]; however, post-radiation sar-coma has not been reported in LS. Widely accepted criteriafor the diagnosis of a post-radiation sarcoma include (1) ahistory of radiation therapy, (2) the development of neo-plasm in the radiation field, (3) a latent period of minimum3–4 years (originally 5 years) and (4) the histological con-firmation of sarcoma [16, 17]. The present case fulfils allthese criteria. Lagrange et al. [18] reported 80 cases ofhistologically confirmed post-radiation sarcoma includingtwo cases of soft tissue liposarcoma, with median latentperiod of 12 years (range, 3–64 years). Pleomorphic lip-osarcoma is the rarest subtype of liposarcoma and accountsfor up to 5 % of liposarcomas [19]. Hornick et al. [20]reported 57 cases of pleomorphic liposarcomas, with 65 %occurring in the extremities. Only two cases (3.5 %) oc-curred in the buttock. The rarity of pleomorphic liposarcomaat this site also supports the likely causative effect of radi-ation therapy in tumorigenesis in the present case.

Post-radiation sarcomas are characterised by an aggres-sive behaviour, with a high incidence of local recurrence anddistant metastasis [21]. The present case developed lungmetastasis 12 months after surgery with the patient subse-quently dying of metastatic disease. This is in contrast to thetwo reported cases of LS-associated malignant fibrous his-tiocytoma, which showed better prognosis than non-LSMFH cases [10].

DNA MMR genes generally function as classical tumoursuppressor genes, where loss of function of both alleles isrequired for the loss of the tumour suppressive effect [4],which conforms to the Knudson two-hit hypothesis [22].Radiation therapy is likely to trigger the second hit in somaticcells, causing gene mutation of the normal allele in LS.

In summary, we present a case of post-radiation pleomor-phic liposarcoma in a man with MSH2 germline mutation.As early recognition and treatment may result in a morefavourable outcome, clinicians caring for individuals withLS, especially those with MSH2 germline mutations, shouldbe aware of and have a high index of suspicion for this rarebut potentially lethal complication of radiotherapy.

Conflict of interest We declare that we have no conflict of interest.

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