Primary pleural epithelioid hemangioendothelioma mimicking as a posterior mediastinal tumor

Primary malignant epithelioid hemangioendothelioma of the pleura: A review and report of a novel case

Epithelioid hemangioendothelioma is considered an uncommon tumor originating from vascular tissues. Although this disease is an extremely rare malignant cancer, its pleural subtype is even less common. We discuss a 68‐year‐old man with isolated pleural epithelioid hemangioendothelioma, along with a literature review of all similar cases.

Surgical Resection for Extensive Pleural Epithelioid Hemangioendothelioma

A 35-year-old male who presented with months of symptomatic nonproductive cough was found to have a large right-sided pleural effusion, diffuse pleural thickening, lymphadenopathy, and partial collapse of the right lung. He was diagnosed with a rare form of vascular tumor; pleural epithelioid hemangioendothelioma (PEHE). He underwent a successful right extrapleural pneumonectomy with diaphragm and pericardial resection and reconstruction. While often managed with first line chemotherapy or radiation therapy, our case shows that up front surgical resection is feasible for extensive PEHE at a high-volume regional center. Whether aggressive resection improves survival is yet to be determined.

Epithelioid hemangioendothelioma: evaluation by 18F-FDG PET/CT

PURPOSE

The purpose of this study was to evaluate the imaging characteristics of epithelioid hemangioendothelioma (EHE) on staging ¹⁸F-FDG PET/CT.

MATERIALS AND METHODS

An IRB-approved retrospective review was conducted for patients with biopsy-proven EHE who underwent FDG PET/CT at our institution between 2005 and 2019. Patients with a history of surgery, chemotherapy, or radiotherapy prior to PET/CT were excluded. PET/CT exams were analyzed, noting metabolic activity, distribution of involvement, and CT morphologic features. PET/CT findings were correlated with comparative CT and MRI performed within three months.

RESULTS

There were 35 patients [21 females, 14 males; average age 55.1±16.9 years (range 15-82 years)]. 18/35 patients (52%) had more than one organ affected on PET/CT. The most common sites were liver [21/35 (60%)], lung [(19/35 (54%)], bone [5/35 (14%)], lymph nodes [4/35 (11%)], and vasculature [4/35 (11%)]. Most patients [30/35, (86%)] presented with multiple lesions. The average largest lesion dimension was 4.0±3.6 cm (range 0.6-15.0 cm). The average SUVmax of the most metabolically active lesion at any site was 5.3±3.3 (range 1.2-17.1), and for bone was 7.9±5.4 (range 3.5-17.1), liver was 5.1±2.1 (range 2.6-10.5), and lung was 3.0±1.9 (range 1.2-8.5). Of patients with pulmonary lesions, 9/19 (47%) showed calcification, and 4/19 (21%) had nodules that were either non FDG-avid or too small for accurate SUV assessment. Of patients with hepatic lesions, 11/21 (52%) demonstrated capsular retraction, and 12/21 (57%) were found to have additional hepatic lesions on contrast-enhanced CT or MRI that were occult on PET/CT.

CONCLUSION

EHE demonstrates variable, but most commonly moderate FDG activity on PET/CT. The most common sites of disease are the liver, lungs, and bones, and most patients present with multiple lesions and more than one organ involved. Given the intrinsic metabolic activity and multi-organ involvement, FDG PET/CT represents an attractive modality for EHE evaluation. However, it may be best used in combination with CT or MRI given that EHE pulmonary or hepatic lesions may be missed by PET/CT.

Epithelioid hemangioendothelioma of the sternum

Epithelioid hemangioendothelioma (EHE) is a rare vascular tumor composed of dendritic and endothelial cells, and accounts for less than 1% of all vascular tumors. The tumor may arise from any location in the body, but it has a predilection for veins of the extremities, the liver, bone, and skin. Herein, we report a case of a 43‐year‐old man who presented with a chest mass accompanied by chest pain. Computed tomography (CT) scan of the chest showed a 3 cm × 2 cm sternal mass in the chest wall. We performed tumor resection and reconstruction of the chest wall. EHE was confirmed via postoperative pathology. The patient underwent postoperative adjuvant radiotherapy, and no evidence of tumor recurrence was discovered during the one‐year follow up.

Pemetrexed for epithelioid haemangioendothelioma of the pleura

A 31‐year‐old woman presented with a 2‐month history of dull left back pain. Chest roentgenography revealed pleural thickening in the left lung apex, whereas chest computed tomography showed a left pleural effusion with diffuse pleural thickening. Based on these findings, malignant mesothelioma was suspected. Video‐assisted thoracoscopic pleural biopsy was performed, and subsequent staining of the specimen revealed negative results for anti‐cytokeratin antibodies and positive results for vascular endothelial immunohistochemical markers. Therefore, a diagnosis of epithelioid hemangioendothelioma (EHE) was made, and chemotherapy with carboplatin, pemetrexed, and bevacizumab was initiated. After the fourth course of treatment, the disease was well controlled with a 90% reduction of the left pleural effusion. This case is very rare in that the EHE originated from the pleura. Additionally, there has been no report of pemetrexed for treatment of EHE.