Myxofibrosarcoma (MFS), although a rare type of tumor, is one of the most common soft tissue sarcomas, i.e., cancerous tumors, that develop in the soft tissues of elderly individuals. Initially considered to be a type of histiocytoma termed fibrous histiocytoma or myxoid variant of malignant fibrous histiocytoma, Angervall et al. termed this tumor myxofibrosarcoma in 1977. In 2020, the World Health Organization reclassified MFS as a separate and distinct tumor in the category of malignant fibroblastic and myofibroblastic tumors. MFS tumors are often treated by surgical resection. However, these tumors have high recurrence rates at the sites of their resections. Local recurrences followed by surgical resections may be repeated multiple times but during these cycles MFS tumors often progress from a lower grade to a higher more aggressive grade, metastasize, and become life-threatening. An uncommon variant of the MFS tumors termed epithelioid myxofibrosarcoma is even more likely to follow an aggressive, recurrent, metastasizing, and life-threatening course than the more common form of the MFS tumors.
Presentation MFS usually afflicts individuals in their fifth to seventh decades of life although uncommon cases occur in adults outside of this age range In one large study, MFS was diagnosed in individuals 21 to 96 years old (median age 66 years). Most studies have diagnosed MFS slightly more often in men than women but one large study conducted in France found it to be 50% more common in men. Individuals with MFS present with a tumor located in an extremity (77% of cases, usually in the lower extremity), trunk (12% of cases), and head and neck areas (3% of cases). Rarely, these tumors have presented in the breast, heart, paratesticular region (i.e. area inside the scrotum including the epididymis the spermatic cord along with its coverings), eye, bone, liver, or multiple sites concurrently. Primary tumors presenting in the abdominal cavity, retroperitoneum, or pelvis have been diagnosed as MFS but larger studies indicate that these tumors are far more likely to be dedifferentiated liposarcomas. MFS tumors usually develop as painless, slowly enlarging masses in a muscle, skin (usually below the fascia i.e. a sheet of connective tissue, primarily collagen, running beneath the skin), or one of the non-cutaneous areas described above. In one study of 69 FBS cases 36 were <5 cm, 23 were between 5 and 10 cm, and 19 were > 10 cm in diameter with the largest tumor being 27 cm. MFS tumors often infiltrate along vascular and fascial planes, are incompletely removed at surgery, and consequently recur at the surgical site. Recurrences of the MFS at the site of surgery have developed in 16% to 57% of patients with a significant proportion (25%–52%) recurring multiple times. In one study, recurrences developed between 2 and 82 months (median 53 months) following primary surgery and metastatic disease developed in 23% of patients within 2 to 77 months (median 10 months) following primary surgery. Recurrent tumors tend to be more aggressive and have a much greater tendency to metastasize than primary MFS tumors. In one study, metastatic disease was detected in 23% of patients and occurred at a median of 10 months (range, 2–77 months) after resection of the primary tumor. In a review of multiple studies, the risk of developing metastases for lower grade MFS (defined in the following section) was <5% and for higher grade tumors was 25–30%. MFS metastasize most commonly to the lungs, bone, and lymph-nodes. Individuals with the epithelioid variant of FBS generally present with a tumor in the limbs; the tumors tend to be somewhat larger, more aggressive, and more likely to metastasize than the tumors in non-variant cases. At least 50% of patients with this variant have developed metastases.
Pathology The microscopic histopathology of hematoxylin and eosin stained FBS tumors varies. Lower-grade MFS tissues consist of scattered large, variability-sized and spindle-shaped-to-variably-shaped tumor cells with darkly stained nuclei. Overall, lower-grade tumors contain relatively few cells within a distinctive myxoid (i.e. more blue or purple compared to normal connective tissue because of excessive uptake of the hematoxylin stain) connective tissue background that contains curvilinear, thin-walled blood vessels. Higher grade FBS tumors consist of relatively large sheets of these spindle-shaped/vatiably-shaped cells in a similar myxoid background containing thin-walled curvilinear blood vessels. Pseudo-lipoblasts (i.e. multivacuolated cells resembling lipoblasts but having vacuoles filled with mucin rather than lipids) are apparent in both lower grade and higher grade tumors. Epithelioid FBS tumors are highly cellular lesions consisting of diffuse proliferations of extremely large, polygonal-shaped epithelioid cells set in a myxoid connective tissue background similar to that seen in the other types of FBS. Epithelioid myxofibrosarcomas appear to behave more aggressively than myxofibrosarcomas dominated by spindle-shaped/variably-shaped cells. While the cells in most types of tumors express specific marker proteins that help in diagnosing them, the tumor cells in FBS and its epithelioid variant have not yet been found to express marker proteins that are sufficiently specific to support either diagnosis.
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