Hereditary leiomyomatosis associated with renal cell carcinoma

Hereditary leiomyomatosis and renal cell cancer linked with FH mutations

The diagnosis of hereditary leiomyomatosis and renal cell cancer was revolutionized over 20 years ago by the establishment of links between fumarate hydratase mutations and the syndrome of cutaneous and uterine leiomyomata, with a risk of potentially fatal renal cell carcinoma. Dermatologists can help with the initial clinical diagnosis and a skin biopsy, as well as long-term clinical screening for leiomyosarcoma.

The preliminary outcome of the combination of immunotherapy and targeted therapy after recurrence and metastasis for hereditary leiomyomatosis and renal cell cancer-a case report

Hereditary leiomyomatosis and renal cell cancer (HLRCC)-associated kidney cancer is a rare and exceptionally aggressive, with early metastasis and die at a young age. Most reported patients usually present with back pain and hematuria, and died within 5 years after diagnosis. Currently, there is not a guideline or census about the management of HLRCC. On April 19, 2019, the Food and Drug Administration (FDA) of the USA approved the combination of pembrolizumab and axitinib for first-line treatment of patients with advanced renal cell carcinoma based on the results of KEYNOTE-426 trial. Thus, the combination of immunotherapy and targeted therapy should be considered for HLRCC. We present a case of 46-year-old man without family history, possessing specific mutation and sensitive to the combination of immunotherapy and targeted therapy. After he completed seven cycles of combined treatments, his discomfort improved and the lesions of pleura almost disappeared and the mass in the left kidney area was basically stable. This patient might be the first one to receive the combination therapy and the efficacy seemed acceptable.

Novel Fumarate Hydratase Mutation in Siblings With Early Onset Uterine Leiomyomas and Hereditary Leiomyomatosis and Renal Cell Cancer Syndrome

Hereditary leiomyomatosis renal cell cancer syndrome is an autosomal dominant disorder characterized by uterine and cutaneous leiomyomas and increased predisposition to renal cell carcinoma, papillary type II. The syndrome is caused by heterozygous mutations to the fumarate hydratase (FH) gene located on chromosome 1. Affected females generally present with early onset, atypical uterine leiomyomas and cutaneous findings, however, delays in diagnosis are very common in patients with isolated uterine findings. We present a case series of 2 sisters in their 20s who presented with isolated uterine leiomyomas and were found to carry a novel mutation for the fumarate hydratase gene. One patient was referred for treatment of infertility and recurrent miscarriages and the other was referred for acute symptomatic anemia due to myomas. Prompt diagnosis of hereditary leiomyomatosis renal cell cancer was made due to a high index of clinical suspicion based on early onset disease and familial clustering as well as characteristic pathologic findings on uterine leiomyoma surgical specimen. Timely diagnosis not only allowed for genetic counseling and renal cancer surveillance, but also for fertility counseling given the increased morbidity associated with uterine leiomyoma due to hereditary leiomyomatosis and renal cell cancer syndrome.

Incidence of mature adipocytic component within cutaneous smooth muscle neoplasms

Angioleiomyoma is a benign smooth muscle tumor of the subcutis. The presence of mature adipocytes has been described in this tumor under the rubric of 'angiolipoleiomyoma' or, erroneously, 'angiomyolipoma' (these are not PEComas). Previous studies have found adipocytes in only 2-3% of angioleiomyoma. Anecdotally, the incidence appeared to be greater than this in our practice. Moreover, the presence of adipocytes has not been evaluated in pilar leiomyoma or cutaneous leiomyosarcoma. We searched the pathology archives from 2007 to 2014 for all cutaneous and subcutaneous leiomyoma and leiomyosarcoma; cases were reviewed to confirm the diagnosis and evaluate for mature adipocytes. Seven of 73 total cases (10%) contained mature adipocytes: 1 of 33 pilar leiomyoma (3%), 4 of 22 angioleiomyoma (18%) and 2 of 18 leiomyosarcoma (11%). In our series, the 18% incidence of 'angioleiomyoma with fat' (our preferred terminology) is higher than the previously reported incidence of 2-3%. We also report the rare presence of mature adipocytes within pilar leiomyoma and cutaneous leiomyosarcoma, a finding not previously reported to our knowledge. Mature adipocytes may be present within cutaneous and subcutaneous leiomyomas and leiomyosarcomas and should not detract from the diagnosis or lead to concern for an adipocytic neoplasm or PEComa.