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Pathology – Research and Practice 211 (2015) 88–91

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Pathology – Research and Practice

 journal homepage: www.elsevier .com/ locate /prp

Teaching cases

Follicular dendritic cell sarcoma of the tonsil

Monique Vorspracha,∗, Thomas Kalinskib, Ulrich Vorwerkc

a Department of Pneumology,Otto-von-Guericke University, Magdeburg, Germanyb Department of Pathology,Otto-von-Guericke University, Magdeburg,Germanyc Department of Otorhinolaryngology,Otto-von-Guericke University, Magdeburg, Germany

a r t i c l e i n f o

 Article history:

Received 8 April 2014

Received in revised form 8 August 2014Accepted 16 September 2014

Keywords:

Follicular dendritic cell sarcoma

Tonsil

Immunohistochemistry

FDCS

a b s t r a c t

Follicular dendritic cell sarcoma (FDCS) is a rare neoplasm that occurs extranodally and nodally. The

following case report describes a 24-year-old male patient who suffered from FDCS of  the tonsil. He

presented at the ENT Department of the University Hospital Magdeburg with throat pain that had lasted

for 3 months. There were neither B symptoms nor abnormal fatigue. An extended tonsillectomy was

performed. The morphological and immunohistochemical findings confirmed the diagnosis of FDCS.

FDCS should be considered as an important differential diagnosis in spindle cell tumors of the tonsil.

© 2014 Elsevier GmbH. All rights reserved.

Introduction

Clinical history

A 24-year-oldmalepatientwas admittedto theUniversityClinicof Magdeburg with a complaint of throat pain which, according

to him, had lasted for almost 3 months. B-symptoms or abnormal

fatigue were not reported by the patient. Before admission to the

hospital, he had visited an otolaryngologist who noticed an asym-

metry of the tonsils, and performed a biopsy of the left tonsil. The

histopathological examination of the biopsy revealed a follicular

dendritic cell sarcoma. At the time of the admission to the hos-

pital, intraoral examination showed a massive swelling of the left

tonsil (Fig. 1). This tonsil was found to be smooth, and exhibited

easy luxation. No necrotic or ulcerated areas were observed. The

tonsil of the opposite side showed signs of chronic tonsillitis and

appearedscarred. Inaddition, theleft tympanicmembrane showed

a retraction pocket and was atrophic. Neck examination revealed

two lymph nodes of approximately 1cm in size on both sides of 

the neck in region II. The results of a general ear nose and throat

examination were normal without any relevant comorbidity.

Diagnostics

Ultrasonography revealed a lymphadenitis that was more

severe on the left side of the neck than on the right side. A tumor

∗ Corresponding author. Tel.: +49391 67 15421.

E-mail address:monique.vorsprach@med.ovgu.de(M. Vorsprach).

mass of approximately 24mm in diameter with a homogenous

structure and low echogenocity (Fig. 2) was found in the left ton-

sillar region.

The MRI scan showed a mass of 25mm×20mm in the area of 

theleft tonsil, whichlimits the spaceof the left oropharynx (Fig. 3).The native 18-fluoro-desoxy-d-glucose-positron-emission-

tomography-computed-tomography (F-18-FDG-PET CT) scan

showed only a slight increase of the glucose metabolism in the

area of the left tonsil. No sign of metastasis was found in other

parts of the body; however, their presence could not be ruled out

with absolute certainty.

Therapy

Extended laser-tonsillectomy was performed with a CO2-laser

on the left tonsil, where the tumor was located, under general

anesthesia. Themargins were free of tumor. Furthermore, conven-

tional tonsillectomy was also performed on the opposite side, as

requested by the patient.

Moreover, the patient was treated with cefuroxime for 10 days

aftertheoperation.Adjuvantradiochemistryorneckdissectionwas

not performed. Nevertheless, the patient was requested to return

to theclinic for furtherregularexaminations.Untilnow,no residual

tumor mass has been detected.

General information on the disease

Follicular dendritic cells (FDCs) are non-phagocytic, non-

lymphoid antigen-presenting cells of the accessory immune

system. These cells of mesenchymal origin are capable of  

http://dx.doi.org/10.1016/j.prp.2014.09.015

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M. Vorsprachet al./ Pathology – Research andPractice 211 (2015) 88–91 89

Fig. 1. Intraoral examination with thetumor of theleft tonsil.

capturing, processing and presenting antigens and immune com-plexes to T-cells and B-cells in order to maintain the humoral

immune response. They are part of the dendritic cell group, which

can be divided into four main categories found in lymphatic tissue:

interdigitating dendritic, indeterminate, Langerhans and follicular

dendritic cells [6]. FDCs are mainly found in the germinal centers

of primary and secondary follicles of lymph nodes, the spleen or

mucosa associated lymphatic tissue (MALT) within the network of 

other local cells.

The first case of a FDC sarcoma was described by Lennert [8].

Then, in 1986, Monda et al. reported the first case of primary neo-

plasm of FDCs in the lymph node [9]. To date, only a few cases

of FDC sarcoma in the tonsil have been described [13]. Few extra

nodal FDCS were reported by Youens and Waugh [14], and in the

pharyngeal or abdominal region [12].

Fig. 2. Ultrasonographyof theleft tonsildepictingthe tumor mass of 24mm diam-

eter.

Fig. 3. MRI scan of the head with the tumor of the left tonsil.

Material andmethods

Histology

Aftercompletetonsillectomy,thetissueofthelefttonsilwascol-

lectedandpreservedin buffered formalin (10%). Subsequently, the

tissuewasdehydrated and embedded in paraffin. Sections (3.0m

thick) fromformalin-fixed, paraffin-embedded tissue werestained

withhematoxylinandeosin(HE). Light microscopy wasperformed

using an Axioplan microscope (Zeiss, Oberkochen, Germany) and

a Hamamatsu Nanozoomer (Hamamatsu Photonics, Hamamatsu,

 Japan).

Immunohistochemistry

Sections(3.0mthick) fromformalin-fixed,paraffin-embedded

tissue were incubated with a panel of standard antibodies against

cytokeratins (MNF116, AE1/AE3), epithelial membrane antigen

(EMA), vimentin, sm-actin, desmin, S-100 protein, HMB45, leuko-

cyte common antigen (LCA), KiM4p, CD23, and ki-67 using a

Benchmark XT (Ventana Medical Systems, Tucson, USA). The reac-

tions were visualized using DAB detection.

Results

Morphology and immunophenotype

The tumor presented as a well-defined mass in an otherwise

regularlystructuredtonsil (Fig.4). Thespindledtumorcellsformed

fasciclesand storiformpatterns. Thenuclei showeddispersedchro-

matin and small nucleoli without significant cytological atypia.

Only a few mitoses were observed (4/10 HPF). Small lymphocytes

werescatteredacross thetumor. Thesurgicalmarginsweretumor-

free.

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90 M. Vorsprachet al./ Pathology – Research andPractice 211 (2015) 88–91

Fig. 4. Histopathological and immunohistological findings after tonsillectomy. (A) Left tonsil with a well-defined tumor mass. (B) Spindled tumor cells forming fascicles or

storiformpatterns.(C) Highermagnificationshowingnuclei ofthe tumorcellswith dispersedchromatinand smallnucleoli,and scatteredsmalllymphocytes.(D) Immunostain

demonstratingpositivity for Vimentin. (E) Immunostain demonstrating positivity for KiM4p.

Immunohistochemically, the tumor cells demonstrated strong

positivity for Vimentin and KiM4p, and partially a slight positivity

for EMA. The tumor cells were negative for cytokeratins (MNF116,

AE1/AE3), sm-actin, desmin, S-100 protein,HMB45, LCA,andCD23.

The ki-67 labeling index was about 10%.

The findings confirmed the diagnosis of a follicular dendritic

sarcoma (FDCS).

Discussion

FDCS is an unusual disease that mainly occurs in middle-aged

males and females between 30 and 50 years [7,10,11]. The FDCS

rarelyoccursextranodally in the head andneck region. This type of 

tumor is usually found as a painless lymph adenopathy in lymph

nodesof theneck,axilla andmediastinum.Nevertheless,FDCSmust

beconsideredanimportantdifferentialdiagnosis ofa tonsillarmass

and, in addition to thehistopathological examination, immunohis-

tochemical methods should be used for diagnostics to confirm the

diagnosis.

Typical characteristics of FDCS in histological examinations are

oval to spindle shaped cells with eosinophilic cytoplasm arrangedin fascicles or sheets with a storiform growth pattern, which leads

to the diagnosis of sarcoma. Due to the typical characterization of 

small lymphocytes, lymphoma might be misdiagnosed [5].

The importance of a precise diagnosis was emphasized by

Duan et al. in their overview of 36 cases of FDCS, in which they

showed that 21 cases had initially been misdiagnosed [4] before

immunohistochemistryrevealedFDCS. Importantdifferential diag-

noses areextracranialmeningioma,peripheral nerve sheathtumor,

malignant melanoma, ectopic thymoma, metastatic carcinoma,

malignant fibrous histiocytoma, large cell lymphoma, and inter-

stitial reticulum cell sarcoma [1,3].

In immunohistochemistry, FDCS are positive for CD21, CD35,

KiM4p, and KiFDC1p, and are variably positive for vimentin, S-

100 protein, CD68 and specific muscle actin [2,5,7]. In our case,

thehistologicalexaminationsshowed typical spindle-shaped cells.

Immunohistochemically, the reactions using antibodies against

vimentin and Ki-M4p were positive and confirmed the diagnosis.

The role of adjuvant therapy is a debated topic in the literature.

Chan et al. [2] consider systemic radiotherapy as the treatment

of choice, while other authors such as Perez-Ordonez and Rosai

[10,13] prefer this therapy as an option for the treatment of lymph

node metastasis of theneck region, positive margins or recurrenceof the tumor.

In 2006, a case report of a 76-year-old woman was presented

by Aydin et al. [1]. This patient, who suffered from an FDCS of the

tonsil, underwent surgery and adjuvant radiotherapy treatment.

She was recurrence-free after 4 years of follow up.

Inour case,we performeda wide excision of the tumor without

any further therapy such as neck dissection or adjuvant radiother-

apy or chemotherapy.

We decided to use this strategy because according to our find-

ings, metastases or suspect lymph nodes were neither found in

the neck region nor in the rest of the body. Considering the fact

that FDCS is a malignancy with a high risk of local recurrence, we

asked thepatient topresent forregular follow-ups inourclinic.We

believe that any adjuvant therapy at this stage will reduce the lifequality of the patient. In case of tumor recurrence or metastasis,

we still have the options to perform a neck dissection or adjuvant

radiotherapy or chemotherapy. We will reconsider our strategy in

order to find the best treatment for the patient.

References

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[2]  J.K. Chan, C.D. Fletcher, S.J. Nayler, K. Cooper, Follicular dendritic cell sarcoma.Clinicopathologicanalysis of 17 cases suggesting a malignant potential higherthan currently recognized, Cancer79 (2) (1997) 294–313.

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