FIBROSARCOMA OF BONE
Malignant Spindle Cell Tumor | No Matrix Production | Diagnosis of Exclusion
Fibrosarcoma Types
Critical Must-Knows
- Fibrosarcoma is a malignant spindle cell tumor producing collagen but NO osteoid or chondroid matrix
- Diagnosis of exclusion requiring extensive immunohistochemistry to rule out other spindle cell tumors
- Herringbone pattern of spindle cells in fascicles is classic histological appearance
- Secondary fibrosarcoma arises in Paget's disease (most common), post-radiation, bone infarct, or chronic osteomyelitis
- Treatment is wide surgical resection; chemotherapy role limited compared to osteosarcoma
Examiner's Pearls
- "Incidence has decreased as immunohistochemistry improves - many cases reclassified as UPS or other entities
- "Must exclude dedifferentiated osteosarcoma (look for focal osteoid), synovial sarcoma (SS18-SSX fusion), and metastatic carcinoma
- "Post-radiation sarcoma requires latency period of at least 3-5 years and arises in previously irradiated field
- "Prognosis depends on grade, with high-grade tumors having 50-60% 5-year survival and low-grade 80-90%
Clinical Imaging
Imaging Gallery
Clinical Imaging
Imaging Gallery
Critical Fibrosarcoma Exam Points
Diagnosis of Exclusion
Fibrosarcoma requires ruling out all other spindle cell tumors. Must exclude: dedifferentiated osteosarcoma (any osteoid present), synovial sarcoma (SS18-SSX fusion), UPS/MFH, leiomyosarcoma, metastatic spindle cell carcinoma. No specific positive markers.
No Matrix Production
Defining feature: NO osteoid or chondroid matrix. Produces collagen only. Even focal osteoid excludes diagnosis and suggests osteosarcoma. Extensive sampling mandatory to exclude osteoid.
Secondary Fibrosarcoma
Arises in abnormal bone: Paget's disease (most common secondary cause), post-radiation (3-20 years latency), bone infarct, chronic osteomyelitis, fibrous dysplasia. Secondary tumors have worse prognosis than primary.
Treatment Principles
Wide surgical resection is mainstay. Chemotherapy less effective than for osteosarcoma (not routinely used). Radiation for positive margins or unresectable. Grade determines prognosis: high-grade 50-60% 5-year survival, low-grade 80-90%.
At a Glance
Fibrosarcoma of bone is a rare malignant spindle cell tumor comprising less than 5% of primary bone sarcomas, with peak incidence in patients aged 30-50 years. The defining histological feature is production of collagen in a classic herringbone pattern without any osteoid or chondroid matrix—even focal osteoid production excludes the diagnosis and suggests osteosarcoma. Fibrosarcoma is truly a diagnosis of exclusion, requiring extensive immunohistochemistry to rule out dedifferentiated osteosarcoma, synovial sarcoma (SS18-SSX fusion), undifferentiated pleomorphic sarcoma (UPS), and metastatic spindle cell carcinoma. Secondary fibrosarcoma arises from pre-existing conditions (Paget's disease most commonly, post-radiation with 3-20 year latency, bone infarct, chronic osteomyelitis) and carries worse prognosis than primary tumors. Treatment is wide surgical resection; chemotherapy is less effective than for osteosarcoma and not routinely used. Prognosis depends on grade: high-grade 50-60% 5-year survival, low-grade 80-90%.
PRICSecondary Fibrosarcoma Causes
Memory Hook:PRIC causes: Paget's most common, Radiation with latency, Infarct chronic, Chronic infection!
FOCUSSpindle Cell Bone Tumors to Exclude
Memory Hook:FOCUS on exclusion: Fibrosarcoma, Osteosarcoma, Carcinoma, UPS, Synovial sarcoma!
CHAMPFibrosarcoma Grading Features
Memory Hook:CHAMP features determine grade: Cellularity, Herringbone, Atypia, Mitoses, Pattern!
Overview and Epidemiology
Fibrosarcoma of bone is a rare primary malignant spindle cell tumor characterized by production of collagen but, critically, no osteoid or chondroid matrix. It represents less than 5% of primary bone sarcomas, with incidence decreasing as improved immunohistochemistry allows reclassification to more specific diagnoses such as undifferentiated pleomorphic sarcoma, synovial sarcoma, or dedifferentiated chondrosarcoma.
Clinical Significance and Historical Context
Fibrosarcoma is clinically important because: (1) it is a diagnosis of exclusion requiring extensive workup to rule out other spindle cell tumors; (2) the incidence has dramatically decreased over past 30 years as immunohistochemistry has improved, suggesting many historical cases were misclassified; (3) secondary fibrosarcoma signals malignant transformation of pre-existing bone pathology; and (4) treatment approach differs from osteosarcoma with limited chemotherapy role.
Demographics
- Age: Peak 30-50 years (range 10-80 years)
- Sex: No significant gender predilection (1:1 ratio)
- Location: Femur and tibia most common (60%), any bone can be affected
- Incidence: Rare and decreasing with improved diagnostics
Anatomical Distribution
- Long bones: Femur (30%), tibia (25%), humerus (15%)
- Axial: Pelvis, mandible, spine (uncommon)
- Location in bone: Metaphyseal most common, can be diaphyseal
- Central vs periosteal: Central (medullary) more common than surface
Primary versus Secondary Fibrosarcoma
Primary versus Secondary Fibrosarcoma
| Feature | Primary Fibrosarcoma | Secondary Fibrosarcoma |
|---|---|---|
| Pre-existing pathology | None (de novo in normal bone) | Paget's, radiation, infarct, osteomyelitis |
| Age at presentation | 30-50 years typically | Older (over 50 years for Paget's, radiation) |
| Latency period | Not applicable | 3-20 years for radiation, variable for Paget's |
| Prognosis | Grade-dependent, 60% 5-year survival high-grade | Worse prognosis, 30-40% 5-year survival |
| Most common cause | De novo | Paget's disease (1% degeneration rate) |
Pathophysiology and Histology
Pathogenesis
Fibrosarcoma arises from primitive mesenchymal cells that differentiate along fibroblastic lineage, producing collagen but failing to produce bone or cartilage matrix. The exact molecular pathogenesis remains incompletely understood, but genetic studies suggest complex karyotypes without consistent chromosomal translocations (unlike synovial sarcoma or Ewing sarcoma).
Diagnosis of Exclusion Principle
Fibrosarcoma has no specific positive immunohistochemical markers. Diagnosis requires: (1) demonstration of spindle cell morphology with collagen production; (2) absence of osteoid or chondroid matrix on extensive sampling; (3) negative immunostains for other entities (S100, cytokeratin, muscle markers, CD99, etc.); and (4) absence of specific genetic translocations. Many historical cases have been reclassified as UPS or other specific entities.
Histological Features
Histological Grading of Fibrosarcoma
| Feature | Low-Grade | Intermediate-Grade | High-Grade |
|---|---|---|---|
| Cellularity | Moderate, uniform distribution | Increased, variable | High, densely packed cells |
| Herringbone pattern | Well-organized fascicles | Less organized, focal disruption | Disorganized, sheet-like areas |
| Nuclear atypia | Mild, uniform nuclei | Moderate pleomorphism | Marked pleomorphism, variation |
| Mitotic rate | Less than 5 per 10 HPF | 5-10 per 10 HPF | Greater than 10 per 10 HPF |
| Collagen production | Abundant, dense | Variable amount | Sparse, immature |
| Necrosis | Absent | Focal (less than 10%) | Extensive (over 10%) |
| Prognosis (5-year survival) | 80-90% | 60-70% | 50-60% |
Classic Microscopic Features
- Spindle cells: Elongated fibroblasts with tapered nuclei
- Herringbone pattern: Fascicles intersecting at acute angles
- Collagen: Varying amounts of collagen production
- No matrix: Critically, no osteoid or chondroid matrix
- Vascular: Variable vascularity, no specific pattern
Immunohistochemistry Profile
- Vimentin: Positive (nonspecific mesenchymal marker)
- S100: Negative (excludes nerve sheath tumor)
- Cytokeratin: Negative (excludes carcinoma, synovial sarcoma)
- Desmin/SMA: Negative (excludes muscle tumors)
- CD99: Negative (excludes Ewing sarcoma)
- MDM2: Negative (excludes dedifferentiated liposarcoma)
Molecular Features
Unlike many sarcomas, fibrosarcoma has no consistent chromosomal translocation. This absence of specific genetic signature contributes to diagnostic challenge. Complex karyotypes are typical but non-specific. Molecular testing is primarily used to exclude other entities:
- SS18-SSX fusion: Absent (excludes synovial sarcoma)
- MDM2 amplification: Absent (excludes dedifferentiated liposarcoma)
- FUS rearrangement: Absent (excludes low-grade fibromyxoid sarcoma)
Clinical Presentation
Symptoms
The presentation of fibrosarcoma is non-specific, similar to other primary bone malignancies. Progressive pain is the most common initial symptom, often present for weeks to months before diagnosis. Unlike benign lesions, pain is typically progressive, not activity-related, and may be present at rest or night.
Pain Characteristics
- Duration: Weeks to months, progressive
- Pattern: Constant, may worsen at night
- Severity: Moderate to severe, progressive
- Relief: Poor response to NSAIDs
- Radiation: May follow nerve distribution if compression
Other Presentations
- Pathological fracture: 10-20% present with fracture
- Swelling/mass: Palpable if soft tissue extension
- Limited motion: If near joint
- Systemic: Usually absent (no fever, weight loss)
- Neurological: Rare unless neural compression
Physical Examination
Systematic Examination Approach
- Swelling: Visible if large soft tissue component
- Skin changes: Usually normal, may see venous prominence
- Gait: Antalgic gait if lower limb affected
- Deformity: May see angular deformity if pathological fracture
- Tenderness: Localized bony tenderness over lesion
- Mass: Firm, fixed to bone if large or cortical breakthrough
- Temperature: Normal (not warm like infection)
- Neurovascular: Assess distal pulses, sensation, motor function
- ROM: May be limited by pain if juxta-articular
- Strength: Reduced if muscle involvement or pain
- Stability: Assess for pathological fracture
- Lymph nodes: Usually not enlarged (bone sarcomas rarely lymphatic spread)
- Distant sites: Examine chest for metastases (rare on exam)
Red Flags Requiring Urgent Assessment
Immediate evaluation needed if:
- Progressive neurological deficit suggesting spinal cord or nerve compression
- Acute onset pain with deformity suggesting pathological fracture
- Rapid increase in swelling suggesting aggressive growth or hemorrhage
- Systemic symptoms (fever, weight loss) suggesting infection or disseminated disease
Secondary Fibrosarcoma Presentation
Clinical Clues to Secondary Fibrosarcoma
| Setting | Clinical Clue | Typical Presentation |
|---|---|---|
| Paget's disease | Known Paget's with sudden pain increase | Elderly patient, alkaline phosphatase elevated, rapid progression |
| Post-radiation | Prior radiation therapy 3-20 years ago | Lesion arises in previously irradiated field, latency period essential |
| Bone infarct | Known chronic infarct with new symptoms | Sickle cell disease, steroid use, expanding infarct on imaging |
| Chronic osteomyelitis | Long-standing draining sinus, new mass | Years of infection, sudden change in character, biopsy needed |
Investigations and Imaging
Plain Radiography
Plain X-rays show a destructive lytic lesion with geographic, moth-eaten, or permeative pattern depending on grade. Higher grade tumors demonstrate more aggressive radiographic features. Critically, there is no matrix calcification or ossification (this would suggest osteosarcoma or chondrosarcoma).
X-ray Findings
- Pattern: Lytic, destructive
- Margin: Geographic (low-grade) to permeative (high-grade)
- Matrix: None (no calcification or ossification)
- Periosteal reaction: Variable, may show Codman triangle in aggressive cases
- Soft tissue mass: Often visible if cortical breakthrough
Pathological Fracture
- Incidence: 10-20% present with fracture
- Pattern: Transverse or oblique through lesion
- Displacement: Variable
- Management impact: May require staged procedure (stabilization then resection)
- Prognosis: Unclear if fracture worsens prognosis
Computed Tomography (CT)
CT provides superior bone detail and is essential for surgical planning. CT chest is mandatory for staging to detect pulmonary metastases (lung is most common metastatic site for bone sarcomas).
CT Protocol for Fibrosarcoma
- Thin slice acquisition (1mm or less)
- Bone and soft tissue windows
- Multiplanar reconstruction
- Assess cortical destruction, soft tissue extent
- Identify neurovascular structures at risk
- Detect pulmonary metastases
- Nodules greater than 5mm suspicious
- Baseline for follow-up comparison
- Alternative: PET-CT for whole-body staging
- Medullary destruction pattern
- Cortical breakthrough location and extent
- Soft tissue mass size and margins
- Relationship to neurovascular bundle
- Skip lesions (rare but important to detect)
Magnetic Resonance Imaging (MRI)
MRI is the imaging modality of choice for local staging, surgical planning, and assessing intramedullary extent. Superior soft tissue contrast allows assessment of muscle, nerve, and vascular involvement.
MRI Signal Characteristics
| Sequence | Signal Intensity | Clinical Significance |
|---|---|---|
| T1-weighted | Low to intermediate signal (isointense to muscle) | Defines anatomical extent, marrow involvement |
| T2-weighted | High signal (heterogeneous) | Soft tissue extent, edema pattern |
| T1 + Gadolinium | Heterogeneous enhancement | Viable tumor (enhances), necrosis (does not enhance) |
| STIR | High signal | Sensitive for marrow edema, extent beyond gross tumor |
| Fat-saturated T2 | High signal in tumor | Differentiates edema from tumor, soft tissue extent |
Biopsy
Histological confirmation is mandatory before definitive treatment. Biopsy should be performed by the treating surgeon or in coordination with the surgical team to ensure proper trajectory that can be excised during definitive surgery.
Biopsy Principles for Sarcoma
Essential biopsy considerations:
- Biopsy performed by or coordinated with treating surgeon
- Core needle biopsy preferred (less contamination than open biopsy)
- Trajectory must be excisable during definitive resection (longitudinal incision in extremity)
- Avoid transarticular or transneural trajectory
- Multiple cores needed (3-5 samples minimum)
- Avoid hematoma (use meticulous hemostasis, avoid drain if possible)
- Send fresh tissue for molecular studies if available
Biopsy Technique
- Approach: CT or fluoroscopy-guided core needle (11-14 gauge)
- Samples: Multiple cores (3-5 minimum) from different areas
- Trajectory: Longitudinal in extremity, excisable during definitive surgery
- Fresh tissue: Send for molecular studies, culture if infection suspected
- Hemostasis: Critical to avoid hematoma and contamination
Pathology Requirements
- Expert review: Musculoskeletal pathologist mandatory
- Extensive sampling: Multiple sections to exclude osteoid
- Immunohistochemistry: Panel to exclude other spindle cell tumors
- Molecular: Consider if diagnosis uncertain (exclude fusions)
- Grading: Low, intermediate, or high-grade determination
Staging Workup
Complete Staging Workup for Fibrosarcoma
| Investigation | Purpose | Findings |
|---|---|---|
| Plain radiograph (local) | Initial assessment, surgical planning | Lytic destructive lesion, no matrix calcification |
| MRI (local) | Soft tissue extent, surgical planning | Intramedullary and extraosseous extent, neurovascular relationship |
| CT chest | Detect pulmonary metastases | Lung nodules if metastatic |
| Whole-body imaging | Detect skip lesions, bone metastases | PET-CT or bone scan |
| Biopsy | Histological diagnosis and grading | Spindle cell tumor, no osteoid, immunophenotype |
| Labs | Baseline, exclude other pathology | Alkaline phosphatase (usually normal unless Paget's), LDH |
Differential Diagnosis
Key Differentials for Spindle Cell Bone Tumor
| Entity | Histology | Immunohistochemistry | Molecular | Key Distinguishing Feature |
|---|---|---|---|---|
| Fibrosarcoma | Herringbone spindle cells, no osteoid | Vimentin+, all others negative | No specific translocation | Diagnosis of exclusion |
| Osteosarcoma (dedifferentiated) | Spindle cells WITH osteoid (even focal) | Variable | Complex karyotype | ANY osteoid production excludes fibrosarcoma |
| Synovial sarcoma | Monophasic (spindle) or biphasic | Cytokeratin+, EMA+, CD99+ | SS18-SSX fusion | Cytokeratin positivity, fusion gene |
| UPS (MFH) | Pleomorphic, storiform pattern | Vimentin+, variable others | Complex karyotype | Storiform pattern, marked pleomorphism |
| Leiomyosarcoma | Spindle cells with cigar-shaped nuclei | SMA+, desmin+, h-caldesmon+ | Variable | Smooth muscle markers positive |
| Metastatic carcinoma | Spindle cell variant (sarcomatoid) | Cytokeratin+, epithelial markers+ | Primary site specific | Epithelial markers, known primary |
Critical Differential: Fibrosarcoma versus Osteosarcoma
Key distinguishing features:
Fibrosarcoma: NO osteoid or chondroid matrix on extensive sampling, spindle cells produce collagen only, herringbone pattern, diagnosis of exclusion after immunohistochemistry panel.
Osteosarcoma: Production of osteoid by definition (even focal osteoid), malignant osteoblasts, more pleomorphic, alkaline phosphatase often elevated.
Exam answer: "The critical difference is osteoid production. Even focal osteoid on extensive sampling excludes fibrosarcoma and indicates osteosarcoma. Fibrosarcoma produces collagen but no bone or cartilage matrix. Thorough sampling of multiple areas is essential as osteosarcoma can have dedifferentiated areas mimicking fibrosarcoma."
Management Algorithm
Treatment Algorithm
Primary Fibrosarcoma Surgical Management
Goal: Complete tumor resection with wide oncological margins while preserving limb function when feasible.
Surgical Approach for Primary Fibrosarcoma
- Multidisciplinary tumor board discussion (surgeon, radiologist, pathologist, oncologist)
- Review all imaging (MRI for extent, CT for bone detail)
- Plan resection margins (1-2cm or fascial barrier)
- Plan reconstruction (allograft, endoprosthesis, autograft)
- Patient counseling: risks, alternatives, functional outcomes
- En bloc resection with wide margins (1-2cm in all directions)
- Include biopsy tract in specimen
- Preserve neurovascular structures if oncologically safe
- Send specimen margins for frozen section
- Reconstruct if structural defect created
- Endoprosthesis: Megaprosthetic replacement (most common for long bones)
- Allograft: Intercalary or osteoarticular allograft
- Allograft-prosthetic composite: Combine advantages
- Autograft: Vascularized fibular graft (less common)
- Arthrodesis: If joint sacrifice necessary and endoprosthesis not suitable
Margin Assessment
Surgical margin definitions (Enneking):
- Intralesional: Tumor violated, gross disease left behind (not acceptable for fibrosarcoma)
- Marginal: Through reactive zone, microscopic disease likely (inadequate, high recurrence)
- Wide: Through normal tissue, may have skip lesions if insufficient margin (goal for fibrosarcoma)
- Radical: Entire compartment removed (rarely necessary for bone sarcomas)
Target for fibrosarcoma: Wide margins (1-2cm or anatomical barrier such as fascia, joint capsule, periosteum of uninvolved bone).
Reconstruction Options After Resection
| Method | Advantages | Disadvantages | Best Use |
|---|---|---|---|
| Endoprosthesis (megaprosthesis) | Immediate stability, early mobilization, predictable | Infection risk, loosening, limited lifespan | Older patients, large defects, poor bone quality |
| Allograft (intercalary) | Biological, potential for remodeling, no foreign material | Fracture risk, nonunion, disease transmission risk, slow incorporation | Young patients, moderate defects |
| Allograft-prosthetic composite | Combines stability with biology, soft tissue attachment | Both allograft and prosthesis complications possible | Juxta-articular resections, need for soft tissue reattachment |
| Vascularized fibular autograft | Biological, living bone, remodels, low infection | Donor site morbidity, stress fracture, technically demanding, slow hypertrophy | Young patients, smaller defects, high-demand patients |
Complications and Outcomes
Complications
Treatment-Related Complications
| Complication | Incidence | Risk Factors | Management |
|---|---|---|---|
| Local recurrence | 10-30% depending on grade and margins | Inadequate margins, high-grade, contaminated biopsy tract | Re-excision with wider margins, consider radiation |
| Pulmonary metastases | 30-40% for high-grade | High-grade, tumor size over 8cm, elevated LDH | Pulmonary metastasectomy if resectable, chemotherapy |
| Infection (prosthetic) | 5-15% | Megaprosthetic reconstruction, long operative time, poor soft tissue coverage | Debridement, antibiotics, may require prosthesis removal |
| Pathological fracture (allograft) | 10-20% | Allograft reconstruction, delayed union, stress riser | Protected weight-bearing, may require revision |
| Neurovascular injury | 2-5% | Tumor proximity to vessels/nerves, extensive dissection | Immediate repair if recognized, consultation |
| Limb dysfunction | Variable | Muscle resection, nerve sacrifice, stiffness | Rehabilitation, physiotherapy, functional bracing |
Prognosis and Survival
Favorable Prognostic Factors
- Low-grade histology: Well-differentiated tumor
- Wide surgical margins: Greater than 1cm in all planes
- Small size: Less than 5cm diameter
- Primary (not secondary): De novo arising in normal bone
- Distal location: Better salvage options if recurrence
- No metastases: At presentation or during treatment
Poor Prognostic Factors
- High-grade histology: Poorly differentiated, high mitotic rate, necrosis
- Marginal or inadequate margins: Less than 1cm or positive
- Large size: Greater than 8cm
- Secondary fibrosarcoma: Arising in Paget's, radiation field, infarct
- Axial location: Pelvis, spine (difficult wide margins)
- Metastatic disease: At presentation or early development
Surveillance Protocol Post-Treatment
Post-treatment surveillance for fibrosarcoma:
- First 2 years: Clinical examination and local imaging (X-ray or MRI) every 3 months, CT chest every 3 months
- Years 3-5: Clinical and local imaging every 4-6 months, CT chest every 6 months
- After 5 years: Annual follow-up, CT chest annually
- Local recurrence: 80% occur within first 2 years, 90% within 5 years
- Metastases: Majority within first 3 years, lung most common site
Surveillance intensity should be higher for high-grade tumors and lower for low-grade.
Evidence Base and Key Studies
Fibrosarcoma of Bone: A Clinicopathological Study of 130 Cases
- Classic series of 130 fibrosarcoma cases from Memorial Sloan Kettering
- Established histological grading system correlates with prognosis
- Low-grade fibrosarcoma 5-year survival 80%, high-grade 50%
- Local recurrence more common with inadequate margins
- Emphasized need for wide surgical margins as primary treatment
Fibrosarcoma of Bone: Outcome in 129 Patients
- 129 patients with fibrosarcoma treated at Mayo Clinic over 40 years
- Overall 5-year survival 60%, 10-year survival 55%
- Grade most important prognostic factor (low-grade 85% vs high-grade 55% 5-year survival)
- Wide margins significantly reduced local recurrence (10% vs 30% marginal)
- Secondary fibrosarcoma (Paget's, radiation) had worse prognosis (30% 5-year survival)
Post-Radiation Sarcomas of Bone: Outcome in 52 Patients
- 52 post-radiation sarcomas reviewed, 25% were fibrosarcoma
- Mean latency period 13 years after radiation (range 4-35 years)
- 5-year survival 28%, significantly worse than primary sarcomas
- Wide resection only treatment with curative potential
- Further radiation limited due to prior dose, surgical margins critical
Declining Incidence of Fibrosarcoma with Improved Immunohistochemistry
- Review of changing diagnostic criteria for fibrosarcoma over 30 years
- Incidence decreased by over 70% with modern immunohistochemistry
- Many historical fibrosarcomas reclassified as UPS, synovial sarcoma, dedifferentiated liposarcoma
- True fibrosarcoma now diagnosis of exclusion requiring negative immunostains
- Fibrosarcoma best regarded as wastebasket diagnosis when all specific entities excluded
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Scenario 1: Primary Fibrosarcoma Diagnosis and Management
"A 40-year-old male presents with 3 months of progressive thigh pain. X-ray shows a 6cm lytic destructive lesion in the mid-femoral diaphysis with no matrix calcification. CT-guided biopsy reports spindle cells in herringbone pattern with no osteoid production. Immunohistochemistry shows vimentin positive, all other stains negative. How would you manage this patient?"
Scenario 2: Secondary Fibrosarcoma in Paget's Disease
"A 72-year-old female with known polyostotic Paget's disease presents with sudden increase in pain in her proximal femur over 2 months. She has had Paget's for 20 years managed with bisphosphonates. X-ray shows a destructive lytic lesion in the proximal femur with cortical breakthrough in an area previously affected by Paget's. Alkaline phosphatase is markedly elevated at 950 (previously 400). What is your differential diagnosis and management approach?"
Scenario 3: Post-Radiation Fibrosarcoma Management
"A 55-year-old male was treated with radiation therapy 12 years ago for Ewing sarcoma of the proximal tibia (limb salvage with resection and allograft). He now presents with progressive pain and a new destructive lesion at the proximal tibia in the previously irradiated field. Biopsy confirms high-grade fibrosarcoma. CT chest shows no metastases. How would you counsel and manage this patient?"
MCQ Practice Points
Diagnostic Criterion
Q: What is the critical histological feature that distinguishes fibrosarcoma from osteosarcoma? A: Absence of osteoid or chondroid matrix production. Fibrosarcoma produces collagen only. Even focal osteoid on extensive sampling excludes fibrosarcoma and indicates osteosarcoma (or dedifferentiated osteosarcoma). This is why thorough sampling of multiple tumor areas is essential.
Diagnosis of Exclusion
Q: Why is fibrosarcoma considered a diagnosis of exclusion? A: Fibrosarcoma has no specific positive immunohistochemical markers or genetic translocations. Diagnosis requires: (1) spindle cell morphology with herringbone pattern, (2) collagen production without osteoid/chondroid, (3) negative immunostains for other entities (S100, cytokeratin, muscle markers, CD99, MDM2), (4) absence of specific fusions (SS18-SSX, FUS). Many historical fibrosarcomas have been reclassified as UPS or other specific entities with modern diagnostics.
Secondary Fibrosarcoma
Q: What are the causes of secondary fibrosarcoma of bone, and which is most common? A: PRIC mnemonic: (1) Paget's disease (most common secondary cause, 1% degeneration rate), (2) Radiation therapy (3-20 year latency), (3) Infarct (chronic bone infarct), (4) Chronic osteomyelitis (very rare, also fibrous dysplasia). Secondary fibrosarcomas have significantly worse prognosis (20-40% 5-year survival) than primary fibrosarcoma (60-90% depending on grade).
Chemotherapy Role
Q: What is the role of chemotherapy in fibrosarcoma of bone, and how does it differ from osteosarcoma? A: Unlike osteosarcoma where neoadjuvant and adjuvant chemotherapy is standard, fibrosarcoma has no proven benefit from chemotherapy. Fibrosarcoma is less chemosensitive than osteosarcoma. Some centers may use chemotherapy for high-grade tumors based on soft tissue sarcoma protocols (doxorubicin, ifosfamide), but evidence is limited and not routine standard of care. Decision should be individualized at multidisciplinary tumor board.
Prognosis
Q: What are the 5-year survival rates for fibrosarcoma based on grade and primary versus secondary? A: Grade-dependent survival: Low-grade 80-90%, high-grade 50-60%. Secondary fibrosarcoma (Paget's, post-radiation, infarct) has significantly worse prognosis at 20-40% 5-year survival. Post-radiation sarcoma specifically has approximately 20-30% 5-year survival. Grade is the most important prognostic factor for primary fibrosarcoma.
Post-Radiation Sarcoma Criteria
Q: What are the diagnostic criteria for post-radiation sarcoma (Cahan criteria)? A: Modified Cahan criteria: (1) Tumor arises in previously irradiated field, (2) Latency period of at least 3-5 years after radiation, (3) Histologically different from original tumor (if radiation for malignancy), (4) Histologically confirmed sarcoma. These criteria distinguish radiation-induced sarcoma from recurrent original tumor or coincidental new tumor.
Australian Context
Sarcoma Referral Centres: Fibrosarcoma should be managed at tertiary sarcoma centres with multidisciplinary tumour boards. Peter MacCallum Cancer Centre in Melbourne and Royal Prince Alfred Hospital in Sydney are major centres.
Diagnostic Imaging Access: MRI and CT are widely available through public and private systems. PET-CT for staging is accessible at major centres with appropriate referral pathways.
Histopathology Review: All bone sarcoma biopsies should be reviewed by specialist musculoskeletal pathologists. Immunohistochemistry panels for spindle cell tumour workup are performed at major tertiary centres.
Treatment Protocols: Australian treatment follows international guidelines with wide resection and limb salvage where possible. Adjuvant chemotherapy for high-grade tumours follows established sarcoma protocols.
Surveillance Programs: Long-term follow-up for recurrence and metastatic disease monitoring at specialised sarcoma units with regular imaging surveillance.
FIBROSARCOMA OF BONE
High-Yield Exam Summary
Key Features
- •Malignant spindle cell tumor producing collagen, NO osteoid or chondroid matrix
- •Less than 5% of primary bone sarcomas, incidence decreasing (reclassification)
- •Peak age 30-50 years, equal gender distribution
- •Femur and tibia most common (60%), metaphyseal predominant
- •Diagnosis of exclusion - no specific positive markers or translocations
Histology and Diagnosis
- •Herringbone pattern of spindle cells in fascicles
- •Collagen production, NO osteoid (critical - excludes osteosarcoma)
- •Graded by cellularity, atypia, mitotic rate, necrosis (low/intermediate/high)
- •Vimentin positive, all other immunostains negative (S100, cytokeratin, desmin, CD99 all negative)
- •Must exclude: osteosarcoma (osteoid), synovial sarcoma (SS18-SSX), UPS, carcinoma
Secondary Fibrosarcoma (PRIC)
- •Paget's disease - most common secondary cause, 1% degeneration rate
- •Radiation - 3-20 year latency, Cahan criteria (field, latency over 3 years, different histology)
- •Infarct - chronic bone infarct, sickle cell or steroid history
- •Chronic osteomyelitis - very rare, also fibrous dysplasia
- •Secondary fibrosarcoma prognosis: 20-40% 5-year survival (vs 60-90% primary)
Imaging and Staging
- •X-ray: Lytic destructive lesion, NO matrix calcification/ossification
- •MRI: Soft tissue extent, neurovascular relationship (T1 low, T2 high, heterogeneous enhancement)
- •CT chest: Mandatory for staging (lung most common metastatic site)
- •Biopsy: Core needle preferred, excisable trajectory, multiple samples to exclude osteoid
- •PET-CT: Whole-body staging, assess for skip lesions
Treatment
- •Wide surgical resection - primary treatment (1-2cm margins or fascial barrier)
- •Reconstruction: Endoprosthesis, allograft, allograft-prosthetic composite, vascularized fibula
- •Chemotherapy: Limited role (NOT standard like osteosarcoma), may consider for high-grade
- •Radiation: Positive margins, unresectable, dose 60-66 Gy
- •Amputation: If wide margins not achievable or unresectable with limb salvage
Prognosis and Surveillance
- •Low-grade: 80-90% 5-year survival
- •High-grade: 50-60% 5-year survival
- •Secondary (Paget's, radiation, infarct): 20-40% 5-year survival
- •Grade most important prognostic factor, also size, margins, primary vs secondary
- •Surveillance: Every 3 months for 2 years (clinical, local imaging, CT chest), then every 6 months to 5 years
Differential Diagnosis (Spindle Cell Tumors)
- •Osteosarcoma (dedifferentiated) - ANY osteoid production excludes fibrosarcoma
- •Synovial sarcoma - Cytokeratin+, EMA+, SS18-SSX fusion
- •UPS (MFH) - Storiform pattern, marked pleomorphism
- •Leiomyosarcoma - SMA+, desmin+, h-caldesmon+ (smooth muscle markers)
- •Metastatic carcinoma - Cytokeratin+, epithelial markers, known primary