Histiocytoid hemangioma of the skin and scapula. A case report with electron microscopy and immunohistochemistry

Epithelioid Hemangioma of Bone: A Potentially Metastasizing Tumor?

The case of a 15-year-old boy with a severe swelling of the 2nd toe in the left foot and a large swelling of the left inguinofemoral region is described. Histologic examination of the foot lesion showed a typical epithelioid hemangioma of bone that extended into the soft tissues, with a secondary location in the groin, suggestive of lymph node involvement. Subsequently, imaging also revealed swelling of iliac and para-aortic lymph nodes, which probably indicates further lymph node spread.. Besides the fact that epithelioid hemangioma of the toe has not been reported yet, our case showed a noncontinuous localization, most likely in draining lymph nodes. This finding suggests metastatic disease, an event that is extremely rare for epithelioid hemangioma. As such, epithelioid hemangioma might be comparable to another benign vascular tumor, the retiform hemangioendothelioma, which occasionally metastasizes to the lymph nodes without systemic spread.

Epithelioid hemangioendothelioma of the proximal phalanx of the left second toe - a rare occurence

INTRODUCTION

Epithelioid hemangioendothelioma (EHE) of the bone is extremely rare and occurs predominantly in males. It most frequently occurs during the second and third decades of life. The lower extremities are most commonly involved. We describe a diagnostically challenging case of epithelioid hemangioendothelioma of proximal phalanx of 2nd toe of left foot with histological features reminiscent of osteoblastomatosis.

CASE REPORT

A 52 year old man presented with history of intermittent pain with swelling in second toe since 6 months. Radiograph showed a lytic lesion in proximal phalanx of the great toe. CT and MRI reported non specific lesion in the toe. Pain was quite severe and as the patient was a labourer and wanted to get back to his work as soon as possible a decision of disarticulation of the second toe at metatarsophalnageal joint was taken. Histopathology confirmed the diagnosis of Epithelioid hemangioendothelioma and patient was called for regular follow up. There are no complications and recurrence at two year follow up.

CONCLUSION

EHE of the bone is extremely rare vascular tumor. To our knowledge, this is the first case of EHE with such features. EHE should be kept as one of the important differential diagnosis while diagnosing vascular tumors. Careful attention to the histopathological features is necessary for the confirmation of the diagnosis.

Epidemiology and treatment of angiolymphoid hyperplasia with eosinophilia (ALHE): A systematic review

BACKGROUND

Current knowledge of angiolymphoid hyperplasia with eosinophilia (ALHE) derives from retrospective reports and case series, leading to a nonevidence-based treatment approach.

OBJECTIVE

We sought to systematically review the literature relating to cutaneous ALHE to estimate its epidemiology and treatment outcomes.

METHODS

A literature search of PubMed, EMBASE, Web of Science, and Google Scholar was conducted. Articles detailing cases of histologically confirmed cutaneous ALHE were included.

RESULTS

In all, 416 studies were included in the review, representing 908 patients. There was no sex predominance among patients with ALHE. Mean age at presentation was 37.6 years. There was a significant association between presence of multiple lesions and pruritus, along with bleeding. Surgical excision was the most commonly reported treatment for ALHE. Treatment failure was lowest for excision and pulsed dye laser. Mean disease-free survival after excision was 4.2 years. There were higher rates of recurrence postexcision with earlier age of onset, longer duration of disease, multiple lesions, bilateral lesions, pruritus, pain, and bleeding.

LIMITATIONS

Potential for publication bias is a limitation.

CONCLUSIONS

Surgical excision appears to be the most effective treatment for ALHE, albeit suboptimal. Pulsed dye and other lasers may be effective treatment options. More studies are needed to improve the treatment of ALHE.

"Soap Bubble" Lesion of the Middle Phalanx: Enchondroma or Epitheloid Hemangioma

Introduction:

Epitheloid hemangioma, a benign vascular tumor that arises in skin and soft tissues can also involve the skeletal system. Occasionally this has been reported from small tubular bones of the hand.

Case Report:

Authors report a case of epitheloid hemangioma of the middle phalanx in a young girl without any cutaneous manifestations. The lesion presented as a swollen middle finger, and plain radiographs showed a geographic area of destruction with cortical thinning and intra lesional calcifications. The case was managed by curettage and bone grafting. Histology confirmed this as a case of epitheloid hemangioma.

Conclusion:

Epitheloid hemangioma should be considered in the differential diagnosis of hand masses with expansile lytic lesions with cortical thinning.

Epithelioid hemangioma of the distal humerus with pathologic fracture

Epithelioid hemangioma is a rare tumor that can have bone involvement. Its clinically and radiographically aggressive appearance mimics a malignant neoplasm. Although epitheliod hemangioma has been described as having an aggressive appearance on magnetic resonance imaging (MRI) and plain radiographs, this is the first reported case of pathologic fracture associated with this lesion to our knowledge. This article describes a case of epithelioid hemangioma involving the distal humerus, which initially presented with progressive pain and fracture of the lateral condyle. The aggressive appearance on plain radiographs and MRI suggested a malignant bone tumor. This preliminary diagnosis was confirmed due to the presence of local lymph node spread on positron emission tomography/computed tomography. After a core needle biopsy revealed nondiagnostic tissue, rather than performing a wide resection based on a presumptive malignant diagnosis, we followed the standard diagnostic algorithm and performed an open biopsy with temporary internal stabilization. The tissue sample was adequate and revealed a diagnosis of epithelioid hemangioma. Based on this finding, we were able to proceed with surgical management, including curettage of the lesion, placement of a bone graft, and internal fixation, rather than a wide resection with elbow joint replacement. This article emphasizes the need for careful adherence to the diagnostic algorithm for musculoskeletal tumors. In doing so, a definitive diagnosis was reached, and our patient was able to resume his occupation as a laborer without the restrictions that would have accompanied elbow arthroplasty.

Epithelioid vascular tumors of bone: a review and proposal of a classification scheme

Skeletal vascular tumors composed of epithelioid endothelial cells commonly result in diagnostic difficulty. Although tumors with this morphology have been recognized for many years, there is a considerable degree of confusion regarding their nomenclature and classification. In this article what is believed to represent the morphologic features of this family of tumors is outlined, the historical context of epithelioid endothelial tumors is briefly discussed, and pertinent literature and texts pertaining to the subject is reviewed. It is proposed that the osseous epithelioid endothelial tumors should be classified in a similar manner to their soft tissue counterparts and it is suggested that this approach should help to clarify the confusion surrounding this subject of surgical pathology.

Hemorrhagic epithelioid and spindle cell hemangioma: a newly recognized, unique vascular tumor of bone

BACKGROUND

Epithelioid vascular tumors of bone are uncommon and include epithelioid hemangioma, epithelioid hemangioendothelioma, and epithelioid angiosarcoma. It is important to distinguish among them because they have significantly different biologic potential and require different forms of therapy. In the current study the authors describe six cases of a distinct benign epithelioid and spindle cell vascular tumor of bone that, because of their unusual morphology, were confused with aggressive vascular neoplasms.

METHODS

Cases were retrieved from the surgical pathology files of the Department of Pathology or from the consultation files of one of the authors. Hematoxylin and eosin stained slides were examined. Immunohistochemistry was performed on two cases and electron microscopy was performed on one case.

RESULTS

The tumors arose in the small bones of the hands and feet and the tibia. Three patients had multifocal bone disease at the time of presentation. Histologically, all lesions were comprised of lobules of spindle cells that grew focally in a fascicular pattern and were associated with abundant hemorrhage. Plump epithelioid cells were intermixed and were present focally in the interlobular areas as well, in which they lined larger, more well developed vascular spaces, often protruding into the vascular lumen in a "tombstone" fashion. Immunohistochemically and ultrastructurally the neoplastic cells had features of endothelium. One case was treated by amputation, one by resection, three by curettage, and one by curettage plus radiation therapy. None of the lesions was locally aggressive nor did any metastasize.

CONCLUSIONS

The authors believe that hemorrhagic epithelioid and spindle cell hemangioma of bone is a histologically benign bone tumor. It should be distinguished from malignant epithelioid vascular tumors of bone, which have metastatic potential and need to be treated more aggressively.

Cutaneous vascular proliferation. Part II. Hyperplasias and benign neoplasms

This second part of our review about vascular proliferations summarizes the clinicopathologic features of the cutaneous vascular hyperplasias and benign neoplasms. Hyperplasias comprise a heterogeneous group of vascular proliferations that eventually show a tendency to regression. Angiolymphoid hyperplasia with eosinophilia is included within the group of hyperplasias because of its historical denomination and its reactive nature, probably as a consequence of an arteriovenous shunt, although usually the lesions do not regress. Pyogenic granuloma, bacillary angiomatosis, intravascular papillary endothelial hyperplasia, and pseudo-Kaposi's sarcoma qualify as vascular hyperplasias because they regress when the stimulus that initiated them is removed. Benign neoplasms form a large group of hemangiomas with distinctive clinicopathologic characteristics, although some of them are of recent description and may produce diagnostic difficulties. We classified cutaneous benign vascular neoplasms according to their cell lineage of differentiation, for example, endothelial, glomus cell, and pericytic differentiation. Subsequent categories are established according to the size of the involved vessels (capillaries, venules and arterioles, or veins and arteries) or the nature of the proliferating vessels (blood or lymphatic vessels). Capillary and cavernous hemangiomas have been the terms classically used to name the most common variants of benign vascular neoplasms (i.e., infantile hemangiomas), but they are not the most appropriate denominations for these lesions. First, these names are not contrasting terms. Furthermore, most of the socalled "cavernous" hemangiomas are not hemangiomas (neoplasms) at all, but venous malformations. The most important conceptual issue is that, at any point in time, a particular hemangioma has its own histopathologic pattern throughout the depth of the lesion. For these reasons, we classified hemangiomas into superficial and deep categories. Some of the lesions reviewed have been recently described in the literature, and they may histopathologically mimic lesions of Kaposi's sarcoma; these include targetoid hemosiderotic hemangioma, microvenular hemangioma, tufted hemangioma, glomeruloid hemangioma, kaposiform hemangioendothelioma, spindle-cell hemangioendothelioma, and benign lymphangioendothelioma. In each of these lesions, we update and emphasize those clinical and histopathologic features that are helpful for differential diagnosis with lesions of authentic Kaposi's sarcoma in any of its three stages of development (patch, plaque, or nodule).

Disseminated cutaneous epithelioid hemangioma

Epithelioid vascular tumors are a heterogeneous group characterized by epithelioid-appearing endothelial cells. Included are benign vascular tumors (epithelioid hemangioma), borderline tumors (epithelioid hemangioendothelioma), and malignant tumors (epithelioid angiosarcoma). We describe a case of multiple epithelioid hemangiomas.

Epithelioid haemangioma (angiolymphoid hyperplasia with eosinophilia) and Kimura's disease in Chinese

Although Kimura's disease has often been considered to be identical to angiolymphoid hyperplasia with eosinophilia (epithelioid haemangioma), recent studies suggest that they are different clinicopathological entities. In this study, we have made a detailed morphological comparison of 10 cases of epithelioid haemangioma and 40 cases of Kimura's disease occurring in the Chinese population. The epithelioid haemangiomas occurred in the subcutaneous tissue, skin and maxillary antrum, whereas Kimura's disease affected the subcutaneous tissue, major salivary glands and lymph nodes. Distinctive features of epithelioid haemangiomas were exuberant proliferation of vessels lined by cuboidal to hobnail endothelial cells with irregular nuclei and cytoplasmic vacuoles, fibromyxoid matrix, involvement of muscular coat of blood vessels and zonation of inflammatory infiltrate towards the peripheral portion of the lesion. Distinctive features of Kimura's disease were florid lymphoid infiltrate with prominent lymphoid follicles, vascularization of germinal centres, germinal centre necrosis, marked eosinophilia with or without eosinophil abscess formation, proliferation of high endothelial venules, and sclerosis. The histological features suggest that epithelioid haemangioma is a proliferation of atypical endothelial cells, possibly neoplastic, that is associated with a variable inflammatory infiltrate, whereas Kimura's disease is primarily an inflammatory condition in which high endothelial venules are usually found.

Fine-needle aspiration cytology of angiolymphoid hyperplasia with eosinophilia: a case report with electron microscopy and immunohistochemistry

Angiolymphoid hyperplasia with eosinophilia (ALHE) is an uncommon vascular inflammatory lesion usually involving the dermis or subcutaneous tissue of the head-neck region of middle-aged women. Histologically, this lesion shows a florid proliferation of vessels lined by particular endothelial cells and an inflammatory infiltrate composed of lymphocytes and eosinophils. The fine-needle aspiration (FNA) cytology of a nodular lesion in the retroauricolar region of a 18-yr-old woman showed spindle-shaped and polygonal cells with vesicular nuclei and deeply eosinophilic cytoplasm containing well-defined vacuoles in a background of eosinophils and lymphocytes. These features were consistent with a proliferation of epithelioid endothelial cells, and a diagnosis of ALHE was suggested. The histology confirmed the preoperatory diagnosis, and ultrastructural and immunohistochemical studies further demonstrated the endothelial nature of epithelial-appearing cells. Because the clinical appearance of the lesion may mimic a large number of benign and malignant diseases, a preoperatory diagnosis of ALHE is rarely made. The FNA cytology may represent a simple and reliable method with which to study and diagnose proliferations of epithelioid endothelial cells.

Angiolymphoid hyperplasia with eosinophilia-acquired port-wine-stain-like lesions: attempt at treatment with the argon laser

An unusual case of angiolymphoid hyperplasia with eosinophilia (ALHE) simulating port-wine stain in a 50-year-old woman is reported. The lesions of ALHE are typically papules or subcutaneous masses that range from light pink to red-brown in color. In addition to the usual histologic findings of ALHE, the biopsy in our patient showed some fibrin-like material and fibrous long-spacing collagen on ultrastructural examination. This unusual lesion necessitates biopsy because the differential diagnosis includes port-wine stain, sarcoidosis, lupus erythematosus, and non-Hodgkin lymphoma (mycosis fungoides). Many different forms of treatment have been attempted for ALHE including radiotherapy, cytotoxic chemotherapy, corticosteroids, and antibiotics. The lesions in our patient responded to argon laser therapy and surgical excision, though there has been recurrence on the border of the treated area. Because laser energy is noncumulative in the tissues and effective in removing the lesions, we recommend it as the treatment of choice for these lesions.

Epitheloid hemangiomatosis mistaken for carcinomatosis

We present a unique case of intra and extra-peritoneal epitheloid hemangioma which was mistaken for diffused carcinomatosis, representing a clinical-pathological problem, and emphasizing the unpredictable behaviour of this tumour. We are dealing with epitheloid vascular tumours, and briefly touch on the differential diagnosis, the principle of biological, pathological and clinical behaviour. Knowledge of this entity would provide an accurate diagnosis and would hence improve dealing with the problem. The conclusion is that this group of Histiocytoid-epitheloid vascular lesions have varying biological potential and this unusual functional state represents a large spectrum of cells, from normal to neoplastic endothelium.