Annals of Orthopedics and Rheumatology

An Undifferentiated Pleomorphic Sarcoma with Massive Intratumoral Hematoma: A Case Report and Literature Review

Case Report | Open Access

  • 1. Department of Orthopedics, the University of Tokushima, Japan
+ Show More - Show Less
Corresponding Authors
Ryosuke Sato, Department of Orthopedics, The University of Tokushima, The Institute of Health Bio Science, Kuramoto, Tokushima, Japan

We here report a case of undifferentiated pleomorphic sarcoma (formerly malignant fibrous histiocytoma) arising in the femoral triangle where the tumor expanded by intratumoral hemorrhage and mimicked an intramuscular hematoma. T1- and T2-weighted magnetic resonance images showed a cystic mass containing septa and multiple nodules of heterogeneous intensity in the adductor muscle of the right thigh. Excisional biopsy indicated the tumor was an undifferentiated pleomorphic sarcoma. Following en-bloc resection, the patient has been free from recurrence or metastasis for 7 years. We discuss the salient features of this case and recent reports on cystic soft tissue tumors.


Undifferentiated pleomorphic sarcoma (UPS) is a soft tissue sarcoma composed of undifferentiated mesenchymal tumor cells and is now regarded as distinct entity following its reclassification from malignant fibrous histiocytoma (MFH). MFH had been considered the most common soft tissue sarcoma of mid and late adulthood. The tumor most frequently arises from the deep fascia or skeletal muscle in an extremity. Occasionally, it exhibits cyst formation, mimicking a hematoma [1], which can lead to a misdiagnosis or delay in diagnosis. Several reports have appeared on large cystic MFH in the abdominal cavity [2, 3] or retroperitoneum that showed rapid hemorrhagic enlargement induced by chemotherapy [4]. We describe here a case with a massive cystic UPS in the femoral triangle where expansion of the tumor, which was 25 cm in longitudinal diameter at initial presentation, was thought to be caused by internal hemorrhage.


Sato R, Takahashi M, Nishisho T, Endo K, Sairyo K (2013) An Undifferentiated Pleomorphic Sarcoma with Massive Intratumoral Hematoma: A Case Report and Literature Review. Ann Orthop Rheumatol 1(1): 1006.

Case report

A 53-year-old man presented with a mass in the right femoral triangle that had grown rapidly over the last 3 months and had not been preceded by trauma. He had been treated for mental illness since the age of 31. Physical examination revealed a strained bulging mass in the right femoral triangle (Figure 1). Despite mild rubor and tenderness over the mass, he did not complain of pain on palpation. Magnetic resonance (MR) imaging revealed an expansive cystic lesion in the adductor muscles of his right thigh, measuring 25.0 × 19.0 × 18.0 cm (Figure 2). T2-weighted images showed a high signal intensity lesion, T1- weighted images showed a relatively high intensity lesion, and both sets of images indicated the lesion contained nodules and septa that had equal signal intensity to muscle. The lesion extended to the surrounding muscles outside of the adductor compartment, contacted the obturator foramen and the lesser trochanter, and was close to the hip joint capsule, femoral artery, and sciatic nerve (Figure 2). Similarly, computed tomography showed the same sized low density area surrounded by tissue with the same density constitution as muscle. Angiography of the femoral artery showed eggshell-shaped staining of the lesion with moderate hypervascularity.

Excisional biopsy from the cyst wall caused the tumor to bleed. Pathological examination showed pleomorphic cells scattered between regions of coagulative necrosis. The patient underwent en bloc resection of the tumor without adjuvant therapy. All branches of the profunda femoris artery and great saphenous vein were sacrificed, as were all adductor muscles and the vastus medialis, gracilis, semimembranosus, rotators of the hip joint, and a part of the iliopsoas. The tumor contained hemorrhage and necrotic tissue, with some hemosiderosis. The cyst wall was coated extensively by relatively bland pleomorphic cells with scattered histiocytes, fibroblastic spindle cells, and inflammatory cells and the wall itself contained tumor cells (Figure 3). Proliferation of some capillary vessels was evident. The tumor cells were negative on immunochemical staining for antitrypsin, antichymotrypsin, lysozyme, c-kit, and platelet-derived growth factor. The pathological diagnosis of UPS (formerly known as MFH) was made based on these features. The patient has had no recurrence of the tumor or evidence of metastasis in the 7 years he has been followed and is ambulant with the aid of a cane.


MFH had been recognized as the most common soft tissue sarcoma in mid and late adulthood. However, with its reclassification in 2002 by WHO, it is no longer regarded as a distinct diagnostic category; for instance, myxoid and angiomatoid MFH have been re-classified into myxofibrosarcoma and angiomatoid fibrous histiocytoma (AFH), respectively. A diagnosis of UPS is appropriate when no line of differentiation is identified. While it remains controversial, the term MFH is still used by some pathologists and clinicians. Recently, Matushansky reported that MFH is associated with mesenchymal stem cells [5], which may be the cells of origin. Radiologic findings of MFH are not specific because of its varied morphologic features. Owing to the infrequency of (~5%) extensive cyst formation1 , there is little information about cystic MFH. To our knowledge, there have been no reports of massive cystic MFH in the extremities but three cases in the abdominal cavity or retroperitoneum [2,3]. The incidence of MFH in general arising in the abdominal cavity and retroperitoneum is relatively uncommon (~16%) compared to that originating in the extremities [1]. If MFH occurs in the abdominal cavity or retroperitoneum, it may manifest late and the tumor may be large on initial presentation. It has been reported that the size of the tumor correlates with the incidence of metastasis [1]. However, although both tumor size and anatomic location are significant for the clinical course of MFH in general, such correlations might not apply to cases of cystic MFH.

The differential diagnosis for soft tissue tumor with cyst formation includes synovial sarcoma [6,7], AFH, malignant tumor containing necrosis, schwannoma, and chronic expanding hematoma. Synovial sarcoma occurs near large joints in young adults. Nakanishi et al. reported that cyst formation in synovial sarcoma was related to the histological grade [8]. However, there is no information regarding the relationship between cyst formation and clinicopathologic features in other soft tissue sarcomas. Features of the cyst in the present case included inflammatory infiltrates, a thick fibrous pseudocapsule, and wide diffusion of tumor cells, indicating the tumor might be an AFH, which was first described by Enzinger as angiomatoid MFH [9]. AFH has been regarded as a tumor of childhood and early adult life with intermediate malignant potential, separated from conventional MFH by its relatively benign behavior [10-12]. Fanburg-Smith et al. reported that patients with AFH range up to 71 years, despite a childhood predominance [10]. The current case must differentiaed carefully UPS from AFH.

There are several reports that describe soft tissue sarcoma mimicking hematoma [13,14]. In those cases, the lesions were misdiagnosed as benign, such as traumatic hematoma, which led to poor clinical outcomes. In a report of six cases where sarcoma was misdiagnosed as hematoma, Imaizumi et al. concluded that meticulous evaluation of MR images contrasted with clinical histories including traumas was important for the differentiation [15]. Gomez et al., however, reported three cases of high-grade sarcoma following trauma and concluded that MR imaging was neither sensitive nor specific enough to rule out malignancy [16]. Reid et al. reported some cases of hematoma that gradually enlarged and were difficult to differentiate between soft tissue tumor and chronic expanding hematoma [17]. In the present case, no traumatic history was identified and the lesion presented as a heterogeneous multi-locular mass with heterogeneous enhancement after gadolinium injection, all of which indicated malignancy.

MR images undoubtedly provide valuable information on soft tissue tumors, and several soft tissue lesions can be diagnosed from MR images alone. However, MR findings of many malignant lesions frequently overlap with those of benign ones. In addition, time-dependent changes such as necrosis and bleeding may complicate the differentiation. Thus far, several attempts at differentiating benign soft tissue lesions from malignant ones by means of ultrasound or 18F-fludeoxyglucose positron emission tomography have proven unsuccessful [18].

The significance of excisional biopsy for malignant soft tissue lesions has been reported [19-22]. In the present case, a percutaneous biopsy under image guidance may have been helpful. Aspiration biopsy is less traumatic for sampling both superficial and deep-seated mass lesions, but in certain cystic sarcomas, it would be difficult to obtain accurate samples. Imaizumi et al. showed that no malignant cells were obtained by aspiration biopsy for 5 patients among 6 with sarcomas mimicking hematoma [15].Thus, excisional biopsy appears to be necessary for differentiating soft tissue sarcoma from expanding hematoma.


1. Weiss SW, Enzinger FM. Malignant fibrous histiocytoma: an analysis of 200 cases. Cancer. 1978; 41: 2250-2266.

2. Huang CC, Ko SF, Ng SH, Lee TY, Wan YL, Lin JW, et al. Cystic malignant fibrous histiocytoma of the gastrocolic ligament. Br J Radiol. 2001; 74: 651-653.

3. Liu DM, Jeffrey RB Jr, Mindelzun RE. Malignant fibrous histiocytoma presenting as cystic pancreatic mass. Abdom Imaging. 1999; 24: 299- 300.

4. Panicek DM, Casper ES, Brennan MF, Hajdu SI, Heelan RT. Hemorrhage simulating tumor growth in malignant fibrous histiocytoma at MR imaging. Radiology. 1991; 181: 398-400.

5. Matushansky I, Charytonowicz E, Mills J, Siddiqi S, Hricik T, CordonCardo C. MFH classification: differentiating undifferentiated pleomorphic sarcoma in the 21st Century. Expert Rev Anticancer Ther. 2009; 9: 1135-1144.

6. Berquist TH, Ehman RL, King BF, Hodgman CG, Ilstrup DM. Value of MR imaging in differentiating benign from malignant soft-tissue masses: study of 95 lesions. AJR Am J Roentgenol. 1990; 155: 1251-1255.

7. Morton MJ, Berquist TH, McLeod RA, Unni KK, Sim FH. MR imaging of synovial sarcoma. AJR Am J Roentgenol. 1991; 156: 337-340.

8. Nakanishi H, Araki N, Sawai Y, Kudawara I, Mano M, Ishiguro S, et al. Cystic synovial sarcomas: imaging features with clinical and histopathologic correlation. Skeletal Radiol. 2003; 32: 701-707.

9. Enzinger FM. Angiomatoid malignant fibrous histiocytoma: a distinct fibrohistiocytic tumor of children and young adults simulating a vascular neoplasm. Cancer. 1979; 44: 2147-2157.

10. Fanburg-Smith JC, Miettinen M. Angiomatoid “malignant” fibrous histiocytoma: a clinicopathologic study of 158 cases and further exploration of the myoid phenotype. Hum Pathol. 1999; 30: 1336- 1343.

11. Costa MJ, Weiss SW. Angiomatoid malignant fibrous histiocytoma. A follow-up study of 108 cases with evaluation of possible histologic predictors of outcome. Am J Surg Pathol. 1990; 14: 1126-1132.

12. Hasegawa T, Seki K, Ono K, Hirohashi S. Angiomatoid (malignant) fibrous histiocytoma: a peculiar low-grade tumor showing immunophenotypic heterogeneity and ultrastructural variations. Pathol Int. 2000; 50: 731-738.

13. Kelm J, Ahlhelm F, Engel C, Duchow J. Synovial sarcoma diagnosed after a sports injury. Am J Sports Med. 2001; 29(3): 367-369.

14. Ogose A, Hotta T, Yamamura S, Shioya Y, Yazawa T. Extraskeletal Ewing’s sarcoma mimicking traumatic hematoma. Arch Orthop Trauma Surg. 1998; 118: 172-173.

15. Imaizumi S, Morita T, Ogose A, Hotta T, Kobayashi H, Ito T, et al. Soft tissue sarcoma mimicking chronic hematoma: value of magnetic resonance imaging in differential diagnosis. J Orthop Sci. 2002; 7: 33- 37

16. Gomez P, Morcuende J. High-grade sarcomas mimicking traumatic intramuscular hematomas: a report of three cases. Iowa Orthop J. 2004; 24: 106-110.

17. Reid JD, Kommareddi S, Lankerani M, Park MC. Chronic expanding hematomas. A clinicopathologic entity. JAMA. 1980; 244: 2441-2442.

18. Hamada K, Myoui A, Ueda T, Higuchi I, Inoue A, Tamai N, et al. FDGPET imaging for chronic expanding hematoma in pelvis with massive bone destruction. Skeletal Radiol. 2005; 34: 807-811.

19. Petrey WB, LeGallo RD, Fox MG, Gaskin CM. Imaging characteristics of angiomatoid fibrous histiocytoma of bone. Skeletal Radiol. 2011; 40: 233-237.

20. Petrey WB, LeGallo RD, Fox MG, Gaskin CM. Imaging characteristics of angiomatoid fibrous histiocytoma of bone. Skeletal Radiol. 2011; 40: 233-237.

21. Bauer A, Jackson B, Marner E, Gilbertson-Dahdal D. Angiomatoid fibrous histiocytoma: a case report and review of the literature. J Radiol Case Rep. 2012; 6: 8-15.

22. Negoro K, Uchida K, Yayama T, Kokubo Y, Baba H. Chronic expanding hematoma of the thigh. Joint Bone Spine. 2012; 79: 192-194

Received : 25 Nov 2013
Accepted : 04 Dec 2013
Published : 07 Dec 2013
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X