Adrenal metastases in a post-radiation malignant fibrous histiocytoma after low-dose radiation for a benign condition
A 29-year-old male noted right leg swelling which rapidly grew over 4 months. Simultaneously, he developed anorexia and pain in his abdomen. At presentation, he had a soft tissue tumor involving the entire right leg with skin infiltration and ulceration []. He also had a large right hypochondrial abdominal mass. Details of past history revealed that 15 years back he had had a local resection of a hemangioma in his right leg. This lesion had recurred a year later which had been treated with local radiotherapy (20 Gy in 5 fractions). Thereafter, he had remained asymptomatic till the current presentation.\nMagnetic resonance imaging showed a large soft tissue mass with heterogeneous signal intensity (areas suggestive of hemorrhage and necrosis) involving the entire right leg including the tibial and fibular diaphysis. Abdominal computerized tomography (CT) scan showed a right suprarenal lesion with mass effect on the kidney and liver infiltration []; additionally inferior vena cava thrombosis was also noted []. Bone scan showed lesions only in the right tibia and fibula; chest CT scan showed lung metastases []. In view of the very large ulcerating tumor, the patient underwent a palliative right above knee amputation. Histopathology of the resected specimen showed an MFH with storiform pattern of growth and 5-6 mitoses per high power field; the cells were highly pleomorphic with presence of tumor giant cells, areas of necrosis, and atypical mitosis; histiocytic nature of the tumor was confirmed by CD68 positivity [Figure –]. Evaluation for a primary adrenal disease revealed normal serum cortisol and urinary catecholamines. Biopsy from the adrenal mass showed a metastatic tumor morphologically similar to the primary leg sarcoma. The patient was started on palliative chemotherapy with single agent doxorubicin; he, however, discontinued after 2 cycles of chemotherapy due to progressive disease.