Epithelioid angiosarcoma of the uterus: a review of management

Angiosarcoma of the Uterus: A Systematic Review

Primary uterine angiosarcoma is an extremely rare neoplasm. Due to its rarity, knowledge regarding this malignancy is limited to a few scattered case reports. To better understand the prognostic factors and optimal management of these neoplasms, we have performed a systematic analysis of the disease. A systematic literature search of this entity yielded 25 reported cases of this entity. In addition, we searched the National Cancer Institute Surveillance, Epidemiology, and End Results database to find 4 additional cases and added a case diagnosed in our institution. We analyzed the patients' demographic characteristics and the different treatment protocols utilized to treat this malignancy. Patients were primarily treated by surgery with or without adjuvant chemotherapy and radiotherapy. Survival analysis was performed to examine the role of various factors in the outcome for the patients. There was no correlation with age of diagnosis, or treatment modality used, however, better outcomes were seen in patients presenting with smaller sized tumors. Our study is the first attempt to systematically study this rare malignancy in hopes of leading to a more standardized, evidence-based, and improved treatment protocol.

Ovarian epithelioid angiosarcoma complicating pregnancy: a case report and review of the literature

Epithelioid angiosarcoma is a rare and highly aggressive soft tissue angiosarcoma most commonly arising in the deep soft tissues. Given that abundant vascular cavities anastomose with each other, most angiosarcomas prone to metastasis recur quickly, and the overall prognosis is poor. We report a 25-year-old woman at 24 weeks’ gestation who presented with a 1-month history of abdominal distension. Ultrasonography suggested a mass in the right adnexa, and she underwent two operations owing to uncontrolled intraperitoneal bleeding with progressive anemia. The right ovarian tumor and right adnexa were removed successively. Biopsy yielded a diagnosis of primary epithelioid angiosarcoma with mature cystic teratoma. The patient died from uncontrolled progressive bleeding 1 week after the second operation. This case revealed that epithelial angiosarcoma is a highly malignant endothelial cell tumor. The results of surgery and chemoradiotherapy tend to be poor, and the recurrence rate is high. The purpose of this study is to raise clinical awareness of epithelial angiosarcoma and its adverse events and to provide new ideas for the treatment of these adverse events. Immunohistochemical staining of pathological specimens can facilitate diagnosis. Pregnancy with malignant tumors may lead to rapid disease progression, extensive lesions, and a poor prognosis.

Primary uterine angiosarcoma: A case report in China with the literature review

Primary uterine angiosarcoma is a very rare malignant tumor in the female genital tract and only 23 cases have been previously reported in the literature. It is often clinically misrecognized as another disease due to its low incidence. In this report, we present a new case of a 78-year-old woman diagnosed on histopathologic observation and immunohistochemical staining. Additionally, available studies are collected and reviewed to summarize the clinical and pathological characteristics of primary uterine angiosarcoma to remind gynecologists and pathologists of this rare disease when they encounter such cases.

Primary Epithelioid Angiosarcoma of the Uterus: A Rare Tumor with Very Aggressive Behavior

Angiosarcoma is a high-grade vascular tumor arising from endothelial cells of blood vessels. It represents less than 1% of the mesenchymal tumors. Uterine angiosarcoma is an extremely rare tumor with less than 25 cases reported in the literature. It usually presents in postmenopausal women as uterine mass and rarely can arise in a leiomyoma. It is included in the group of tumors of aggressive behavior and poor prognosis. Herein, we present a case of primary uterine angiosarcoma in a 56-year-old female patient with a history of fibroids presenting with pelvic pain and weight loss. Abdominal CT scan showed a large uterine mass and enlarged pelvic lymph nodes. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed, and on histopathologic examination, it was found to be primary epithelioid angiosarcoma of the uterus. Immunohistochemical stains for CD31, keratin MAK-6, and keratin AE1/AE3 confirmed the diagnosis. In conclusion, uterine angiosarcoma should be suspected in any rapidly growing hemorrhagic uterine mass, and appropriate sampling and immunohistochemical stains should be considered.

Epithelioid Angiosarcoma Arising from a Huge Leiomyoma: A Case Report and a Literature Review

Uterine mesenchymal tumors other than leiomyosarcoma, carcinosarcoma, and endometrial stromal sarcomas are extremely uncommon. We describe a case of epithelioid angiosarcoma of the uterus and review previous literature on such rare tumors. A 48-year-old woman presented with a 1-year history of abdominal fullness and 10kg weight loss. Pelvic magnetic resonance imaging (MRI) revealed a huge (30×18cm) uterus accompanied by degeneration and necrosis. She underwent supracervical hysterectomy and right salpingo-oophorectomy. We postoperatively diagnosed the mass as an epithelioid angiosarcoma arising from a leiomyoma. Vasodilatation was observed within the range of 2 cm × several mm in the leiomyoma, and proliferation of atypical cells was observed covering the surface of the luminal side. The tumor showed a partly fine vascular structure and was associated with obvious nuclear atypia and mitotic figures. She received 6 courses of adjuvant chemotherapy with paclitaxel, epirubicin, and carboplatin, and there have been no signs of recurrence for 10 months.

Epithelioid angiosarcoma of bone and soft tissue: A report of seven cases with emphasis on morphologic diversity, immunohistochemical features and clinical outcome

Aims and background

Epithelioid angiosarcoma is a rare histopathologic variant of angiosarcoma characterized by an epithelioid morphology. This subset can histologically mimic non-vascular neoplasms and impose serious challenges in reaching a correct diagnosis, especially in the context of limited tissue sampling (e.g., needle core biopsy). To improve recognition of epithelioid angiosarcoma – and the spectrum of morphologic diversity associated with this rare variant – and to avoid a misdiagnosis, we describe the clinical, histopathologic, and immunohistochemical findings of cases of epithelioid angiosarcoma diagnosed at our institution.

Methods and study design

Seven cases of epithelioid angiosarcoma with appropriate pathologic material were identified from our archives. Immunohistochemistry was used to detect the expression of CD31, CD34, Factor VIII, cytokeratin, epithelial membrane antigen, vimentin, HMB45, CD1a, CD68, lysozyme, CD45, desmin, and smooth muscle actin in all cases. Follow-up information was obtained by reviewing medical records or by direct communication with family members.

Results

The lesions involved the bone (n = 4) and soft tissues (n = 3). Microscopically, all tumors had a predominantly diffuse growth pattern, with a focal nested architecture in 6 cases, which closely mimicked metastatic carcinoma. The initial biopsy was performed in 2 of 6 patients and revealed the presence of a malignant neoplasm suggestive of metastatic carcinoma. Immunohistochemically, the epithelioid endothelial cells usually showed strong reactivity for CD31 (7/7), variable or focal positive staining for CD34 (5/7), Factor VIII (4/7), cytokeratin (6/7), epithelial membrane antigen (2/7), vimentin (7/7), and CD68 (3/7). In contrast, they were negative for CD1a, HMB45, lysozyme, CD45, desmin, and smooth muscle actin. Three patients died of disease within one year of the diagnosis, 2 patients developed local recurrence or metastases, and another 2 were disease-free at this writing.

Conclusions

With any unusual epithelioid neoplasm displaying some or all of the morphologic features described above, epithelioid angiosarcoma should be included in the differential diagnosis. In such an instance, endothelial markers should be incorporated in the immunohistochemical analysis to avoid misdiagnosis, particularly with limited sampling.

Uterine Angiosarcoma: A Case Report and Literature Review

Uterine angiosarcoma is a rare, extremely malignant vascular tumor. Here, we report a case of giant uterine angiosarcoma in a 56-yr-old woman. The tumor was diagnosed as an epithelioid uterine angiosarcoma based on histopathologic findings. The tumor cells showed vascular differentiation; they were positive for the vascular endothelial markers CD31, CD34, and was negative for lymphatic endothelial marker D2-40. In addition, the tumor cells showed overexpression of cell-cycle regulatory protein cyclin D1 and were positive for epithelial-mesenchymal transition marker vimentin. Although it was reported previously that there was breakage in YWHAE, NUTM2A (FAM22A), and NUTM2B (FAM22B) in a case of uterine angiosarcoma, no breakage in these loci was detected by fluorescence in situ hybridization in the present case.

Successful Treatment of Cardiac Angiosarcoma Associated with Disseminated Intravascular Coagulation with Nab-Paclitaxel: A Case Report and Review of the Literature

Angiosarcoma of the heart is an uncommon soft tissue sarcoma. A few cases of disseminated intravascular coagulation (DIC) associated with angiosarcoma occurring in various organs, but not the heart, have been reported. Although taxane is commonly used in the treatment of metastatic angiosarcoma, data on the efficacy of nab-paclitaxel for angiosarcoma are limited. Here, we report probably the first case of a patient with primary cardiac angiosarcoma with coexisting DIC who was successfully treated with nab-paclitaxel. A 62-year-old female with chief complaints of nausea and shortness of breath was diagnosed as having cardiac angiosarcoma with liver metastases. Four months after the resection of her primary tumor, the hepatic metastatic lesions progressed rapidly accompanied by new metastatic lesions in the right iliac bone and signs of DIC. She received nab-paclitaxel as first-line chemotherapy. A response of stable disease was achieved after 2 treatment cycles and DIC was successfully controlled for at least 4 months. This report suggests potential utility of nab-paclitaxel for angiosarcoma complicated with DIC. We also review the literature for all cases of angiosarcoma with DIC reported so far.

Primary Epithelioid Angiosarcoma of Spleen: A Case Report and Review of Literature

Splenic angiosarcomas are usually secondary tumours, and only few primary cases have been encountered. We report a unique primary case of epithelioid angiosarcoma arising in the spleen in a male patient 55-year-old and presented to our hospital as a medical emergency with acute abdomen and haemorrhagic ascitis. CT revealed splenic focal lesion and suggested that this abdominal haemorrhage was due to ruptured splenic haemangioma, thus abdominal exploration and splenectomy were done. The histopathological examination showed an infiltrating ill-defined growth formed of high grade epithelioid cells arranged in sheet-like growth pattern, with occasional papillary appearance. The presence of rudimentary vascular channels lined by epithelioid endothelial cells with occasional intraluminal erythrocytes suggested vascular tumour origin. The neoplastic cells showed diffuse expression of CD31 together with focal expression of cytokeratin (CK) and CD34. Because of its epithelioid morphology and unmistakable positivity for CK, this case may be easily misdiagnosed as a metastatic carcinoma, which is not uncommon finding in the spleen. Epithelioid angiosarcoma is a rare type of vascular tumour in the spleen, which co-expresses vascular and epithelial markers making its distinction from metastatic carcinoma is sometimes difficult.

Curative effect of bevacizumab combined with chemotherapy in advanced or recurrent uterine sarcoma

The aim of this study was to investigate the clinical effect of bevacizumab (BEV) combined with chemotherapy in advanced or recurrent uterine sarcoma. The clinical data of 4 patients with advanced or recurrenct uterine sarcoma, who received treatment with BEV combined with chemotherapy in our hospital between May, 2006 and May, 2014, were retrospectively analyzed. We estimated the chemotherapy response rate [complete response (CR) + partial response (PR)], clinical benefit rate [CR + PR+ stable disease (SD)], progression-free survival (PFS) and overall survival (OS), and evaluated treatment safety and toxicity reactions. Of the 4 patients, 1 achieved CR, with a disease-free survival time of 96 months; 1 achieved PR, with a PFS of 13 months and an OS of 25 months; 1 achieved SD, with a PFS of 9 months and an OS of 24 months; and 1 developed progressive disease, with a PFS of 3 months and an OS of 9 months. The response rate (CR+PR) was 50%, and the clinical benefit rate (CR+PR+SD) was 75%. Treatment-related adverse reactions occurred in all 4 patients, including bone marrow suppression and gastrointestinal reactions. Of the 4 patients, 1 developed grade 4 bone marrow suppression (thrombocytopenia), whereas the remaining 3 patients developed grade 2 bone marrow suppression (leukopenia). Of the 4 cases, 2 developed grade 2 gastrointestinal reactions, and the remaining 2 patients grade 1 gastrointestinal reactions. Therefore, BEV combined with chemotherapy was able to effectively control advanced or recurrent uterine sarcoma, was well-tolerated, and is considered to be a safe and effective candidate treatment for this type of tumor.

Primary pleural angiosarcoma associated with pneumoconiosis: An autopsy case

We report a case of pleural angiosarcoma in an adult male patient confirmed by autopsy and possibly associated with pneumoconiosis. The lesion was characterized by thickened pleura of both lungs with nodular tumors. Histologically, the tumor was composed of spindle-to-polygonal epithelioid cells that were positive for CD31, CD34, vimentin, and cytokeratin on immunohistochemical staining but were negative for calretinin. Further examination revealed mix-dust pathological findings consistent with the existence of pneumoconiosis; dystrophic ossification, anthracosis, and fractal small dust particles were observed in the lung parenchyma and a hilar lymph node. The current case suggests that pneumoconiosis-associated pathologies may be risk factors for the development of angiosarcoma in the pleura.

Angiosarcomas of primary gynecologic origin: a clinicopathologic review and quantitative analysis of survival

OBJECTIVE

Angiosarcomas are aggressive, malignant soft tissue neoplasms of endothelial origin and occur rarely in the female genital tract. There is lack of consensus on risk factors for poor outcome and optimal treatment. To this end, we performed a clinicopathologic review and survival analysis.

METHODS

We report a case of a woman with an angiosarcoma of the vagina. Published English literature was reviewed for angiosarcomas of the vulva, vagina, uterus, and ovary. Survival was evaluated by using Kaplan-Meier analysis and the effect of clinical and demographic variables on survival by using Cox regression analysis.

RESULTS

A total of 51 patients were identified with a median age of 47 years (range, 17-87 years). Two of the patients had an angiosarcoma of the vulva; 2 had an angiosarcoma of the vagina; 18 had an angiosarcoma of the uterus, and 29 had an angiosarcoma of the ovary. Five-year overall survival was 27% (SE, 8%). Most patients presented with locoregional disease, having surgery as their primary intervention. Overall, adjuvant therapy significantly improved survival (hazards ratio, 0.17; 95% confidence interval, 0.05-0.59; adjusted for age and tumor size). Adjuvant treatment consisted of radiotherapy for angiosarcomas of the vulva, vagina, and uterus and chemotherapy for ovarian angiosarcomas. Subgroup analysis of the female genital tract site was hampered by the small number of cases.

CONCLUSIONS

This review supports the use of surgical and adjuvant radiotherapy for angiosarcomas of the vulva, vagina, and uterus. Cytoreductive surgery and adjuvant chemotherapy remain the primary treatment of angiosarcomas of the ovary.

Epithelioid angiosarcoma of the kidney: A case report and literature review

Epithelioid angiosarcoma (EAS) is a rare disease which presents a great diagnostic challenge. The present study reports a case of EAS in the kidney in a 75-year-old male who presented with gross hematuria. An abdominal computed tomography scan revealed space-occupying lesions of the right kidney and renal cell carcinoma was suspected. Histological examination of the resected specimens showed pleomorphic epithelioid cells with vesicular nuclei, prominent nucleoli and eosinophilic cytoplasm that lined irregular vascular spaces. Immunohistochemical staining revealed that the tumor cells were positive for AE1/AE3, cytokeratin (CK) 7, vimentin, cluster of differentiation (CD) 31 and E-cadherin, but showed no staining for CD10, CD34, factor VIII, CK20, carcinoembryonic antigen or desmin. Based on the histopathological and immunohistochemical findings, the patient was diagnosed with epithelioid angiosarcoma. Postoperative radiation therapy was administered and no recurrence was observed six months after surgery.

Low-Grade Uterine Epithelioid Hemangioendothelioma Presented as a Submucosal Leiomyoma during Labor

With the exception of leiomyomas, soft tissue tumors of the uterine corpus are not common. This is particularly true for vascular neoplasms, with the epithelioid hemangioendothelioma being a curiosity; not more than twenty-two cases of malignant hemangioendotheliomas have been reported in the literature so far, all of which were high-grade hemangioendotheliomas (hemangiosarcomas). We present herewith a unique case of low-grade epithelioid hemangioendothelioma of the uterus in a pregnant woman aged 29 years. The clinical, histological, and immunohistochemical characteristics of this entity, together with its differential diagnosis, are discussed.

Multicentric epithelioid angiosarcoma of bone

Bone epithelioid angiosarcoma is rare and generally shows positive immunostaining for epithelial markers. Multicentric bone epithelioid angiosarcoma is easily misdiagnosed as carcinoma, including metastatic carcinoma, multiple myeloma, and multiple lymphoma of bone. This article describes a case of multicentric bone epithelioid angiosarcoma. The patient was first misdiagnosed as having metastatic carcinoma. Examination showed osteolytic lesions in the bilateral heels and the lower left humerus. The diagnosis was confirmed postoperatively and corrected after immunohistochemical analysis of the biopsy. The immunohistochemical analysis revealed that the tumor mass was strongly positive for CD31, factor VIII, vimentin, and neuron-specific enolase. The patient refused chemotherapy and died of lung metastasis 4 months postoperatively.Most bone epithelioid angiosarcomas are immunopositive for epithelial markers (ie, keratin, cytokeratin, high-molecular-weight keratin, and epithelial membrane antigen), vascular endothelial markers (ie, CD31, CD34, and von Willebrand factor), and factor VIII-associated antigen. Bone epithelioid angiosarcoma shows a relatively high degree of malignancy. Patients often die of distant metastasis, including those found in the lung and lymph node tissue. A wide excision of epithelioid angiosarcoma should be performed during the operation of the primary tumor. A better understanding of the clinicopathologic features of this disease may help to clarify the confusion, provide better treatment, and improve the clinical prognosis.

High grade angiosarcoma arising in fibroadenoma

Primary angiosarcoma of the breast is a rare tumour that account for fewer than 0.05% of all malignant mammary tumours. Angiosarcoma may have an perfidious clinical onset. Radiologic findings are often nonspecific and may appear completely normal in one-third of cases with primary angiosarcoma. The prognosis is usually poor because of the high rates of local recurrence and early development of metastases. Aggressive surgical resection is the mainstay of treatment. The role of adjuvant therapy has not yet been well established.

Here we present a case of a 53 year old, postmenopausal women with primary angiosarcoma arising in fibroadenoma. To our knowledge, this is the first case described in the literature to date.

Primary epithelioid angiosarcoma of the breast masquerading as carcinoma

Here we report a case of primary epithelioid angiosarcoma (eas) of the breast occurring in a 30-year-old woman. Following fine-needle asspiration cytology (fnac) and tru-cut biopsy, the patient was initially diagnosed with mammary carcinoma and thereafter underwent modified radical mastectomy. Postoperative histopathologic examination and immunohistochemistry revealed a diagnosis of primary epithelioid angiosarcoma of the breast. The patient received postoperative radiotherapy to the chest wall and was started on adjuvant thalidomide. Preoperatively, eas can be mistaken for carcinoma because it is difficult to appreciate the typical morphology on fnac or tru-cut biopsy. Indeed, this is an area of potential diagnostic error because, nowadays, neoadjuvant therapy is often instituted after core biopsy of a breast mass. This case is being reported not only for its diagnostic difficulty, but also because of its rarity in English literature.

Heterologous and rare homologous sarcomas of the uterine corpus: a clinicopathologic review

Pure sarcomas of the uterine corpus are uncommon, constituting less than 3% of all malignancies at this site, and most of them are leiomyosarcomas and endometrial stromal sarcomas. Rare histotypes of homologous sarcomas and heterologous sarcomas are occasionally encountered, and the absence of significant accumulated experience with these histotypes at this location may potentially raise diagnostic and patient management difficulties. In this article, the clinicopathologic attributes of all earlier reported sarcomas of the uterine corpus other than leiomyosarcomas and endometrial stromal sarcomas are summarized. Included are embryonal rhabdomyosarcoma, pleomorphic rhabdomyosarcoma, angiosarcoma, alveolar soft part sarcoma, malignant perivascular epithelioid cell tumors (PEComas), osteosarcoma, chondrosarcoma, liposarcomatous tumors, malignant extrarenal rhabdoid tumors, Ewing sarcoma/primitive neuroectodermal tumor, and other rare histotypes. Embryonal rhabdomyosarcoma (20%), Ewing sarcoma/primitive neuroectodermal tumor (17%), angiosarcoma (14%), and pleomorphic rhabdomyosarcoma (13%) appeared to be more common than the others, although there was no single overwhelmingly prevalent histotype in the group. A subset, including embryonal rhabdomyosarcoma, alveolar soft part sarcoma, and PEComas, peak in the premenopausal years, but most of the others were observed in postmenopausal women. Favorable outcomes have been reported for the patients diagnosed with alveolar soft part sarcoma, and the prognosis for their counterparts with PEComa remains a matter of debate. Multimodal therapeutic approaches to contemporary patients with embryonal rhabdomyosarcomas have resulted in significantly improved outcomes. Unfortunately, most of the other sarcomas have been associated with rapid tumor progression and unfavorable patient outcomes. The differential diagnosis for these sarcomas is often extensive and varies by histotype, but their accurate diagnosis fundamentally requires the careful exclusion of biphasic malignancies.

A rare cardiac neoplasm: case report of cardiac epithelioid angiosarcoma

Primary cardiac angiosarcoma is a rare neoplasm and the epithelioid variant is exceedingly rare. We report a case of an epithelioid angiosarcoma that involved the right atrium and aorta of a 47-year-old male. The patient presented with atrial fibrillation and presyncopal spells. Following clinical evaluation, including computed tomography scan and trans-esophageal echocardiography, the neoplasm was surgically removed. It was a poorly differentiated malignant neoplasm composed of medium-sized epithelioid cells with a moderate amount of amphophilic cytoplasm. Immunohistochemical staining, including positive staining for CK22, AE1/AE3, melan-A, vimentin, and CD31, indicated the neoplasm was best categorized as an epithelioid angiosarcoma.

Management of adult soft-tissue sarcoma of the extremities and trunk

Soft-tissue sarcomas are a heterogeneous group of tumors consisting of approximately 100 distinct diagnoses. Management requires a multimodality approach with the input of pathologists, surgeons, radiation oncologists, medical oncologists and radiologists. In localized disease, the primary modality of treatment is wide-resection surgery, and the use of radiation therapy has improved local control rates for high-grade tumors. Currently, most localized tumors can be managed with limb-sparing treatment, and local control rates of 80-90% can be seen with appropriate management. Improvements in classification and diagnosis of these tumors have led to the current idea that the specific histology is an important consideration when developing a treatment plan and may affect prognosis, although existing staging systems have not yet incorporated this parameter. Treatment of metastatic disease continues to be difficult, but current research focuses on clarifying molecular mechanisms of disease and identifying new potential targets for medical therapy. This review focuses on the current status of management of these tumors including a review of epidemiology, initial evaluation, and treatment including surgical, radiation, and medical aspects.

Miscellaneous Pseudotumors and Mesenchymal Tumors of the Female Genital Tract

Benign and malignant soft tissue tumors and pseudotumors can rarely arise anywhere in the female genital tract. Their pathologic features as well as behavior typically overlap with those described in tumors involving typical locations. However, due to their rarity, not infrequently these tumors represent a diagnostic challenge. Their diagnosis should be based on careful gross examination, thorough sampling, and morphologic evaluation, applying a selected immunohistochemical panel and molecular studies. Accurate classification of these tumors is important because their clinical behavior, prognosis, and therapy differ markedly. This article outlines several mesenchymal lesions reported in the female genital tract, encompassing recent histologic, immunohistochemical, and molecular findings, with special emphasis on problems in the differential diagnosis.