Immunohistochemical ALK Expression in Granular Cell Atypical Fibroxanthoma: A Diagnostic Pitfall for ALK-Rearranged Non-neural Granular Cell Tumor

ABSTRACT

Atypical fibroxanthoma (AFX) is a neoplasm that most commonly occurs on sun-damaged skin of the head and neck in elderly patients and that usually exhibits indolent clinical behavior with complete excision. The granular cell variant of AFX demonstrates overlapping histopathologic features with dermal non-neural granular cell tumor (NNGCT), which typically arises on the extremities of young to middle aged adults with rare reports of regional metastasis. A subset of NNGCT harbors ALK rearrangements and expresses ALK by immunohistochemistry. Here, we present 2 cases of granular cell AFX occurring on the scalp of males aged 73 and 87 with ALK expression by immunohistochemistry and no evidence of an ALK rearrangement on fluorescence in situ hybridization, representing a diagnostic pitfall for NNGCT.

Clinicopathological and Genomic Profiles of Atypical Fibroxanthoma and Pleomorphic Dermal Sarcoma Identify Overlapping Signatures with a High Mutational Burden

Atypical fibroxanthoma (AFX) and pleomorphic dermal sarcoma (PDS) are rare tumors developing in chronically sun-exposed skin. Clinicopathological features are similar, but they differ in prognosis, while PDS has a more aggressive course with a higher risk for local recurrence and metastases. In current clinical practice, they are diagnosed by exclusion using immunohistochemistry. Thus, stringent diagnostic criteria and correct differentiation are critical in management and treatment for optimal outcomes. This retrospective single-center study collected clinicopathological data and tumor samples of 10 AFX and 18 PDS. Extracted genomic DNA from tumor specimens was analyzed by a next-generation sequencing (NGS) platform (FoundationOne-CDx™). Among 65 identified mutations, TP53 inactivating mutations were observed in all tumor specimens. In both AFX and PDS, the known pathogenic gene alterations in CDKN2A, TERT promoter, and NOTCH1 were frequently present, along with high mutational burden and stable Micro-Satellite Instability status. The mutational profiles differed only in ASXL1, which was only present in AFX. Further differences were identified in likely pathogenic and unknown gene alterations. Similarities in their genomic signatures could help to distinguish them from other malignancies, but they are not distinguishable between each other using the FoundationOne-CDx™ NGS panel. Therefore, histological criteria to determine diagnosis remain valid. For further insight, performing deep tumor profiling may be necessary.

Lipodystrophies-Disorders of the Fatty Tissue

Lipodystrophies are a heterogeneous group of physiological changes characterized by a selective loss of fatty tissue. Here, no fat cells are present, either through lack of differentiation, loss of function or premature apoptosis. As a consequence, lipids can only be stored ectopically in non-adipocytes with the major health consequences as fatty liver and insulin resistance. This is a crucial difference to being slim where the fat cells are present and store lipids if needed. A simple clinical classification of lipodystrophies is based on congenital vs. acquired and generalized vs. partial disturbance of fat distribution. Complications in patients with lipodystrophy depend on the clinical manifestations. For example, in diabetes mellitus microangiopathic complications such as nephropathy, retinopathy and neuropathy may develop. In addition, due to ectopic lipid accumulation in the liver, fatty liver hepatitis may also develop, possibly with cirrhosis. The consequences of extreme hypertriglyceridemia are typically acute pancreatitis or eruptive xanthomas. The combination of severe hyperglycemia with dyslipidemia and signs of insulin resistance can lead to premature atherosclerosis with its associated complications of coronary heart disease, peripheral vascular disease and cerebrovascular changes. Overall, lipodystrophy is rare with an estimated incidence for congenital (<1/1.000.000) and acquired (1-9/100.000) forms. Due to the rarity of the syndrome and the phenotypic range of metabolic complications, only studies with limited patient numbers can be considered. Experimental animal models are therefore useful to understand the molecular mechanisms in lipodystrophy and to identify possible therapeutic approaches.

Xanthogranuloma of the sellar region: A case report

RATIONALE

Xanthogranuloma of the sellar region is exceedingly rare, and described in only a handful of case reports. Herein, we present a case of xanthogranuloma of the sellar region to improve our knowledge for the diagnosis and management of this unusual disease.

PATIENT CONCERNS

A 50-year-old female presented with the symptoms of intermittent vomiting, occasional head discomfort, and diabetes insipidus of 1 month duration.

DIAGNOSES

Magnetic resonance imaging showed a large well-defined, vase-like, heterogeneous mass in the sellar region. The lesion showed mixed signal with hierarchical signal presentation. Fluid-fluid level sign can be found within the lesion. The upper part of the lesion was hyperintense, and the lower part was hypointense on both T1-weighted images and T2-weighted images. The lesion showed no enhancement following the intravenous administration of gadolinium. The normal pituitary tissue was not clearly visible. Optic chiasm was compressed and displaced by the lesion. Initial diagnosis of pituitary macroadenoma with hemorrhage in the sellar region was made before surgery. Final diagnosis of sellar xanthogranuloma was confirmed by histopathological examination after surgical resection.

INTERVENTIONS

Gross total resection of the lesion was achieved using the microscope through endonasal transsphenoidal approach.

OUTCOMES

The patient recovered well with improved binocular vision and no symptom of diabetes insipidus, and was discharged 5 days after operation.

LESSONS

Sellar xanthogranuloma should receive diagnostic consideration for the lesion that is a heterogeneously mixed mass with a degree of T1-weighted images hyperintense in the sellar region.

Eruptive Xanthomas: A Dermatologic Clue to the Diagnosis of an Underlying Metabolic Disorder

A 32-year-old man presented to the dermatology department with generalized asymptomatic yellowish papules on an erythematous base, arms, thighs, and buttocks. These lesions had appeared in the previous month (Figure 1). Dermoscopy revealed a homogeneous yellow color, corresponding to dermal xanthomatous deposits, with interconnected fine and dotted vessels (Figure 2). The laboratory findings showed extremely high levels of triglycerides (4.842 mg/dL; normal <150), as well as increased total cholesterol (576 mg/dL; normal <200), fasting blood glucose (294 mg/dL), and glycated hemoglobin 12.3% (normal range 4% to 6%). A skin biopsy demonstrated foamy cells, with extracellular lipid between collagen bundles in the dermis (Figure 3).

Verruciform Xanthoma of the Oral Mucosa: A Series of Eight Typical and Three Anomalous Cases

In this series, there are 8 typical verruciform xanthomas of the oral mucosa and 3 anomalies, 1 polypoid, 1 florid, and 1 carcinomatous. All were characterized by infiltrates of CD68-positive xanthomatous histiocytes in the lamina propria. The 11 patients comprised 6 men and 5 women (mean age = 54.5 years, range = 40-69). Both keratinized and nonkeratinized sites were affected. A history of lichenoid inflammation was recorded in 5 patients. The polypoid xanthoma presented in a woman aged 54 years as a polyp of the labial commissure. The florid lesion affected the dorsum of the tongue of a man aged 54 years and at 20 mm was the largest of the 11 lesions, but the only one with candidal infection. The squamous cell carcinoma manifested as a papilloverrucous hyperkeratosis of the palatal gingiva in a man aged 69 years. The latter 2 (and 1 "typical" verruciform xanthoma) required re-excision, but none has since recurred.

Extended resection for xanthogranulomatous cholecystitis mimicking gallbladder carcinoma: Cases and review of diagnostic approach

Xanthogranulomatous cholecystitis is a rare variant of chronic cholecystitis, which can involve adjacent organs including liver, colon and duodenum mimicking gallbladder cancer. Preoperative and intraoperative differentiation of xanthogranulomatous cholecystitis from gallbladder cancer is often difficult and the final diagnosis is made on histopathology of the resected specimen. We hereby report four cases of xanthogranulomatous chol ec ystitis w hich were misdiagnosed as cases of advanced gallbladder cancer based on presentation and radiological findings and underwent radical resections but the final histopathology was a diagnostic surprise. Xanthogranulomatous cholecystitis is still a diagnostic challenge as no single modality has been helpful to diagnose this entity till date. Radical resection seems justified in patients who present with the features mimicking gallbladder cancer.

Eruptive xanthomas in a patient with soft-drink diabetic ketosis and apolipoprotein E4/2

Soft-drink diabetic ketosis, characterized by acute onset ketosis induced by excessive ingestion of sugar-containing drinks, is often seen in obese, young patients, even with undiagnosed type 2 diabetes. We herein report a 15-year-old obese patient with the apolipoprotein E4/2 phenotype, in whom eruptive xanthomas lead to a diagnosis of soft-drink diabetic ketosis. He developed multiple asymptomatic yellowish papules on the auricles, back, buttocks and the extensor surfaces of the elbows and knees. He initially visited a dermatology clinic and his blood triglyceride and HbA1c levels were found to be 6,490 mg/dL and 16.5%, respectively. He was referred to our hospital for treatment of hyperglycemia and hypertyriglyceridemia. On admission, he had ketonuria and increased blood levels of 3-hydroxybutylate and acetoacetate. He habitually drank 1-3 litters of sweet beverages daily to quench his thirst. Therefore, "soft-drink diabetic ketosis" was diagnosed. Severe hypertriglyceridemia was considered to have been a consequence of impaired insulin action and his apolipoprotein E4/2 phenotype. We treated the diabetic ketosis and hypertriglyceridemia with intensive insulin therapy and a fat-restricted diet. At discharge, he no longer required insulin therapy and his blood glucose levels were controlled with metformin and voglibose. Along with amelioration of the hyperglycemia, triglyceride levels decreased to 247 mg/dL without administration of anti-hyperlipidemia agents. The eruptive xanthoma lesions gradually diminished in size and number and eventually disappeared by 12 months. This case provides an instructive example of eruptive xanthomas serving as a sign of severe dysregulation, not only of lipid, but also glucose, metabolism.

Bilateral xanthomas of tendoachilles in a slow learner adolescent - A rare case report of van bogaert scherer epstein disease

Van Bogaert Scherer Epstein Disease is a rare autosomal recessive condition involving abnormal deposition of cholesterol and cholestanol in various parts of body, various clinical symptoms manifest on different age group, significantly neurological impairment in late presentation. We are reporting a slow learner young lady presented with bilateral painless ankle swelling, our initial clinical impression were torn Achilles tendon or Haglund's deformity. On further detail history taking, it leads us towards this disease and confirmed with biopsy. A proper history taking and assessment can easily diagnose this condition, early treatment can perhaps change the fate of these unfortunate patients.

Fox-Fordyce disease: report of two cases with perifollicular xanthomatosis on histological image

Fox-Fordyce disease is a relatively infrequent pathology of the apocrine glands that affects almost exclusively young women. The disease is characterized by the presence of pruritic follicular papules mainly in the armpits that respond poorly to treatment and severely affect the patient's quality of life. We report two cases with clinical diagnosis and histopathological confirmation, presenting perifollicular xanthomatosis on histological examination, recently described as a distinctive, consistent, and specific feature of this disease.

[Eruptive Xanthomas: A Cardinal Manifestation of Serious Metabolic Disease]

Eruptive cutaneous xanthomas develop as a result of rapid intracellular and dermal deposition of lipids and are a cardinal sign of high cardiovascular risk. We describe the case of a 47-year-old male with multiple dome-shaped, yellowish and firm, slightly pruriginous papules distributed over the buttocks, lumbar region, abdominal wall, elbows and neck, for about two months. Previous medical history included alcohol abuse, non-medicated type 2 diabetes mellitus, dyslipidemia and recent onset of therapy with olanzapine for depressive syndrome. Work-up revealed hypertriglyceridemia (7474 mg/dL), hypercholesterolemia (1054 mg/dL) and hemoglobin A1c of 12.1%. Histopathologic examination of an abdominal papule showed clusters of foamy histiocytes in the dermis confirming the diagnosis of eruptive xanthomas. In this case, the introduction of olanzapine may have aggravated the previous history of metabolic disease which may have led to the rapid onset of skin lesions. Proper recognition of eruptive xanthomas can have a profound impact on diagnosis, treatment and prognosis of patients who suffer from an underlying systemic disease.

Xanthogranulomatous Cholecystitis Associated with Gallbladder Adenocarinoma. A Clinicopathologic Study. of 5 Cases

The simultaneous presence of xanthogranulomatous cholecystitis and adenocarcinoma of the gallbladder has rarely been reported. A review of 53 cases of gallbladder adenocarcinoma in a 15-year period revealed 5 cases in which a concomitant diffuse xanthogranulomatous disease was observed. Clinical and pathologic features of these cases are commented and the diagnostic importance stressed. Both inflammatory and neoplastic components were closely mixed in 3 cases, thus making a prompt diagnosis difficult. Etiologic factors implicated in the development of both entities are considered.

Infiltrative xanthogranulomatous cholecystitis mimicking aggressive gallbladder carcinoma: A diagnostic and therapeutic dilemma

Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis. The perioperative findings in aggressive cases may be indistinguishable from those of gallbladder or biliary tract carcinomas. Three patients presented mass lesions that infiltrated the hepatic hilum, provoked biliary dilatation and jaundice, and were indicative of malignancy. Surgical excision was performed following oncological principles and included extirpation of the gallbladder, extrahepatic bile duct, and hilar lymph nodes, as well as partial hepatectomy. Postoperative morbidity was minimal. Surgical pathology demonstrated XGC and absence of malignancy in all three cases. All three patients are alive and well after years of follow-up. XGC may have such an aggressive presentation that carcinoma may only be ruled out on surgical pathology. In such cases, the best option may be radical resection following oncological principles performed by expert surgeons, in order that postoperative complications may be minimized if not avoided altogether.

Xanthomatosis in bilateral hands mimicking rheumatoid arthritis: A case report

RATIONALE

Xanthomatosis often accompanies familial hypercholesterolemia. This disease usually occurs in tendons, most commonly located in the Achilles tendon; occasionally it can also be seen in other systems. Although there are previous reports for bilateral hand extensor tendon involvement, to our knowledge there is no report in English literature regarding bilateral hands with small joint synovium presenting as rheumatoid arthritis. Therefore, the case that is presented in this report is unique.

PATIENT CONCERNS

An 18-year-old woman was admitted to our department because she presented with morning stiffness, joint deformation, and swelling in both hands. Computed tomography of the right hand showed soft tissue swelling on multiple small joints, including metacarpophalangeal and proximal interphalangeal joints, but without obvious bone destruction. There was soft tissue swelling around the small joints, which were hypointensities on T1-weighted and hyperintensities on T2-weighted images, not uniformly enhanced appearances on magnetic resonance imaging.

DIAGNOSES

Biopsy from the 3rd metacarpophalangeal joint capsule of the left hand confirmed xanthoma.

INTERVENTIONS

She was treated with statin drugs to reduce blood fat.

OUTCOMES

After 3 months of follow-up, no recurrence or complications were detected regarding a full range of motion remaining of the affected joints.

LESSONS

The young patient with symptoms of small joint synovium involved in both hands and the performance of magnetic resonance imaging similar to rheumatoid arthritis may be suffering from xanthomatosis.

Oral verruciform xanthoma and erythroplakia associated with chronic graft-versus-host disease: a rare case report and review of the literature

BACKGROUND

Oral verruciform xanthoma is an uncommon benign lesion. Although oral verruciform xanthoma occurs in healthy individuals, it has been also reported in association with some inflammatory conditions. The aim of this study is to report a case of oral verruciform xanthoma associated with chronic graft-versus-host disease and to review the literature on this topic.

CASE PRESENTATION

A 47-year-old Caucasian male presented to the Sector of Oral Medicine "V. Margiotta", University Policlinic "P. Giaccone" of Palermo complaining of a mass on the gingiva. He first noticed the painless mass 1 year ago. He reported to have undergone allogenic hematopoietic stem cell transplantation 15 years ago for acute lymphoblastic leukaemia. Intraoral examination revealed a well-circumscribed, sessile yellowish and verrucous nodule upon canine, multiple yellowish and verrucous nodules on the hard palate, yellowish and verrucous nodules on left buccal mucosa. In addiction an area of white striae in a reticular pattern with erythema and ulceration was present on the dorsum of the tongue. This lesion was consistent with a known history of oral chronic graft versus host disease. Moreover, we observed a suspected area of oral erythroplakia yet on the dorsum of the tongue. In biopsy specimen of hard palate histopathological examination revealed a diagnosis of verrucous xanthoma of the oral cavity; in addiction in biopsy specimen of the dorsum of the tongue revealed the presence of erythroplakia with high grade dysplasia.

CONCLUSION

Verruciform xanthoma of the oral cavity associated with chronic graft-versus-host disease is a rare condition with a usually benign clinical course but malignant transformation has been described in association with oral potential malignant disorder (e.g. chronic graft versus host disease, erythroplakia). Very rare cases showed association with oral chronic graft versus-host-disease. To date, only eight cases were published in the world literature. Therefore it could be important follow up patients also for oral verruciform xanthoma onset.

[A Case of Xanthogranulomatous Cholecystitis That Changed Over Time and Was Difficult to Distinguish from Advanced Gallbladder Cancer]

A 70-year-old man was referred because of suspected gallbladder cancer and gallstones. Contrast-enhanced CT, EOB-MRI and PET-CT could not completely rule out gallbladder cancer. The patient preferred follow-up without surgery. At 4 months after initial examination, the gallbladder wall thickening showed improvement, but appeared worse at 9 months after initial examination. Therefore, we decided to perform surgery. Since malignant findings were not observed on rapid intraoperative pathology, we performed a cholecystectomy and right hemicolectomy because of inflammation in the transverse colon. Pathological examination diagnosed xanthogranulomatous cholecystitis. The imaging appearance of xanthogranulomatous cholecystitis varies, and also changes over time, making it difficult to distinguish from advanced gallbladder cancer. We experienced a case of xanthogranulomatous cholecystitis that changed over time, and report this case with a review of the literature.