Deletions of both alpha 5(IV) and alpha 6(IV) collagen genes in Alport syndrome and in Alport syndrome associated with smooth muscle tumours

Diffuse oesophageal leiomyomatosis (DL), an inherited smooth muscle proliferation process, has been reported to be associated with Alport syndrome (AS), a familial nephropathy, mainly dominant X-linked inherited, and characterized by ultrastructural changes of the glomerular basement membrane. The COL4A5 gene, encoding the alpha 5 chain of type IV collagen, has been identified as the site of mutations in families with X-linked AS. Recently, a novel alpha 6(IV) collagen chain encoding gene has been mapped closely upstream of COL4A5, and disruption of the 5' end of both genes has been reported in four patients with DL and AS (DL-AS). Here, we report a long-range restriction map around the COL4A6 locus, and show that the COL4A5/COL4A6 deletion observed in seven patients with DL-AS encompasses only the two first exons of COL4A6, with a breakpoint located in the second intron of COL4A6, whose size exceeds 65 kb. Furthermore, we demonstrate that three patients with AS without DL, known to have a deletion of the 5' part of the COL4A5 gene, display a larger deletion in COL4A6. Moreover, a COL4A6 mRNA product was detected by reverse-transcription-polymerase chain reaction in an oesophageal tumour sample of a patient with DL-AS. These results suggest that DL-AS could be caused by an abnormal truncated alpha 6(IV) chain.

Relation between side of plagiocephaly, dislocation of hip, scoliosis, bat ears, and sternomastoid tumours

A relation is described between plagiocephaly and four structural lesions in children who have two or more of these five features. The flat temple in plagiocephaly, a unilateral congenitally dislocated hip, a scoliotic convexity in a young child, and a sternomastoid tumour tend to be on the same side, and a unilateral bat ear on the opposite side.

Inflammatory myofibroblastic tumour of paranasal sinuses with fatal outcome: reactive lesion or tumour?

Inflammatory myofibroblastic tumours (IMTs) are clinicopathologically distinctive but biologically controversial entities, which have been described in the lungs, abdomen, retroperitoneum, and extremities, but rarely affect the head and neck region. IMT usually follows a benign clinical course after radical excision, but invasive, locally recurrent, and metastatic forms of abdominal and mediastinal IMT have also been described. This report describes a case of IMT of the paranasal sinuses with a fatal outcome. A 22 year old woman was admitted to hospital as a result of epistaxis. Computed tomography scan and magnetic resonance imaging showed an expansive process in the paranasal sinuses, extending into the nasal cavity, orbita, and endocranium. The tumour progressed despite several surgical procedures. Radiotherapy, corticosteroids, and chemotherapy were unsuccessful, and the patient died four years after diagnosis, as a result of extensive intracranial spread of the tumour. This is the first known case of an IMT of the head and neck region with a fatal outcome. It shows that the aggressive behaviour of IMTs is not limited to abdominal and mediastinal locations, and supports recent observations that at least a subset of IMTs represents true neoplasia rather than reactive myofibroblastic proliferation.

Inflammatory myofibroblastic tumor of the central nervous system: clinicopathologic analysis of 10 cases

To verify the pathologic features, anaplastic lymphoma kinase (ALK) expression and biologic behavior of inflammatory myofibroblastic tumors (IMTs) of the central nervous system (CNS), we analyzed 10 cases of IMTs-CNS (8 cranial, 1 spinal, and 1 orbital). Our series of IMTs of the CNS showed a male predominance (male:female = 6:4) and a wide age range (10-60 years; mean age, 46.7 years). Lesion location also varied, but they were basically dura-based. Radiologically, they showed two patterns: isolated mass forming (n = 6) and an en plaque-like pattern (n = 4). Histopathologically, plasma cell granuloma (PCG)-like (n = 5) or fibrohistiocytic (FHC) variant (n = 5) was present. No correlation was found between the radiologic and histopathologic patterns. Spindle-shaped mesenchymal cells of IMTs expressed smooth muscle actin (SMA) in all cases. ALK expression was not found in our IMTs of the CNS. Late recurrence was found in 2 cases in different sites (20%). Pathologically, IMT-CNS could be subclassified into PCG-like and FHC. Immunostaining for SMA was found to helpfully discriminate myofibroblastic cells and to make a differential diagnosis. Although our cases did not show ALK immunoreactivity, some IMTs-CNS can recur, which suggests the neoplastic potential of these tumors. The rearrangement of the ALK gene in IMTs-CNS should be verified by an examination of more cases.

Successful Preoperative Treatment of Pediatric Bladder Inflammatory Myofibroblastic Tumor with Anti-Inflammatory Therapy

Inflammatory myofibroblastic tumors are rare, locally invasive tumors that can involve the genitourinary tract. Therapy has consisted primarily of surgery, and anecdotal experience using both chemotherapy and radiotherapy, which have yielded unimpressive results. We report the first case of a bladder inflammatory myofibroblastic tumor that responded to an anti-inflammatory regimen (prednisone and Cox-2 inhibitor) before surgical extirpation.

Transient uniocular visual loss on deviation of the eye in association with intraorbital tumours

Five patients with unilateral orbital tumours are described in whom transient loss of vision occurred on deviation of the affected eye from the primary position. Other presenting features were diplopia, proptosis, poor visual acuity, visual field defects, pupillary abnormalities, fundal changes and altered colour vision. Abnormalities on fluorescein angiography suggest that the visual loss is due to transient ischaemia. Temporary uniocular loss of vision on eye movement may be an early sign of an intra-orbital mass.

Liposarcoma with orbital metastases. Case report

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Respiratory obstruction caused by a multicentric granular cell tumor of the laryngotracheobronchial tree

An unusual case of acute respiratory obstruction caused by multicentric granular cell tumors of the laryngotracheobronchial tree is presented. The patient also had granular cell tumors in the tongue, vulva, and chest wall. Multiplicity of the lesions in the left lung and recurrent episodes of intercurrent pulmonary infections necessitated left pneumonectomy. The extreme rarity of such a clinical circumstance is illustrated by a review of the literature. Salient clinical and pathological features of the tumor are briefly discussed.

Mammary epithelioid myofibroblastoma arising in bilateral gynecomastia: case report with immunohistochemical profile

Myofibroblastoma of the breast is a rare benign neoplasm, which has rarely been reported in association with gynecomastia. We report a case of a 25-year-old male patient with an epithelioid myofibroblastoma arising in a context of bilateral gynecomastia. The lesion was composed of nests and cords of epithelioid cells, with round to oval nuclei, granular chromatin, and distinct nucleoli dispersed in a myxoid to collagenous stroma with marked vascular proliferation. Immunohistochemical profile showed diffuse positivity for vimentin and focal immunoreactivity for desmin, whereas cytokeratins (CAM5.2 and AE1/AE3), EMA, alpha smooth muscle actin, actin HHF35, CEA, S100, factor VIII, neuron-specific enolase, CD31, and CD34 were all negative. We emphasize that this diagnosis is difficult to establish, owing to the rarity of this variant and clinical presentation.

Cluster headache as a manifestation of intracranial inflammatory myofibroblastic tumour: a case report with pathophysiological considerations

We report a patient with a secondary form of chronic cluster headache, caused by an intracranial presentation of inflammatory myofibroblastic pseudotumour located in the posterior fossa, with total remission of the pain after resection. The headaches were resistant to many of the usual treatments for cluster headache. The patient had two normal computed tomography scans and one normal magnetic resonance imaging of the head before the additional diagnosis of brain tumour was made. This is an unusual cause of cluster headache with intracranial mass, with an unexpected clinical presentation, a rare triggering manoeuvre, unusual pathology and successful treatment. This patient probably had the hypothalamic biological predisposition to cluster headache and, when a small mass disturbed pain-sensitive structures in the posterior fossa, it excited the trigeminovascular system via posterior fossa trigeminal and upper cervical afferents, and triggered the pathophysiological processes that resulted in a secondary form of chronic cluster headache.

Granular cell myoblastoma of the pituitary. Case report

✓ A rare case of granular cell myoblastoma of the pituitary is reported and discussed. It is not affected by radiation and should be surgically removed to preserve vision.

Surgical management of endobronchial inflammatory myofibroblastic tumors

BACKGROUND

Endobronchial myofibroblastic tumors are neoplasms composed of clonal populations of smooth muscle cells and a variable lymphocytic inflammatory component. They represent a challenge with respect to diagnosis, classification, and surgical resection due to their infrequent occurrence.

METHODS

We retrospectively reviewed our experience with patients who had myofibroblastic tumors in the major airways over a 15-year period, in order to understand the incidence, natural biology, treatment, and long-term outcome of individuals with this type of neoplasm in an endobronchial location.

RESULTS

Between 1995 and 2010, 11 patients (9 female, 2 male) underwent surgical resection of a myofibroblastic tumor arising within the tracheobronchial tree. The mean age was 39.6 years (range, 22.3 to 53.6 years). All patients were symptomatic, with cough and dyspnea as the most common presenting complaints. Rigid bronchoscopy with endobronchial biopsy was utilized to establish the diagnosis in 9 of 11 patients. Laser-mechanical debulking was performed to relieve airway obstruction prior to operation in 10 of 11 patients. Because of wide submucosal infiltration of the neoplasms, surgical resection for complete removal was required for all individuals. Tracheal resection was performed in 3 patients, carinal resection in 1 patient, mainstem bronchial resection in 2 patients, sleeve resection in 3 patients, bilobectomy in 1 patient, and right lower lobectomy in 1 patient. Resection with tumor-free margins was accomplished in all patients. Mean tumor size was 2.3 cm (range, 1.5 to 3.5 cm). There were no operative deaths, with all patients alive and disease-free at a mean of 6.1 ± 3.7 years.

CONCLUSIONS

Complete surgical resection of inflammatory myofibroblastic tumors presenting in a major airway is safe and leads to excellent survival for patients with this uncommon disease.

So-called "inflammatory leiomyosarcoma'': a series of 3 cases providing additional insights into a rare entity

Inflammatory leiomyosarcoma, a rare entity first described in 1995, has been characterized by smooth muscle differentiation, a near-haploid karyotype, and a surprisingly good prognosis. The morphology is similar to that of conventional leiomyosarcoma admixed with a chronic inflammatory infiltrate. Thus far, only 15 cases have been reported in the English language literature. We report the clinical and pathological features of 3 additional cases of inflammatory leiomyosarcoma. Two women (ages 64 and 25, respectively) and 1 man (age 32) presented with a thigh, ovary, and lung mass, respectively. Inflammatory symptoms, such as anorexia, fever, night sweats, abdominal pain, and diarrhea, coincided with the thigh and ovarian primaries. Immunohistochemical studies revealed diffuse positivity for desmin and poor expression for other smooth muscle and skeletal muscle markers (muscle-specific actin [0/3], alpha-smooth muscle actin 1/3 [focal], calponin [1/3], caldesmon [0/3], and myogenin [0/3]). CD68 was diffusely positive in both the histiocytes and spindle cell component in all cases. Ultrastructural evaluation of 1 case (lung primary) lacked definitive smooth muscle differentiation. Cytogenetic analysis in 1 of 2 cases that were karyotyped, identified a near-haploid karyotype, which has been reported in other cases of inflammatory leiomyosarcoma. The other case showed 2 clonal populations of cells with interstitial deletions of the short arm of chromosome 8 and the long arm of chromosome 9, respectively. The case without cytogenetic data was intimately associated with an ovarian mature teratoma. These data also suggest that inflammatory leiomyosarcoma may lack smooth muscle differentiation, characterized by diffuse immunoreactivity for desmin but lack of immunoreactivity for alpha-smooth muscle actin, calponin, and caldesmon. In addition, 2 of the 3 cases developed distant metastases to the lungs, which suggests that these lesions may have a worse prognosis than previously believed.

Granular cell tumor of the proximal esophagus. A rare disease

In 1926, Abrikossoff described a tumor, usually benign, which only rarely appears in the esophagus. In a 40-year-old woman, the authors found a multicentric granular cell tumor which was localized in the cervical esophagus and in the subcutaneous tissues over the right scapula; it was removed surgically. Granular cell tumors causing stenosis of the upper esophagus have been described only four times in the literature. Characteristics and treatment are discussed.

Liver transplantation for a hilar inflammatory myofibroblastic tumor

A 7-yr-old boy presented with obstructive jaundice secondary to an inflammatory myofibroblastic tumor centered on the hepatic hilum and extending into the liver. The tumor was further complicated by portal vein phlebitis and occlusion. Attempted resection of the tumor with portal vein reconstruction and bilioenteric drainage was unsuccessful and he required urgent orthotopic liver transplantation. In contrast to more peripheral inflammatory myofibroblastic tumors in the liver, hilar lesions are locally aggressive, causing occlusive portal phlebitis and biliary obstruction. Successful management may include the need for liver transplantation.

Percutaneous transhepatic cholangiography. Problems in interpretation

The patient who presents with jaundice, regardless of the etiology, cannot be adequately examined by a gallbladder series and intravenous cholangiography. Clinical evaluation aided by laboratory analysis will not always differentiate between primary liver parenchymal disease and biliary tract obstruction. Percutaneous transhepatic cholangiography, when successfully performed, answers the question of whether the jaundice is due to primary liver parenchymal disease or due to biliary tract obstruction. The point to emphasize is that under no circumstances is it appropriate to presume any information if the biliary system is not entered and visualized successfully. The proper interpretation of the level of block can fall prey to the mistake of incomplete aspiration of the thick, inspissated bile in the obstructed biliary tree before injection of contrast material. The problem will be worsened by a peripheral entrance into the biliary system rather than a more central one. Gastrointestinal series should always be available to aid in identifying pathology at the entrace of the common bile duct into the duodenum. Lastly, identifying the etiology at the site of the block will require additional procedures. Selective visceral angiography has contributed greatly in this area. During the 20 years of clinical usage of percutaneous transhepatic cholangiography, we feel it has become the single examination capable of preventing unnecessary exploration of the jaundiced patient with primary liver parenchymal disease and the most useful potential source of practical information if laparotomy is necessary to correct biliary tract obstruction.

Inflammatory myofibroblastic tumor of the liver

We report a case of hepatic inflammatory myofibroblastic tumor in a 26-year-old African American man who presented with right upper quadrant pain, weight loss, and fatigue during the previous year. Hepatomegaly was found on physical examination. Laboratory findings were significant for mild normocytic, normochromic anemia and elevated erythrocyte sedimentation rate. Imaging studies showed 2 contiguous masses suspicious for malignancy. A left partial hepatectomy was performed; the preoperative differential diagnosis was for angiosarcoma and hepatocellular carcinoma. The resected liver specimen showed 2 contiguous, firm, tan-white nodules that microscopically represented a proliferation of spindled myofibroblast cells set in an inflammatory and collagenized background. The spindle cells were strongly reactive for smooth muscle actin but negative for ALK-1. The morphologic and immunophenotypic findings, coupled with the clinical presentation, were consistent with an inflammatory myofibroblastic tumor of the liver.

Locally aggressive granular cell tumor causing priapism of the crus of the clitoris. A light and ultrastructural study, with observations concerning the pathogenesis of fibrosis of the corpus cavernosum in priapism

A case of focal priapism of the clitoris caused by a microscopic granular cell tumor (GCT) is described. This neoplasm is considered locally aggressive because it invades the lumens of peripheral cavernous sinuses of the crus of the clitoris. Caverns adjacent to those invaded by tumor exhibit stasis, telangiectasia, and necrosis of the smooth muscle of the trabecular wall. These alterations lead to telescoping collapse and compression of the cavernous spaces and culminate in fibrosis. Ultrastructurally, replicated basal lamina is found surrounding clusters of granular cells. We suspect that the multilayered lamina, in addition to being produced by tumor cells, is derived from the trabecular endothelium surrounding the caverns invaded by the GCT. The replication of the basal lamina may be provoked by cycles of injury and repair to these vessels caused by repeated episodes of prolonged vascular stasis. A peculiar large vein with perforating branches was observed in the center of the cavernous spaces of the crus. This vein is not found in normal crura and, therefore, represents a morphologic adaptation created to drain the cavernous spaces.