Calcifying aponeurotic fibroma around posterior tibialis tendon in an elderly patient with flatfoot: A case report

RATIONALE

Calcifying aponeurotic fibroma (CAF) is a rare benign fibroblastic tumor that is commonly in the hand or foot of children or adolescents.

PATIENT CONCERNS

A 74-year-old female presented with a progressive pain on the medial foot for 3 years ago. The pain aggravated while walking or in a standing position for more than 20 minutes. She also complained of skin contact along the medial aspect of the foot while trying to wear a shoe.

DIAGNOSIS

Physical examination revealed a firm, immobile, nontender mass accompanied with flexible flatfoot. On the single heel raise test, loss of the balance and intensification of the pain were observed. Faintly calcified soft tissue mass is shown in plain radiographs without bone involvement. Magnetic resonance imaging revealed a subcutaneous mass with ill-defined circumscribed subcutaneous mass adherent to the thickened PTT.

INTERVENTIONS

The patient underwent a complete excisional biopsy, followed by medial displacement calcaneal osteotomy.

OUTCOMES

The excised mass was diagnosed to be CAF on the histologic examination. At the 1-year follow-up, patient remained asymptomatic with no evidence of recurrence and all the radiographic parameters demonstrating flat foot improved.

LESSONS

This is the first case of CAF located at PTT presenting with both foot pain and functional disability. In this case, complete excision of the causative structure along with alignment correction can contribute to successful postoperative outcome.

Similar appearance of different multifocal carpal bone destructing disease entities in 3 patients: A case report

RATIONALE

Several diseases feature tumors, or tumor-mimicking lesions, that further invade the bone and surrounding joints of the wrist region. Here, we describe 3 rare cases of multiple destructed carpal bones and adjacent joints in different disease entities confirmed via pathologic diagnosis.

PATIENT CONCERNS

All 3 cases were examined between January 2016 and December 2019. Three patients presented with similar clinical manifestations and radiographic features, with multiple osteolytic lesions in the carpal bones and metacarpal bone base.

DIAGNOSES

The 3 cases were diagnosed as diffuse type tenosynovial giant cell tumor, calcifying aponeurotic fibroma, and rheumatoid arthritis.

INTERVENTIONS

Separate, experienced radiologist and pathologist took part in the interpretation and compartmentalization of radiographs and pathological findings, respectively. Even magnetic resonance imaging could not achieve a diagnosis; surgical excision was therefore required, with subsequent pathological assessment for treatment and final diagnosis.

OUTCOMES

functional outcomes also differed among patients, poorest in rheumatoid arthritis patient.

LESSONS

We report 3 rare disease entities, presenting with multifocal osteolytic lesions in the wrist. They all presented with similar clinical manifestations, and the final diagnoses were made via pathological evaluation. Compared with tenosynovial giant cell tumor and calcifying aponeurotic fibroma, rheumatoid arthritis had the poorest outcome.

Ultrasound and Magnetic Resonance Imaging Features of Calcifying Aponeurotic Fibromas

OBJECTIVES

To report characteristic imaging findings of calcifying aponeurotic fibromas (CAFs) on ultrasound (US) and magnetic resonance imaging (MRI).

METHODS

Eight patients with CAF based on our institutional pathology database from 2000 to 2019 were consecutively included. Images were assessed as follows: with plain radiographs for the presence of soft tissue calcifications; with US for the presence of microlithiasis (a nonshadowing hyperechoic focus <3 mm) and discrete calcifications, size, location, margin, echogenicity, and relationship with surrounding structures; and with MRI for the presence of MRI microlithiasis (scattered tiny signal-void dots), margin, signal intensity, contrast enhancement pattern, and relationship with surrounding structures.

RESULTS

Calcifying aponeurotic fibromas occurred most commonly in the foot (n = 5), followed by the hand, ankle, and knee, respectively. Half of the lesions (n = 4) showed intralesional calcifications on plain radiographs. On US, all lesions showed microlithiasis. They involved the subcutaneous (n = 5), perifascial (n = 2), and intermuscular (n = 1) layers. Margins were circumscribed (n = 3) or irregular (n = 5), whereas the echogenicity of the underlying tumor matrix was hyperechoic (n = 4), isoechoic (n = 2), or hypoechoic (n = 2). All lesions were abutting (n = 7) or encasing (n = 1) an adjacent tendon. On MRI, all CAFs showed tiny signal-void dots and irregular margins. Signal intensity was mostly hyperintense (n = 5) on T2-weighted images and all hypointense on T1-weighted images. Three lesions showed heterogeneous contrast enhancement, and 3 showed uneven marginal enhancement.

CONCLUSIONS

A CAF should be considered a differential diagnosis if a soft tissue mass abutting or encasing the tendon or fascia shows US or MRI microlithiasis.

Multiple calcifying aponeurotic fibroma: case report and review of the literature

We describe the first case of diagnosis of generalized calcifying aponeurotic fibroma in 52 year-old man receiving long-term therapy for seronegative rheumatoid arthritis with rheumatoid nodules. The prevalence of lesions (presence of multiple subcutaneous nodules in the aponeuroses and fascia of the head, neck, trunk, upper and lower extremities with massive deposition of calcium salts), and a combination with monoclonal secretion (IgGκ serum, BJκ in the urine), raised inflammation markers, suggest that this case of the disease is unique, so both in domestic and foreign literature contains no description of this unusual course of this type of mesenchymal tumor. We have shown that subcutaneous nodules biopsy followed by morphological and immunohistochemical study is required in the diagnosis of the disease. We have given the literature data on the clinical manifestations, methods of diagnosis and differential diagnosis of this disease with a variety of pathologies, accompanied by the development of multiple calcification.

FN1-EGF gene fusions are recurrent in calcifying aponeurotic fibroma

Calcifying aponeurotic fibroma (CAF) is a soft tissue neoplasm with a predilection for the hands and feet in children and adolescents. Its molecular basis is unknown. We used chromosome banding analysis, fluorescence in situ hybridization (FISH), mRNA sequencing (RNA-seq), RT-PCR, and immunohistochemistry to characterize a series of CAFs. An insertion ins(2;4)(q35;q25q?) was identified in the index case. Fusion of the FN1 and EGF genes, mapping to the breakpoint regions on chromosomes 2 and 4, respectively, was detected by RNA-seq and confirmed by RT-PCR in the index case and two additional cases. FISH on five additional tumours identified FN1-EGF fusions in all cases. CAFs analysed by RT-PCR showed that FN1 exon 23, 27 or 42 was fused to EGF exon 17 or 19. High-level expression of the entire FN1 gene in CAF suggests that strong FN1 promoter activity drives inappropriate expression of the biologically active portion of EGF, which was detected immunohistochemically in 8/9 cases. The FN1-EGF fusion, which has not been observed in any other neoplasm, appears to be the main driver mutation in CAF. Although further functional studies are required to understand the exact pathogenesis of CAF, the composition of the chimera suggests an autocrine/paracrine mechanism of transformation. Copyright © 2015 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Calcifying aponeurotic fibroma of the finger in an elderly patient: CT and MRI findings with pathologic correlation

Calcifying aponeurotic fibroma (CAF) is a rare, locally aggressive fibroblastic lesion that occurs predominantly in the distal extremities of children and adolescents. In the present study, a case of pathologically proven CAF arising in the right little finger of a 69-year-old woman is presented. Physical examination revealed a firm, immobile, non-tender mass. Plain radiographs showed a faintly calcified soft tissue mass without bone involvement and computed tomography scans clearly demonstrated the presence of the lesion. Magnetic resonance imaging revealed that the lesion exhibited low to intermediate signal intensity on T1-weighted images and heterogeneous high signal intensity with small foci of low signal intensity on T2-weighted spectral presaturation with inversion recovery images. Contrast-enhanced fat-suppressed T1-weighted images demonstrated intense heterogeneous enhancement throughout the mass. The patient underwent an excisional biopsy. Histologically, the tumor showed a biphasic pattern, composed of a moderately cellular fibromatosis-like component and irregular calcified areas with polygonal epithelioid cells. There has been no evidence of local recurrence four months following surgery. To the best of our knowledge, this case report describes the oldest patient with this condition.