Aspiration cytopathology of epithelioid angiosarcoma

A Case of Epithelioid Angiosarcoma Diagnosed From Gross Examination of a Pulmonary Tumor Utilizing Imprint Cytology and Immunocytochemistry

BACKGROUND

Angiosarcoma, a very rare malignant tumor constituting 2%-4% of soft tissue sarcomas, manifest in diverse organs including skin, soft tissues, and bones. Histologically, angiosarcoma presents a wide range of morphologies, with epithelioid angiosarcoma (EAS) resemblance to carcinoma. The difficulty arises from the shared epithelial-like morphology and expression of epithelial markers in immunohistochemistry.

CASE

This study reports a case where EAS diagnosis was achieved through a combination of gross findings in a lung resection sample, imprint cytology, and immunocytochemistry. Imprint cytology revealed clusters of epithelioid cells, while immunocytochemistry showed positive results for CD31, ERG, Fli-1, and AE1/AE3, proving instrumental in diagnosing EAS. The described immunocytochemical protocol facilitates prompt diagnosis exclusively through cytology samples.

CONCLUSION

This report emphasizes the potential for diagnosing EAS using cytological specimens, which is especially useful in cases where obtaining tissue samples proves challenging.

Childhood sarcomas: fine-needle aspiration cytopathology with an emphasis on the use of molecular studies

INTRODUCTION

In children and adolescents, most sarcoma subtypes have a simple karyotype with a single genetic alteration; cytologic findings combined with ancillary testing can lead to a specific diagnosis. The goal of this study was to review the use of fine-needle aspiration in conjunction with immunohistochemistry and molecular studies as a part of an integrated, multidisciplinary diagnostic workup for bone and soft tissue sarcomas in this population.

MATERIALS AND METHODS

We searched for cases aged ≤18 years old with a malignant bone or soft tissue tumor that had corresponding cytology specimens from 3 institutions. Clinical data, cytologic findings and diagnoses, histologic diagnoses, and ancillary testing were documented.

RESULTS

Of 99 cases, 55% were male with a mean age of 12 years. Ninety-four cases (95%) had a specific histologic diagnosis, and 84 cases (85%) were primary neoplasms. Ninety-four cases (95%) had a malignant cytologic diagnosis, and 71 cases (72%) had a specific cytologic diagnosis concordant with the histologic diagnosis. Among primary tumors with a specific histologic diagnosis, a specific cytologic diagnosis was made in 63 cases (79%). After excluding osteosarcoma, 74% of the tumors (n = 50) had molecular studies. Specific genetic alterations supporting a definitive diagnosis were found in 42 cases (84%), the majority of which were demonstrated using Fluorescence In Situ Hybridization (n = 33, 79%).

CONCLUSIONS

We found that fine-needle aspiration in conjunction with core needle biopsy, immunohistochemistry, and molecular studies allowed cytopathologists to accurately classify sarcomas in a pediatric age group.

Angiosarcoma after popliteal aneurysm exclusion surgery. A systematic review

OBJECTIVE

Expansion after popliteal artery aneurysm exclusion with bypass is a common phenomenon. Popliteal angiosarcoma is seldom reported in literature and in most cases after popliteal artery aneurysm surgery. This paper aims to present the case of a popliteal angiosarcoma, initially diagnosed as late aneurysmal growth after exclusion surgery, to conduct a systematic review of popliteal angiosarcoma and assess any association between angiosarcoma and previous popliteal aneurysm surgery.

METHODS

We performed a secondary popliteal aneurysmorraphy through posterior approach for symptomatic aneurysm expansion in a 79-year-old woman, 9 years after medial femoropopliteal venous bypass and aneurysm exclusion. The postoperative course was complicated by recurrent hematomas and wound spillages requiring multiple revisions. Pathological analysis identified an angiosarcoma. Staging revealed bone invasion and pulmonary metastasis. Despite transfemoral amputation and adjuvant chemotherapy the patient died eight months later. We performed a systematic review through MEDLINE on 'primary' and 'secondary' (with previous vascular surgery) angiosarcoma in popliteal artery aneurysm. Research was done using the terms '(hem)angiosarcoma', 'aneurysm', 'popliteal aneurysm or artery', 'femoral aneurysm or artery'. Other soft tissue sarcoma or non-popliteal locations were excluded.

RESULTS

Including this case, only 13 angiosarcomas in popliteal aneurysms are currently described. Two were reported without previous surgery considered a primary angiosarcoma and 11 after popliteal artery aneurysm surgery (secondary angiosarcoma). Patient age ranges from 8 months to 83 years with a male predominance (10/3). Nine of the 11 patients with secondary angiosarcoma were initially diagnosed as popliteal aneurysm expansion after previous bypass surgery, the two other secondary cases presented respectively with pain and inflammatory syndrome without expansion. All prior surgical exclusion were carried out by a medial approach. Interval with the index operation ranges from 3 months to 15 years. Death was reported in 8 of the 13 cases within the first year of diagnosis.

CONCLUSION

Although seldom reported, popliteal angiosarcomas are mainly described after popliteal artery aneurysm exclusion surgery, raising suspicion on a potential association, yet causality cannot be demonstrated. Angiosarcoma should be included in the differential diagnosis of popliteal aneurysm growth or unexpected outcome after exclusion bypass surgery. Systematic imaging and pathological studies should be undertaken to allow early diagnosis and treatment. Routine use of a posterior approach, with aneurysm resection, when feasible as initial popliteal artery aneurysm treatment, might reduce the risk of late sarcomatous transformation.

Diagnostic use of fine-needle aspiration cytology and core-needle biopsy in head and neck sarcomas

The diagnostic role of fine-needle aspiration cytology (FNAC) and core-needle biopsy (CNB) has not been comprehensively assessed in head and neck sarcomas. A systematic review of published cases (1990-2020) was conducted. Diagnostic performance of both FNAC/CNB to determine tumor dignity and histopathological diagnosis was calculated. One hundred and sixty-eight cases were included for which FNAC (n = 156), CNB (n = 8), or both (n = 4) were used. Predominant histologies were skeletal muscle, chondrogenic and vascular sarcomas. FNAC correctly assessed dignity in 76.3% and histology in 45% of cases. Dignity was significantly better for vascular tumors, metastatic and recurrent specimens, and worse for chondrogenic sarcomas. CNB showed a 92% accuracy to identify dignity and 83% for histopathology. FNAC and CNB are useful methods for the diagnosis of head and neck sarcomas, particularly well-suited in the context of recurrent or metastatic disease. The role of CNB remains largely unexplored for this indication.

Mediastinal sarcomas: experience using fine needle aspiration cytopathology

Fine needle aspiration (FNA) cytology is a sparsely used diagnostic method in the evaluation of mediastinal sarcomas in most medical centers worldwide with most literature citations regarding this category of malignancies consisting of small series and individual case reports. Most of these published studies highlight vascular sarcomas such as epithelioid hemangioendothelioma, and angiosarcoma, various subtypes of liposarcoma including well-differentiated liposarcoma, myxoid liposarcoma, and pleomorphic liposarcoma, malignant peripheral nerve sheath tumor, and sarcomas of uncertain differentiation, primary synovial sarcoma and the Ewing sarcoma family of tumors. This paucity of cytopathology reports regarding mediastinal sarcomas is in marked contrast to the almost daily application of endobronchial ultrasound (EBUS)-guided FNA biopsy for sampling mediastinal lymph nodes and mediastinal masses for primary and metastatic carcinomas which, of course, are considerably more common that any type of sarcoma in this location. EBUS, endoscopic ultrasound-guided (EUS) needle biopsy, and percutaneous image-guided biopsy using either core needle, fine-needle, or both can serve a potentially useful role for diagnostic sampling of mediastinal sarcomas, be they primary or metastatic. This review catalogues much of the published data regarding FNA cytopathology and its application to mediastinal sarcomas. An attempt is made to primarily highlight case series rather than individual case reports; however, due to the paucity of these, case reports are cited and discussed where appropriate.

Cytopathology of classic type epithelioid sarcoma: a series of 20 cases and review of the literature

INTRODUCTION

As a rare soft tissue malignancy, epithelioid sarcoma (EpS) is infrequently subjected to cytopathologic analysis. With the exception of a few series, the cytology literature regarding EpS is largely limited to single case reports. Our purpose was to evaluate our experience with EpS, and review the literature regarding its cytopathology.

MATERIALS AND METHODS

A search was made of our cytopathology and surgical pathology databases for cases diagnosed as EpS. Fine-needle aspiration biopsy smears and imprint smears were performed and examined using standard technique. Effusion samples were processed using liquid-based slides.

RESULTS

Twenty cases of EpS were retrieved from 10 patients (M:F 1:1; mean age = 36 years). One patient had 5, 1 patient had 3, and 3 patients had 2 separate specimens. All patients had prior or subsequent tissue confirmation of EpS; all were of the classic/distal type. Seven were new patient cases, 7 were locally recurrent, and 6 were metastases. Sites included lower extremity (8 cases), upper extremity (4), trunk (4), serous effusion (2), scalp (1), and mediastinum (1). Specific cytologic diagnosis were EpS (13 cases), sarcoma not otherwise specified (5), and malignant neoplasm (2). All cases where cell-block SMARCB-1 staining was used were specifically recognized as EpS. Cytomorphology was composed primarily of epithelioid/plasmacytoid cells having eccentrically positioned nuclei, moderate cytoplasm, and variable nuclear pleomorphism.

CONCLUSION

The cytopathology of EpS is somewhat variable, morphologically non-specific, and mimics that of other neoplasms with epithelioid features. Ancillary immunostaining is necessary for a specific diagnosis in newly encountered patients.

A case of metastatic angiosarcoma diagnosed by liquid-based preparation: peculiar cytoplasmic changes

Angiosarcoma with predominantly epithelioid features is a rare soft tissue neoplasm and the interpretation of its cytopathologic findings may be difficult. We report a case of metastatic angiosarcoma with predominantly epithelioid features diagnosed by liquid-based cytology. The cytopathologic findings in this case differed from those of the conventional preparation and we found a clean background, no hyperchromatic nuclei and several cytoplasmic changes, including intracytoplasmic vacuoles with peculiar shapes, juxtanuclear condensation and perinuclear clearing. Identification of these changes using liquid-based cytology supplemented with immunochemistry may be helpful in reaching a correct cytopathologic diagnosis.

Cytopathologic characteristics of epithelioid vascular malignancies

OBJECTIVES

Epithelioid hemangioendothelioma (EHE) and epithelioid angiosarcoma (EAS) are rare vascular neoplasms that share many morphological characteristics on histology but demonstrate different clinical behavior. Given the many reported clinical and morphological features shared between EAS and EHE, we examined all cases of EAS and EHE diagnosed primarily on fine needle aspiration (FNA) at our three institutions that were confirmed by a tissue diagnosis.

STUDY DESIGN

A total of 29 cases from 25 patients were identified: 15 EHE from 11 patients and 14 EAS from 14 patients.

RESULTS

Many cytomorphological features existed on a spectrum that overlapped considerably between EAS and EHE cases. Common features between the two entities include epithelioid morphology and eccentrically placed nucleus. Intracytoplasmic lumens (ICL), a morphological feature that may suggest vascular origin, can be found in both entities but are not always present.

CONCLUSIONS

Given the general absence of vascular cytomorphological features, such as ICL, the proper classification of these tumors depends on the successful use of immunoperoxidase markers such as factor VIII-related antigen, ERG, or CD31 as well as a high index of suspicion. The distinction between EAS and EHE on FNA alone is treacherous at best.

Epithelioid angiosarcoma of the kidney: a diagnostic dilemma in fine-needle aspiration cytology

Epithelioid angiosarcomas (EAS) of kidney are rare and aggressive tumors with noncharacteristic imaging features that overlap with those of inflammatory conditions and renal cell carcinoma (RCC). We report the fine-needle aspiration (FNA) cytology findings of a case of EAS that involved the left kidney of an 83-year-old male. The smears and cell block sections showed pleomorphic epithelioid cells with ample cytoplasm, eccentric nuclei, occasional cytoplasmic hyaline globules, and rare intracytoplasmic lumina. Immunohistochemical stains performed on cellblock sections showed that the tumor cells were positive for vimentin, CD31, CD34, Factor VIII, and CD10, but showed no staining for cytokeratins AE1/AE3 and 8/18, HMB45, CD45, smooth muscle actin, and S100. The morphological and immunohistochemical distinction between EAS, primary tumors of the kidney, and other epithelioid and rhabdoid neoplasms is discussed.

Fine-needle aspiration of metastatic radiation-induced cutaneous epithelioid angiosarcoma of the breast to the liver: A diagnostic dilemma

Radiation therapy is a significant risk factor for the development of angiosarcoma. With the increase in breast conservation treatment, the incidence of cutaneous radiation-induced angiosarcoma of the breast is rising. If the angiosarcoma demonstrates epithelioid features, the tumor cells may present a diagnostic dilemma on fine-needle aspiration cytology. We present a case of metastatic radiation-induced cutaneous epithelioid angiosarcoma of the breast to the liver and a review of the literature.

Fine needle aspiration biopsy of epithelioid hemangioendothelioma of the oral cavity: Report of one case and review of literature

Epithelioid hemangioendothelioma (EHE) is an uncommon vascular tumor with biological behavior intermediate between hemangioma and angiosarcoma. It rarely occurs in the oral cavity. We report a case of an 81-yr-old woman with a 2-mo history of a 2 x 2 cm2 submucosal buccal mass. Fine needle aspiration (FNA) smears were paucicellular and showed mainly single atypical large epithelioid cells in a bloody background. The atypical cells had abundant dense cytoplasm, some with fine vacuoles. Occasionally, cells with large cytoplasmic lumina were seen. Cytology preparations from fresh tissue received for frozen section revealed numerous neoplastic cells with large intracytoplasmic lumina, some of which contained red blood cells. In addition, cells with distinct intranuclear inclusions were present. Histologic sections and immunohistochemical stains confirmed the diagnosis of EHE. Although the histologic features of EHE are well recognized, reports of FNA cytology findings are sparsely existent in the literature as several case reports. The characteristic cytological features of EHE are reviewed in this report. We believe that the diagnosis of this rare tumor can be suggested when an adequate FNA specimen is obtained.

Epithelioid hemangioma: Morphological presentation on aspiration smears

Epithelioid hemangioma (EH) or angiolymphoid hyperplasia with eosinophilia is an uncommon but distinctive lesion seen principally in the skin and subcutaneous tissue. The histopathology of this disease is very characteristic, but error in diagnosis is possible on cytopathology. There are very few case reports describing the cytomorphology of this lesion. We describe the findings of fine-needle aspiration of two cases of EH both arising in the subcutaneous tissue of the head and neck. Both the cases were misdiagnosed on cytology with one case being misinterpreted for an epithelioid sarcoma and the other for a reactive lymph node. The cytological findings of these cases are described and the problems encountered in the diagnosis of this entity are highlighted in this case report.

Angiosarcoma after breast-conserving therapy: Fine-needle aspiration biopsy, immunocytochemistry, and clinicopathologic correlates

BACKGROUND

Angiosarcoma that arises after breast-conserving therapy can present clinically as a cutaneous and/or subcutaneous breast lump, which is misinterpreted easily as a recurrence of carcinoma. To the authors' knowledge, the role of fine-needle aspiration (FNA) cytology in the early diagnosis of this life-threatening complication of breast carcinoma therapy has not been established fully.

METHODS

The authors studied three new patients with this type of secondary angiosarcoma diagnosed by FNA biopsy and immunocytochemistry, reviewed the literature on the topic, and examined relevant differential diagnostic issues.

RESULTS

Patients presented with a discrete skin lump that had arisen several years after breast-conservative therapy for early-stage breast carcinoma near the scar from the previous surgery. The lesions were interpreted clinically as recurrent carcinoma. FNA yielded moderately cellular to highly cellular samples with variable patterns of cellular aggregation. Cells were epithelioid and spindle-shaped. Angioformative changes were subtle, and the overall picture suggested an epithelial malignancy, possibly a metaplastic carcinoma. Immunostaining of smears, however, provided conclusive evidence of the endothelial differentiation of tumor cells, and an FNA diagnosis of angiosarcoma was rendered in all patients. The histopathology of all surgically excised tumors confirmed the diagnosis of high-grade angiosarcoma.

CONCLUSIONS

Based on the authors' experience, the FNA cytologic appearance of angiosarcoma that presented as a breast skin nodule in a breast carcinoma survivor easily could have been misinterpreted as carcinoma. A correct diagnosis of this tumor relies on the proper evaluation of clinical findings and, as also shown by a review of the literature, requires immunocytochemical evidence of endothelial differentiation.

Fine-needle aspiration cytology of epithelioid angiosarcoma: A diagnostic dilemma

A 28-year-old woman with a 2-yr history of unilateral chronic leg swelling, initially thought to be secondary to deep vein thrombosis, later thought to be due to congenital venous malformation, eventually developed a pelvic mass, which was biopsied by fine-needle aspiration. On the basis of cytologic features on smears, high-grade sarcoma was reported. The patient underwent surgery to resect the pelvic mass, which showed anastomosing vascular channels arising from external iliac vein in histology. However, the tumor cells unexpectedly showed strong and diffuse immunohistochemical expression of cytokeratin and epithelial membrane antigen. The case was sent for expert consultation, and the expert's opinion was epithelioid angiosarcoma. The expert's diagnosis was confirmed 2 yr later by local recurrence. The clinical presentation, cytology, histology, and immunohistochemistry of the current case and 15 other cases of epithelioid angiosarcoma found in the cytology literature are summarized. This case illustrates that morphology with clinicopathologic correlation tends to be a better guide than available special techniques.

Malignant Epithelioid Angiosarcoma of the External Iliac Vein Presenting as Venous Thrombosis

A case is reported of a 28-year-old female who initially presented with a right iliac deep venous thrombosis of unclear etiology. A stenosis in the iliac vein was seen, but no intrinsic or extrinsic mass was noted on multiple imaging studies. The patient presented 2 years later with right hydronephrosis, and at that time a right pelvic mass was discovered. Resection was performed with concomitant reconstruction of the right iliac arterial system, and pathology revealed a malignant epithelioid angiosarcoma.

Metastatic epithelioid angiosarcoma of the heart in peritoneal fluid

Angiosarcoma is the most common malignant neoplasm of the heart. Recurrent pericardial effusions are a common manifestation of cardiac angiosarcomas. The diagnosis of metastatic disease in effusions is often established histologically; few cases have been described in exfoliative cytology. We report a case of metastatic cardiac epithelioid angiosarcoma in peritoneal fluid.

Cytological features of epithelioid mesenchymal neoplasms: A study of 21 cases

Epithelioid mesenchymal neoplasms (EMNs) are rare tumors that share cytological, histological, and immunohistochemical features with epithelial tumors. It is important to distinguish EMNs from epithelial tumors in cytology specimens due to their different clinical management and prognosis. The cytomorphological features of histologically confirmed EMN were reviewed. Twenty-one cytological specimens of EMN were evaluated and characterized by polygonal cells with moderate to abundant dense cytoplasm, prominent nucleoli, and pleomorphism. Additional findings included the presence of a distinct population of spindle cells, hemosiderin-containing cells, multinucleated cells, and granuloma-like structures in selected cases. Cytokeratin immunoreactivity was seen in two cases and was negative in one case. This study shows that the cytological features of EMNs and epithelial tumors overlap; nonetheless, some features are more helpful in suggesting EMN. A panel of immunocytochemical studies must include specific mesenchymal markers to avoid a misdiagnosis of carcinoma in cases of cytokeratin-positive EMN.

Cytohistologic correlations in angiosarcoma including classic and epithelioid variants: Institut Curie's experience

To characterize the cytological features of angiosarcomas, we reviewed the fine-needle aspiration material and corresponding histologic sections of 29 tumors in 23 patients. Histologically, 24 tumors were of the classic type, and 5 were epithelioid angiosarcomas. The original corresponding cytologic diagnoses were as follows: angiosarcoma, 17 cases; sarcoma not otherwise specified, 8 cases; and rhabdomyosarcoma, 1 case. Three samples were cell-poor and were considered suspicious of malignancy. The review of cytology samples showed that smears were cell-rich in 17 tumors and cell-poor in 12 tumors. A hemorrhagic background was present in 9 cases. Tumor cells were polymorphous, including spindle-shaped, round to oval, and polygonal epithelioid cells and giant cells in different proportions. Erythrophagocytosis was seen in 12 tumors. Smears of classic angiosarcomas were polymorphous and lacking specific characteristics, whereas smears of epithelioid tumors were morphologically similar and composed of round to oval and polygonal, epithelial cells frequently arranged in clusters, and showing erythrophagocytosis. The wide spectrum of cellular components of angiosarcomas accounts for the difficulty in establishing accurate tumor typing, particularly with cell-poor samples and low-grade classic angiosarcoma. Entities to consider in the differential diagnosis are carcinoma, epithelioid sarcoma, pleomorphic rhabdomyosarcoma, and malignant melanoma.

Fine-needle aspiration cytology of "proximal-type" epithelioid sarcoma

The cytologic and immunocytologic findings in a case of recurrent "proximal-type" epithelioid sarcoma (ES) of the vulva are presented. This is a recently described neoplasm that differs clinically and morphologically from conventional ES. Cytologic smears showed a dissociated population of large, atypical neoplastic cells with bi- and multinucleated cells, abundant cytoplasm, and rhabdoid-like morphology. Due to its different clinical management it must be differentiated from metastatic carcinoma and melanoma. From a practical perspective, its differentiation from other epithelial-like sarcomas is less important. In conclusion the cytopathologic findings of "proximal-type" ES show a good correlation with histopathology, permitting the diagnosis of recurrences and metastases. When accompanied by adequate clinical information and ancillary studies, a specific preoperative recognition seems possible.