A malignant epithelioid tumor with EWSR1 fusion mimics primary pulmonary myxoid sarcoma (PPMS): a variant of PPMS or under-recognized entity?

A malignant epithelioid tumor with EWSR1 fusion mimics primary pulmonary myxoid sarcoma (PPMS): a variant of PPMS or under-recognized entity? | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A malignant epithelioid tumor with EWSR1 fusion mimics primary pulmonary myxoid sarcoma (PPMS): a variant of PPMS or under-recognized entity? Bingxia Zhang, Yuan Li, Ziling Huang, Yan Jin, Yue Wang, Keke Wang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4488939/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Primary pulmonary myxoid sarcoma (PPMS) is an extremely rare soft tissue tumor that is characterized in most cases by the oncogenic fusion gene EWSR1-CREB1 . Tumor cells with epithelioid differentiation have not been described in PPMS. We report a primary lung tumor with morphological, immunohistochemical and molecular features closely mimics PPMS, but with concomitant epithelioid differentiation. Is this a variant of PPMS or under-recognized entity? Case presentation: A 34-year-old female patient showed a CT scan showing nodular opacities around the upper lobe of the left lung with a diameter of 8 mm, which was mildly unevenly enhanced after enhancement. Histologically there were two tumor areas, one of which presented a typical PPMS morphology, and the tumor cells were stellate, polygonal, epithelial and arranged as reticular and cords in abundant myxoid stroma. The other tumor area presented an epithelioid cell morphology. The tumor cell immunophenotype was positive for vimentin, INI1 and negative for TTF-1, P40, S-100, SOX10, CK5/6, SMA, Desmin, PAX8, Brachyury and WT1. Interestingly, immunohistochemistry confirmed positive AE1/AE3 in epithelioid cell regions, while AE1/AE3 was negative in typical PPMS regions. Molecular analysis demonstrated the presence of EWSR1-CREB1 gene fusions in the tumor. Conclusion PPMS is a very rare lung malignant soft tissue tumor with distinct histological and genetic features. Our challenge case had morphological, immunohistochemical and molecular features similar to PPMS, but with epithelioid differentiation.We prefer to describe this tumour as a variant of PPMS instead of a new entity. lung myxoid sarcoma epithelioid cell EWSR1- CREB1 fusion Figures Figure 1 Figure 2 1. Background Primary pulmonary myxoid sarcoma is a rare, low-grade sarcoma with an incidence of approximately 0.2 percent [ 1 ]. In 1999, Nicholson first reported two cases of low-grade bronchial mucinous tumors [ 2 ]. In 2011, Thway found that tumors had characteristic chromosomal translocations (2; 22) (q33; q12), resulting in EWSR1-CREB1 fusion [ 3 ]. It is currently included in the 2015 edition of the World Health Organization Tissue Classification of Lung Tumors for the first time in lung stromal tumors [ 4 ]. PPSM typically occurs in large airways, grows as lobules, and consists of spindle, stellate, or polygonal cells in a prominent mucinoid matrix [ 3 ]. However, tumor cells with epithelioid differentiation have not been described in PPMS. Herein, we report a primary lung tumor with morphological, immunohistochemical and molecular features similar to PPMS, but with concomitant epithelioid differentiation. To our knowledge, this is the first reported case with pathological and genetic hallmarks indistinguishable from those of PPMS, but at the same time tumor cells with epithelioid differentiation. 2. Case presentation 2.1 Clinical data One 34-year-old female patient was consulted in the Department of Pathology. The patient had no symptoms, no symptoms of pulmonary obstruction or pneumonia. The patient do not use alcohol or tobacco products. General physical examination and laboratory tests are not remarkable. Chest CT showed an 8 mm nodular opacity in the upper lobe of the left lung, which was mildly unevenly enhanced after enhancement (Fig. 1 A). Bronchoscopy and cytology were unremarkable. Routine blood count and tumor marker levels are normal. Adjuvant chemotherapy was not administered postoperatively.The patient is currently being followed up for more than a year and has no recurrence after surgical treatment. 2.2 Pathological examination In general, the tumor size is 8 mm with a well-defined mass, the surface capsule is not obvious, the cut surface is medium to tough, and the color is gray-white, gray-yellow, and jelly-like. Microscopically, two regions with different growth patterns can be seen, one of which is mainly composed of spindle and astrocyte cells, arranged in a cord-like, beam-like or reticular structure, and a rich basophilic myxoid interstitium can be seen in the background. The other area has a fibrous pseudocapsule, and the tumor cells grow in sheets or nests, and the tumor cells are mainly composed of polygonal, round, or ovoid epithelioid cells (Fig. 1 B). Mild chronic inflammatory cell infiltrates are seen in the interstitium of both regions, mainly lymphocytes and plasma cells, with a small amount of eosinophils and foamy histiocytes. The degree of atypia of tumor cells varies, with a nuclear division of (0–7) cells/10 HPF. No hemorrhage or necrosis was seen within the tumor. 2.3 Results of immunohistochemistry and FISH The tumor cell immunophenotype was positive for vimentin, INI1 and negative for TTF-1, P40, S-100, SOX10, CK5/6, SMA, Desmin, PAX8, Brachyury and WT1. Interestingly, immunohistochemistry confirmed positive AE1/AE3 in epithelioid cell regions, while AE1/AE3 was negative in typical PPMS regions (Fig. 1 C). In addition to this, ALK is expressed non-specifically in two tumor cell regions. The results of FISH analysis showed that there was EWSR1 gene-related ectopia, EWSR1-CREB1 (E8:C7) gene fusion, and the proportion of positive cells was greater than 50% (Fig. 2 ). 3. Discussion For the first time, we report a primary lung tumor with morphological, immunohistochemical and molecular features similar to PPMS, but with concomitant epithelioid differentiation. PPMS has the oncogenic fusion gene EWSR1-CREB1 like the tumour we reported [ 3 , 4 ]. To date, 38 cases of PPMS have been described in the English literature [ 5 – 12 ]. The clinical manifestations of PPSM are relatively nonspecific and include cough, hemoptysis, and weight loss. Although initial reports were predominantly of bronchial growths associated with bronchial trees, there are also tumors that are not associated with bronchial trees [ 8 , 9 , 11 ], as in our case. According to the reported literature, the morphology of PPMS is characterized by a lobulated structure with elliptical, fusiform, or stellate bundles embedded in a prominent mucus matrix [ 3 ]. The atypia of the cells varies from mild to overt atypia. The number of fission is (0 ~ 32) per 10 HPF, and most of them do not exceed 5 cells/10 HPF. Immunohistochemical staining showed that Vimentin was expressed in almost all cases, and EMA was weakly expressed in some cases, while other markers such as AE1/AE3, S-100, Desmin, SMA, Syn, CD34 and CD68 were negatively expressed, and the Ki-67 value-added index was low in most cases. In PPMS, the dominance of epithelioid differentiated tumor cells in PPMS has not been reported in the literature. In stark contrast, some of the tumor cells in our case exhibited epithelioid cell morphology and were positive for AE1/AE3 on immunohistochemistry. It cannot be ignored that this case we reported shares some features with PPSM, including oval, spindle, or stellate tumor cell bundles embedded in prominent mucous matrix and chronic inflammatory cell infiltration in the interstitium. Morphologically, the tumour we reported should be distinguished from the following diseases. Extraosseous myxoid chondrosarcoma (EMC) typically occurs in the proximal extremities and deep soft tissues of the limb band, but can also occur in the lungs [ 13 , 14 ]. Histologically, EMC is composed of cytoplasmically sparse bundles soaked in a rich mucus matrix, similar to PPMS. However, 20%~50% EMC expresses S-100. In molecular genetics, EMC does not have EWSR1-CREB1 translocations, but has characteristic NR4A3-EWSR1 gene translocations (75%) and NR4A3-TAF15 gene translocations (15%). These molecular and genetic features distinguish the case from EMC. Pulmonary microcystic fibromyxoma (PMF) consists of faint fusiform to stellate cells with nuclei evenly distributed within a fibromyxoid matrix, allizin blue positive, and hyaluronidase sensitive [ 16 ]. Unlike the case we reported, there is no EWSR1-CREB1 gene fusion in PMF. Another differential diagnosis is inflammatory myofibroblastoma (IMT), which may have a mucinoid stroma and inflammatory infiltrates. The stellate tumor cells in IMT were positive for SMA, Desmin, and ALK immunophenotypes, and negative for the case we reported. EWSR1 encodes the EWSR1 protein, a member of the TET family of transcription factors, and its rearrangements can occur in a variety of tumors, including Ewing family tumors (EFTs) [ 17 ], hemangiomatoid fibrous histiocytoma (AFH) [ 18 ], soft tissue clear cell sarcoma (CCS) [ 19 ], EMC, and clear cell tumors of the gastrointestinal tract sarcoma-like tumor of the gastrointestinal tract (CCSLGT) [ 20 ], etc. In addition to PPMS, tumors with EWSR1-CREB1 gene translocations include CCSLGT, CCS, and AFH, so EWSR1-CREB1 gene translocations are not specific genetic changes to a particular type of tumor, but need to be based on histomorphology to make an accurate diagnosis. CCSLGT consists of cytoplasmic clear cells or eosinophilic round or oval cells mixed with CD68-expressing osteoclast-like giant cells in the interstitium. Tumor cells consistently express S-100 and sox10. The polygonal or spindle-shaped tumor cells of CCS are separated by fibrous septums into nests or bundles, the cytoplasmic eosinophilic or hyaline, the nuclei are distinctly vacuolated, and the nucleoli are distinct.Tumor cells express S-100 and HMB-45. AFH consists of sheety and insular spindle epithelioid cells with flat, oval, loose interstitium and abundant eosinophilic plasm. Morphologically, AFH is very similar to the tumour we reported, and there is also genetic overlap. But AFH has a significant peripheral cuff of lymphocytes. In addition, desmin is expressed in 50% AFH and is not present in the tumour we reported. Based on the above differential diagnosis, we prefer to describe this tumor as a variant of PPMS rather than a new entity. 4. Conclusion We confirmed the occurrence of aberrant CK-positive lung malignant primary tumors with EWSR1-CREB fusions and morphological and immunohistochemical closely mimics PPMS. We prefer to describe this tumour as a variant of PPMS instead of a new entity. Therefore, further accumulation of similar cases is required to identify the origin, pathologic and clinical features of this characteristic tumour. Declarations Funding information National Key Research and Development Program of China (No.2021YFF1201001, Yuan Li) and the Institution and Governmental Cooperative Project, Shanghai Xuhui District Science and Technology Committee (No.23XHYD-12, Yuan Li). The funders had no role in study design, data collection and interpretation, or the decision to submit the work for publication. Additional information Declaration of competing interest All the authors report no conflicts of interest related to this manuscript. Ethics statement This retrospective study was approved by The Ethics Committee of the Fudan University Shanghai Cancer Center. Author Contribution Bingxia Zhang wrote the main manuscript text.Yuan Jin prepared figure 2.All authors reviewed the manuscript. Data availability statement All datasets included in the current study are available from the corresponding author on reasonable request. References Attanoos RL, Appleton MA, Gibbs AR. Primary sarcomas of the lung: a clinicopathological and immunohistochemical study of 14 cases.Histopathology. 1996;29:29–36. Nicholson AG, Baandrup U, Florio R, Sheppard MN, Fisher C. Malignant myxoid endobronchial tumour: a report of two cases with a unique histological pattern. Histopathology. 1999;35:313–8. Thway K, Nicholson AG, Lawson K, Gonzalez D, Rice A, Balzer B, Swansbury J, Min T, Thomp-son L, Adu-Poku K, Campbell A, Fisher C. Primary pulmonary myxoid sarcoma with EWSR1-CREB1 fusion: a new tumor entity. Am J Surg Pathol. 2011;35:1722–32. Travis WD, Brambilla E, Burke AP, Marx A, Nicholson AG. Introduction to the 2015 World Health Organization classification of tumors of the lung, pleura, thymus, and heart. J Thorac Oncol. 2015;10:1240–2. Prieto-Granada CN, Ganim RB, Zhang L, Antonescu C, Mueller J. Primary pulmonary myxoid sarcoma: A newly described entity-report of a case and review of the literature. Int J Surg Pathol. 2017;25:518–25. Tomoki N, Tsunehiro I, Osamu I, Eiichi K, Akihiko Y. Primary Pulmonary Myxoid Sarcoma with EWSR1::ATF1 Fusion: A Case Report. Int J Surg Pathol. 2023;31(1):88–91. Chen ZW, Yang YH, Chen RM, Ng CS, Shi HQ. Primary pulmonary myxoid sarcoma with EWSR1-CREB1 fusion: a case report and review of the literature. 2020; 15(1):15. Christian K, Luca T, Olaf N, Claus PH, Ralf E, Hauke W, Albrecht S, Gunhild M. Primary pulmonary myxoid sarcoma with an unusual gene fusion between exon 7 of EWSR1 and exon 5 of CREB1. Virchows Arch. 2020;476(5):787–91. Kim S, Song SY, Yun JS, Choi YD, Na KJ. Primary pulmonary myxoid sarcoma located in interlobar fissure without parenchymal invasion. Thorac Cancer. 2017;8:535–8. Yanagida R, Balzer BL, Mckenna RJ, Fuller CB. Primary pulmonary myxoid sarcoma, a potential mimic of metastatic extraskeletal myxoid chondrosarcoma. Pathology. 2017;49:792–4. Opitz I, Lauk O, Schneiter D, Ulrich S, Maisano F, Weder W, et al. Intraluminal EWSR1-CREB1 gene rearranged, low-grade myxoid sarcoma of the pulmonary artery resembling extraskeletal myxoid chondrosarcoma. Histopathology. 2019;74:526–30. Agaimy A, Duell T, Morresi-Hauf AT. EWSR1-fusion-negative, SMARCB1-deficient primary pulmonary myxoid sarcoma. Pol J Pathol. 2017;68:261–7. Balanzá R, Arrangoiz R, Cordera F, Muñoz M, Luque-de-León E, Moreno E, et al. Pulmonary extraskeletal myxoid chondrosarcoma: A case report and literature review. Int J Surg Case Rep. 2016;27:96–101. Zhou Q, Lu G, Liu A, Kohno T. Extraskeletal myxoid chondrosarcoma in the lung: asymptomatic lung mass with severe anemia. Diagn Pathol. 2012;7:112. Thway K, Nicholson AG, Wallace WA, AI-Nafussi A, Pilling J, Fisher C. Endobronchial pulmonary angiomatoid fibrous histiocytoma: two cases with EWSR1-CREB1 and EWSR1-ATF1 fusions. Am J Surg Pathol. 2012;36:883–8. Shilo K, Miettinen M, Travis WD, Timens W, Nogueira R, Franks TJ. Pulmonary microcystic fibromyxoma: report of 3 cases. Am J Surg Pathol. 2006;30:1432–5. Sudha SM, Sandhya DG, Sundaram C, Daphne VM, Vishal F, Senthil BR, K V V N JR, R TSR. FISH for EWSR1 in Ewing's sarcoma family of tumors: Experience from a tertiary care cancer center. Indian J Pathol Microbiol. 2021;64(1):96–101. Gerardo C, Carmelo L, Nadia C,Flavia R,Andrea M, Anna C,Eliano C,Senia MRT,Giuseppe I,Biagio M. Eugenio M,Vito P,Leonardo R. Angiomatoid Fibrous Histiocytoma (AFH) of the Right Arm: An Exceptional Case with Pulmonary Metastasis and Confirmatory EWSR1::CREB1 Translocation. Diagnostics (Basel). 2022;12(11):2616. Benjamin BO, Li L, Emily RW, Alexander JL,Jared JB. Kevin BJ.EWSR1::ATF1 Orchestrates the Clear Cell Sarcoma Transcriptome in Human Tumors and a Mouse Genetic Model. Cancers (Basel). 2023;15(24):5750. Keiko S, Shintaro S, Tomoyuki A, Terufumi K, Hiroko A, Taro S, Yumika I, Mitsuhiro T, Hiromi F, Makoto E, Tadashi H. Detection of specific gene rearrangements by fluorescence in situ hybridization in 16 cases of clear cell sarcoma of soft tissue and 6 cases of clear cell sarcoma-like gastrointestinal tumor. Diagn Pathol. 2018;13(1):73. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4488939","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":311802070,"identity":"ab944f38-a711-41a0-9bc8-e654add9f110","order_by":0,"name":"Bingxia Zhang","email":"","orcid":"","institution":"Fudan University Shanghai Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Bingxia","middleName":"","lastName":"Zhang","suffix":""},{"id":311802073,"identity":"2798cd64-3576-43c5-82e1-5dbde4346acd","order_by":1,"name":"Yuan Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYBACPhiDn5mx8cEHAxs7glrYYAzJ9ubDhjMK0pKJ12Jw5liaNM+HQ4wNBLVIZCc+5m2zy2O4kWMmbWNwgJmB/fDRDfi15G42nNmWXMw4I8fYOsfgDh8DT1raDQJatkl8bGNObJbIMbydY/CMmUGCx4ywlsS2+sQ2iRwDaQuDw4wNRGn52HY4sYfnWJI0A1FaeN5uNpxx7njiDHZgIPcYpCWzEfILP3vuxsc8ZdWJ+w8Do/LHHxs7fvbDx/BqwWIvacpHwSgYBaNgFGADAHJhSHvJbeMNAAAAAElFTkSuQmCC","orcid":"","institution":"Fudan University Shanghai Cancer Center","correspondingAuthor":true,"prefix":"","firstName":"Yuan","middleName":"","lastName":"Li","suffix":""},{"id":311802075,"identity":"f1dd869f-4b78-4e13-9030-af4db4dbd4ee","order_by":2,"name":"Ziling Huang","email":"","orcid":"","institution":"Fudan University Shanghai Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Ziling","middleName":"","lastName":"Huang","suffix":""},{"id":311802077,"identity":"1bb73bb6-0450-46cf-a732-57ed59e07c8b","order_by":3,"name":"Yan Jin","email":"","orcid":"","institution":"Fudan University Shanghai Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Jin","suffix":""},{"id":311802079,"identity":"d26c7aef-fb58-4432-beab-aed7eb281d39","order_by":4,"name":"Yue Wang","email":"","orcid":"","institution":"Fudan University Shanghai Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Yue","middleName":"","lastName":"Wang","suffix":""},{"id":311802081,"identity":"7283982e-f8a4-48b8-97b4-cf52df7e398b","order_by":5,"name":"Keke Wang","email":"","orcid":"","institution":"Fudan University Shanghai Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Keke","middleName":"","lastName":"Wang","suffix":""},{"id":311802082,"identity":"08619145-ddd0-4ead-945b-994101acf587","order_by":6,"name":"Huan Li","email":"","orcid":"","institution":"Fudan University Shanghai Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Huan","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2024-05-28 07:33:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4488939/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4488939/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":58759779,"identity":"d812318b-310d-474c-921c-ba32e64fc8f5","added_by":"auto","created_at":"2024-06-20 18:46:00","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":7688175,"visible":true,"origin":"","legend":"\u003cp\u003eA.\u003cstrong\u003e \u003c/strong\u003eChest computed tomography showed an 8 mm nodular opacity in the upper lobe of the left lung, which was mildly unevenly enhanced after enhancement . B\u0026amp;C. An overview of the resected tumor is shown (hematoxylin-eosin). Two regions with different growth patterns can be seen, one of which is mainly composed of spindle and astrocyte cells, arranged in a beam-like or reticular structure, with rich basophilic myxoid interstitium (B: magnification×20, C: magnification ×100 ). D. In the other area, the tumor cells are mainly composed of polygonal, round, or ovoid epithelioid cells (D: magnification×100). E\u0026amp;F\u0026amp;G. Tumor cell immunohistochemical positive expression of AE1/AE3 in epithelioid cell regions and negative expression of AE1/AE3 in typical PPMS regions (E: magnification ×20, F: magnification ×100, G: magnification ×100).\u003c/p\u003e","description":"","filename":"figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4488939/v1/6d2152195661ba292aca1eed.png"},{"id":58759751,"identity":"1ed22df7-6e63-4c5f-8ba6-a1932adf0459","added_by":"auto","created_at":"2024-06-20 18:45:53","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1093234,"visible":true,"origin":"","legend":"\u003cp\u003eA\u0026amp;B\u0026amp;C. Molecular genetic studies.\u003cem\u003e EWSR1-CREB\u003c/em\u003e fusions were identified using FISH, and the proportion of positive cells was greater than 50%. The arrow indicates \u003cem\u003eEWSR1-CREB\u003c/em\u003e fusions.\u003c/p\u003e","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4488939/v1/2b4e73def88b0373b1694297.png"},{"id":59531448,"identity":"38cb3374-eb79-4625-9bca-9974e96eb5d4","added_by":"auto","created_at":"2024-07-03 00:16:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":11549064,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4488939/v1/6b0ed60d-f942-4d2b-9da0-b45c377828a4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A malignant epithelioid tumor with EWSR1 fusion mimics primary pulmonary myxoid sarcoma (PPMS): a variant of PPMS or under-recognized entity?","fulltext":[{"header":"1. Background","content":"\u003cp\u003ePrimary pulmonary myxoid sarcoma is a rare, low-grade sarcoma with an incidence of approximately 0.2 percent [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In 1999, Nicholson first reported two cases of low-grade bronchial mucinous tumors [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In 2011, Thway found that tumors had characteristic chromosomal translocations (2; 22) (q33; q12), resulting in \u003cem\u003eEWSR1-CREB1\u003c/em\u003e fusion [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. It is currently included in the 2015 edition of the World Health Organization Tissue Classification of Lung Tumors for the first time in lung stromal tumors [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. PPSM typically occurs in large airways, grows as lobules, and consists of spindle, stellate, or polygonal cells in a prominent mucinoid matrix [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, tumor cells with epithelioid differentiation have not been described in PPMS. Herein, we report a primary lung tumor with morphological, immunohistochemical and molecular features similar to PPMS, but with concomitant epithelioid differentiation. To our knowledge, this is the first reported case with pathological and genetic hallmarks indistinguishable from those of PPMS, but at the same time tumor cells with epithelioid differentiation.\u003c/p\u003e"},{"header":"2. Case presentation","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Clinical data\u003c/h2\u003e \u003cp\u003eOne 34-year-old female patient was consulted in the Department of Pathology. The patient had no symptoms, no symptoms of pulmonary obstruction or pneumonia. The patient do not use alcohol or tobacco products. General physical examination and laboratory tests are not remarkable. Chest CT showed an 8 mm nodular opacity in the upper lobe of the left lung, which was mildly unevenly enhanced after enhancement (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). Bronchoscopy and cytology were unremarkable. Routine blood count and tumor marker levels are normal. Adjuvant chemotherapy was not administered postoperatively.The patient is currently being followed up for more than a year and has no recurrence after surgical treatment.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Pathological examination\u003c/h2\u003e \u003cp\u003eIn general, the tumor size is 8 mm with a well-defined mass, the surface capsule is not obvious, the cut surface is medium to tough, and the color is gray-white, gray-yellow, and jelly-like. Microscopically, two regions with different growth patterns can be seen, one of which is mainly composed of spindle and astrocyte cells, arranged in a cord-like, beam-like or reticular structure, and a rich basophilic myxoid interstitium can be seen in the background. The other area has a fibrous pseudocapsule, and the tumor cells grow in sheets or nests, and the tumor cells are mainly composed of polygonal, round, or ovoid epithelioid cells (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). Mild chronic inflammatory cell infiltrates are seen in the interstitium of both regions, mainly lymphocytes and plasma cells, with a small amount of eosinophils and foamy histiocytes. The degree of atypia of tumor cells varies, with a nuclear division of (0\u0026ndash;7) cells/10 HPF. No hemorrhage or necrosis was seen within the tumor.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Results of immunohistochemistry and FISH\u003c/h2\u003e \u003cp\u003eThe tumor cell immunophenotype was positive for vimentin, INI1 and negative for TTF-1, P40, S-100, SOX10, CK5/6, SMA, Desmin, PAX8, Brachyury and WT1. Interestingly, immunohistochemistry confirmed positive AE1/AE3 in epithelioid cell regions, while AE1/AE3 was negative in typical PPMS regions (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC). In addition to this, ALK is expressed non-specifically in two tumor cell regions. The results of FISH analysis showed that there was \u003cem\u003eEWSR1\u003c/em\u003e gene-related ectopia, \u003cem\u003eEWSR1-CREB1\u003c/em\u003e (E8:C7) gene fusion, and the proportion of positive cells was greater than 50% (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"3. Discussion","content":"\u003cp\u003eFor the first time, we report a primary lung tumor with morphological, immunohistochemical and molecular features similar to PPMS, but with concomitant epithelioid differentiation. PPMS has the oncogenic fusion gene \u003cem\u003eEWSR1-CREB1\u003c/em\u003e like the tumour we reported [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. To date, 38 cases of PPMS have been described in the English literature [\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9 CR10 CR11\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The clinical manifestations of PPSM are relatively nonspecific and include cough, hemoptysis, and weight loss. Although initial reports were predominantly of bronchial growths associated with bronchial trees, there are also tumors that are not associated with bronchial trees [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], as in our case. According to the reported literature, the morphology of PPMS is characterized by a lobulated structure with elliptical, fusiform, or stellate bundles embedded in a prominent mucus matrix [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The atypia of the cells varies from mild to overt atypia. The number of fission is (0\u0026thinsp;~\u0026thinsp;32) per 10 HPF, and most of them do not exceed 5 cells/10 HPF. Immunohistochemical staining showed that Vimentin was expressed in almost all cases, and EMA was weakly expressed in some cases, while other markers such as AE1/AE3, S-100, Desmin, SMA, Syn, CD34 and CD68 were negatively expressed, and the Ki-67 value-added index was low in most cases.\u003c/p\u003e \u003cp\u003eIn PPMS, the dominance of epithelioid differentiated tumor cells in PPMS has not been reported in the literature. In stark contrast, some of the tumor cells in our case exhibited epithelioid cell morphology and were positive for AE1/AE3 on immunohistochemistry. It cannot be ignored that this case we reported shares some features with PPSM, including oval, spindle, or stellate tumor cell bundles embedded in prominent mucous matrix and chronic inflammatory cell infiltration in the interstitium.\u003c/p\u003e \u003cp\u003eMorphologically, the tumour we reported should be distinguished from the following diseases. Extraosseous myxoid chondrosarcoma (EMC) typically occurs in the proximal extremities and deep soft tissues of the limb band, but can also occur in the lungs [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Histologically, EMC is composed of cytoplasmically sparse bundles soaked in a rich mucus matrix, similar to PPMS. However, 20%~50% EMC expresses S-100. In molecular genetics, EMC does not have \u003cem\u003eEWSR1-CREB1\u003c/em\u003e translocations, but has characteristic \u003cem\u003eNR4A3-EWSR1\u003c/em\u003e gene translocations (75%) and \u003cem\u003eNR4A3-TAF15\u003c/em\u003e gene translocations (15%). These molecular and genetic features distinguish the case from EMC. Pulmonary microcystic fibromyxoma (PMF) consists of faint fusiform to stellate cells with nuclei evenly distributed within a fibromyxoid matrix, allizin blue positive, and hyaluronidase sensitive [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Unlike the case we reported, there is no \u003cem\u003eEWSR1-CREB1\u003c/em\u003e gene fusion in PMF. Another differential diagnosis is inflammatory myofibroblastoma (IMT), which may have a mucinoid stroma and inflammatory infiltrates. The stellate tumor cells in IMT were positive for SMA, Desmin, and ALK immunophenotypes, and negative for the case we reported.\u003c/p\u003e \u003cp\u003e \u003cem\u003eEWSR1\u003c/em\u003e encodes the EWSR1 protein, a member of the TET family of transcription factors, and its rearrangements can occur in a variety of tumors, including Ewing family tumors (EFTs) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], hemangiomatoid fibrous histiocytoma (AFH) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], soft tissue clear cell sarcoma (CCS) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], EMC, and clear cell tumors of the gastrointestinal tract sarcoma-like tumor of the gastrointestinal tract (CCSLGT) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], etc. In addition to PPMS, tumors with EWSR1-CREB1 gene translocations include CCSLGT, CCS, and AFH, so \u003cem\u003eEWSR1-CREB1\u003c/em\u003e gene translocations are not specific genetic changes to a particular type of tumor, but need to be based on histomorphology to make an accurate diagnosis.\u003c/p\u003e \u003cp\u003eCCSLGT consists of cytoplasmic clear cells or eosinophilic round or oval cells mixed with CD68-expressing osteoclast-like giant cells in the interstitium. Tumor cells consistently express S-100 and sox10. The polygonal or spindle-shaped tumor cells of CCS are separated by fibrous septums into nests or bundles, the cytoplasmic eosinophilic or hyaline, the nuclei are distinctly vacuolated, and the nucleoli are distinct.Tumor cells express S-100 and HMB-45. AFH consists of sheety and insular spindle epithelioid cells with flat, oval, loose interstitium and abundant eosinophilic plasm. Morphologically, AFH is very similar to the tumour we reported, and there is also genetic overlap. But AFH has a significant peripheral cuff of lymphocytes. In addition, desmin is expressed in 50% AFH and is not present in the tumour we reported. Based on the above differential diagnosis, we prefer to describe this tumor as a variant of PPMS rather than a new entity.\u003c/p\u003e"},{"header":"4. Conclusion","content":"\u003cp\u003eWe confirmed the occurrence of aberrant CK-positive lung malignant primary tumors with \u003cem\u003eEWSR1-CREB\u003c/em\u003e fusions and morphological and immunohistochemical closely mimics PPMS. We prefer to describe this tumour as a variant of PPMS instead of a new entity. Therefore, further accumulation of similar cases is required to identify the origin, pathologic and clinical features of this characteristic tumour.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eFunding information\u003c/h2\u003e \u003cp\u003eNational Key Research and Development Program of China (No.2021YFF1201001, Yuan Li) and the Institution and Governmental Cooperative Project, Shanghai Xuhui District Science and Technology Committee (No.23XHYD-12, Yuan Li).\u003c/p\u003e \u003cp\u003eThe funders had no role in study design, data collection and interpretation, or the decision to submit the work for publication.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003e \u003cb\u003eAdditional information\u003c/b\u003e \u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eDeclaration of competing interest\u003c/strong\u003e \u003cp\u003eAll the authors report no conflicts of interest related to this manuscript.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eEthics statement\u003c/h2\u003e \u003cp\u003eThis retrospective study was approved by The Ethics Committee of the Fudan University Shanghai Cancer Center.\u003c/p\u003e \u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eBingxia Zhang wrote the main manuscript text.Yuan Jin prepared figure 2.All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eData availability statement\u003c/h2\u003e \u003cp\u003eAll datasets included in the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAttanoos RL, Appleton MA, Gibbs AR. Primary sarcomas of the lung: a clinicopathological and immunohistochemical study of 14 cases.Histopathology. 1996;29:29\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNicholson AG, Baandrup U, Florio R, Sheppard MN, Fisher C. Malignant myxoid endobronchial tumour: a report of two cases with a unique histological pattern. Histopathology. 1999;35:313\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThway K, Nicholson AG, Lawson K, Gonzalez D, Rice A, Balzer B, Swansbury J, Min T, Thomp-son L, Adu-Poku K, Campbell A, Fisher C. Primary pulmonary myxoid sarcoma with EWSR1-CREB1 fusion: a new tumor entity. Am J Surg Pathol. 2011;35:1722\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTravis WD, Brambilla E, Burke AP, Marx A, Nicholson AG. Introduction to the 2015 World Health Organization classification of tumors of the lung, pleura, thymus, and heart. J Thorac Oncol. 2015;10:1240\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrieto-Granada CN, Ganim RB, Zhang L, Antonescu C, Mueller J. Primary pulmonary myxoid sarcoma: A newly described entity-report of a case and review of the literature. Int J Surg Pathol. 2017;25:518\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTomoki N, Tsunehiro I, Osamu I, Eiichi K, Akihiko Y. Primary Pulmonary Myxoid Sarcoma with EWSR1::ATF1 Fusion: A Case Report. Int J Surg Pathol. 2023;31(1):88\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen ZW, Yang YH, Chen RM, Ng CS, Shi HQ. Primary pulmonary myxoid sarcoma with EWSR1-CREB1 fusion: a case report and review of the literature. 2020; 15(1):15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChristian K, Luca T, Olaf N, Claus PH, Ralf E, Hauke W, Albrecht S, Gunhild M. Primary pulmonary myxoid sarcoma with an unusual gene fusion between exon 7 of EWSR1 and exon 5 of CREB1. Virchows Arch. 2020;476(5):787\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim S, Song SY, Yun JS, Choi YD, Na KJ. Primary pulmonary myxoid sarcoma located in interlobar fissure without parenchymal invasion. Thorac Cancer. 2017;8:535\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYanagida R, Balzer BL, Mckenna RJ, Fuller CB. Primary pulmonary myxoid sarcoma, a potential mimic of metastatic extraskeletal myxoid chondrosarcoma. Pathology. 2017;49:792\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOpitz I, Lauk O, Schneiter D, Ulrich S, Maisano F, Weder W, et al. Intraluminal EWSR1-CREB1 gene rearranged, low-grade myxoid sarcoma of the pulmonary artery resembling extraskeletal myxoid chondrosarcoma. Histopathology. 2019;74:526\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgaimy A, Duell T, Morresi-Hauf AT. EWSR1-fusion-negative, SMARCB1-deficient primary pulmonary myxoid sarcoma. Pol J Pathol. 2017;68:261\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBalanz\u0026aacute; R, Arrangoiz R, Cordera F, Mu\u0026ntilde;oz M, Luque-de-Le\u0026oacute;n E, Moreno E, et al. Pulmonary extraskeletal myxoid chondrosarcoma: A case report and literature review. Int J Surg Case Rep. 2016;27:96\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou Q, Lu G, Liu A, Kohno T. Extraskeletal myxoid chondrosarcoma in the lung: asymptomatic lung mass with severe anemia. Diagn Pathol. 2012;7:112.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThway K, Nicholson AG, Wallace WA, AI-Nafussi A, Pilling J, Fisher C. Endobronchial pulmonary angiomatoid fibrous histiocytoma: two cases with EWSR1-CREB1 and EWSR1-ATF1 fusions. Am J Surg Pathol. 2012;36:883\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShilo K, Miettinen M, Travis WD, Timens W, Nogueira R, Franks TJ. Pulmonary microcystic fibromyxoma: report of 3 cases. Am J Surg Pathol. 2006;30:1432\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSudha SM, Sandhya DG, Sundaram C, Daphne VM, Vishal F, Senthil BR, K V V N JR, R TSR. FISH for EWSR1 in Ewing's sarcoma family of tumors: Experience from a tertiary care cancer center. Indian J Pathol Microbiol. 2021;64(1):96\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGerardo C, Carmelo L, Nadia C,Flavia R,Andrea M, Anna C,Eliano C,Senia MRT,Giuseppe I,Biagio M. Eugenio M,Vito P,Leonardo R. Angiomatoid Fibrous Histiocytoma (AFH) of the Right Arm: An Exceptional Case with Pulmonary Metastasis and Confirmatory EWSR1::CREB1 Translocation. Diagnostics (Basel). 2022;12(11):2616.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenjamin BO, Li L, Emily RW, Alexander JL,Jared JB. Kevin BJ.EWSR1::ATF1 Orchestrates the Clear Cell Sarcoma Transcriptome in Human Tumors and a Mouse Genetic Model. Cancers (Basel). 2023;15(24):5750.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKeiko S, Shintaro S, Tomoyuki A, Terufumi K, Hiroko A, Taro S, Yumika I, Mitsuhiro T, Hiromi F, Makoto E, Tadashi H. Detection of specific gene rearrangements by fluorescence in situ hybridization in 16 cases of clear cell sarcoma of soft tissue and 6 cases of clear cell sarcoma-like gastrointestinal tumor. Diagn Pathol. 2018;13(1):73.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"lung, myxoid, sarcoma, epithelioid cell, EWSR1- CREB1 fusion","lastPublishedDoi":"10.21203/rs.3.rs-4488939/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4488939/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePrimary pulmonary myxoid sarcoma (PPMS) is an extremely rare soft tissue tumor that is characterized in most cases by the oncogenic fusion gene \u003cem\u003eEWSR1-CREB1\u003c/em\u003e. Tumor cells with epithelioid differentiation have not been described in PPMS. We report a primary lung tumor with morphological, immunohistochemical and molecular features closely mimics PPMS, but with concomitant epithelioid differentiation. Is this a variant of PPMS or under-recognized entity?\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eA 34-year-old female patient showed a CT scan showing nodular opacities around the upper lobe of the left lung with a diameter of 8 mm, which was mildly unevenly enhanced after enhancement. Histologically there were two tumor areas, one of which presented a typical PPMS morphology, and the tumor cells were stellate, polygonal, epithelial and arranged as reticular and cords in abundant myxoid stroma. The other tumor area presented an epithelioid cell morphology. The tumor cell immunophenotype was positive for vimentin, INI1 and negative for TTF-1, P40, S-100, SOX10, CK5/6, SMA, Desmin, PAX8, Brachyury and WT1. Interestingly, immunohistochemistry confirmed positive AE1/AE3 in epithelioid cell regions, while AE1/AE3 was negative in typical PPMS regions. Molecular analysis demonstrated the presence of \u003cem\u003eEWSR1-CREB1\u003c/em\u003e gene fusions in the tumor.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePPMS is a very rare lung malignant soft tissue tumor with distinct histological and genetic features. Our challenge case had morphological, immunohistochemical and molecular features similar to PPMS, but with epithelioid differentiation.We prefer to describe this tumour as a variant of PPMS instead of a new entity.\u003c/p\u003e","manuscriptTitle":"A malignant epithelioid tumor with EWSR1 fusion mimics primary pulmonary myxoid sarcoma (PPMS): a variant of PPMS or under-recognized entity?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-20 18:45:29","doi":"10.21203/rs.3.rs-4488939/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"13c0f1cc-3a46-433d-a3f1-9464e368b67a","owner":[],"postedDate":"June 20th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-03T00:08:21+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-20 18:45:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4488939","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4488939","identity":"rs-4488939","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}