Expanding the Spectrum of Ubiquitin-specific Proteases-Fused Neoplasms

Mesenchymal spindle cell tumors represent a heterogeneous group of neoplasms defined by distinct clinicopathologic features and diverse molecular alterations. While USP6 rearrangements are well-established in nodular fasciitis and related entities, fusions involving other ubiquitin-specific proteases, such as USP2 and USP8, have only recently emerged. Prompted by sporadic reports of USP8 fusions in matrix-rich neoplasms, we aimed to characterize the clinicopathologic and molecular spectrum of USP2/USP8-rearranged mesenchymal tumors. We retrospectively analyzed 19 tumors, evaluating clinical, histopathologic features, immunohistochemical profiles, whole-transcriptome RNA sequencing, and DNA methylation profiling. Nineteen tumors were identified, harboring either USP8 (n=12) or USP2 (n=7) fusions. The cohort included patients aged 3 to 70 years (median: 32). Tumors primarily affected the distal extremities, with the notable exception of 2 intracardiac cases in pediatric patients, harboring USP8 fusions (CBLB::USP8 and SPPL2A::USP8). Histologically, all cases were composed of bland spindle cells arranged in either a myofibromatous or an inflammatory pattern; notably, USP2-fused tumors exhibited an exclusively myofibromatous morphology. Immunohistochemically, SMA was frequently expressed, while desmin, h-caldesmon, ALK, ROS1, panTRK, and CD34 were consistently negative. Transcriptomic analysis demonstrated proximity to myofibroma and nodular fasciitis profiles, rather than forming a distinct USP2/8-specific cluster. No cases showed malignant behavior or recurrence during the available follow-up period. USP2/8-rearranged neoplasms represent a morphologically diverse but biologically indolent subset of myofibroblastic tumors. They exhibit significant overlap with USP6-associated lesions and PDGFR-altered myofibromas. Recognizing these fusions is critical to avoid diagnostic pitfalls and overtreatment, particularly when they present in unusual sites, such as the heart.