Dowling oration 1976. Malignant vascular tumours

Lymph nodes as sites of metastases from sarcomas of soft tissue

Records of 323 patients with TNM Stage M0 sarcoma of soft tissue treated by the Radiation Medicine Service of the Massachusetts General Hospital over a 14-year period were reviewed to study the incidence and the implication of regional lymph node involvement. Nineteen patients (5.9%) had evidence of sarcoma metastatic to draining lymph nodes, zero of 63 (0%) were Grade 1 sarcomas, two of 118 (2%) were Grade 2, and 17 of 142 (12%) were Grade 3 sarcomas. Among patients with Grade 3 sarcomas, rhabdomyosarcoma (five of 14), vascular sarcoma (two of five), and epithelioid sarcoma (four of five) were associated with a higher incidence of lymph node involvement than synovial sarcomas (zero of four), fibrosarcomas (zero of 16), malignant fibrohistiocytomas (one of 29), neurofibrosarcomas (one of eight), liposarcomas (one of 14), and leiomyosarcomas (one of ten). From the 19 patients who had evidence of metastatic nodes, six (32%) were alive more than 58 months after the treatment of the nodes; four of six patients were without further tumor. The data of this study are compared with those cited in a review of the literature.

Angiosarcoma of the face and scalp, prognosis and treatment

72 patients with angiosarcoma (AS) of the face and scalp have been analyzed with respect of various prognostic factors and the effects of different treatment regimes. This disease predominantly occurs in the elderly (age range, 56-92 years), and affects men rather more frequently than women (men: 44, women: 28). The clinical presentation varied, and included bruise-like lesions, dusky plaques, chronic edema or cellulitis, ulcerated nodules, pyoderma, and infected conditions. Due to lack of clinical awareness and problems with histologic assessment, delays in diagnosis were frequent. The majority of the tumors arose in the upper part of the face or scalp. Less commonly, the central part of the face was affected while only three tumors developed in the mandibular region. Overall the prognosis was poor; one half of the patients died within 15 months of presentation. Only 12% of the patients survived 5 years or more. Patients with lesions that were less than 10 cm in diameter responded better to treatment and statistically survived longer than those with larger lesions, emphasizing the crucial importance of early diagnosis. There is some indication that men, younger patients, patients with lesions on the central part of the face survived longer, but this was not of statistical significance. The histologic differentiation of the tumors at presentation also was of doubtful prognostic significance. Despite the overall poor prognosis, radical radiotherapy (mostly wide-field electron-beam therapy) in seven patients resulted in the apparent eradication of the local skin disease and prolonged survival of the patients. Pulmonary metastases developed 10 years later in two of those patients, however, but the face and scalp remained tumor-free.

The histogenesis of angiosarcoma of the face and scalp: an immunohistochemical and ultrastructural study

Thirteen cases of angiosarcoma of the face and scalp have been examined using immunohistochemistry and electron microscopy. Endothelial cell markers have been employed in an immunoperoxidase technique on tissue that has either been routinely processed, periodate-lysine paraformaldehyde fixed (PLP) and cold processed, or fixed in methacarn. A consistent pattern of endothelial cell labeling was only achieved in the PLP fixed tissue. In this fixative the angiosarcomas were factor VIII related antigen negative, Ulex europaeus lectin positive, laminin positive, unlabelled by the monoclonal antibody PAL-E, and positively labelled by the monoclonal antibody EN4. Ultrastructural examination of four cases showed evidence of vascular lumina in all tumours. Weibel-Palade bodies were seen in only one case but three tumours showed some evidence of tight junction formation and marginal folding. Thus, our cell marker studies can be interpreted as consistent with a lymphatic derivation for this type of angiosarcoma but in contra-distinction the ultrastructural studies showed tumour channels with features suggestive of blood vessel differentiation.

Histogenesis of Kaposi's sarcoma in patients with and without acquired immune deficiency syndrome (AIDS)

Immunohistochemical studies were performed in thirty skin biopsies from patients with Kaposi's sarcoma, who did and did not have the acquired immune deficiency syndrome (AIDS). Tumour histogenesis was rigorously tested using a battery of endothelial cell markers, which included two new monoclonal antibodies, EN4 and PAL E. These are both specific for endothelial cells and can be visualised in appropriately fixed paraffin embedded tissue. Whereas EN4 labels all endothelial cells, PAL E is negative in endothelium of lymphatic derivation. Lectin binding with Ulex europaeus agglutinin 1 (UEA-1) and the presence of factor VIII related antigen (FVIIIRA) and laminin were also examined. In nodular lesions of Kaposi's sarcoma the spindle cell areas were positive with EN4 and UEA-1, negative with PAL E, and showed focal staining for FVIIIRA and laminin. These results confirm that the tumour is of endothelial cell origin. Six patch stage lesions showed a network of angulated spaces, lined by cells that were positive with EN4 and UEA-1, negative with PAL E and anti-FVIIIRA, and showed only weak staining for laminin. This pattern was observed in both AIDS and non-AIDS related cases and strongly favours a lymphatic derivation for the tumour. This has important implications as it suggests that lymphatic endothelium may have special characteristics that lead to neoplastic transformation in patients with retrovirus infection.

Cardiac angiosarcomas. A review and a case report

Forty-five cases of cardiac angiosarcomas were reviewed, and the data were compared with those of a 1968 review of 41 other cases which revealed these tumors to be typically located within the right atrium as large symptomatic masses and to be rapidly fatal, with the diagnoses usually determined only at autopsy. The relationship of these tumors to Kaposi's sarcoma was also examined. The findings paralleled those of the previous review. Additionally, the following points emerged: With the aid of newer imaging techniques, localization, biopsy diagnosis and resection of the atrial tumors are now being achieved more often, with some improvement in survival. Like angiosarcomas of other organs, atrial angiosarcomas exhibit highly variable histologic patterns, which often overlap those of Kaposi's sarcoma, and may also present metastatic patterns simulating widespread Kaposi's sarcoma or malignant melanoma. In reported cases of classical, endemic, or epidemic Kaposi's sarcoma, cardiac lesions are uncommon and typically are small, asymptomatic, restricted to the epicardium/or pericardium and, thus, are clearly different, both clinically and pathologically, from the atrial tumor group. The justification for designating cases of the latter group as "primary cardiac Kaposi's sarcoma" is open to debate. A case report illustrates many of the above points.

Angiolymphoid hyperplasia with eosinophilia

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Angiolymphoid hyperplasia with eosinophilia. A clinicopathologic study of 116 patients

The clinicopathologic spectrum of angiolymphoid hyperplasia with eosinophilia (ALHE) is reported through a study of 116 cases (67 male and 49 female) submitted to the Armed Forces Institute of Pathology. The lesions are most common in the head-neck region and are characterized by single or multiple smooth-top papules or plaques of varying color. Microscopically, ALHE consists of anomalous vascular proliferations and varying degrees of nodular and diffuse lymphocytic infiltrates with eosinophils at all levels of the corium and subcutaneous tissue. In fifty-three cases an arterial structure, confirmed by the presence of an internal elastic lamina, was observed in close association with venular structures or was the site of endothelial cell proliferation. ALHE comprises a spectrum of unusual vascular proliferation with inflammation, encompassing such entities as inflammatory angiomatous nodules, pseudo or atypical pyogenic granuloma, histiocytoid hemangioma, epithelioid hemangioma, and Kimura's disease. The existence of arterial structures among venules and endothelial cell proliferations suggests the presence of arteriovenous (AV) shunts, which may help explain the pathogenesis and biologic behavior of this condition.

Malignant angiosarcoma of the scalp: a case report with immunohistochemical studies

A case of angiosarcoma of the scalp is reported. The histogenesis of this tumour is discussed in terms of the ultrastructural and immunohistochemical findings. This type of angiosarcoma is uncommon and carries a poor prognosis: the therapeutic alternatives are discussed.

Unusual vascular tumour of the scalp in association with lymphoid aggregates: a variant of angiolymphoid hyperplasia?

A 51-year-old mason presented with a large tumour on his scalp which had developed over the previous 2 years. Histological examination showed the presence of large vessels with muscular coats some of which appeared to be venules and others arterioles. They had markedly swollen cuboidal endothelial cells and a surrounding mononuclear cell infiltrate which in areas formed lymphoid follicles some of which had germinal centers. There was no evidence of tissue or blood eosinophilia. The unusual clinical and histological features of this case are emphasized and the nosology of this rare condition is discussed.

Cutaneous Angiosarcoma in a Site of Healed Herpes Zoster

A 57-year-old woman presented with an erythematous plaque of the left postauricular area that was diagnosed as metastatic carcinoma on clinical and histologic bases. It was revealed that herpes zoster had been diagnosed in the same dermatomal distribution 10 years previously. The lesion recurred 2 years after irradiation, and angiosarcoma was diagnosed. Recent evidence linking viral infection and vascular tumors is examined as it might apply to the pathogenesis of angiosarcoma. Repeat biopsy, reticulum stain, and electronmicroscopic examination of a lesion of the head and neck region that histologically suggests metastatic carcinoma are recommended if no primary malignancy is discovered.

Acquired progressive lymphangioma

A 5-year-old Japanese boy, who developed dark brown, erythematous lesions (two separate lesions) on his face, scalp, and left upper arm within 2 years, was reported. Biopsy specimens revealed many dilated channels lined by a single layer of endothelial cells without obvious atypicality throughout the dermis. These channels split collagen bundles, giving a "dissection of collagen" appearance. From these clinical and histopathologic findings, we have diagnosed these lesions as acquired progressive lymphangioma. Our patient is the youngest reported patient in the literature, and we were interested in that the two lesions developed separately following previous trauma and they had the tendency to regress following oral prednisolone therapy.

Angiosarcoma of skin and soft tissue: a study of forty-four cases

Forty-four cases of skin and soft tissue angiosarcoma seen at M. D. Anderson Hospital before 1976 were reviewed. The cases fell into six different clinical groups: scalp-face, 17 cases; postmastectomy, 14 cases; postradiation, 5 cases; leg with vascular stasis, 2 cases; breast, 2 cases; and miscellaneous, 4 cases. In all cases in the first four groups, the tumors involved primarily the dermis and subcutis and showed similar blends of vasoformative and solid histologic patterns. Two tumors in the miscellaneous group closely resembled those in the larger groups, but the other two in that group (both located in deeper soft tissue sites) and the two breast angiosarcomas had a somewhat different microscopic appearance. Survival was generally poor in all groups, owing to frequent local recurrence and early metastasis; median survival for the entire series was 20 months. Findings of significantly favorable prognostic importance were tumor size less than 5 cm (in the scalp-face group) and a moderate or marked lymphoid infiltrate in and around the tumor. Less significant favorable factors were a distal location ( in the postmastectomy group) and a low degree of pleomorphism. Only nine patients had long-term, disease-free survival.

Giant pseudomalignant granuloma

A patient who developed rapidly growing, multicentric, cutaneous tumors clinically resembling pyogenic granuloma is reported. In spite of the fact that the local lesions expanded rapidly and contained cytologically "malignant" cells which appeared to invade dermal vessels, the patient had a benign clinical course. The differential diagnosis of "giant pseudomalignant granuloma" is discussed.

Intravascular papillary endothelial hyperplasia in the skin and subcutaneous tissue

Twenty-four cases of Intravascular Papillary Endothelial Hyperplasia (IPEH) have been studied. IPEH comprises approximately 2% of benign and malignant vascular tumours of the skin and subcutaneous tissue. This peculiar tumour-like process lacks specific clinical characteristics and its diagnosis must be based on microscopic examination. Histologically is is characterised by a papillary proliferation of endothelial cells forming vascular channels, commonly associated with thrombus and in some cases simulating angiosarcoma.--Follow-up of 10 cases indicates a benign clinical course.

Intravenous pyogenic granuloma: case report with ultrastructural findings

A nodule, attached to the intimal surface of the external jugular vein of a 12-year-old boy, showed the light microscopic features of a pyogenic granuloma. The small muscular arteries in the adventitia contained numerous tufted intraluminal capillaries, and it is possible that the angiomatous proliferation within the jugular vein originated from the vasa vasorum, with subsequent growth into the venous lumen. This intraluminal growth dispersed the tunica elastica into the pyogenic granuloma. Ultrastructural examination showed, the lesion to be composed of capillaries lined by low and cuboidal endothelial cells, with occasional pericytes surrounded by focally multiple basal luminae. In some locations, the capillary endothelial basal lamina abutted directly on collagen with no intervening pericyte. In the stroma of the tumor there were cells with myofibroblastic features. This benign intravascular growth should be distinguished from other benign but atypical intravascular and vascular proliferations.

Cell proliferation in a malignant angioendothelioma during sequential chemotherapy

The rate of cellular proliferation was studied in the neoplastic cells of a malignant angioendothelioma and in its inflammatory infiltrate by means of optical radioautography after incorporation ex vivo of tritiated thymidine. One third of the normal looking, as well as the atypical, endothelial cells were engaged in the cell cycle of proliferation. This large pool has been effectively suppressed during subsequent chemotherapy which resulted in partial regression of the neoplasm. The proliferative activity of the infiltrate was higher inside the neoplasm than at its periphery.

The histiocytoid hemangiomas. A unifying concept embracing several previously described entities of skin, soft tissue, large vessels, bone, and heart

The proposal is made that a number of previously described entities of skin, soft tissue, large vessels, bone, and heart actually constitute different manifestations of the same basic process, characterized by the proliferation of a highly distinctive type of cell descriptively identified as a "histiocytoid endothelial cell." The entities in question are angiolymphoid hyperplasia with eosinophilia and related cutaneous and subcutaneous disorders, atypical vascular proliferation of large vessels, hemangioendothelioma of bone, and endocardial benign angioreticuloma of the heart. The main cell that proliferates in all these conditions has the basic features of an endothelial cell, but also exhibits histochemical and ultrastructural characteristics that are more akin to those of a histiocyte. These unusual features could be the expression of a morphologic abnormality or represent an overgrowth of a specific and as yet undefined subpopulation of endothelial cells, such as Majno's "contractile endothelial cell." Whether this group of proliferative diseases is of a reactive or a neoplastic nature is not immediately apparent, although the latter seems more likely. However, it is clear that the behavior of these lesions, as a group, is quite indolent and even self-limited, in contrast to the aggressive behavior and often fatal outcome of the true angiosarcomas that they so closely resemble on microscopic grounds. The term "histiocytoid hemangioma" is suggested for this group of disorders.

Cutaneous angiosarcoma of the head and neck

Between 1920 and 1970, 13 patients (7 men and 6 women) with cutaneous angiosarcomas of the head or neck were treated at the Mayo Clinic; the mean age of the patients was 66 years. Three clinical patterns were noted: a superficial spreading type, a nodular type, and an ulcerating type. There were no predisposing benign lesions; however, in one patient, angiosarcoma developed in an area of previously irradiated skin. Three modes of therapy were used: surgery alone, radiation alone, and surgery with postoperative irradiation. Of the 13 patients, 2 survived more than 5 years and 2 were alive within 1 year of therapy. Because cervical lymph node spread is common, lymph node clearance is recommended for patients with lateralized lesion or with palpable lymphadenopathy at presentation.

Lymphangioma-like Kaposi's sarcoma. A report of three cases

Details of three patients with Kaposi's sarcoma are presented. Each case, although clinically typical, displayed unusual histological changes suggestive of lymphangioendothelioma. The significance of these changes with regard to the histogenesis of Kaposi's sarcoma is discussed.

Pseudopyogenic granuloma: enzyme histochemical and ultrastructural study

In an attempt to elucidate the nature of the abnormal vessels in pseudopyogenic granuloma, we performed enzyme histochemical analysis of 10 lesions and correlated them with electron microscopic findings in four lesions. The dermal vessels of pseudopyogenic granuloma possess voluminous endothelial cells demonstrating marked activity of various hydrolytic and respiratory enzymes. The alkaline phosphatase activity, however, is characteristically faint or absent. Electron microscopy reveals that mitochondria and the other common cytoplasmic organelles are abundant in the hypertrophic endothelial cells, probably reflecting increased metabolic cellular activity, whereas specific endothelial granules (Weibel-Palade bodies) are generally sparse in these abnormal cells. Other notable features occurring in several endothelial cells are cytoplasmic vacuolation and the acquisition in the subnuclear zone of dense bodies associated with fine actin-like filaments, 55 to 75 A thick. The latter change is interpreted as evidence of endothelial contraction. Classification of the abnormal dermal vessels using available criteria has proved difficult, but it is suggested that they arise predominantly from the venous side of the microcirculation and are mainly postcapillary venules, although involvement of both larger and smaller caliber vessels also occurs.