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COMMENTARY
Year : 2012? |? Volume : 1? |? Issue : 2? |? Page : 130-131

Commentary

Angel Fernandez-Flores
Department of Pathology, Hospital El Bierzo, Ponferrada, Spain

Date of Submission 18-Sep-2012
Date of Acceptance 21-Sep-2012
Date of Web Publication 8-Jan-2013

Correspondence Address:
Angel Fernandez-Flores
Department of Cellular Pathology, Hospital El Bierzo, Medicos sin frontreas 7, 24411, Fuentesnuevas, Leon
Spain
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How to cite this article:
Fernandez-Flores A. Commentary. J Cranio Max Dis 2012;1:130-1

How to cite this URL:
Fernandez-Flores A. Commentary. J Cranio Max Dis [serial online] 2012 [cited?2013 Apr 16];1:130-1. Available from:?https://craniomaxillary.com/text.asp?2012/1/2/130/105705

Atypical fibroxanthoma (AFX) is a low-grade sarcoma of fibrohistiocytic origin with, probably, a myofibrocytic differentiation, a recurrence rate of about 5%, and no risk of metastasis. [1] It usually presents as a polypoid tumor with a history of rapid growth, ulceration, and bleeding. [2],[3] In the report presented in this number by Erdem et al., [4] the authors present a new case of AFX and review the literature about this tumor. AFX is related to light exposure [5],[6] (with no apparent relation with polyomaviruses) [7] and, therefore, is not a rare tumor: Many laboratories receive at least one case every month. [1] As a consequence, there are very good reviews including a significant amount of cases regarding several aspects of this entity. [1],[3],[8],[9] Another etiologic important factor in some cases seems to be immunosuppression. [10]

There are some remarkable facts to remember before rendering a diagnosis of AFX. [1] First, the differential diagnosis has to be made with other spindle cell neoplasms, such as sarcomatous carcinomas, melanoma, leiomyosarcoma, angiosarcoma, or neural sarcomas, among others. The use of ancillary techniques is, therefore, obligatory. There should be no positivity for vascular, melanocytic, muscular, epidermal, and neural markers, as well as lack of expression of CD34. [10] Some have suggested that an algorithmic immunohistochemical approach is the most reasonable. [11] Keratin markers are especially worth mentioning: AFX can sometimes aberrantly express cytokeratins, [12],[13],[14] although usually in a weak way (so-called keratin-positive AFX). In the past, AFX was actually suggested as a type of squamous cell carcinoma, [15] which is not admitted by most. [11] Recently, p63 has been proposed as a useful marker for the differential diagnosis with squamous cell carcinoma, avoiding the use of a wide panel of keratins, since spindle cell carcinoma is commonly positive for p63 (even if only multifocal), while AFX is commonly negative. [16],[17]

Second, there are some morphologic criteria that are not admitted any longer in the diagnosis of AFX, such as necrosis and either vascular or perineural invasion. The subject of the grade of subcutaneous invasion that is allowed in the diagnosis of AFX is not straightforward consensus. While it is mentioned in literature how invasion of the superficial subcutis is not incompatible with a diagnosis of AFX, others prefer to apply the terms "pleomorphic dermal sarcoma," "undifferentiated pleomorphic sarcoma of the skin," or "superficial malignant fibrous histiocytoma" when subcutaneous invasion happens, especially if deep. [1],[10],[18],[19],[20],[21],[22],[23] In any case, deep subcutaneous invasion is not compatible with the diagnosis of AFX, because such feature confers to the malignancy, a risk of metastasis (although low), [18] with the capability of spreading to regional lymph nodes, parotid gland and visceral organs, particularly the lung. [24] Other morphologic criteria should also be absent in AFX, such as connection with the epidermis (suggesting a carcinoma instead), squamous or melanocytic differentiation, melanocytic pigment or overlying melanoma "in situ" and vasoformative elements. [10]

In general, with all the above-mentioned morphologic and immunohistochemical considerations, the diagnosis of AFX can be made with confidence, meaning, therefore, that the neoplasm has no metastatic potential.

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??References ? Top

1. Mirza B, Weedon D. Atypical fibroxanthoma: A clinicopathological study of 89 cases. Australas J Dermatol 2005;46:235-8.??Back to cited text no. 1
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2. Dahl I. Atypical fibroxanthoma of the skin. A clinico-pathological study of 57 cases. Acta Pathol Microbiol Scand A 1976;84:183-97.??Back to cited text no. 2
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3. Fretzin DF, Helwig EB. Atypical fibroxanthoma of the skin. A clinicopathologic study of 140 cases. Cancer 1973;31:1541-52.??Back to cited text no. 3
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4. Erdem H, Turan H, Alia?ao?lu C, Kad?o?lu N, Sezen GY, ?skender A. Atypical fibroxanthoma in a woman and literature review. J Cranio-maxillary Dis 2012;1: 126-30.??Back to cited text no. 4
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5. Dei Tos AP, Doglioni C, Laurino L, Barbareschi M, Fletcher CD. p53 protein expression in non-neoplastic lesions and benign and malignant neoplasms of soft tissue. Histopathology 1993;22:45-50.??Back to cited text no. 5
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6. Sakamoto A, Oda Y, Itakura E, Oshiro Y, Nikaido O, Iwamoto Y, et al. Immunoexpression of ultraviolet photoproducts and p53 mutation analysis in atypical fibroxanthoma and superficial malignant fibrous histiocytoma. Mod Pathol 2001;14:581-8.??Back to cited text no. 6
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7. Scola N, Wieland U, Silling S, Altmeyer P, Stucker M, Kreuter A. Prevalence of human polyomaviruses in common and rare types of non-Merkel cell carcinoma skin cancer. Br J Dermatol 2012;14:1365-2133.??Back to cited text no. 7
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8. Beer TW, Drury P, Heenan PJ. Atypical fibroxanthoma: A histological and immunohistochemical review of 171 cases. Am J Dermatopathol 2010;32:533-40.??Back to cited text no. 8
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9. Kaddu S, McMenamin ME, Fletcher CD. Atypical fibrous histiocytoma of the skin: Clinicopathologic analysis of 59 cases with evidence of infrequent metastasis. Am J Surg Pathol 2002;26:35-46.??Back to cited text no. 9
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10. Miller K, Goodlad JR, Brenn T. Pleomorphic dermal sarcoma: Adverse histologic features predict aggressive behavior and allow distinction from atypical fibroxanthoma. Am J Surg Pathol 2012;36:1317-26.??Back to cited text no. 10
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11. McCalmont TH. AFX: What we now know. J Cutan Pathol 2011;38:853-6.??Back to cited text no. 11
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12. Bansal C, Sinkre P, Stewart D, Cockerell CJ. Two cases of cytokeratin positivity in atypical fibroxanthoma. J Clin Pathol 2007;60:716-7.??Back to cited text no. 12
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13. Suarez-Vilela D, Izquierdo FM, Escobar-Stein J, Mendez-Alvarez JR. Atypical fibroxanthoma with T-cytotoxic inflammatory infiltrate and aberrant expression of cytokeratin. J Cutan Pathol 2011;38:930-2.??Back to cited text no. 13
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14. Mc Calmont TH. Brother (and sister), can you spare the S100? J Cutan Pathol 2010;37:299-300.??Back to cited text no. 14
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15. Zelger B SH. Between scylla and charybdis; mythology in dermatopathology. Dermatopathol Pract Conceptual 2000;6:348-55.??Back to cited text no. 15
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16. Chen JT, Hsu JD, Yao CC, Han LW, Han CP. Anti-cytokeratin CAM 5.2 does not act as a surrogate of the cytokeratin 8/18 monoclonal antibody. Comment on: "Utility of p63 in the differential diagnosis of atypical fibroxanthoma and spindle cell squamous cell carcinoma", in J Cutan Pathol 2009; 36: 543. J Cutan Pathol 2010;37:1123-4.??Back to cited text no. 16
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17. Dotto JE, Glusac EJ. p63 is a useful marker for cutaneous spindle cell squamous cell carcinoma. J Cutan Pathol 2006;33:413-7.??Back to cited text no. 17
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18. McCalmont TH. Correction and clarification regarding AFX and pleomorphic dermal sarcoma. J Cutan Pathol 2012;39:8.??Back to cited text no. 18
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19. Davidson JS, Demsey D. Atypical fibroxanthoma: Clinicopathologic determinants for recurrence and implications for surgical management. J Surg Oncol 2012;105:559-62.??Back to cited text no. 19
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20. Luzar B, Calonje E. Morphological and immunohistochemical characteristics of atypical fibroxanthoma with a special emphasis on potential diagnostic pitfalls: A review. J Cutan Pathol 2010;37:301-9.??Back to cited text no. 20
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21. Mentzel T. Sarcomas of the skin in the elderly. Clin Dermatol 2011;29:80-90.??Back to cited text no. 21
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22. Thum C, Hollowood K, Birch J, Goodlad JR, Brenn T. Aberrant Melan-A expression in atypical fibroxanthoma and undifferentiated pleomorphic sarcoma of the skin. J Cutan Pathol 2011;38:954-60.??Back to cited text no. 22
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23. Withers AH, Brougham ND, Barber RM, Tan ST. Atypical fibroxanthoma and malignant fibrous histiocytoma. J Plast Reconstr Aesthet Surg 2011;64:e273-8.??Back to cited text no. 23
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24. Kargi E, Gungor E, Verdi M, Kuiacogiu S, Erdogan B, Alli N, et al. Atypical fibroxanthoma and metastasis to the lung. Plast Reconstr Surg 2003;111:1760-2.??Back to cited text no. 24
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