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Weissferdt A, Moran CA. Primary epithelioid hemangioendotheliomas and angiosarcomas of the pleura: a clinicopathological and immunohistochemical analysis of 13 cases. Hum Pathol 2023; 138:68-75. [PMID: 37364825 DOI: 10.1016/j.humpath.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 06/13/2023] [Accepted: 06/21/2023] [Indexed: 06/28/2023]
Abstract
Thirteen cases of primary epithelioid hemangioendotheliomas (EHE) and epithelioid angiosarcomas (EA) of the pleura are presented. The patients were 7 men and 6 women between the ages of 34 and 65 years (mean: 47 years). The patients presented with non-specific symptoms of cough, dyspnea, and chest pain. Diagnostic imaging revealed the presence of either diffuse pleural thickening or pleural nodules involving the serosal surfaces. Open surgical biopsies were obtained in all cases. Histologically, eight tumors were characterized by the presence of a cellular proliferation composed of medium-sized epithelioid cells embedded in a myxohyaline stroma and a variable spindle cell component. Cellular atypia was mild to moderate and mitotic activity ranged from 1 to 2 per 2 mm2. Immunohistochemical stains for vascular markers, including CAMTA1 were positive, confirming a diagnosis of EHE. Five cases of epithelioid angiosarcomas were characterized by a neoplastic cellular proliferation admixed with areas of necrosis and hemorrhage and characterized by medium-sized epithelioid to spindle-shaped cells with eosinophilic cytoplasm, round to oval nuclei and prominent nucleoli. In addition, marked cytologic atypia and a mitotic activity ranging from 3 to 5 per 2 mm2 were identified. Immunohistochemical studies demonstrated positive staining for vascular markers; however, CAMTA1 was negative. Clinical follow-up obtained in eleven cases showed that all patients had died within 30 months post diagnosis. The current study highlights that even though it may be important to histologically separate EHE from EA for academic purposes, primary pleural origin of these tumors appears to portent an aggressive clinical behavior.
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Affiliation(s)
- Annikka Weissferdt
- Department of Pathology, University of Texas, MD Anderson Cancer Center, Houston, TX 77030, USA.
| | - Cesar A Moran
- Department of Pathology, University of Texas, MD Anderson Cancer Center, Houston, TX 77030, USA
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2
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Szczyrek M, Bitkowska P, Jutrzenka M, Szudy-Szczyrek A, Drelich-Zbroja A, Milanowski J. Pleural Neoplasms-What Could MRI Change? Cancers (Basel) 2023; 15:3261. [PMID: 37370871 DOI: 10.3390/cancers15123261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/16/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
The primary pleural neoplasms constitute around 10% of the pleural tumors. The currently recommended method for their imaging is CT which has been shown to have certain limitations. Strong development of the MRI within the last two decades has provided us with a number of sequences that could potentially be superior to CT when it comes to the pleural malignancies' detection and characterization. This literature review discusses the possible applications of the MRI as a diagnostic tool in patients with pleural neoplasms. Although selected MRI techniques have been shown to have a number of advantages over CT, further research is required in order to confirm the obtained results, broaden our knowledge on the topic, and pinpoint the sequences most optimal for pleural imaging, as well as the best methods for reading and analysis of the obtained data.
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Affiliation(s)
- Michał Szczyrek
- Department of Pneumology, Oncology and Allergology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Paulina Bitkowska
- Department of Pneumology, Oncology and Allergology, Medical University of Lublin, 20-090 Lublin, Poland
| | - Marta Jutrzenka
- Collegium Medicum, University of Warmia and Mazury in Olsztyn, Aleja Warszawska 30, 11-041 Olsztyn, Poland
| | - Aneta Szudy-Szczyrek
- Department of Haematooncology and Bone Marrow Transplantation, Medical University of Lublin, 20-090 Lublin, Poland
| | - Anna Drelich-Zbroja
- Department of Radiology and Neuroradiology, Medical University of Lublin, 20-954 Lublin, Poland
| | - Janusz Milanowski
- Department of Pneumology, Oncology and Allergology, Medical University of Lublin, 20-090 Lublin, Poland
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3
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Rezvani A, Shahriarirad R, Erfani A, Ranjbar K. Primary malignant epithelioid hemangioendothelioma of the pleura: A review and report of a novel case. Clin Case Rep 2022; 10:e6211. [PMID: 35979384 PMCID: PMC9366930 DOI: 10.1002/ccr3.6211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 06/27/2022] [Accepted: 07/23/2022] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Alireza Rezvani
- Bone Marrow Transplantation Center, Nemazi Hospital Shiraz University of Medical Sciences Shiraz Iran
- Thoracic and Vascular Surgery Research Center Shiraz University of Medical Science Shiraz Iran
| | - Reza Shahriarirad
- Thoracic and Vascular Surgery Research Center Shiraz University of Medical Science Shiraz Iran
- Student Research Committee Shiraz University of Medical Sciences Shiraz Iran
| | - Amirhossein Erfani
- Thoracic and Vascular Surgery Research Center Shiraz University of Medical Science Shiraz Iran
- Student Research Committee Shiraz University of Medical Sciences Shiraz Iran
| | - Keivan Ranjbar
- Thoracic and Vascular Surgery Research Center Shiraz University of Medical Science Shiraz Iran
- Student Research Committee Shiraz University of Medical Sciences Shiraz Iran
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4
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Tossan P, Pichon E, Arbion F, Sizaret D, Simionca G, Marchand-Adam S. Hémangioendothéliome épithélioïde pleural, une tumeur rare de diagnostic difficile : à propos d’un cas et revue de la littérature. Rev Mal Respir 2022; 39:398-406. [DOI: 10.1016/j.rmr.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 02/24/2022] [Indexed: 11/26/2022]
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5
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Askari E, Yaghmaei S, Haseli S, Pouradollah Totkaboni M. Primary Pleural Hemangioendothelioma: A Case Report and Literature Review. Case Rep Oncol 2021; 14:1201-1211. [PMID: 34703437 PMCID: PMC8460936 DOI: 10.1159/000518243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 06/26/2021] [Indexed: 12/02/2022] Open
Abstract
Epithelioid hemangioendothelioma (EHE) is a rare tumor of the vascular endothelial cells. It can originate from any tissue; however, it occurs most frequently in the liver and lung. Pleural epithelioid hemangioendothelioma (PEH), EHE developing from pleura, is even more infrequent and less reported in the literature. In the following report, we discuss a 40-year-old man who initially presented with right-sided chest pain. Computed tomography revealed pleural thickening and effusion in his right thoracic cavity. PEH diagnosis was confirmed with immunohistochemistry. In order to provide the readers with an inclusive understanding of the disease, we collected the PEH cases reported in the literature. Despite the scarcity of the reported PEH cases (to our best knowledge), the compiled literature review of the disease enables the readers to grasp a better comprehension of the disease.
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Affiliation(s)
- Elham Askari
- Department of Pathology, Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shekoofeh Yaghmaei
- Department of General Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sara Haseli
- Department of Radiology, Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mihan Pouradollah Totkaboni
- Department of Pathology, Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran
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6
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Witte S, Weidema M, Kaal S, Versleijen-Jonkers Y, Flucke U, van der Graaf W, Desar I. The heterogeneity of Epithelioid Hemangioendothelioma (EHE): A case series and review of the literature with emphasis on treatment options. Semin Oncol 2021; 48:111-118. [PMID: 34176654 DOI: 10.1053/j.seminoncol.2021.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 04/07/2021] [Accepted: 04/14/2021] [Indexed: 12/28/2022]
Abstract
Epithelioid hemangioendothelioma (EHE) is an extremely rare vascular sarcoma with a very heterogeneous presentation and prognosis. We here present five cases of EHE emphasizing diversity in presentation, treatment, and prognosis. Furthermore, we present a review of the literature on EHE treatment options.
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Affiliation(s)
- Stijn Witte
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Marije Weidema
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Suzanne Kaal
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | | | - Uta Flucke
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Winette van der Graaf
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ingrid Desar
- Department of Medical Oncology, Radboud University Medical Centre, Nijmegen, The Netherlands.
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7
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Song W, Zhen Z, Li L, Ye J, Zhou S, Wu Q, Xu L, Li H, Lin F. Epithelioid hemangioendothelioma of the sternum. Thorac Cancer 2020; 11:1741-1745. [PMID: 32347015 PMCID: PMC7262933 DOI: 10.1111/1759-7714.13454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 04/05/2020] [Accepted: 04/07/2020] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Wenpeng Song
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China.,West China School of Medicine, Sichuan University, Chengdu, China
| | - Zeng Zhen
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Lin Li
- Pathology Department, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Ye
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Sicheng Zhou
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Qiyou Wu
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Liu Xu
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Huilin Li
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Feng Lin
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
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8
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Fan Y, Wang F, Li S, Ye C, Ying Y, Mao H. Pleural Epithelioid Hemangioendothelioma: A Case Report and Literature Review. J Natl Med Assoc 2018; 108:124-9. [PMID: 27372473 DOI: 10.1016/j.jnma.2016.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 05/05/2016] [Accepted: 05/05/2016] [Indexed: 02/05/2023]
Abstract
Epithelioid hemangioendothelioma (EHE) is a rare neoplasm of vascular origin that can arise in multiple and varied tissue sites. Pleural epithelioid hemangioendothelioma (PEH), a subtype of EHE, is particularly less reported. Herein, we describe a case of PEH presented with left-sided back pain in a 68-year-old female, and her chest CT scan revealed thickening of the left pleura and left pleural effusion, the histological diagnosis was confirmed by both conventional examination and immunohistochemistry. A literature search utilizing PubMed, Embase, Ovid and Cochrane, Wanfang and Chinese National Knowledge infrastructure (CNKI) for PEH was conducted to investigate the characteristics of the disease, 26 related articles were retrieved and 40 cases of PEH were reported. According to available literature, the average age at presentation is 51.8 years and the disease occurred more often in men than women. The etiology of the disease remained unknown. Chest pain, cough, and dyspnea were the common symptoms. Computed tomography usually revealed pleural effusion and pleural thickening. Histological examinations revealed mainly epithelioid cells. Immunohistochemical stains were positive for vascular endothelial markers. PEH tends to have more aggressive behavior than tumors in other locations, thus effective treatment has not yet been established until now. Further studies are needed to analyze the prognostic factors, clinical features and treatment of PEH.
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Affiliation(s)
- Yingqi Fan
- Department of Respiratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Faping Wang
- Department of Respiratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Suyun Li
- Department of Respiratory Medicine, First Affiliated Hospital of Henan College of Traditional Chinese Medicine, Zhengzhou 450000, China
| | - Cheng Ye
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Ying Ying
- Department of Pathology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Hui Mao
- Department of Respiratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, China.
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9
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Ferreiro L, San-José E, Suárez-Antelo J, Abdulkader I, Martínez-de-Alegría A, González-Barcala FJ, Valdés L. Spontaneous bilateral haemothorax as presentation of primary pleural epithelioid haemangioendothelioma. CLINICAL RESPIRATORY JOURNAL 2015; 11:1079-1085. [PMID: 26620871 DOI: 10.1111/crj.12421] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 10/05/2015] [Accepted: 11/13/2015] [Indexed: 12/26/2022]
Abstract
Pleural epithelioid haemangioendothelioma (EHE) is a rare tumour that originates in the vascular endothelium with an intermediate degree of malignancy between haemangioma and angiosarcoma. Smoking and asbestos exposure are unproven risk factors and diagnosis is usually confirmed by thoracoscopy, since pleural fluid (PF) cytology is often not conclusive. Immunohistochemistry can also help to confirm the diagnosis. We report an 85-year-old patient with bilateral pleural EHE diagnosed by thoracoscopy, who debuted with a spontaneous bilateral haemothorax, the second described so far, and we conducted a thorough review of the literature to describe the clinical, radiological and prognostic features, as well as the PF, of this rare tumour.
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Affiliation(s)
- Lucía Ferreiro
- Department of Pulmonology, University of Santiago Hospital Complex, Santiago de Compostela, Spain
| | - Esther San-José
- Department of Clinical Analysis, University of Santiago Hospital Complex, Santiago de Compostela, Spain.,Interdisciplinary Pulmonology Research Group, Health Research Institute of Santiago (IDIS), University of Santiago Hospital Complex, Santiago de Compostela, Spain
| | - Juan Suárez-Antelo
- Department of Pulmonology, University of Santiago Hospital Complex, Santiago de Compostela, Spain
| | - Ihab Abdulkader
- Department of Pathology, University of Santiago Hospital Complex, Santiago de Compostela, Spain
| | | | - Francisco-Javier González-Barcala
- Department of Pulmonology, University of Santiago Hospital Complex, Santiago de Compostela, Spain.,Interdisciplinary Pulmonology Research Group, Health Research Institute of Santiago (IDIS), University of Santiago Hospital Complex, Santiago de Compostela, Spain
| | - Luis Valdés
- Department of Pulmonology, University of Santiago Hospital Complex, Santiago de Compostela, Spain.,Interdisciplinary Pulmonology Research Group, Health Research Institute of Santiago (IDIS), University of Santiago Hospital Complex, Santiago de Compostela, Spain
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10
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Salijevska J, Watson R, Clifford A, Ritchie AI, Mauri F, Adeboyeku D. Pleural epithelioid hemangioendothelioma: literature summary and novel case report. J Clin Med Res 2015; 7:566-70. [PMID: 26015825 PMCID: PMC4432902 DOI: 10.14740/jocmr2174w] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2015] [Indexed: 12/16/2022] Open
Abstract
Epithelioid hemangioendothelioma (EHE) is a rare malignant cancer of vascular origin that can affect multiple and varied tissue sites. A subtype of EHE, pulmonary epithelioid hemangioendothelioma (PHE), is more unusual with only 200 reported cases. Of these, only 27 have been classified as pleural in origin. Based on available literature, the average age of presentation of pleural PHE is 45.7 years with a male preponderance of 2.375. A summary of all published case reports reveals significant heterogeneity both in presentation and management. Here we add to this knowledge-base with a report of an unusual case of pleural PHE in a 36-year-old female who presented with a 6-week history of chest pain and breathlessness. Significant challenges in the diagnosis and management of patients with pleural PHE exist, including a wide initial differential diagnosis and difficulties in obtaining tissue specimens, coupled with relatively limited treatment options. Early referral to a cardiothoracic center for video-assisted thoracoscopic biopsy is crucial in facilitating a diagnosis and allowing adequate pleural drainage for symptomatic relief.
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Affiliation(s)
- Julita Salijevska
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
- Corresponding Author: Julita Salijevska, Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK.
| | - Robert Watson
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
| | - Amy Clifford
- The North West London Hospitals NHS Trust, Northwick Park Hospital, Watford Road, Harrow, Middlesex, HA1 3UJ, UK
| | - Andrew I. Ritchie
- The North West London Hospitals NHS Trust, Northwick Park Hospital, Watford Road, Harrow, Middlesex, HA1 3UJ, UK
| | - Francisco Mauri
- Imperial College Healthcare NHS Trust, The Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - David Adeboyeku
- The North West London Hospitals NHS Trust, Northwick Park Hospital, Watford Road, Harrow, Middlesex, HA1 3UJ, UK
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Malignant pleuropulmonary epithelioid hemangioendothelioma – Unusual presentation of an aggressive angiogenic neoplasm. Pathol Res Pract 2014; 210:613-8. [DOI: 10.1016/j.prp.2014.04.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 03/11/2014] [Accepted: 04/15/2014] [Indexed: 11/20/2022]
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12
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The computed tomographic findings of pulmonary epithelioid hemangioendothelioma. Radiol Med 2014; 119:705-13. [PMID: 24715271 DOI: 10.1007/s11547-013-0376-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 07/30/2013] [Indexed: 02/07/2023]
Abstract
PURPOSE The aim of this study is to analyse the computed tomographic (CT) findings of pulmonary epithelioid haemangioendothelioma (EHE). MATERIALS AND METHODS The CT features and clinical presentations of six patients (five women, one man; mean age, 53 years) with pathology-proven pulmonary EHE were reviewed. Noncontrast CT images were available for three patients and enhanced CT images for three patients. The image characteristics included the number of tumours, tumour location and size, tumour margins, the presence of calcification/necrosis/cavity, the presence of perivascular location, the presence of pleural lesions, tumour homogeneity at contrast-enhanced CT, tumour enhancement relative to the adjacent muscle and the presence of extrapulmonary lesions. RESULTS Multiple nodules/masses with irregular margin were shown in all cases, and reticulonodular opacities and ground-glass opacities were found in one case. Overall, the six cases showed 178 nodules/masses, 90 % (160/178) of which were <1 cm in diameter. The average size of the largest nodules/masses in each case was 2.7 cm. The nodules/masses were mostly (93 %, 166/178) located in the subpleural region (<2 cm from the pleura). A total of 48 % (86/178) of nodules/masses showed punctate calcification in four of six cases. All nodules/masses showed perivascular location. Pleural indentation was shown in all cases, as well as pleural-thickening in five cases and pleural effusion in two cases. On contrast-enhanced CT, EHE showed a mildly heterogeneous hyperdense appearance. CONCLUSIONS With predilection for subpleural and perivascular location, typical pulmonary EHE appears as multiple irregular nodules with punctate calcification and pleural indentation.
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Pleural epithelioid hemangioendothelioma harboring CAMTA1 rearrangement. Lung Cancer 2014; 83:411-5. [PMID: 24461304 DOI: 10.1016/j.lungcan.2013.12.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 12/30/2013] [Indexed: 12/25/2022]
Abstract
Pleural epithelioid hemangioendothelioma (EHE) is a very rare disease with adverse clinical outcomes. Recently, CAMTA1 rearrangement has been introduced as a consistent genetic abnormality in EHEs of different anatomical locations. We report a 71-year-old man with pleural EHE harboring CAMTA1 rearrangement confirmed by fluorescence in situ hybridization on paraffin embedded tissue.
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