case_images: PMC8225413_01
case_images: Local recurrence and lymph node metastasis at the initial visit. (a) Visual appearance of the ankle region during the patient's first visit to our hospital. (b) Axial image of the ankle region acquired using T1-weighted MRI. (c) Axial image of the ankle region acquired using T2-weighted MRI. (d) Axial image focused on the inguinal iliac lymph node acquired using positron emission tomography (PET). (e) Axial image focused on the external iliac lymph node acquired using PET.
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case_images: PMC8225413_01_CRIONM2021-5532258.001.jpg
case_images: fig1
case_images: After a while, she was referred to our hospital because of re-recurrence and came with an approximately 5 cm tumor with skin breakdown in the same region (Figure 1(a)). Magnetic resonance imaging (MRI) revealed a tumor in the ankle region's subcutaneous tissue presenting isointensity and high intensity in the inner cystic region on T1- and T2-weighted images, respectively (Figures 1(b) and 1(c)). Moreover, lymph node enlargement was detected in the right inguinal and external iliac regions (Figures 1(d) and 1(e)).
case_images: Photomicrographs of the angiomatoid fibrous histiocytoma. (a) Local recurrence featuring solid nodules of epithelioid to spindle cells arranged in a syncytial pattern with peripheral blood cells (hematoxylin and eosin (HE) stain, x200). Tumor cells negative for (b) S-100 protein, (c) smooth muscle actin, (d) CD31, and (e) STAT6 (immunohistochemical stains, x200). (f) Excisional biopsy revealing inguinal node metastasis of the tumor (HE, x20).
case_images: CRIONM2021-5532258.002.jpg
case_images: PMC8225413_01_CRIONM2021-5532258.002.jpg
case_images: fig2
case_images: AFH. A proliferation of uniform spindle-shaped histiocytoid cells with blunt nuclear atypia and scattered mitoses, accompanying pseudoangiomatous spaces and a pericapsular lymphoplasmacytic rim, was seen with immunohistochemical negativity for S-100 protein, smooth muscle actin (SMA), CD31, and STAT6 (Figures 2(a)-2(e)). The treatment plan was determined by conducting an open biopsy of the right inguinal lymph node swelling, resulting in the diagnosis of lymph node metastasis of AFH (Figure 2(f)).
case_images: Tumor progression of the local recurrent tumor during tocilizumab treatment. (a) Axial image of the recurrence tumor in the ankle region acquired using T2-weighted MRI at the time of recurrence. (b) Axial image of the recurrence tumor in the ankle region acquired using T2-weighted MRI 2 months after starting on tocilizumab treatment. (c) Axial image of the recurrence tumor in the ankle region acquired using T2-weighted MRI 4 months after the first evaluation. The tumor is indicated by the arrows in red.
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case_images: PMC8225413_01_CRIONM2021-5532258.003.jpg
case_images: fig3
case_images: Eight months postoperatively, MRI showed a local recurrence (Figure 3(a)). Images showed that both the ankle tumor and external iliac lymph node metastasis retained their size 2 months following the start of tocilizumab treatment (Figure 3(b)). It indicates that tocilizumab had no suppressive effect on AFH growth (Figure 3(c)).  Figure 4 shows the tumor sizes and CRP levels according to the treatment course.
case_images: Scheme of the treatment indicating the tumor sizes and CRP levels. The time of tumor recurrence was regarded as time zero.
case_images: CRIONM2021-5532258.004.jpg
case_images: PMC8225413_01_CRIONM2021-5532258.004.jpg
case_images: fig4
case_images: It indicates that tocilizumab had no suppressive effect on AFH growth (Figure 3(c)).  Figure 4 shows the tumor sizes and CRP levels according to the treatment course.