Hidden intruder: Plasmacytoma causing uncontrolled epistaxis in an elderly patient

Extramedullary plasmacytoma (EMP) is an uncommon tumor marked by the monoclonal growth of plasma cells without the characteristics of multiple myeloma. EMP represents 3% of all plasma cell tumors. An 89-year-old male patient with hypertension was admitted to our tertiary care hospital with uncontrolled unilateral epistaxis. After a year and a half of recurring epistaxis, the patient's bleeding became more frequent and could no longer be controlled with nasal packing. Angiofibroma was suspected as the initial differential diagnosis, and angiofibroma embolization was performed. The patient experienced difficulty swallowing and slurred speech and was diagnosed with an ischemic stroke. However, antiplatelet and tranexamic acid medications were contraindicated due to bleeding risks. The patient underwent functional endoscopic sinus surgery, and unexpectedly, histology results revealed a plasmacytoma. After surgery, the patient remained stable and was discharged for further management.

Cellular angiofibroma arising from the rectocutaneous fistula in an adult: A case report

BACKGROUND

Rectocutaneous fistulae are common. The infection originates within the anal glands and subsequently extends into adjacent regions, ultimately resulting in fistula development. Cellular angiofibroma (CAF), also known as an angiomyofibroblastoma-like tumor, is a rare benign soft tissue neoplasm predominantly observed in the scrotum, perineum, and inguinal area in males and in the vulva in females. We describe the first documented case CAF that developed within a rectocutaneous fistula and manifested as a perineal mass.

CASE SUMMARY

In the outpatient setting, a 52-year-old male patient presented with a 2-year history of a growing perineal mass, accompanied by throbbing pain and minor scrotal abrasion. Physical examination revealed a soft, well-defined, non-tender mass at the left buttock that extended towards the perineum, without a visible opening. The initial assessment identified a soft tissue tumor, and the laboratory data were within normal ranges. Abdominal and pelvic computed tomography (CT) revealed swelling of the abscess cavity that was linked to a rectal cutaneous fistula, with a track-like lesion measuring 6 cm × 0.7 cm in the left perineal region and attached to the left rectum. Rectoscope examination found no significant inner orifices. A left medial gluteal incision revealed a thick-walled mass, which was excised along with the extending tract, and curettage was performed. Histopathological examination confirmed CAF diagnosis. The patient achieved total resolution during follow-up assessments and did not require additional hospitalization.

CONCLUSION

CT imaging supports perineal lesion diagnosis and management. Perineal angiofibromas, even with a cutaneous fistula, can be excised transperineally.

Role of CD34-immunopositive Microvascular Density in Juvenile Nasopharyngeal Angiofibroma

Objective

To assess the microvascular density (MVD) in juvenile nasopharyngeal angiofibroma (JNA) with CD34 immunostaining and evaluate its relationship with clinico-demographic features.

Methods

This prospective study included patients with JNA undergoing endoscopic excision. The histopathological specimen was stained using CD-34 antibodies to calculate MVD. MVD and clinico-demographic features were correlated.

Results

The study included 12 patients with a median age of 15.5 years. The mean MVD was 39 vessels/high power field (range 5 to 151 vessels). MVD was significantly associated only with the volume of tumour (r = 0.65, p = 0.02). The recurrence occurred in one patient with an MVD of 107. The median follow-up was 38 months.

Conclusion

MVD is significantly associated with tumour volume in JNA, which implies a robust role of angiogenesis in the pathology of the tumour. Also, higher MVD may be a risk factor for recurrence.

Pre-auricular Subtemporal Approach for Intracranial Angiofibroma

Introduction

In around 10-20% of angiofibroma cases, the tumor penetrates the skull base to involve intracranial structures, posing difficulty in treating them surgically. Today, advancement in skull base surgery has brought about a paradigm shift, and extensive angiofibroma tumors with intracranial extension are approached surgically today with minimal morbidity.

Materials and Methods

This study was a retrospective analysis of angiofibroma with significant intracranial extension Radkowski staging IIIb from 2011 to 2021 who came to our center. There were seven children of angiofibroma with significant intracranial extension Radkowski staging IIIb, out of whom, four patients had undergone surgical resection at our center. Three patients underwent surgery by pre-auricular lateral subtemporal approach and one patient by maxillary swing approach. Preoperative embolization was done in all the patients one day before the day of operation.

Results

Gross total removal of the tumor was achieved in all three patients who had undergone pre-auricular lateral subtemporal approach with no permanent complication. All three patients had a minimum follow-up of one year with no recurrence.

Conclusion

The pre-auricular lateral subtemporal approach provides the shortest shallow route to the affected skull base with direct visualization of the tumor base. Hence recommended for angiofibroma with Radkowski staging IIIb.

Successful use of a patient specific 3D-printed biomodel as surgical guide for excision of juvenile nasopharyngeal angiofibroma extending to skull base: A case report

Background

3-Dimensional (3D) printing has proven its role in various fields. Recently, 3D printing has also been introduced in the otolaryngology domain. The nasopharynx, paranasal sinuses, and the anterior skull base have a complex anatomy. Critical structures must be delicately protected and preserved during a surgical procedure. It is, therefore, very important for the surgeon to have an excellent spatial understanding of the complex surgical field that is being traversed.

Case Description

Our case is of a 19-year-old male with a 2-month history of recurrent epistaxis, nasal blockage, and headache. Based on the computed tomography scan and the clinical presentation, the patient was diagnosed with juvenile nasopharyngeal angiofibroma. The patient underwent angioembolization of the tumor followed by endoscopic surgical resection. The patient remained stable postoperatively and demonstrated a good recovery in the follow-up visit with no signs of cranial deficits. This case report highlights the use of a patient-specific 3D-printed biomodel to visualize this rare tumor of the nasopharynx. The benefits of using the model in surgical planning, patient education, and resident training are reported. We found that the ability to visualize the tumor on a tangible model, viewing its actual size in relation to the adjacent anatomy and all the structures associated with it, greatly enhances the surgeon's capacity to tackle such a difficult tumor endoscopically.

Conclusion

Incorporating 3D-printed biomodels in surgical practice should result in improved outcomes for the patients.

Solitary Extramedullary Plasmacytoma of Nasal Cavity

Solitary extramedullary plasmacytoma (SEP) of the nasal cavity is a rare neoplastic condition characterized by the localized proliferation of abnormal plasma cells. We present a case of SEP involving the nasal cavity in a 40-year-old male patient who presented with nasal obstruction and recurrent epistaxis. The diagnosis was confirmed through clinical evaluation, imaging studies, and histopathological examination of excised specimen. The patient underwent trans-nasal endoscopic excision of nasal mass without any adjuvant therapy, which resulted in successful local control. This case report highlights the clinical presentation, diagnostic approach, treatment modalities, and favourable prognosis associated with solitary extramedullary plasmacytoma of the nasal cavity.

Successful Long-Term Multimodality Management of Facial Lesions in Tuberous Sclerosis Complex in an Adult Patient

Angiofibroma and shagreen patches are common cutaneous manifestations of tuberous sclerosis complex (TSC) and have significant physical and psychological repercussions for patients. Several treatments have been proposed to improve lesions; however, clear treatment guidelines have not yet been presented. Thus, we introduce a case of angiofibroma and shagreen patch improved by application of pulsed dye laser, ablative fractional CO2 laser, and topical rapamycin, and present clinical implications for the treatment of angiofibroma and shagreen patch in TSC.

Microvessel density (Cluster of Differentiation-34 & Vascular Endothelial growth factor) in Nasopharyngeal Angiofibroma: Clinical correlation

BACKGROUND

The literature on microvessel density (MVD) signifying neoangiogenesis/tumour-activity in juvenile nasopharyngeal angiofibroma (JNA) is limited. Accordingly, this study evaluates and correlates MVD characteristics with clinical parameters/aggressiveness/recurrence.

MATERIAL AND METHODS

Sixty-two paraffin blocks of JNA were studied histopathologically and MVD was assessed following immunohistochemistry using VEGF and CD34 as vascular markers. A clinical correlation of MVD was undertaken in 43 cases.

RESULTS

MVD scores of VEGF and CD34 showed strong inter-correlation. The 'age', 'duration of disease' and 'haemoglobin%' were the only clinical parameters that revealed significance with MVD. Significantly higher MVD scores were appreciated in recurrent cases as well as some other clinical differences from upfront cases.

CONCLUSION

This is the first study of MVD with CD34 and VEGF simultaneously depicting clinical correlation. The strong correlation, supports a prognostic role of MVD scores in JNA and this can be better established in a larger multicentre study involving comprehensive examination of tumour dimensions.

[Association between vascularization and its impact for recurrence of juvenile nasoangiofibroma]

Background

Juvenile nasoangiofibroma (JNA) is a rare, highly vascular, locally aggressive benign tumor which affects male adolescents. It accounts for 0.05-0.5% of head and neck tumors with recurrence rates of 6-50%. The internal maxillary artery is the main source of JNA.

Objective

To evaluate the relationship between vascular supply as a factor associated with JNA recurrence.

Material and methods

An cohort study was performed in patients diagnosed with NAJ. We collected demographic data, vascular contribution by angiography and tomography results to classify them according to their stage (Radkowski classification), and if they received adjuvant radiotherapy. Post-surgical CT scans were requested to evaluate recurrence and if any of the variables were related to this.

Results

A sample of 14 male patients who met the inclusion criteria was collected. The mean age was 14.71 ± 4.08 years. According to Radkowski classification, stage IA, IIA and IIC were reported in 14.3%, IIB and IIB in 7.1% and IIIA in 42.9%. 42.9% had recurrence and out of these, 66.7% had irrigation of the right carotid system and the same percentage of patients received radiotherapy as adjuvant treatment.

Conclusions

There is a tendency in tumor recurrence associated with vascular contribution from the right carotid system, as well as with patients who received radiotherapy.

A Narrative Review of Flutamide in Juvenile Nasopharyngeal Angiofibroma

The detection of androgen receptors within Juvenile Nasopharyngeal Angiofibroma (JNA) has prompted investigation of the role of Flutamide. The aim of this review is to evaluate Flutamide as a possible neo-adjuvant treatment for JNA. Literature searches were conducted using MEDLINE, EMBASE and Web of Science. The Joanna Briggs Institute (JBI) checklist was used to assess risk of bias. The Oxford Centre of Evidence-Based Medicine (OCEBM) Levels of Evidence was used to stratify the evidence level. Literature searches were conducted using MEDLINE, EMBASE and Web of Science. Flutamide as neo-adjuvant treatment potentially causes a reduction in JNA tumor volume by ≥ 25%. Based on the current limited evidence, Flutamide has a limited role in JNA management and further research is required. Its utilization should only follow discussion with the patient, their families, and within the multidisciplinary team.

Angiofibroma of the mandible: Rare sight for juvenile tumor

Angiofibroma also called juvenile nasopharyngeal angiofibroma are tumors of adolescence and the commonest site is the nasopharynx. Extra nasopharyngeal sites include upper respiratory and digestive tracts, oral cavity, tonsils, larynx, trachea, and esophagus. Intraosseous angiofibroma is the rarest of a rare entity.

Successful retrieval of ethylene vinyl alcohol (EVOH) from the left middle cerebral artery during preoperative embolization of a juvenile nasopharyngeal angiofibroma (JNA)

Preoperative embolization of a juvenile nasopharyngeal angiofibroma (JNA) using ethyl vinyl alcohol (EVOH) is an effective adjunctive treatment prior to surgical resection. While liquid embolic agents are safe to use, we present a unique case involving the migration of EVOH into the left middle cerebral artery (MCA) through an external carotid artery-internal carotid artery (ECA-ICA) collateral during preoperative embolization using a dual-lumen balloon catheter. A 16-year-old male presented with left-sided nasal congestion, new nasal intonation in voice, and epistaxis. CT imaging showed a hypervascular mass centered within the left posterior nasal cavity and nasopharynx with expansion of the ipsilateral sphenopalatine foramen. A JNA was diagnosed, and preoperative embolization was performed prior to surgical resection. During the embolization procedure, EVOH migrated into the intracranial circulation through a hypertrophied ECA-ICA collateral. Angiography confirmed embolic material at the left MCA bifurcation. The embolic material was successfully removed using a balloon guide catheter and stentriever. This case is presented to highlight potential complications and rescue techniques used in the setting of non-target embolization occurring during JNA embolization.

[Special mesenchymal neoplasms of the head and neck: Update from the 2022 WHO]

Similar to the approach adopted in the classification of tumors in other organs, a new feature of the current Word Health Organization (WHO) classification of the head and neck tumors is the exclusion of soft tissue tumors from single organs and their inclusion in a separate chapter devoted to them. This applies to tumors that are principally ubiquitous but show a predilection for the head and neck sites. The only exception to this rule represents those entities that are almost restricted to a specific head and neck site/organ (such as nasopharyngeal angiofibroma, sinonasal glomangiopericytoma, and biphenotypic sinonasal sarcoma), which remain in their respective organ chapters. Included among soft tissue tumors are some old but still underrecognized entities, such as phosphaturic mesenchymal tumors, and newly defined entities, such as GLI1-altered tumors. The aim of including these entities is to enhance recognition of these uncommon but likely under-recognized entities to better characterize them in the future. This review summarizes the main features of these rare entities and discusses their differential diagnoses.

Recurrent Pediatric Extranasopharyngeal Angiofibroma of the Epiglottis: Case Report

Angiofibroma is a non-encapsulated, highly vascular tumor that usually originates in the nasopharynx. Laryngeal cases of extranasopharyngeal angiofibroma (ENA) are a very rare pathology, especially in children. Only eight ENA laryngeal cases have been described in the literature, and only one of them is a pediatric case. In this report we present an 11-year-old child with epiglottic ENA resected with transoral endoscopic ultrasonic surgery (TOUSS) with review of the literature. Because of reccurrence after five months he underwent re-excision with CO2 laser. Recurrences in ENA are infrequent, but as demonstrated in our case, close endoscopic follow-up is mandatory in this location. Endoscopic hemostatic procedures like TOUSS and CO2 laser ensure bloodless surgery for the management of this type of vascular laryngeal tumors.

Nasopharyngeal Fibroangioma: Revisiting the "Other End" of the Spectrum

Significance StatementNasopharyngeal angiofibroma rarely presents in post-adolescent and elderly men, either as the natural evolution of a pre-existing lesion or as a de novo skull-base tumor. As the lesion ages, its composition changes from vessel-predominant to stroma-predominant-the angiofibroma-fibroangioma spectrum. As a fibroangioma, it has restrained clinical features (asymptomatic or occasional epistaxis), minimal avidity for contrast agents, and limited spread potential evident on imaging. These atypical features lead to a diagnostic dilemma when an innocuous choanal/nasopharyngeal fibrovascular mass is encountered in hitherto asymptomatic adult men presenting with epistaxis.

Topical Sirolimus 0.2% Gel for the Management of Tuberous Sclerosis Complex-Related Cutaneous Manifestations: An Interim Analysis of Postmarketing Surveillance in Japan

INTRODUCTION

Tuberous sclerosis complex (TSC) is a rare autosomal dominant genetic disorder affecting several organs, including skin. We sought to assess the real-world effectiveness and safety of a topical sirolimus 0.2% gel treatment for TSC-related cutaneous manifestations.

METHODS

We conducted an interim analysis of postmarketing surveillance conducted in Japan over 52 weeks. A total of 635 and 630 patients were included in the safety and efficacy analysis sets, respectively. Improvement rate of overall cutaneous manifestations, responder rate of improvement in individual lesions, adverse events (AEs), adverse drug reactions (ADRs), and patient satisfaction level of topical sirolimus 0.2% gel treatment were evaluated along with patient characteristics associated with the improvement rate of cutaneous manifestations or safety.

RESULTS

The mean age of the patients was 22.9 years and 46.1% were men. At week 52 of treatment, the overall improvement rate was 74.8% and the responder rate was the highest for facial angiofibroma (86.2%). Overall, the incidence rates of AEs and ADRs were 24.6% and 18.4%, respectively. Efficacy was associated with age (< 15, ≥ 15 to < 65, and ≥ 65 years, p = 0.010), duration of use (p < 0.001), and total dosage (p = 0.005). Safety was associated with age (< 15, ≥ 15 to < 65, and ≥ 65 years, p = 0.011) and duration of use (p < 0.001). However, when the broad age group (≥ 15 to < 65) was subcategorized by 10-year intervals, the incidence of ADRs was similar among the age groups with no significant differences. Hepatic or renal impairment or concomitant use of systemic mTOR inhibitors had no effect on the effectiveness or safety. Overall, 53% of patients were "very satisfied" or "satisfied" with the treatment received.

CONCLUSIONS

Topical sirolimus 0.2% gel is effective in the management of TSC-related cutaneous manifestations and generally well tolerated. Age and duration of usage had a significant association with the effectiveness or safety of topical sirolimus 0.2% gel, whereas total dosage had a significant association with the effectiveness.

Tuberous Sclerosis Complex-Varied Presentations in Family Clusters

Tuberous sclerosis complex (TSC) is a disease of varying presentations characterised by the presence of multiple hamartomas in various organ systems in the body. This is an Autosomal dominant disease with damages in two suppressor genes namely TSC1 and TSC2 located on chromosome 9 (9q34-hamartin) and chromosome 16 (16p13.3-tuberin). It is a lifelong disease with neurological manifestations, for example, epilepsy, mental retardation and autism and major dermatological features like facial fibromas (adenoma sebaceum), periungual fibromas, shagreen patches and hypopigmented macules. Some conditions, for example, autosomal dominant polycystic kidney disease can co-exist with TSC as a result of concurrent deletion of both polycystic kidney disease 1 and TSC2 genes present on chromosome 16p13.3. We present a cluster of three families with TSC having varied presentations.

Use of mTOR inhibitors (rapalogs) for the treatment of skin changes in tuberous sclerosis complex

BACKGROUND

Skin manifestations of Tuberous Sclerosis Complex (TSC) are present in more than 90% of patients. Facial angiofibromas (AF) are considered a skin hallmark of TSC. They are responsible for esthetic impact in patients. We aimed at reviewing the data available on the use of rapamycin (sirolimus) and everolimus for the oral or topical treatment of AF and other TSC-related skin changes and reporting our preliminary experience at Angers University Hospital.

METHODS

The literature search has been performed in combining the terms "rapamycin", "sirolimus", "everolimus", "tuberous sclerosis complex", "skin" and "trial". We have splited the findings of the literature search into two parts: 1) the value of rapalogs used systemically for extracutaneous purposes and 2) the role of topical rapalogs used specifically for skin lesions.

RESULTS

Large clinical trials using rapamycin or everolimus for the treatment of brain, lung or kidney manifestations of TSC unfortunately poorly define the "skin lesion response rate" they report. Conversely, the trials with topical rapamycin demonstrate significant, albeit transient, efficacy on AF size and visibility and acceptable tolerance. Several trials suggest better efficacy in younger patients than in adults. Long-term evaluation (up to 136 weeks) point to sustained response and good local and systemic tolerance. However, maintenance therapy appears to be mandatory to preserve skin response. Other skin changes, especially shagreen fibrotic plaques, hypomelanotic macules and ungual tumors still need far more research. Our experience in 124 patients (children and adults) treated for facial AF at Angers University Hospital showed that about 80% of them had an impressive and sustained response.

CONCLUSION

The issues of cost and access to affordable topical rapamycin formulations are critical for the patients even if skin changes do not cause serious harm in the context of TSC. We strongly suggest to improve and standardize the formulation of topical rapamycin, to encourage the pharmaceutical industry for providing commercial products, and the Health systems (social welfare) to reimburse them. © 2022 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.

Extra Nasopharyngeal Angiofibroma Arising From Oropharynx: A Clinical Report

Angiofibroma arising from sites other than nasopharynx is rare and termed as Extra nasopharyngeal angiofibroma (ENA). ENAs commonly arise from nasal septum, maxillary sinus, and inferior turbinate. But angiofibroma arising from oropharynx have not been frequently reported. We present here a case of middle-aged male who presented with a large pedunculated oropharyngeal mass attached to palatopharyngeal fold. Endoscopic radiofrequency assisted transoral excision of mass was done. Histopathological features were consistent with angiofibroma arising from oropharynx. Patient recovered well with no evidence of recurrence till 18 months of follow up. In this report, we have tried to emphasize the diagnostic workup for oropharyngeal mass. This report also provides an insight into the clinical and pathological behavior of extra nasopharyngeal angiofibroma.

Endoscopic Modified Denker's Approach for the Treatment of Juvenile Nasopharyngeal Angiofibroma

Juvenile nasopharyngeal angiofibroma is a benign vascular lesion with propensity of bony erosion leading to skull base involvement and intracranial extension. It involves multiple compartments which are difficult to access surgically. With surgical expertise endoscopic resection of angiofibroma has become the preferred choice of surgical management. This article presents our experience with endoscopic approach for angiofibroma and establishes the modified Denker's procedure as a effective approach for removal of tumor. A prospective case study was done on 25 cases of juvenile nasopharyngeal angiofibroma treated surgically by endonasal endoscopic modified Denker's approach in the department of ENT at BJ Medical College, Ahmedabad over a period of 4 years from January 2015 to January 2019. This technique was used up to Fisch stage 3b with extension up to infratemporal fossa. Using this technique no major recurrence or major morbidity was observed and did not produce any late serious complications. The endoscopic technique allows the surgeon to achieve an extensive exposure of the sinuses and control of the sphenopalatine and internal maxillary arteries without the risk of palatal dysfunction, oronasal fistula, or facial scarring. In addition, the modified Denkers approach can be an effective and less mutilating technique in managing recurrences.

Efficacy and Safety of Topical Timolol for the Treatment of Facial Angiofibroma in Children with Tuberous Sclerosis Complex

Objective

This study aimed to assess the efficacy and safety of topical timolol in treating facial angiofibromas (FAs) in pediatric patients with tuberous sclerosis complex (TSC).

Methods

A prospective clinical trial was conducted involving 15 children diagnosed with TSC and presenting with FAs. The participants were administered topical timolol gel 0.5% twice daily. Prior to the intervention, the severity of FAs in each patient was evaluated using the FA severity index (FASI), which assessed erythema, size, and extent of lesions. Clinical response was assessed at weeks 2 and 4 during the intervention period as well as 1 month after discontinuation of treatment.

Findings

Four weeks after discontinuing topical timolol 0.5%, statistically significant reductions were observed in the mean FASI score, erythema, size, and extent of lesions (P < 0.0001, P < 0.0001, P = 0.012, P = 0.008, respectively). FASI scores at 4 and 12 weeks postintervention, as well as 4 weeks after treatment cessation, demonstrated a significant decrease compared to baseline (P < 0.001). Erythema and extension scores also exhibited a significant decrease 1 month after treatment cessation compared to baseline (P < 0.05), while the mean size of lesions before and after the intervention did not show a statistically significant difference (P = 0.004).

Conclusion

Topical timolol 0.5% represents a cost-effective and readily available treatment option for pediatric patients with FAs associated with tuberous sclerosis.

The Maxillary Swing: An Efficacious Approach to Surgical Management of Advanced Stage Juvenile Nasopharyngeal Angiofibroma

The objective of this study was to evaluate the efficacy and outcome using the maxillary swing approach for the management of extensive nasopharyngeal angiofibroma. A retrospective case series analysis in a tertiary care centre revealed eighteen cases with extensive nasal angiofibroma operated using the maxillary swing approach between 2011 and 2017. All patients had tumour extension to the lateral most portions of the infratemporal fossa with complete occupation and destruction of the lateral wall of the sphenoid sinus causing abutment to the cavernous sinus and complete involvement of the pterygopalatine fossa and pterygoid base. One patient displayed full occupancy of the maxillary sinus as a consequence of erosion of the posterior and medial walls of the maxillary sinus. All patients underwent tumour excision using the maxillary swing approach. Patients were followed up for a minimum period of 1 year after surgery. The maxillary swing approach gave optimal exposure of the entire central skull base including the infratemporal fossa and its extreme lateral and superior aspects. Adequate tumour exposure and vascular control could be achieved in all cases resulting in complete tumour excision. The mean operative time was 3 h 15 min. Post-operative healing was satisfactory with palatal fistula formation in four cases and all patients remaining disease-free up to the present time. One had minimal misalignment of the halves of the upper jaw and two had epiphora, of which one required dacryocystorhinostomy. The maxillary swing is an effective approach in the management of extensive nasopharyngeal angiofibroma and leads to optimal anatomical exposure with minimal morbidity.

Pseudogenes in Juvenile Nasopharyngeal Angiofibroma: First Pilot Observation

To investigate the role of Pseudogenes (PG) in juvenile nasopharyngeal angiofibroma (JNA) that were once considered to be junk-DNA or 'genomic fossils'. Five to 10 fresh JNA samples were analyzed for molecular expressions of 5 PG/respective parent genes (VEGFR1P1/VEGFR; FGFR3P1/FGFR3; PDGFAP1/PDGFA; IL6RP1/IL6R; POU5F1B/POU5F1) and clinical details correlated. IL6R, PDGFA, VEGFR2, FGF3 and their respective PG (VEGFR1P1, PDGFAP1, IL6RP1, FGFR3P1) were highly expressed but POU5F1/POU5F1B were not. The difference in expression between IL6R & IL6RP1 was substantially larger compared with other 4 pairs. While VEGFR1P1, PDGFAP1 & POU5F1B were expressed more than their respective parent genes; IL6RP1 & FGFR3P1 showed reduced expression. No clinical significance was apparent in any parameter nor was any difference noted between recurrent and upfront cases. A definite implication of pseudogene in JNA is evident in this ever first global study but future studies are needed to validate the current findings as well as further characterize its role/profile in larger sample. This may explain extreme variability of JNA, its heterogenous etiopathogenesis, evolving patterns and molecular characterization for possible targeted therapy.

Arthroscopic Excision of Intra-articular AHRR-NCOA2- positive Angiofibroma of Soft Tissue of the Knee: A Case Report

BACKGROUND/AIM

Angiofibroma of soft tissue (AFST) is a rare benign soft-tissue tumor that most frequently occurs in the lower extremities. It has a characteristic genetic feature with a balanced chromosomal translocation t(5;8)(p15;q13), resulting in a fusion of aryl hydrocarbon receptor repressor (AHRR) and nuclear receptor coactivator 2 (NCOA2).

CASE REPORT

A 55-year-old woman presented with a 2-year history of left knee pain and recently noticed the development of a palpable mass. Magnetic resonance imaging exhibited a well-defined intra-articular mass with iso-signal intensity relative to skeletal muscle on T1-weighted sequences, heterogeneous high signal intensity on T2-weighted sequences and avid, diffuse enhancement on contrast-enhanced fat-suppressed T1-weighted sequences. After an ultrasound-guided core needle biopsy, the lesion was successfully treated by arthroscopically-assisted complete excision. Histologically, the tumor was composed of uniform bland spindle cells in a myxoid to collagenous stroma with a prominent vascular network. Immunohistochemically, the spindle cells were diffusely positive for CD163 and CD68 and focally positive for estrogen receptor. Moreover, AHRR-NCOA2 fusion gene was detected by reverse transcription-polymerase chain reaction. There has been no clinical evidence of local recurrence at 1-year follow-up.

CONCLUSION

This is the first report of the detection of an AHRR-NCOA2 gene fusion associated with intra-articular AFST. AFST should be included in the extended differential diagnosis of an intra-articular soft-tissue mass, particularly if the mass is vascular.

Less common extracerebral tumors

This chapter examines the results of GKNS on a variety of extraparenchymal skull base tumors some benign and some malignant. For the benign tumors there is good evidence on the effectiveness of the method for pretty much all diagnoses. For malignant extraparenchymal tumors the results are more limited and GKNS only has a supportive role in these lesions.

Neuroendocrine pancreatic tumor in a patient with dual diagnosis of tuberous sclerosis complex and basement membrane disease: A case report and review of the literature

Tuberous Sclerosis is a complex genetic disease that has well-defined clinical criteria. These criteria don't include pancreatic neuroendocrine tumors. We represent a rare case of a patient, with a non-functioning pancreatic neuroendocrine tumor and concomitant diagnosis of tuberous sclerosis complex, and basement membrane disease. The patient was diagnosed based on typical radiologic findings. We have suggested close monitoring and during follow-up studies, the disease was stable. Interestingly the patient tested negative for Tuberous Sclerosis Complex (TSC), which suggests that she might be a somatic mosaic and the mutation level in blood lymphocytes was below the detection level. Moreover, a heterozygous pathogenic variant p.(Gly774Arg) and a heterozygous likely pathogenic variant p.(Gly1465Asp) were identified in the COL4A4 gene. COL4A4 gene is responsible for causing autosomal dominant basement membrane disease. In this case report, we discuss clinical, radiologic, and genetic aspects of these diseases, as well as optimal treatment and follow-up strategies. Thus, by presenting this case we would like to increase awareness of pancreatic neuroendocrine tumors in TSC and emphasize the need for follow-up monitoring.

Omental mass combined with indirect inguinal hernia leads to a scrotal mass: A case report

BACKGROUND

Primary omental tumors are uncommon, and omental fibromas account for 2% of these tumors. Due to the low incidence of omental fibromas and the limited relevant literature, it is challenging for clinicians to make an accurate diagnosis of this condition, especially before surgery.

CASE SUMMARY

A 30-year-old man was admitted to the hospital because of a left epididymal mass with vague discomfort for more than 1 mo. A physical examination was performed, and the findings showed that the epididymal mass may have entered the abdominal cavity. Pelvic computed tomography was performed in our hospital and revealed a left inguinal hernia with a mass in the hernial contents, and no masses were found in the left epididymis. A traditional inguinal hernia incision was made. Intraoperative hernia contents were found to be of the greater omentum, and a 2.5 cm-diameter mass was found at the distal end of the greater omentum. The scrotum and epididymis did not exhibit other masses. Then, the mass of the greater omentum was excised. Intraoperative frozen pathological examination suggested a spindle cell tumor. The postoperative pathological examination suggested that the mass was an omental angiofibroma. Postoperatively, the patient recovered well and was discharged. Outpatient re-examinations were performed at 1 mo and half a year after the operation and showed no obvious abnormalities.

CONCLUSION

Due to the low morbidity rate associated with and latent nature of omental tumors, these tumors are difficult to diagnose preoperatively; thorough medical history taking, detailed physical examinations, and necessary imaging auxiliary examinations can help clinicians diagnose and treat these cases.

A unique intraluminal growth of juvenile nasopharyngeal angiofibroma: A case report

Juvenile nasopharyngeal angiofibroma (JNA) is a rare, hypervascular, benign tumor which is mainly seen among male adolescents. The tumor typically originates from the sphenopalatine fossa, but could spread through natural foramens and fissures.

There are some reports of atypical growth of this tumor in literature but the intraluminal growth, which could be seen in paraganglioma and glomus tumors, has not reported yet in angiofibroma. In this article we present a case of extensive angiofoibroma with intraluminal involvement of the ophthalmic vein.

Our patient was a 19-year-old boy with a complaint of nasal obstruction and occasional epistaxis since a year ago, without any visual or neurologic complaints. The patient underwent an endoscopic resection of the tumor after embolization via the nasal cavity.

The intraoperative findings revealed the tumor extension to the orbit, intracranial space and cavernous sinus via inferior orbital fissure. The intracranial extension of the tumor was extradural and was successfully excised without CSF leakage. An interesting finding in this patient, was an intraluminal extension of the tumor in to the ophthalmic vein, which was completely excised endoscopically. (pre and post operation pictures are available in the full text). The definitive treatment of angiofibroma is surgical excision. Different surgical approaches are used but nowadays endoscopic resection with or without pre-operative embolization is the first choice of treatment. The intraluminal growth of the tumor was also excised as a pedunculated mass separately.

A case report

Cellular angiofibroma is a recently described rare benign soft-tissue tumor more commonly presenting in middle-aged women, often mimicking malignancy. The vulva is most common location. Complete local excision is the best curative treatment and usually there is no recurrence after surgery. We describe a 49-year-old woman with a painless tumor in the left ischiorectal fossa. It was a random finding in a routine computed tomography (CT) scan after resection of ear melanoma 3 years previously. Ultrasonography showed a solid mass, and further magnetic resonance imaging (MRI) suggested a rhabdomyosarcoma. Altogether, these findings indicated malignant disease. An uncomplicated simple excision of the tumor was done in the operating theatre. The mass measured 7×5×5 cm and the histopathological examination found that it was a cellular angiofibroma, a benign lesion. There were no postoperative complications. This case report highlights the need for multidisciplinary team management of rare tumors such as cellular angiofibromas.

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Soft tissue angiofibromas are benign, fibrovascular tumors with average size <3 cm that can occasionally be localized in the genital area.

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The vulva is the most common genital location.

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This report describes the management of an exceptionally large angiofibroma of the perineum in a 49-years-old woman with a history of melanoma.

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Minimally invasive transperineal excision was successfully performed by a gynecologist and a general surgeon.

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Joint multidisciplinary approach involving gynecologists, colo-rectal surgeons, radiologists, and pathologists, is necessary for management.

Nasal septal angiofibroma: less vascular behaviour than observed in radiological imaging, a rare case in a 51-year-old woman

Angiofibroma of the head and neck is classically found in the nasopharynx of an adolescent male. We present a rare case where an angiofibroma was diagnosed in the anterior nasal septum of a 51-year-old woman, the eighth nasal septal angiofibroma reported in a female. This case highlights how an angiofibroma in an older woman has a less vascular behaviour than one in an adolescent male, even though radiological enhancement may suggest that the lesion is highly vascularised. Nasal septal angiofibromas can be managed by biopsy and removed by simple endoscopic resection with minimal haemorrhage. Although very rare, extranasopharyngeal angiofibroma/nasal septal angiofibroma should be included in the differential diagnosis when patients of all ages present with nasal obstruction secondary to a nasal mass, with or without epistaxis.

Plasma ablation-assisted endoscopic excision versus traditional technique of endoscopic excision of juvenile nasopharyngeal angiofibroma

BACKGROUND

Juvenile nasopharyngeal angiofibroma is the vascular and locally aggressive tumor of the posterior nares and nasopharynx. Endoscopic excision is the preferred surgical modality in early Radkowski stages. The prime challenge is intraoperative bleeding. Literature is in favor of the use of plasma ablation to overcome surgical challenges.

OBJECTIVE

To evaluate the effectiveness of plasma ablation technique in the surgical management of juvenile nasopharyngeal angiofibroma.

MATERIALS AND METHODS

The current study recruited 36 patients of clinico-radiologically diagnosed cases of primary JNA of stage I and II (Modified Radkowski). In prospective arm, 18 consecutive patients were recruited, who underwent plasma ablation assisted endoscopic excision. In retrospective arm, 18 consecutive patients who underwent excision by traditional endoscopic instruments in the past two years, were recruited. Both the groups were compared for baseline characteristics, intraoperative blood loss, duration of surgery, length of hospital stay, and recurrence rates.

RESULTS

The use of plasma ablation decreased overall blood loss by 338 ml (mean difference) which was not statistically significant (p = 0.26). On subgroup analysis, the use of plasma ablation significantly decreased mean blood loss (648 ml, p = 0.046) and duration of surgery (83 min, p < 0.001) in patients who underwent embolization. No statistically significant difference was noted between two groups in length of hospital stay (p = 0.36) and recurrence rates (p = 0.64).

CONCLUSION

Plasma ablation is an effective technique available to decrease blood loss and duration of surgery during endoscopic excision of post embolized stage I and II patients of JNA.

Clinical Utility of 68Ga-DOTANOC Positron Emission Tomography-Computed Tomography Scan on Postoperative Assessment of Juvenile Nasal Angiofibroma

Somatostatin cell surface receptors are expressed on the peritumoral vessels of various benign and malignant neoplasms including angiofibromas. Positive initial uptake on positron emission tomography-computed tomography (PET/CT) imaging with ⁶⁸Ga-labeled DOTANOC is noted in a patient with juvenile nasal angiofibroma (JNA), and the same is noted to be absent following complete surgical excision. Functional ⁶⁸Ga-DOTANOC PET/CT may be an early useful tool for JNA residual/recurrence identification and precise postoperative surveillance.

Olfaction in Juvenile Nasopharyngeal Angiofibroma: The first study

BACKGROUND

To study the pattern of olfactory dysfunction/recovery in juvenile nasopharyngeal angiofibroma (JNA).

METHODS

Olfactory assessment was undertaken in 30 patients (category1) both pre- & post-operatively and in another 18 (category 2) only postoperative. All patients underwent transpalatal excision and variables of interest included age, radiological stage/parameters & tumor size.

RESULTS

Objective olfactory dysfunction was seen in 60% while involvement of olfactory strip was suggested in 50%. Despite some marginal trends only noted between size/age with change of olfaction, Pearson's correlation test did not reveal any significance amongst multiple variables. However a better recovery of olfaction following surgery was evident in Category-2 where Chi-Square test (p < 0.05) significantly revealed this to be a function of postoperative duration. This regenerative course in JNA suggests an optimum period of 4 years for full recovery after surgery.

CONCLUSION

In this first study of olfaction in JNA many new trends have been appreciated. In general, deteriorations of olfaction were seen due to 'vascular-concussion' effect in early postoperative phase where post-surgical clearance of airway showed minimal effect in terms of improvement. The hypervascularity of olfactory epithelium with possible hormonal effects may be responsible for the unique pattern of olfactory function and recovery in JNA.

Recurrent pterygo-palatal angiofibroma with intracranial extension: case report

We report the case of a patient with recurrent pterygo-palatal angiofibroma and its treatment. A 21-year-old male patient had a long history of recurrent epistaxis with progressive nasal obstruction. He was diagnosed with an angiofibroma centered in the right pterygo-palatine fossa. Initially, he underwent surgical excision with removal of the entire tumor. The evolution was clinically good with no signs of recurrence on the cervico-facial scan of control (CT). Nine months after, he presented a reappearance of epistaxis. A cervico-facial MRI was performed and showed a recurrence of the tumor process, which this time was considered inextirpable, hence the decision to opt for radiotherapy with intensity modulated radiation therapy (IMRT). He has improved clinically with a clear reduction in tumor mass on CT scan. This technique represents an interesting alternative to overcome anatomical complexity of the region, cover the tumor and preserve the organs at risk.

Juvenile Nasal Angiofibroma on 68Ga-DOTANOC PET/CT: Exploring Theranostic Avenues

Somatostatin (SST) cell surface receptors (SSTRs) are expressed in many different malignant, benign, and neuroendocrine tumors. SSTRs are also expressed in the endothelium of human vessels during angiogenesis and not in the nonproliferating vessels. We present a case of 19-year-old boy with juvenile nasal angiofibroma (JNA), who underwent ⁶⁸Ga-DOTANOC PET/CT to explore SSTRs expression and theranostic potential. The scan revealed high uptake in the tumor, and in certain areas, the uptake was similar to that of the pituitary gland. Performance of DOTANOC PET/CT in JNA opens up new frontiers with respect to radiological staging, early recurrence identification, better delineation from postoperative scar tissue, possible preoperative treatment with SST analogs, and perhaps even radiopharmaceutical based-ligand therapy of inoperable/residual/recurrent JNAs in the future.

Clinical Applications of 68Ga-PSMA PET/CT on Residual Disease Assessment of Juvenile Nasopharyngeal Angiofibroma (JNA)

We present a case of a 16-year-old boy who underwent ⁶⁸Ga-PSMA PET/CT for residual disease assessment of juvenile nasal angiofibroma. Positive uptake was noted in residual tumor on PET/CT imaging. However, there was no abnormal uptake in surrounding scar tissues as compared with contrast-enhanced magnetic resonance imaging. These findings were confirmed by biopsy from the scar tissue on posterior ethmoids. ⁶⁸Ga-PSMA PET/CT may be a potentially valuable tool especially in distinguishing recurrences from surgical site reparative tissue and in planning and delivering stereotactic radiotherapy.

Use of Topical Rapamycin as Maintenance Treatment after a Single Session of Fractionated CO2 Laser Ablation: A Method to Enhance Percutaneous Drug Delivery

Tuberous sclerosis complex (TSC) is an autosomal dominant neurocutaneous disorder with an incidence of approximately 1 in 5,000 to 10,000 live births. TSC has various clinical manifestations such as multiple hamartomas in systemic organs, including the skin. Angiofibromas are the most common skin lesions in patients with TSC. Although benign, angiofibromas develop in childhood and puberty, and can be psychosocially disfiguring for patients. Skin lesions in TSC, specifically angiofibromas, have no significant risk of malignant transformation after puberty; thus, they require no treatment if not prominent. However, the presentation of TSC is important owing to its impact on patient cosmesis. Surgical treatment and laser therapy are the mainstream treatments for angiofibromas. Although the evidence is limited, topical mammalian target of rapamycin inhibitors such as sirolimus (rapamycin) are effective in facial angiofibroma treatment. We describe an adult patient with an angiofibroma who had an excellent response to treatment with topical rapamycin after a single session of carbon dioxide (CO₂) laser ablation. The patient showed no sign of relapse or recurring lesions for a year. CO₂ laser ablation may serve as a new paradigm of treatment for angiofibromas in TSC. Since the selection of laser devices can be limited for some institutions, we suggest a rather basic but highly effective approach for angiofibroma treatment that can be generally applied with the classic CO₂ device.

Nasal septum angiofibroma: a rare condition with an unusual onset

The characteristics of extra-nasopharyngeal angiofibromas tend to be different from angiofibromas of the nasopharynx according to patient gender, patient age, prevalence, affected site, pathogenesis, and clinical and epidemiological features. We report a case of an extra-nasopharyngeal angiofibroma in a 28-year-old man referred to the ENT Clinic for right-sided epistaxis, airflow impairment and nasal swelling. The right nostril was completely occluded works by a reddish-yellow mass that bled easily. The computed tomography scan revealed an "inhomogeneous solid lesion in the nasal fossa". With the patient under general anesthesia, the formation in the anterior portion of the right side of the nasal septum was removed up to its vascular base. Although electrical cauterization efficiently controlled the bleeding, we abraded the sub-perichondral area to prevent further bleeding as well as recurrence. The histological exam report confirmed the diagnosis of angiofibroma. As in our case, epistaxis is commonly the presenting sign of angiofibroma. Yet its onset was peculiar, given that the bleeding started with a low impact trauma. The nasal swelling was also a relevant feature as well as the breathing impairment. Although uncommon, nasal septal angiofibromas should considered in patients with epistaxis.

Extranasopharyngeal Angiofibroma Localized in the Nasal Dorsum: A Rare Location for This Tumor

Although extranasopharyngeal angiofibroma (ENA) is a rare condition, its diagnosis should be considered during differential diagnosis of nasal masses. We report a rare case of ENA originating from the left lateral side of nasal tip.

A 43-year-old man with an ENA mass located on the left lateral side of the nasal tip presented to our hospital. The nasal mass caused nasal obstruction and swelling at the nasal tip and was surgically removed. Histopathological examination revealed ENA. The patient is being followed up and remains free of disease.

ENAs are rare and differ from nasopharyngeal angiofibromas regarding clinical and radiological features. Although it is rare, the diagnosis should be considered during differential diagnosis of a patient with one sided nasal mass and/or with refractory epistaxis, regardless of the patient’s age or sex.

[Angiofibroma of soft tissue: a clinicopathologic analysis of 24 cases]

Objective: To investigate the clinicopathologic and genetic features, pathologic diagnosis and differential diagnosis of angiofibroma of soft tissue(AFST). Methods: The clinicopathologic characteristics of 24 cases diagnosed at Fudan University Shanghai Cancer Center from 2011 to 2017 were analyzed; immunohistochemical staining and interphase fluorescence in situ hybridization (FISH) were performed, and the literatures were also reviewed. Results: There were 15 male and 9 female (male∶female=1.7∶1.0) patients with age of onset ranging from 8 to 68 years (mean, 45 years). Fourteen cases occurred in extremities, including upper limbs (n=3) and lower limbs (n=11); seven cases were in the trunk, and 1 case each was in the temporal region, retroperitoneum and liver, respectively. Clinically, the tumors usually presented as a slowly growing painless mass. Tumor sizes ranged from 0.8 to 14 cm (mean 4.6 cm). Microscopically, most lesions were well-circumscribed, with fibrous capsules. Few cases infiltrated the surrounding fibrofatty tissue focally. The tumors were mainly composed of sparse short spindle cells and numerous small, branching, thin-walled blood vessels distributed in amyxoid, fibromyxoid or collagenous matrix, often accompanied by medium-sized, round or irregular and ecstatic vessels at the tumor periphery.By immunohistochemistry, all tested cases expressed vimentin (5/5), and showed variable positivity for EMA (2/4), ER (1/2), PR (2/3), α-SMA (1/18)and desmin (1/10). Ki-67 proliferation index were all less than 5%. CD34, CD31 and ERG staining clearly outlined the contours of blood vessels in the stroma. Four cases were tested for NCOA2 gene rearrangement by FISH, of which three were positive. Follow-up data was available in 17 patients (range, 3 to 69 months; mean, 30 months) were all free of disease. Conclusions: Soft tissue angiofibroma is a benign fibroblastic neoplasm characterized by a prominent and complex vasculature set in a myxoid-to-collagenous stroma, and cytogenetically a distinctive NCOA2 gene rearrangement. Caution should be exercised for the possibility of potentially misinterpretation of AFST as vascular tumors and other myxoid soft tissue tumors.

Extranasopharyngeal angiofibroma mimicking choanal polyp in patients with chronic paranasal sinusitis

Extranasopharyngeal angiofibroma (ENA) is an angiofibroma that occurs in the extranasopharynx. It shows pathologic findings, such as juvenile angiofibroma (JNA), which accounts for 0.5% of head and neck mass. However, compared with JNA, the prevalence, affected site, and clinical characteristics are completely different, which leads some physicians to classify ENA as a disease different from JNA. ENA of the nasal turbinate origin are rarely reported in the literature. In addition, choanal polyp originating from the posterior part of the nasal turbinate is uncommonly reported. Recently, we encountered two cases of ENA, which were not diagnosed by intraoperative frozen section examination, but were histopathologically diagnosed post-operatively. Although we were unable to diagnose and perform embolization pre-operatively, ENA has been successfully treated by endoscopic surgery, without profuse bleeding.

Comparative Effects of Topical 0.2% Sirolimus for Angiofibromas in Adults and Pediatric Patients with Tuberous Sclerosis Complex

BACKGROUND

Recent reports have suggested that the topical formulation of sirolimus is effective in treating facial angiofibromas in tuberous sclerosis complex (TSC). Here, we determined the safety and efficacy of 0.2% topical sirolimus for the treatment of facial angiofibroma and compared its effects based on age.

METHOD

This was a retrospective study which involved 36 TSC patients with facial angiofibromas who were treated with 0.2% sirolimus ointment. Its effect was evaluated using the Facial Angiofibroma Severity Index (FASI). In order to observe its comparative effect based on patient age, a subgroup analysis was performed, between the adult group (> 18 years old) and the pediatric group (≤18 years old).

RESULTS

The total FASI as well as its subcategories (erythema, size, and extent) showed statistically significant improvements after the topical treatment with 0.2% sirolimus ointment (FASI before treatment: 7.2 ± 1.1, FASI after treatment: 4.4± 1.4, p < 0.001). Among the subcategories of FASI, the erythema was most significantly reduced with the fastest response to the treatment. In a subgroup analysis, the pediatric group showed significantly greater improvements in FASI (improvement of FASI in the pediatric group = 49.7 ± 12.2%, adult group = 27.9 ± 15.6%, p < 0.001). The serial improvement analysis also showed that the pediatric group achieved a consistently greater improvement in FASI at all visits. Its 1-year application in 3 patients demonstrated a continuous maintenance effect. No significant adverse effects were observed.

CONCLUSION

0.2% sirolimus ointment is safe and effective for facial angiofibromas. Considering its higher efficacy in younger patients, an early initiation of the treatment is recommended.

Assisted resection of lateral extension of juvenile nasopharyngeal angiofibroma using a sphenopalatine fossa dissector

BACKGROUND

Juvenile nasopharyngeal angiofibroma often attaches firmly to the adjoining bony region around the sphenopalatine foramina-sphenopalatine fossa-pterygomaxillary fissure. This can result in hourglass-shaped constriction and predispose to incomplete resection (residual disease) with a transpalatal approach. This paper describes attempts to address this 'inaccessible' area with a novel instrument, used since 2012.

METHODS

Measurements of the sphenopalatine foramen, nasal septum, posterior nasopharyngeal wall and hard palate were undertaken in 20 skulls and 10 computed tomography scans (lateral extension). A device was designed (in terms of angulation and length) following several trials with malleable wire. A search of patents was also undertaken. Recurrence rates were compared in cases of device use and non-use.

RESULTS

The novelty of the sphenopalatine fossa dissector was established and the device was patented. This device has significantly improved our 17.59 per cent recurrence rate of the past 4 decades; of 63 cases over 3 years, there were only 3 recurrences and 2 residual disease cases. Findings of our previous studies with or without the device are compared.

CONCLUSION

Existing evidence supports the incorporation of this inexpensive instrument in the armamentarium for resecting lateral extension of juvenile nasopharyngeal angiofibroma during a transpalatal approach.

Microphthalmia-associated transcription factor (MiTF): Promiscuous staining patterns in fibrohistiocytic lesions is a potential pitfall

Microphthalmia-associated transcription factor (MiTF) is used as a marker of melanocytic differentiation. However, MiTF immunoexpression has also been observed in histiocytes, macrophages, smooth muscle cells and fibroblasts, which raise the concern of fibrohistiocytic (FH) lesions being misdiagnosed as melanoma based on MiTF immunoreactivity. MiTF has been known to be positive in FH tumors, but this is the first study evaluating ninety-three fibrohistiocytic neoplasms to understand and delineate the staining pattern of MiTF in these tumors. Ninety-three cases of FH, 30 cases of melanocytic lesions, and 20 miscellaneous cases were studied. The FH cases included benign fibrous histiocytoma (BFH, n = 29), angiofibroma (AF, n = 11), fibromatosis (FM, n = 14), keloid (KE, n = 10), atypical fibroxanthoma (AFX, n = 7), dermal scar (DS, n = 9), dermatofibrosarcoma protuberans (DFSP, n = 12), and pigmented DFSP (Bednar tumor, n = 1). Benign fibrous histiocytoma were sub-categorized into dermatofibroma (n = 15) and epithelioid fibrous histiocytoma (n = 14). The melanocytic lesions included desmoplastic melanoma (DM, n = 8), melanoma in-situ (MIS, n = 5), re-excision-free of melanoma (RFM, n = 10), blue nevus (BN, n = 5), and spitz nevus (SN, n = 3). The miscellaneous category included osteosarcoma (OS, n = 3), pigmented basal cell carcinoma (PBCC, n = 5), spindle cell squamous cell carcinoma (SCA, n = 2), and giant cell tumor of tendon sheath (GCTTS, n = 10). All BFH, AF, AFX, KE, and DS cases showed a positive MiTF staining of variable extent and intensity. MiTF positivity was observed in 86% (n = 12) cases of FM and 17% (n = 2) cases of DFSP. Amongst the miscellaneous category, all cases of PBCC and GCTTS and 50% (n = 1) cases of SCA were immunoreactive for MiTF. All melanocytic lesions were positive for MiTF. None of the OS and pigmented DFSP showed positive labeling. Because of the promiscuity of MiTF labeling, awareness of its pattern in FH proliferations may avoid potential pitfalls in the diagnosis of spindle cell lesions.

[Extrapleural solitary fibrous tumor with uncommon histology: a clinicopathologic analysis of 7 cases]

Objective: To investigate the clinicopathologic characteristics, immunophenotypes, and differential diagnostic features of extra-pleural solitary fibrous tumor (SFT) with uncommon histology. Methods: Seven cases of extra-pleural SFT with uncommon histology were collected during January 2015 and December 2016 in Zhejiang Provincal People's Hospital; the clinical and radiologic features, histomorphology, immunophenotype and prognosis were analyzed. EnVision method was used for immunohistochemical staining of STAT6, CD34 and other differential diagnosis associated markers. Results: There were five male and two female patients, age from 23 to 54 years (mean=39 years). Three tumors were located in the soft tissue of head and neck, two in trunk subcutaneous soft tissue, one in sella region, and one in the kidney. Grossly the tumors ranged from 0.4 to 8.0 cm (mean=3.1 cm). Microscopically, all three head and neck cases resembled giant cell angiofibroma/giant cell subtype SFT, and one case showed sheet-like pattern of the multinucleated syncytial cells, creating a biphasic arrangement similar to myofibroma. Both truncal tumor resembled lipomatous type SFT, with one similar to dermatofibrosarcoma protuberans and the other to atypical spindle cell lipomatous tumor. The sella tumor showed morphology of a conventional SFT with high grade sarcomatous transformation. The renal tumor demonstrated a malignant SFT with entrapped benign renal tubules, mimicking a biphase synovial sarcoma or a malignant mixed epithelial and stromal tumor. By immunohistochemistry, all seven SFTs showed diffuse and strong nuclear reactivity to antibody against STAT6. Conclusions: Extra-pleural SFTs show a significant heterogeneity of morphology and biological behavior which could cause differential confusion.Careful attention to its characteristic histomorphology with the use of STAT6 immunohistochemistry can help distinguish this tumor from its many mimickers.

[Retroperitoneal Cellular Angiofibroma: A Rare Gynecological Entity]

Cellular angiofibroma is a mesenchymal tumor, described in 1997, without gender preference, that usually appears at age 40. The vulvovaginal area is the most common site in women, mimicking vulvar benign tumors, like Bartholin gland cyst. However, there are a few described cases of a deep or extra-pelvic angiofibroma. Excision is the treatment of choice and the recurrence rate appears to be low. We present the case of a woman with a heterogeneous tumor in the right adnexial region. At the surgery, a retroperitoneal tumor was excised and the histopathological tissue analysis revealed a cellular angiofibroma.

A rare case of extra-nasopharyngeal angiofibroma of the septum in a female child

BACKGROUND

Extra-nasopharyngeal angiofibroma is a rare but distinct clinical entity, different from juvenile angiofibroma.

METHODS

This clinical record elucidates the only case of extra-nasopharyngeal angiofibroma arising from the septum in a female child, who presented with epistaxis.

RESULTS

The histopathological diagnosis was confirmed by immunohistochemistry, and the case was managed surgically with no recurrence.

CONCLUSION

In a female paediatric patient presenting with epistaxis, extra-nasopharyngeal angiofibroma (of the inferior turbinate) is a rare albeit important differential diagnosis, as it challenges the hormonal theory of angiofibroma aetiopathogenesis.

The Natural Growth Rate of Residual Juvenile Angiofibroma

Objectives  Examine the postoperative growth rate of residual juvenile angiofibroma (JA) in a large series of patients relative to pediatric growth parameters and other prognostic factors. Establish an algorithm for postoperative surveillance of patients with JA. Design  Retrospective case series. Setting  Tertiary referral academic center. Participants  Pediatric patients undergoing surgical resection of JA between September 2005 and June 2015. Main Outcome Measures  Postoperative recurrence and tumor growth rates. Results  Thirty-eight patients were identified with a mean follow-up of 24.1 months. Sixty-eight percent (26/34) of patients achieved gross total resection, and 32% (12/38) had persistent postoperative disease. Of those with postoperative residual tumor, all had preoperative skull base involvement and residual blood supply from the internal carotid artery following embolization. Sixty-seven percent (8/12) of patients with postoperative residual tumor demonstrated radiographic stability of disease with scans being completed approximately every 6 months. Radiographic rates of disease progression ranged from 4.1 to 9.22 mm/year. Conclusions  Patients with preoperative skull base involvement and residual vascularity following preoperative embolization are more likely to have residual postoperative disease, and a longer postoperative follow-up is warranted in these patients. Progression of residual disease occurred approximately 7.5 months postoperatively. Younger patients may be more likely to need further intervention for postoperative residual disease, and postoperative imaging at 6-month intervals appears appropriate.

The Four-Port Bradoo Technique: An Alternative to the Modified Endoscopic Denker's Approach for Giant JNA

The aim of this study is to emphasise the importance of preserving the anterior facial skeleton in angiofibroma surgery and to introduce a new approach by which tumors with far lateral extensions can be operated upon successfully without disruption of the anterior facial skeleton. This is a prospective study conducted at a tertiary referral academic centre. Two patients with extensive juvenile nasopharyngeal angiofibroma with far lateral extensions were recruited and they underwent surgery between July and August 2016. Both patients were not embolised prior to surgery. Complete tumor removal was achieved in both cases without any evidence of recurrence of disease. The facial contour was well maintained. They are under regular follow-up at our centre, having completed their third 3 monthly follow-up. The main outcome measures are preservation of the anterior facial skeleton and complete tumor removal. The Four-Port Bradoo Technique allows for maximum access to the angiofibroma whilst maintaining the anterior facial skeleton, thus ensuring complete removal with minimal morbidity to the patient.

Endoscopic Management of Vascular Sinonasal Tumors, Including Angiofibroma

The greatest challenge in the surgical treatment of angiofibromas is dealing with the hypervascularity of these tumors. Staging systems that take into account the vascularity of the tumor may be more prognostic. A variety of treatment strategies are used to deal with the vascularity of angiofibromas, including preoperative embolization, segmentation of the tumor into vascular territories, use of hemostatic tools, and staging of surgery. Even large angiofibromas with intracranial extension and residual vascularity can be successfully managed by a skull base team using endoscopic techniques.