The First Case Of The Myopericytomatosis Of The Foot With RAF1 Rearrangement Involving Intron 7 (ATG7-RAF- 1)

Introduction/Objective

Myopericytomatosis, recently described by Yin P. Hung et al [1], is an extremely rare myopericytic proliferation with only less than 15 reported cases in the English literature. This neoplasm has been described as dermal or subcutaneous well-circumscribed nodules composed of ovoid to spindled cells in a perivascular distribution, with no significant necrosis, atypia or mitosis. It usually involves the lower extremities with the ankle being the most common location. Next-generation DNA sequencing (NGS) in all the previously reported cases exhibited PDGFRB alterations with no BRAF, NOTCH, and/or GLI1 alterations [1].

Methods

We report a 47-year-old man who presented multiple well-encapsulated nodules on his right foot that were localized to the fascia/subcutaneous fat by MRI; fibromas were the main radiologic differential diagnosis.

Results

The biopsy and subsequent excisional specimens showed diffuse involvement by numerous discrete myopericytomatous nodules composed of bland spindled to ovoid cells. Immunohistochemical staining demonstrated that the myopericytic cells are strongly positive for SMA, focally positive for caldesmon with a patchy cytoplasmic CD99 staining. Ki-67 showed a low proliferation rate of 1–2%. Desmin, CD31, CD34, HHV8, STAT6, S100, HMB45, and Melan-A immunostains were negative. The diagnosis of myopericytomatosis was made. The NGS revealed that the tumor cells are positive for RAF1 rearrangement involving intron 7 (ATG7-RAF-1) with no other findings, including PDGFRB alterations.

Conclusion

Myopericytomatosis is an exceedingly rare entity with most of the previously reported cases involving the lower extremities and only two cases involving the foot. In all the prior cases, the PDGFRB mutation N666K was noted [1]. We report the first case of RAF1 rearrangement in myopericytomatosis of the foot with no other genetic alterations.

Fibroadenoma of Ectopic Breast Tissue in the Groin – A Rare Disease Entity

Introduction/Objective

Ectopic breast tissue (EBT) is a well-documented anomaly of the breast and commonly presents along the embryonic milk line extending between the axilla and groin. Reported incidence of accessory breast is 0.4–6% in females. Pathologies developing in an EBT are reported as a rare entity in the literature.

Carcinoma is reported as the common pathology followed by inflammation and fibroadenoma

Methods

We present a case of 43-year- old female who presented with a painless mass in her right groin for the past year which gradually increased in size. CT abdomen pelvis with contrast showed a 2.2 x 3.0 x 4.4 cm superficial soft tissue mass in the right groin which was suspected to be a lymph node. Further investigation and histopathological report of biopsy showed ectopic breast tissue with admixed chronic inflammation and reactive changes.However, excision of the mass three months later showed showed proloferation of both glandular and stromal elements.

Results

The tissue from the biopsy was positive for GATA 3, mammoglobin, GCDFP and CD 10 and the histological features on excision was confirmatory of fibroadenoma.

Conclusion

In conclusion, when tumors or nodules are found along the mammary line, the presence of breast tissue should be considered during the investigation. It is clinically wise to evaluate and screen carefully cases of supernumerary breast for any pathology and for any associated urogenital anomalies such as supernumerary kidneys, polycystic kidneys and renal cell adenocaricnoma. In our case, patient had no associated urogenital anomalies and she is on follow up.

The Rare First Manifestation Of Mantle Cell Lymphoma As Immune Complex Glomerulonephritis With Crescents And Membranoproliferative Features

Introduction/Objective

Initial presentation of Non-Hodgkin Lymphoma (NHL) with immune complex glomerulonephritis (ICGN) is rare. Mantle cell lymphoma (MCL) is a rare aggressive lymphoma comprising 3–7 % of all NHL and ICGN as the first manifestation of MCL is very unusual.

Methods

We report a 73 year-old-man with increased serum creatinine (2.1 mg/dl) from normal baseline 3 months ago. Urinalysis showed the presence of dysmorphic RBCs, RBC casts and 300 mg/dl of protein. Physical examination revealed diffuse lymphadenopathy. Hepatitis C and B Ab, HIV screen, ANA, ANCA, Anti dsDNA Ab, Anti GBM Ab, and Serum protein electrophoresis were normal or negative.

Results

The renal biopsy showed Immune complex glomerulonephritis with (25%) fibrocellular/cellular crescents and focal membranoproliferative (MPGN) features. There were foci of dense monomorphic lymphoid aggregates of small lymphocytes and 30% interstitial fibrosis with corresponding tubular atrophy. No tubulitis was present. Direct Immunofluorescence showed 2+ to 4+ granular mesangial and capillary loop staining for Total Ig, IgG, IgA, IgM, C1q, C3 and C4. The lymphoid aggregate was monoclonal Kappa. Electron microscopy showed widespread podocyte foot process effacement, subendothelial and rare mesangial dense deposits. Excisional lymph node biopsy flow cytometry showed a monoclonal population of CD19+, CD20+, CD22+, CD5+, skappa-restricted, CD10-, CD11c-, CD23-, CD25- CD38-, CD103-, CD200- B- cells. Cyclin D1 was positive on immunostain, consistent with stage IV (renal) MCL. He received chemotherapy with steroids, bendamustine, and rituximab leading to resolution of lymphadenopathy and proteinuria and improvement in serum creatinine.

Conclusion

It is important to recognize that the first manifestation of MCL may present as renal involvement in the form of ICGN and, as in this case, with fibrocellular/cellular crescents and a focal MPGN pattern. This is an extremely rare, but important, cause of renal insufficiency that can be successfully treated with lymphoma chemotherapy.

Epstein - Barr Virus (EBV) Associated B-Cell Lymphoma: An Unusual Involvement Of The Heart And Kidney In An HIV Positive Patient With Concurrent Cytomegalovirus (CMV) Pneumonia And Pneumocystis Jirovecii Pneumonia (PCP)

Introduction/Objective

We report a 68-year-old man with Human immunodeficiency virus (HIV) infection and significant weight loss during the past two years who presented with dyspnea. He was not receiving any treatment for HIV infection, and his viral load and CD4 count were 178000 copies/ml and 8 cells/mm3, respectively. The radiologic examination was concerning for Pneumocystis jirovecii pneumonia. The Bronchoalveolar lavage was positive for Pneumocystis jirovecii. The patient expired despite the comprehensive treatment, and the autopsy was requested.

Methods

The autopsy showed heavy lungs with diffuse consolidation and white discoloration involving all lobes. The left ventricular wall and right kidney cortex showed foci of white discoloration measuring 1 and 0.8 cm, respectively.

Results

The microscopic examination of lungs showed concurrent CMV pneumonia, and PCP confirmed by immunohistochemical staining for CMV and GMS special stain. The histologic evaluation of the heart and the right kidney and immunohistochemical staining for CD20 and CD3 in addition to in situ hybridization (ISH) for EBER revealed infiltrative malignant cells, which were positive for CD20 and EBER and negative for CD3. The EBV associated B-cell lymphoma involving the heart, and the right kidney was diagnosed

Conclusion

EBV is involved in human lymphomagenesis, particularly in HIV patients. There is a tendency for the lymphoma to involve the extranodal sites, including the CNS, gastrointestinal tract, liver, and bone marrow. However, the involvement of the heart and kidneys occurs very rarely. The autopsy findings of Lung co-infection with PCP and CMV and EBV associated lymphoma involving atypical locations is a rare and unique combination of AIDS-defining illnesses in this patient.