[Solitary bone epithelioid hemangioendothelioma. Case report and literature review]

We report the case of a 54 year-old male with a solitary bone epithelioid hemangioendothelioma located in the right iliopubic ramus. Clinical manifestations included right inguinal pain without functional limitation. We stress the importance of the anatomopathologic study to make the diagnosis and determine the histologic grade of the malignancy. This helps decide which is the most appropriate treatment and provides the prognosis.

[A case of multiple hepatic epithelioid hemangioendothelioma mimicking metastatic hepatic tumor]

We report a case of multiple hepatic epithelioid hemangioendothelioma( EHE) mimicking hepatic metastasis of colon cancer. A 71-year-old man was referred to our hospital for further evaluation of multiple hepatic tumors. Enhanced CT scan was not performed because of renal dysfunction. Total colonoscopy revealed a type 1 cancer at the rectosigmoid junction. We therefore diagnosed the hepatic tumors as metastases from rectal cancer. Anterior resection was performed and postoperative chemotherapy targeting the hepatic tumors was carried out. Unfortunately, the size of the hepatic tumors increased. We therefore performed lateral segmentectomy and partial hepatectomies (11 lesions). The macroscopic findings indicated basically localized tumor without diffuse infiltration. Microscopically, spindle and oval-shaped cells with abundant eosinophilic cytoplasm were observed; immunohistochemical staining was positive for factor VIII and CD34. These data were conclusive for EHE. EHE of the liver is a rare neoplasm of which little is currently known. We herein report a case of EHE in the liver, misdiagnosed as colorectal metastatic tumor.

Epithelioid hemangioma of bone and soft tissue: a reappraisal of a controversial entity

BACKGROUND

The controversy surrounding diagnosis of an epithelioid hemangioma (EH), particularly when arising in skeletal locations, stems not only from its overlapping features with other malignant vascular neoplasms, but also from its somewhat aggressive clinical characteristics, including multifocal presentation and occasional lymph node involvement. Specifically, the distinction from epithelioid hemangioendothelioma (EHE) has been controversial. The recurrent t(1;3)(p36;q25) chromosomal translocation, resulting in WWTR1-CAMTA1 fusion, recently identified in EHE of various anatomic sites, but not in EH or other epithelioid vascular neoplasms, suggests distinct pathogeneses.

QUESTION/PURPOSES

We investigated the clinicopathologic and radiologic characteristics of bone and soft tissue EHs in patients treated at our institution with available tissue for molecular testing.

PATIENTS AND METHODS

Seventeen patients were selected after confirming the pathologic diagnosis and fluorescence in situ hybridization analysis for the WWTR1 and/or CAMTA1 rearrangements. Four patients had multifocal presentation. Most patients with EH of bone were treated by intralesional curettage. None of the patients died of disease and only four patients had a local recurrence.

RESULTS

Our results, using molecular testing to support the pathologic diagnosis of EH, reinforce prior data that EH is a benign lesion characterized by an indolent clinical course with an occasional multifocal presentation and rare metastatic potential to locoregional lymph nodes.

CONCLUSION

These findings highlight the importance of distinguishing EH from other malignant epithelioid vascular tumors as a result of differences in their management and clinical outcome.

LEVEL OF EVIDENCE

Level IV, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Primary vascular tumors of bone: a spectrum of entities?

Vascular tumors of bone are a heterogeneous group. Numerous terms have been introduced as well as different classification systems. None of the classification schemes have been accepted due to lack of consistent terminology, accepted histologic criteria, and limited correlation with clinical outcome. It is acknowledged that vascular tumors of bone originate from endothelial cells, resulting in variable expression of endothelial markers. None of these markers are useful to discriminate between benign and malignant lesions. Although radiologic appearance is not specific, radiologic multifocality should trigger to include a vascular neoplasm in the differential diagnosis. This review gives an overview of current literature by describing all different histologic subtypes in correspondence with clinical, radiologic and genetic data. We propose the classification of vascular tumors of bone according to the three-tiered World Health Organization classification scheme for soft tissue tumors dividing entities into a benign, intermediate and malignant category. Hemangioma is the most often and commonly recognized benign lesion. Epithelioid hemangioma has been better defined over the past few years. Based on its locally aggressive behavior and occurrence of lymph node metastases, classification within the intermediate category could be considered. Angiosarcoma is the only accepted term for high-grade malignant vascular tumor of bone and so far, epithelioid hemangioendothelioma is the only accepted low-grade malignant vascular tumor of bone. It is still unclear whether other low-grade malignant vascular tumors of bone (e.g. hemangioendothelioma) truly exist. Unfortunately, molecular / genetic studies of vascular tumors of bone which might support the proposed classification are very sparse.

A novel WWTR1-CAMTA1 gene fusion is a consistent abnormality in epithelioid hemangioendothelioma of different anatomic sites

The classification of epithelioid vascular tumors remains challenging, as there is considerable morphological overlap between tumor subtypes, across the spectrum from benign to malignant categories. A t(1;3)(p36.3;q25) translocation was reported in two cases of epithelioid hemangioendothelioma (EHE), however, no follow-up studies have been performed to identify the gene fusion or to assess its prevalence in a larger cohort of patients. We undertook a systematic molecular analysis of 17 EHE, characterized by classic morphological and immunophenotypic features, from various anatomical locations and with different malignant potential. For comparison, we analyzed 13 epithelioid hemangiomas, five epithelioid angiosarcomas, and four epithelioid sarcoma-like EHE. A fluorescence in situ hybridization (FISH) positional cloning strategy, spanning the cytogenetically defined regions on chromosomes 1p36.3 and 3q25, confirmed rearrangements in two candidate genes from these loci in all EHE cases tested. None of the other benign or malignant epithelioid vascular tumors examined demonstrated these abnormalities. Subsequent reverse transcription-polymerase chain reaction (RT-PCR) confirmed in three EHE the WWTR1-CAMTA1 fusion product. CAMTA1 and WWTR1 have been previously shown to play important roles in oncogenesis. Our results demonstrate the presence of a WWTR1-CAMTA1 fusion in all EHE tested from bone, soft tissue, and visceral location (liver, lung) in keeping with a unique and specific pathological entity. Thus, FISH or RT-PCR analysis for the presence of WWTR1-CAMTA1 fusion may serve as a useful molecular diagnostic tool in challenging diagnoses.

A case of pulmonary epithelioid hemangioendothelioma surviving 10 years without treatment

A 19-year-old woman was referred to our hospital because of bilateral multiple nodular shadows on the chest radiograph. She complained of no symptoms. The pulmonary lesions were diagnosed pathologically as epithelioid hemangioendothelioma. She has been followed without treatment for more than 10 years. Among all lesions, only two pulmonary nodules enlarged slightly, and it is interesting that one showed significant uptake in a fluorodeoxyglucose positron emission tomography (FDG-PET) scan. The current case suggests the clinical usefulness of an FDG-PET scan in a pulmonary epithelioid hemangioendothelioma (PEH) patient.

Malignant hepatic epithelioid hemangioendothelioma with rapid progression and fatal outcome

A 46-year-old woman was admitted to our hospital because of pain in the right upper quadrant and dyspnea. Abdominal and chest computed tomography (CT) scans revealed areas of low attenuation in both hepatic lobes, left pleural effusion, and multiple nodules in both lungs. Laboratory data indicated disseminated intravascular coagulation. She developed rapidly progressive respiratory and hepatic failure despite intensive treatment including mechanical ventilation and died of respiratory failure 3 weeks after admission. Immunohistochemical analysis of liver necropsy and cytology of the left plural effusion stained positive for factor VIII-related antigen and CD31. Based on these observations, a diagnosis of hemangioendothelioma (EHE), a rare vascular tumor, was made. A rapid clinical course and fatal outcome, as in the present case, are rare clinical manifestations in EHE.

[A man with epitheloid hemangioendothelioma. The suspicion of a vascular tumor often occurs late]

A 58-year-old man presented at the dermatology outpatient clinic with a subcutaneous nodule on his left hand. The patient could not recall a previous injury. Excision revealed an epithelioid hemangioendothelioma, a rare and malignant vascular tumour, characterized by slow progression and often located on the upper and lower extremities. The patient was referred to a specialist group for soft-tissue tumours. He underwent excision, after which the wound was closed using a non-invasive adhesive wound closure. Since the excision was not very extensive, supplementary radiotherapy was given. Four years later there was no relapse or occurrence of metastases. Invasive investigation of a soft-tissue tumour, such as skin biopsy or diagnostic excision, may interfere with potential MRI - the diagnostic imaging tool indicated in the guidelines. However, a soft-tissue tumour is often only suspected at the last moment. When a soft-tissue tumour is suspected, the doctor should refer the patient to one of the specialist groups for soft-tissue tumours for further diagnosis and therapy.

Epithelioid haemangioendothelioma of the anterior skull base: what is the optimal treatment?

We report an unusual malignant tumour affecting an unusual site. Epithelioid haemangioendothelioma was formerly considered a tumour of intermediate malignancy but has been reclassified as fully malignant. It is important to be aware of this clinical entity as the best hope of cure is timely radical resection. There is a paucity of evidence concerning the efficacy of alternative treatments because the tumour is very rare.

Laryngeal kaposiform hemangioendothelioma: case report and literature review

The kaposiform hemangioendothelioma (KHE) is an uncommon vascular neoplasm of borderline or intermediate malignant potential in which involvement of the head and neck region is rare. A 5-year-old girl was admitted to the emergency room with abrupt massive hemoptysis. Transoral laryngoscopy revealed a round, reddish mass with active bleeding on the anterior portion of the left vocal fold region. Since re-hemoptysis and large amount of aspiration caused breathing difficulties for the patient, suspension exam was performed under general anesthesia. Mass excision and thorough bleeding control was performed with laser assisted laryngo-micro system. Postoperatively, there was no further bleeding. The pathologic diagnosis of the tumor was KHE. To the best of our knowledge, this is the first report of a KHE in the larynx presenting as recurrent hemoptysis in childhood.

Giant retrovesical epithelioid hemangioendothelioma presenting with acute urinary retention: a case report

Epithelioid hemangioendothelioma (EH) is a very rare vascular tumor of intermediate biological behavior. It can arise from various sites including bone, liver, spleen, pleura, lung, skin, or soft tissue. We report a case of a 24-year-old man who presented with a history of acute urinary retention and a palpable lump in the lower abdomen. Imaging showed a large pelvic mass displaying heterogeneous texture with solid and cystic components compressing and displacing adjacent structures. The patient underwent exploratory laparotomy with excision of the pelvic mass. Histopathological examination confirmed the diagnosis of EH. Pelvic soft tissue origin of EH is extremely rare. The diagnosis of EH may be suggested by characteristic magnetic resonance imaging (MRI) findings.

Hepatic epithelial hemangioendothelioma in pregnancy

BACKGROUND

Epithelioid hemangioendothelioma (EHE) is a rare vascular neoplasm that affects various tissues including liver, lung, gastrointestinal tract, head and neck, bone, heart and the central nervous system.

CASE REPORT

A case of EHE is presented with lung and liver involvement during pregnancy. The patient had an uncomplicated antenatal course and delivery. Because of her asymptomatic presentation and the lack of safe and effective treatment during pregnancy, the decision was made to continue expectant management during her pregnancy. To our knowledge, this is the only published case report on this tumor with lung and liver involvement during pregnancy.

CONCLUSION

Expectant management of hepatic EHE is possible during pregnancy and can result in good maternal and fetal outcomes.

[Proliferative cutaneous epithelioid angiomatous nodule]

The cutaneous epithelioid angiomatous nodule is an uncommon benign vascular proliferation that has only recently been described. Clinically, it usually presents as a solitary, fast-growing, small reddish papulous or nodular lesion on the trunk or limbs of adults. Histopathologic study reveals a proliferation of epithelioid cells and predominantly solid, well delimited, unilobular growth in the superficial dermis. Well defined vessels are often found permeating the lesion, which also shows a certain degree of inflammatory infiltration. The cells contain abundant pink cytoplasm, often with vacuoles, and vesicular nuclei with prominent nucleoli. The morphology of these cells is relatively uniform, without atypia or pleomorphism, although mitoses are not uncommon. We report 2 new cases of cutaneous epithelioid angiomatous nodules, the first in a 28-year-old pregnant woman and the second in a 27-year-old man. In both cases, the usual characteristics of this entity were present, but with the peculiarity of a high mitotic index. We discuss the differential diagnosis of cutaneous epithelioid angiomatous nodules with other vascular proliferations that exhibit epithelioid cytology.

[Long term follow-up of a case of pulmonary epithelioid hemangioendothelioma]

A 54-year-old woman was referred to our hospital for bilateral multiple nodular shadows on a medical checkup chest X-ray film. Computed tomography also showed multiple small nodules in bilateral lung fields. Thoracoscopic lung biopsy was performed. The tumor cells showed immunohistochemically positive staining for factor VIII-related antigen, CD 34, and vimentin. The tumor therefore was diagnosed as pulmonary epithelioid hemangioendothelioma. The patient had been followed without any treatment, and died 12-years and 4 months after the diagnosis.

Pleural epithelioid hemangioendothelioma

Epithelioid hemangioendothelioma (EHE) is a rare tumor of vascular origin. While it can be found in any tissue, it is most often found in lung and liver and usually has an intermediate behavior. EHEs originating from pleural tissue have been less frequently described than those from other sites. Furthermore, to date, all of the cited pleural EHEs were described as highly aggressive. In the present report, we describe a rare case of pleural EHE extending to lung and bone in a 31-year-old woman. The histological diagnosis was confirmed by both conventional examination and immunohistochemistry. Her disease stabilized during the 4th course of adriamycin (45 mg/m(2), day 1-3), dacarbazine (300 mg/m(2), day 1-3) and ifosfamide (2,500 mg/m(2), day 1-3) with mesna, and she survived for 10 months after the diagnosis.