Cytology of epithelioid hemangioendothelioma

Epithelioid hemangioendothelioma: a study of 14 cytopathology cases

INTRODUCTION

The cytopathologic diagnosis of the rare vascular tumor epithelioid hemangioendothelioma (EHE) in patients who have no previous history of EHE or who have a complicated and/or misleading disease history is challenging. Furthermore, few studies have described the cytopathology of EHE. Herein, we identify 14 cases of EHE from 10 patients, some of whom had a history of epithelial tumor, and provide a detailed report of the cytomorphology of EHE, discuss the tumor's differential diagnoses, and describe ancillary examinations that may be helpful in diagnosing EHE cytologically, especially in patients with a complex disease history.

MATERIALS AND METHODS

We retrieved the slides of 14 cases of EHE archived between 2002 and 2009 in our institution's cytology section. Conventional direct smears and cell block sections were prepared from most fine-needle aspiration samples and from all effusion samples. Cell block sections were subjected to immunostaining for vascular, mesothelial, and epithelial markers.

RESULTS

EHE shared many morphologic features with other, more common tumors such as adenocarcinoma and mesothelioma. The defining cytologic feature of EHE was an intracellular lumen containing entrapped intact and degenerating erythrocytes, which was not present in every case. EHE cells were positive for the vascular markers CD34, CD31, factor VIII, and friend leukemia integration 1 transcription factor (FLI-1) and negative for epithelial and mesothelial markers. Clinicians provided information important to the diagnosis of EHE.

CONCLUSIONS

Carefully examining the smear and cell block sections for morphologic features indicative of EHE (eg, prominent cytoplasmic vacuolization, intranuclear cytoplasmic inclusions, and intracellular lumen containing entrapped intact and degenerating erythrocytes), confirming these findings with immunocytochemical staining, and communicating with clinicians are all important to correctly diagnosing EHE.

Pitfalls in the diagnosis of hepatic epithelioid hemangioendothelioma by FNA and needle core biopsy

Epithelioid hemangioendothelioma (EHE) of the liver is an extremely rare tumor that masquerades as an epithelial neoplasm and poses significant diagnostic pitfalls for the cytopathologist. This report describes a 64-year-old woman whom on computerized tomography was found to have multiple peripherally calcified hypodense lesions throughout the liver and an ipsilateral adrenal mass. Fine needle aspiration and needle cores biopsies of the largest liver lesion showed epithelioid cells and spindle cells in fibrous stroma. The epithelioid cells had round or oval, hyperchromatic nuclei with smooth nuclear contours, delicate cytoplasm and indistinct cytoplasmic borders. Rare cells had intracellular vascular lumen containing fragmented or intact red blood cells. The cells were individually dispersed or arranged in nests and vague tubular arrays. No mitotic figures or necrosis were seen. An immunohistochemical profile demonstrated diffuse CD31 and focal CD 34 and nuclear Fli-1 immunoexpression and low Ki-67 proliferative activity (1%) within lesional cells confirming the diagnosis of EHE. The differential diagnosis of EHE which includes cholangiocarcinoma, hepatocellular carcinoma, metastatic carcinoma and melanoma is discussed.

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 hemangioendothelioma of the radial artery

Epithelioid hemangioendothelioma (EHE) is an extremely rare vascular tumor of intermediate malignancy. Generally it develops from the peripheral veins (usually the femoral vein). We report on a case of EHE of the radial artery, developed in a 26-year-old male patient, which presented as a solitary painless mass. He had a complete resection of the tumor and of the segment of radial artery involved. The histologic examination revealed an intravascular EHE, with low mitotic index and with insufficient histologic anormalities.

Malignant epithelioid hemangioendothelioma presenting as an aneurysm of the superficial palmar arch: a case report

A patient with a malignant epithelioid hemangioendothelioma that presented as an aneurysm of the superficial palmar arch and third common digital artery had complete excision of the aneurysm and vascular reanastomosis. After pathologic diagnosis and surgical staging she received local irradiation to the hand. This case suggests that an aneurysm in the hand may develop in the setting of an underlying malignancy of blood vessel. When aneurysms in the hand require surgical intervention, we recommend that resection be complete, pathologic examination undertaken, and marginal tissue well-labeled to allow precise pathologic examination.

Epithelioid hemangioendothelioma of the common femoral vein: Case report and review of the literature

A young competitive skier had venous claudication. A stenosis of the left common femoral vein was revealed by means of an examination. Exploration and vein patch angioplasty were performed, and because of both the unusual appearance (focal thickening of vein wall) and the unclear etiology of the lesion, frozen and permanent sections of the wall were obtained. Epithelioid hemangioendothelioma, a rare intravascular sarcoma, was revealed by means of an examination of the permanent sections. Two additional procedures were required to completely excise the epithelioid hemangioendothelioma. We discuss these rare vascular malignancies and include a review of the available literature. Also, oncologic principles important in both the diagnosis and therapy of intravascular sarcomas are discussed.