Hepatic epithelioid hemangioendothelioma

Primary hepatic epithelioid hemangioendothelioma masquerading as metastases: A rare case report

Epithelioid hemangioendothelioma (EHE) of the liver is an extremely rare malignant tumor of vascular origin, representing less than 1 % of all vascular tumors. Nearly 260 cases have been reported in English literature. Radiologically it is seen as multifocal lesions. It can be seen at different sites like lungs, bones, lymph nodes, breasts, and soft tissue. Often it is misdiagnosed with metastases, cholangiocarcinoma, or angiosarcoma. No definite treatment protocol is available due to its rarity, however, these malignancies are treated by radical resection of the tumor or liver transplant and/or chemotherapy. Here we present a primary hepatic epithelioid hemangioendothelioma (HEHE) which was mimicking metastases in a 42-year-old male who was treated with chemotherapy and radiotherapy. Sadly the patient expired after 1 year of complete course of treatment. Imaging features can help to improve the diagnostic accuracy of this tumor.

Epithelioid Hemangioendothelioma: Incidence, Mortality, Prognostic Factors, and Survival Analysis Using the Surveillance, Epidemiology, and End Results Database

Background

Although epithelioid hemangioendothelioma (EHE) is a rare and aggressive vascular tumor, its demographic characteristics remain unclear. We used the surveillance, epidemiology, and end results (SEER) database to determine the clinical features, incidence, and prognostic factors associated with overall survival in patients with EHE.

Methods

The demographic and clinical data of patients with EHE were extracted from the SEER database (1975-2019) to calculate the incidence of EHE and survival rate in these patients. The Cox proportional hazards model and Kaplan-Meier method were used to analyze the prognostic factors of overall survival in these patients. A nomogram and time-dependent receiver operating characteristic (ROC) curve were employed to predict the 3- and 5-year survival rate.

Results

The overall incidence rate (IR) of EHE was 0.230 (95%confidence interval [CI] = 0.201–0.263) per 1,000,000 person-years. According to the age-stratified IR, the highest age-adjusted IR was observed in patients aged 60–79 years (0.524 per 1,000,000 person-years, 95%CI = 0.406–0.665). The majority (30.8%) of the tumors were located in the soft tissue and skin, followed by lesions in the abdomen (28%), respiratory system (19%), bone and joint (8.6%), and others. The 5-year overall survival rate was 55.6% (95%CI = 32.8–73.5%). Multiple Cox regression analysis revealed that age >80 years (hazard ratio [HR] = 8.57, 95%CI = 2.32–31.63, P < 0.001), African-American race (HR = 2.52, 95%CI = 1.31–4.85, P < 0.01), “American Indian/Alaska Native” or “Asian or Pacific Islander” (HR = 2.99, 95%CI = 1.5–5.96, P < 0.01) race, and respiratory tumors (HR = 2.55, 95%CI = 1.37–4.75, P < 0.01) were distinctly related to worse overall survival. The calibration plots demonstrated good consistency between nomogram-predicted and actual survival. The area under the time-dependent ROC curve was 0.721 (95%CI = 0.63–0.81) and 0.719 (95%CI = 0.63–0.81) for the 3- and 5-year survival, respectively. For the convenience of researchers and clinicians, we designed an online dynamics nomogram to predict the survival rate.

Conclusion

EHE is a relatively rare vascular tumor, which principally occurs in the soft tissue and skin. It most commonly occurs in patients aged 60–79 years and its incidence has increased in recent years. Age at diagnosis, race, and tumor location may affect the overall survival outcomes.

Hepatic hemangioendothelioma - A rare case report

Introduction and importance

Hepatic hemangioendothelioma (HHE) is a very rare mild-moderate malignant tumor of the hepatic vascular endothelium. The etiology is yet not fully understood. Patients can be asymptomatic or may present with non-specific symptoms or hepatic insufficiency. CT and MRI scans show various radiographic features but a definitive diagnosis can be made with histological analysis and immunohistochemistry. Here we report a case of a patient who presented with a non-resectable disease for which living donor liver transplantation was done.

Case presentation

A 19-year-old female patient presented with intermittent moderate dull pain in the right hypochondrium for 9 months. Examination revealed mild tender hepatomegaly. On abdominal ultrasound, two hypoechoic lesions were noted in both lobes of the liver that were confirmed on CT scan. Histologic examination of the ultrasound-guided fine-needle aspiration cytology of the voluminous right lobe lesion clinched the diagnosis of HHE. The patient underwent successful living donor liver transplantation due to the multifocal bi-lobar nature of the lesions. At 8 months follow up, she is fine and doing well.

Conclusion

HHE is a very rare mild-moderate malignant tumor of hepatic vascular origin. Resection is the preferable treatment option in patients with resectable disease. However, liver transplantation has become the treatment of choice for patients with non-resectable multifocal and bi-lobar lesions. The long-term outcome of this malignancy is not fully known and there is a need for long-term follow-up studies to determine the actual recurrence rate of this disease.

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HHE is a very rare malignant tumor of hepatic vascular endothelium.

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Patients may be asymptomatic or may present with non-specific symptoms/hepatic insufficiency.

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Ultrasound, CT scan and MRI show various radiographic features but definitive diagnosis can be made on histology and immunohistochemistry.

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Liver transplantation is the only hope for patients with multifocal disease where surgical resection cannot be offered.

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The long term course of the disease is not known and thus needs proper follow up.

Contrast-enhanced ultrasound of histologically proven hepatic epithelioid hemangioendothelioma

AIM: To analyze contrast-enhanced ultrasound (CEUS) features of histologically proven hepatic epithelioid hemangioendothelioma (HEHE) in comparison to other multilocular benign focal liver lesions (FLL).

METHODS: Twenty-five patients with histologically proven HEHE and 45 patients with histologically proven multilocular benign FLL were retrospectively reviewed. Four radiologists assessed the CEUS enhancement pattern in consensus.

RESULTS: HEHE manifested as a single (n = 3) or multinodular (n = 22) FLL. On CEUS, HEHE showed rim-like (18/25, 72%) or heterogeneous hyperenhancement (7/25, 28%) in the arterial phase and hypoenhancement (25/25, 100%) in the portal venous and late phases (PVLP), a sign of malignancy. Eighteen patients showed central unenhanced areas (18/25, 72%); in seven patients (7/25, 28%), more lesions were detected in the PVLP. In contrast, all patients with hemangioma and focal nodular hyperplasia showed hyperenhancement as the most distinctive feature (P < 0.01).

CONCLUSION: CEUS allows for characterization of unequivocal FLL. By analyzing the hypoenhancement in the PVLP, CEUS can determine the malignant nature of HEHE.

Hepatic epithelioid hemangioendothelioma: Pitfalls in the diagnosis on fine needle cytology and "small biopsy" and review of the literature

Hepatic epithelioid hemangioendothelioma is a rare vascular neoplasm with an unpredictable malignant potential. Different therapeutic options are available, depending on the basis of disease extension and the patient's overall condition. A correct pathological diagnosis is necessary and is often based on scant material. Here, we report a case diagnosed on fine needle aspiration and on a small surgical biopsy. In addition, we will review the literature. The patient is a 54-year-old woman who presented with persistent pain in the right hypochondrium and suffered from weight loss. Ultrasound examination and CT scan showed several focal and confluent hepatic lesions. Thus, an ultrasound-guided fine-needle aspiration (US-FNA) was performed. A cytological diagnosis of vascular proliferation with epithelioid component was performed. Afterwards, a hepatic "small biopsy" (SB) was made. Histological and immunohistochemical data were consistent with a hepatic epithelioid hemangioendothelioma diagnosis. The patient, however, is in good general condition and is waiting for a hepatic transplantation; repeated total CT scan showed no signs of metastasis. The literature was reviewed in order to define the pathological features that were helpful in the cytological and histological diagnosis of hepatic epithelioid hemangioendothelioma, and to better understand if pathological data is prognostically useful.

Malignant epithelioid hemangioendothelioma: a case report

Malignant epithelioid hemangioendothelioma (EH) is a rare tumor of vascular origin. We report a case of a woman who was found to have multiple hepatic masses in the right lobe of the liver on radiologic investigations, initially misdiagnosed as a metastatic carcinoma. The diagnosis of EH was made on histopathological study and confirmed by immunohistochemistry, which showed diffuse response for CD34 marker and no response to tissue CEA, HMB-45 or S-100 protein. Partial hepatectomy was made with good results.