Inflammatory myofibroblastic tumor of the upper arm: A case report

RATIONALE

Inflammatory myofibroblastic tumor (IMT) is an uncommon benign myofibroblastic tumor that usually occurs in the lung, mediastinum, abdomen and vulvovaginal region. IMT of the upper arm is exceedingly rare with unknown etiology. Pathology plays a major role in the diagnosis of IMT, and radiological characteristics of the condition are crucial for differential diagnosis.

PATIENT CONCERNS

A 62-year-old woman was admitted to our hospital for a complaint of a mass in her left upper limb with progressive numbness in the extremity. Ultrasound examination of the brachial artery (BA) revealed a hypoechoic mass with well-defined borders and a substantial blood flow, and the mass was also shown to be greatly enhanced on computed tomography (CT) and magnetic resonance imaging (MRI).

DIAGNOSIS

The subsequent histopathological and immunohistochemical studies led to the diagnosis of IMT.

INTERVENTION

The patient was referred for surgery. The soft tissue tumor resection, left median nerve release operation, brachial artery vascular grafting, and arterial anastomosis were performed.

OUTCOME

Favorable outcome was observed. The patient recovered well from the procedure and did not experience any further complications or tumor recurrence.

LESSONS

In this report, we describe a case of IMT of the upper arm with BA involvement. The case expands the differential diagnosis of limb neoplasm and broadens the understanding of its ultrasonic and radiological imaging features. It also serves as a further example of an uncommon region distinct from conventional IMT. Further studies on the etiology and therapeutic strategies are needed.

A Novel CASC15-ALK and TFG-ROS1 Fusion Observed in Uterine Inflammatory Myofibroblastic Tumor

The majority of inflammatory myofibroblastic tumors (IMTs) in the gynecologic tract occur in the uterine corpus and harbor anaplastic lymphoma kinase ( ALK ) rearrangement. Herein, we report 1 uterine IMT case with a novel fusion involving ALK and 1 uterine IMT case with ROS1 rearrangement. The ages of the patients were 56 and 57 yr, respectively. The tumor size was 10.0 and 8.0 cm, respectively. Both patients had stage IB disease. Histologically, the 2 IMT cases had classic morphologic features and predominantly comprised bland spindle cells with hypercellular (fascicular/storiform) and hypocellular (myxoid rich) areas admixed with variably prominent lymphoplasmacytic infiltration. Immunohistochemically, the ALK -rearranged case was positive for ALK , and the ROS1 -rearranged case was positive for ROS1 . Both cases were diffusely positive for desmin. The tumor cells were variably positive for estrogen receptor (1/2 cases, 50.0%) and progesterone receptor (1/2 cases, 50.0%). Targeted RNA sequencing revealed one case each with either a novel CASC15-ALK or TFG-ROS 1 fusion. We identified a novel ALK fusion partner CASC15 in IMT and described the first uterine IMT with a TFG-ROS1 fusion. This study improves our understanding of molecular events in IMT.

Treatment modalities of ALK-positive relapsed/refractory inflammatory myofibroblastic tumor of the brain and lungs in 7-year-old girl: case-based reviews

PURPOSE

Inflammatory myofibroblastic tumor (IMT) belongs to mesenchymal neoplasm of intermediate malignancy in WHO classification. Primary CNS disease or CNS metastases (CNS-IMT) occur in minority. We describe a case of relapsed/refractory IMT of lungs with multiple brain metastases in young child who achieved long-term complete response after alectinib. This systematic review also summarizes treatment modalities and outcome of children and adolescent with CNS-IMT.

METHODS

PRISMA 2020 guideline was applied to select an article from PubMed, Scopus, and Cochrane databases without time limits. This review focused on children and adolescent 0-24 years of age with CNS-IMT or inflammatory pseudotumor (CNS-IPT). The clinical characteristics and treatment outcome were explored.

RESULTS

A total of 51 patients in 49 publications were identified. Median age of patients with CNS-IMT/IPT was 15-year-old and 60.8% were male. The most common location of tumor was cerebral cortex (54.9%). Complete resection of CNS-IMT/IPT was performed in 27 cases with 100% complete response and 18.5% recurrence. Nearly half of patients who received partial resection without adjuvant therapy experienced progressive disease, while the contrast group totally achieved partial response. Overall responses in 7 patients treating with ALK inhibitors were 57.1% durable complete response and 42.9% transient partial response.

CONCLUSION

First-line treatment of CNS-IMT/IPT is complete resection. Patients who received partial tumor removal might have benefit from adjuvant therapy. ALK inhibitors reveal a promising result in unresectable CNS-IMT/IPT. Our case has shown a success in treating relapsed and refractory CNS-IMT as well as the primary site using 2nd-generation ALK inhibitor.

Update of pediatric soft tissue tumors with review of conventional MRI appearance-part 1: tumor-like lesions, adipocytic tumors, fibroblastic and myofibroblastic tumors, and perivascular tumors

There are numerous soft tissue tumors and tumor-like conditions in the pediatric population. Magnetic resonance imaging is the most useful modality for imaging these lesions. Although certain soft tissue lesions exhibit magnetic resonance features characteristic of a specific diagnosis, most lesions are indeterminate, and a biopsy is necessary for diagnosis. We provide a detailed update of soft tissue tumors and tumor-like conditions that occur in the pediatric population, emphasizing each lesion's conventional magnetic resonance imaging appearance, using the recently released 5th edition of the World Health Organization Classification of Soft Tissue and Bone Tumors as a guide. In part one of this review, pediatric tumor-like lesions, adipocytic tumors, fibroblastic and myofibroblastic tumors, and perivascular tumors are discussed. In part two, vascular lesions, fibrohistiocytic tumors, muscle tumors, peripheral nerve sheath tumors, tumors of uncertain differentiation, and undifferentiated small round cell sarcomas are reviewed. Per the convention of the WHO, these lesions involve the connective, subcutaneous, and other non-parenchymatous-organ soft tissues, as well as the peripheral and autonomic nervous system.

CT Signs and Differential Diagnosis of Peripheral Lung Cancer and Inflammatory Pseudotumor: A Meta-Analysis

We aimed to systematically evaluate the imaging features of peripheral lung cancer and inflammatory pseudotumor. PubMed, Embase, Cochrane Library, Chinese Knowledge Infrastructure (CNKI), Wanfang database (Wanfang), and Chinese Biomedical Network (CBM) were searched to collect relevant studies on CT image comparison of peripheral lung cancer and inflammatory pseudotumor. The search time was from database establishment to July 15, 2021. The search language was limited to Chinese and English. Data from the literature were screened and extracted, and meta-analysis was performed using Stata 16.0 software. A total of 8 cohort studies were included in this meta-analysis, including 675 patients. Meta-analysis showed that the lesion size of inflammatory pseudotumor was greater than that of peripheral lung cancer, and the difference had statistical significance [SMD = 0.29, 95% CI (0.01, 0.58), P < 0.05]. The difference in HU value between inflammatory pseudotumor and peripheral lung cancer CT had no statistical significance [SMD = -0.09, 95% CI (-0.79, 0.60), P > 0.05]. The HU value of enhanced CT of inflammatory pseudotumor was higher than that of peripheral lung cancer, and the difference had statistical significance [SMD = 0.75, 95% CI (0.15, 1.34), P < 0.05]. The incidence of calcification of inflammatory pseudotumor was significantly higher than that of peripheral lung cancer, and the difference had statistical significance [RR = 2.85, 95% CI (1.33, 6.11), P < 0.05]. The incidence of long hair puncture sign of inflammatory pseudotumor was lower than that of peripheral lung cancer, and the difference had statistical significance [RR = 0.49, 95% CI (0.24, 0.97), P < 0.05]. There was no significant difference between inflammatory pseudotumor and peripheral lung cancer in terms of cavity incidence, vacuole sign, pleural indentation, and bronchial inflation sign (P > 0.05). Based on the available literature evidence, it can be found that there are differences in the CT signs between peripheral lung cancer and inflammatory pseudotumor, and the lesion size, HU value on enhanced CT, incidence of calcification, and incidence of burr sign may be important indicators for differentiating peripheral lung cancer from inflammatory pseudotumor.

Plasma cell granuloma of the conjunctiva in a young female

Plasma cell granuloma is a rare non-neoplastic inflammatory condition of unknown etiology commonly involving lung and gastrointestinal tract. Conjunctival disease per se is very rare and usually associated with involvement of other organs. We report a case of conjunctival plasma cell granuloma without any systemic involvement in a 9-year-old girl who presented with bilateral reddish vascularised subconjunctival episcleral mass. An excision biopsy of the mass in the left eye followed by histopathologic examination and Immunohistochemistry confirmed the diagnosis. At 1 year follow-up, the child had no recurrence in the operated eye whereas the lesion remained the same in the other eye despite systemic treatment with immunosuppressants. This case is being reported for its rarity and to insist on the mandatory need for a thorough systemic workup to identify multiorgan involvement as well as to rule out other systemic disorders.

Inflammatory myofibroblastic tumor in the head and neck-a neoplasm with both tumor features and inflammation

OBJECTIVE

The aim of this study was to unveil the reciprocal relation of tumor characteristics and inflammation in inflammatory myofibroblastic tumor in the head and neck.

STUDY DESIGN

The study included a retrospective cohort of patients with inflammatory myofibroblastic tumors treated between 2005 and 2017 in a tertiary hospital. Tumor features and inflammation were assessed through the expression of anaplastic lymphoma kinase (ALK), the degree of inflammation and cyclooxygenase-2 (COX-2) expression. The prognostic factors were analyzed for overall survival (OS) and disease-free survival (DFS) in univariate and multivariate analyses.

RESULTS

Forty-one patients diagnosed with inflammatory myofibroblastic tumors were followed up, and 41 paraffin sections were obtained. The positive rate of ALK expression was 21 (51.2%) of 41 patients. Nineteen patients had high-grade ALK expression, and 22 patients had low-grade ALK expression. Thirty-nine patients had high-grade inflammation, and 2 had low-grade inflammation. The positive rate of COX-2 expression was 100%. Tumors with both high-grade ALK expression and inflammation had worse DFS (P = .015). The multivariate Cox analysis showed that the grades of ALK expression and inflammation (P = .004) were independent risk factors for DFS.

CONCLUSIONS

Because of the latent synergistic effects of ALK and inflammation in the tumorigenesis of inflammatory myofibroblastic tumor, the combined therapy of ALK and COX-2 inhibitors shows promise.

Calcifying fibrous tumor of the gastrointestinal tract: A clinicopathologic review and update

Calcifying fibrous tumor (CFT) is a rare mesenchymal lesion that has been documented throughout the gastrointestinal tract. Gastrointestinal CFTs may occur at virtually any age, with a predilection for adults and for females. They occur most commonly in the stomach and the small and large intestines. CFTs are most often found incidentally, cured by local resection, and have a low risk of recurrence. Histology shows three characteristic features: Spindle cell proliferations within a densely hyalinized stroma, scattered calcifications, and lymphoplasmacytic inflammation. CFTs are immunoreactive for CD34, vimentin and factor XIIIa, helping to distinguish them from other benign mesenchymal neoplasms. The differential diagnosis of CFTs includes sclerosing gastrointestinal stromal tumor, leiomyoma, schwannoma, solitary fibrous tumor, inflammatory myofibroblastic tumor, plexiform fibromyxoma, fibromatosis, sclerosing mesenteritis, and reactive nodular fibrous pseudotumor. The pathogenesis of CFTs remains unclear, but some have hypothesized that they may be linked to IgG4-related disease, inflammatory myofibroblastic lesions, hyaline vascular type Castleman disease, sclerosing angiomatoid nodular transformation of the spleen, or trauma.

The dynamic enhanced characterization with low mechanical index gray-scale harmonic imaging inflammatory pseudotumor of liver compared with hepatic VX2 tumor and normal liver

BACKGROUND

Inflammatory pseudotumor of the liver (IPTL) is misdiagnosed usually as a malignant tumor based on the imaging findings. Differential diagnosis should be established to avoid hepatic resection. At imaging, IPTL has been misdiagnosed usually as hepatocellular carcinoma (HCC). It is usually found firstly using conventional ultrasonic examination, which cannot give a definitive diagnosis. Because of its atypical clinical presentation and radiological appearance, a presumptive diagnosis of malignancy is frequently made. With the development of ultrasound systems and ultrasound contrast agents (UCA), contrast-enhanced ultrasound is widely used in diagnosing focal lesions of the liver.

OBJECTIVES

To delineate the hemodynamic features of IPTL compared with hepatic VX2 tumor and normal liver using contrast-enhanced ultrasound.

MATERIAL AND METHODS

Freund's complete adjuvant (FCA) was injected using a modified method into the desirable portion of the liver in rabbits. Two weeks after the injection, solitary IPTLs were formed (which was proved with pathological examination). Ten rabbits with IPTL, 10 rabbits with VX2 carcinoma and 10 healthy rabbits were studied using contrast-enhanced ultrasound with bolus injection of SonoVueTM through the peripheral vein. Corresponding parameters such as time to enhancement (ET), time to peak intensity (PIT), time to ascent (AT), and time to lighten (LT) were measured with wash-in/wash-out curve.

RESULTS

Contrast-enhanced imaging clearly delineated the dynamic enhancement of the lesions and liver parenchyma during the whole phase. Inflammatory pseudotumor of the liver showed the same enhanced features as the liver parenchyma. In VX2 tumors, hyperechoic enhancement in arterial phase and hypoechoic enhancement was observed in the portal and delayed phase compared with the surrounding hepatic parenchyma. The normal liver showed whole of liver parenchyma enhanced in portal phase.

CONCLUSIONS

The study showed that contrast-enhanced ultrasound provided useful information about perfusion in IPTL and VX2 carcinoma. Contrast-enhanced ultrasound is a useful technique in the differential diagnosis of focal liver lesions if combined with time-intensity curve.

Imaging features of hepatic inflammatory pseudotumor: distinction from colorectal liver metastasis using gadoxetate disodium-enhanced magnetic resonance imaging

PURPOSE

To identify gadoxetate disodium-enhanced MRI features distinguishing hepatic IPT from CLM.

METHODS

From February 2008 to December 2019, 162 lesions (IPT, n = 31 and CLM, n = 131) from 94 patients (mean age 65.1 ± 12.2 years; 65 men and 29 women) were retrospectively assessed for the presence or absence of obscure boundary, rim enhancement on arterial phase (AP), persistent rim enhancement during AP to transitional phase (TP), blood vessel penetration, peritumoral parenchymal enhancement on AP, peritumoral parenchymal hypointensity on hepatobiliary phase (HBP), peritumoral parenchymal hyperintensity on T2-weighted imaging (T2WI), biliary dilatation, central hypointensity with a relatively hyperintense periphery on HBP, peripheral hyperintensity on diffusion-weighted imaging (DWI) and T2WI, and lesion to liver signal intensity ratio (SIR_lesion/liver) on HBP and DWI. Relevant features for differentiating between ITP and CLM were identified by univariate and multivariate analyses.

RESULTS

Univariate analysis revealed significantly higher frequencies of the following features in IPT than CLM: younger age, obscure boundary, blood vessel penetration, central hypointensity with a relatively hyperintense periphery on HBP, higher SIR_lesion/liver on HBP, and lower SIR_lesion/liver on DWI (P < 0.001‒0.035). Rim enhancement on AP and persistent rim enhancement during AP to TP were significantly more common in CLM than in IPT (P ≤ 0.001). Multivariate analysis revealed that a central hypointensity with a relatively peripheral hyperintensity on HBP, higher SIR_lesion/liver on HBP, and lower SIR_lesion/liver on DWI were predictive of IPT (P = 0.003‒0.039).

CONCLUSION

Central hypointensity with a relatively peripheral hyperintensity on HBP and SIR_lesion/liver on HBP and DWI may be reliable gadoxetate disodium-enhanced MRI features for distinguishing IPT from CLM.

Unusual Behaviour Of A Lung Inflammatory Myofibroblastic Tumour

Inflammatory myofibroblastic tumours (IMTs) are rare lesions. We report a case of a 55 year-old male, admitted with a pneumonia. Further investigation revealed a left lower lobe mass and enlarged mediastinal lymph nodes. Cytology of the bronchoalveolar lavage suggested a squamous cell carcinoma. He received four cycles of chemotherapy followed by a left lower lobectomy. Pathological analysis was compatible with IMT. Three months after surgery, a new IMT nodule located in the lingula was excised. Four months later,endobronchial involvement and the presence of liver nodules were detected.Ten months after the first surgery a CT revealed a sacrum lesion. Histology was compatible with undifferentiated sarcoma and a sarcomatous transformation was assumed.

[Thoracic extramedullary subdural and epidural of inflammatory myofibroblastoma: a case report]

We present here a rare case of thoracic extramedullary subdural and epidural of leisions. The initial diagnosis of preoperation was hypertrophy of ligamentum flavum, however, after excision of the epidural lesions, the symptoms got worse. A second operation found the subdural leisions which were then totally resected. Two pathological examinations confirmed it was inflammatory myofibroblastic tumor (IMT). The incidence of this disease is extremely low. IMT is benign in histology, but it can be aggressive. The exact pathogenesis is still unknown. Tumor resection is the first choice to treat. Long-term follow-up with MRI is required for the patient.

Huge inflammatory myofibroblastic tumor of pleura with concomitant nuchal fibroma

Inflammatory myofibroblastic tumor (IMT) is a rare benign neoplasm. It is a challenging disease because the symptoms and radiologic findings are diverse and nonspecific. Although pulmonary IMT is the most common form, pleural origin is an extremely rare clinical entity. Nuchal fibroma (NF) is another rare benign neoplasm. We report herein a case of pleural IMT with concomitant NF in a 15-year-old girl. To the best of our knowledge, this is the first report suggesting an association between IMT and NF, and our case had the largest reported intrathoracic IMT. Moreover, we found a possible association between IMT and increased CA-125 levels.

Inflammatory pseudotumour of skull base - diagnostic challenge and treatment outcome

We report a case of an inflammatory pseudotumour (IP) involving the floor of the skull base, which demonstrated aggressive behavior both clinically and radiologically. In this case, the diagnosis was established by clinical presentation, magnetic resonance imaging (MRI), histopathological examination (HPE) and the dramatic response towards high dose steroid therapy. The clinical features improved with oral cyclophosphamide in combination with oral steroid, which were given for a period of three months.

[Malignant inflammatory myofibroblastic tumor of the left mandible: a case report]

A case of malignant inflammatory myofibroblastic tumor was reported. The relevant literatures were reviewed to discuss the clinical and pathologic characteristics, diagnosis and therapy of malignant inflammatory myofibroblastic tumor.

Inflammatory fibroid polyp of the ileum causing intussusception

Intussusception in adults is a rare cause for intestinal obstruction and is usually secondary to some lesion in the gastrointestinal tract GIT. We report a case of intestinal obstruction due to ileo-colic intussusception; an inflammatory fibroid polyp formed the leading edge of the intussusceptum, which is a rare polypoidal lesion of the GIT.

Uterine leiomyoma with massive lymphoid infiltration: Case report and review of the literature

Uterine leiomyoma with massive lymphoid infiltration is a rare and unusual pathological finding. Only 13 cases have been reported in English literature. A case of uterine leiomyoma showing massive lymphoid infiltration in a 45-year-old woman is described. The tumor was relatively soft compared with usual leiomyomas. Microscopically, the tumor showed the typical features of leiomyoma with moderate to severe lymphocytic infiltrate consisting of mature lymphocytes, a few plasma cells and occasional histiocytes. This cellular infiltration was confined to the leiomyoma. Immunohistochemically, the diffusely infiltrated lymphoid cells were stained by antibodies to CD45RO, CD3 and CD8. Germinal centers were stained by antibodies to CD20 and CD79a. Some CD68+ histiocytes were seen. Lymphoid infiltration within the leiomyoma is a peculiar histological morphology, although the cause is not clear. The recognition of its distinct histological features is important to avoid possible confusion with differential diagnoses including malignant lymphoma, inflammatory pseudotumor and pyomyoma.

[Inflammatory pseudotumors of the kidney. Report of 2 cases]

Inflammatory pseudotumours of the kidney are rare and raise a problem of differential diagnosis with renal cancer. The authors discuss the diagnostic difficulties of this disease in the light of two patients, aged 32 years and 60 years, admitted for left low back pain (2 cases), large kidney (1 case) and haematuria (1 case). The combination of renal ultrasound and CT suggested a renal tumour or a renal cyst, and MRI suggested a necrotic tumour. Surgical exploration led to tumour excision in one case and surgical biopsy in the other case due to the unresectable appearance of the tumour. Histological examination revealed an inflammatory mass with no signs of malignancy in the two cases. A favourable course was observed in both cases with a normal kidney on subsequent CT. The preoperative diagnosis of pseudotumour remains difficult, despite progress in medical imaging and often requires surgical exploration. The diagnosis is based on a correlation of radiological and histological findings.

Lymphohistiocytoid mesothelioma. An often misdiagnosed variant of sarcomatoid malignant mesothelioma

Three cases of lympho-histiocytoid mesothelioma, a rare variant of pleural sarcomatoid malignant mesothelioma, are described. Histologically, the neoplasms were characterized by a diffuse discohesive proliferation of atypical histiocytoid cells intermixed with a marked lymphocytic and lesser plasmacytic infiltrate. One case initially was misdiagnosed as a ganglioneuroma, a second case was misinterpreted as malignant lymphoma, and a third case was sent in consultation with the differential diagnosis of inflammatory pseudotumor vs mesothelioma. Immunohistochemical studies showed strong and generalized expression of cytokeratins and vimentin by the neoplastic histiocytoid cells in all 3 cases. Two cases were positive for calretinin, one of which also was positive for HBME-1, thrombomodulin, and LeuM1. None of the cases stained with the epithelial glycoprotein markers carcinoembryonic antigen, B72.3, and Ber-EP4, or the blood group antigen, BG-8. The immunophenotype of the lymphoplasmacytic infiltrate revealed predominantly reactive, mature T cells, with fewer polytypic plasma cells, histiocytes, and B cells. In lymphohistiocytoid mesothelioma, as in the usual examples of sarcomatoid mesothelioma, the demonstration of cytokeratin expression by the neoplastic cells is the most useful diagnostic finding that allows exclusion of other neoplasms with which this entity may be confused.

Plasma cell granuloma of lips, mouth and larynx

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