Diagnostic and therapeutic challenges in hepatic epithelioid hemangioendothelioma

68 Ga-PSMA Versus 18 F-FDG PET/CT in the Evaluation of Epithelioid Hemangioendothelioma

ABSTRACT

A 32-year-old man with epithelioid hemangioendothelioma was imaged with 68 Ga-PSMA PET/CT to evaluate the potential of 177 Lu-PSMA radionuclide therapy after progression findings were observed on follow-up 18 F-FDG PET/CT imaging. Liver lesions showed low FDG SUV max . The lesion-to-background ratio (TBR) was calculated as 5.1/2.9 on 18 F-FDG PET/CT imaging. However, 68 Ga-PSMA PET/CT showed moderate PSMA SUV max . TBR was calculated as 4.5/1.1. In conclusion, in this case report, we demonstrated that 68 Ga-PSMA with moderate TBR in epithelioid hemangioendothelioma may be promising for 177 Lu-PSMA radionuclide therapy.

Advanced epithelioid hemangioendothelioma of the liver: could lenvatinib offer a bridge treatment to liver transplantation?

In this article, we describe the case of a 34-year-old woman presenting a multifocal and metastatic epithelioid hemangioendothelioma (HEHE) of the liver. Under classical chemotherapy using cyclophosphamide, there was a fast tumor progression in liver and extra-hepatic metastatic sites (lungs and mediastinal lymph node). Taking into account the patient’s age and the natural history of the HEHE, our goal was to try to bring her to liver transplantation (LT) and lenvatinib was an acceptable candidate for this reason. Shortly after the initiation of lenvatinib before LT and surgery, we observed the enlargement of large devascularized necrotic areas in most of the liver HEHE masses, suggesting a good response. The patient was finally transplanted 6 months after initiation of lenvatinib treatment. Eight months after LT, progression occurred (ascites, peritoneal recurrence, and mediastinal lymph node). After restarting lenvatinib, ascites disappeared and the lymph node decreased in size, suggesting a good response, more than 1 year after her transplantation. This is the first case report to our knowledge that illustrates the benefit of lenvatinib as a neoadjuvant bridge until LT for a multifocal and metastatic HEHE. In addition, this drug has also shown a benefit in term of disease control after a late recurrence of the tumor. We suggest that lenvatinib should be proposed as a bridge to the LT for nonresectable HEHE. Moreover, this drug was also beneficial in the treatment of late recurrence after LT. The absence of pharmacologic interactions between classical immunosuppressive drugs and lenvatinib may allow its use as an early adjuvant approach when the risk of recurrence is high. The strength of our case consists in the long follow-up and the innovative message allowing changing palliative strategies into curative ones in case of advanced HEHE.

Diagnosis of epithelioid hemangioendothelioma eight days postpartum: Is there a link with pregnancy? A case report and review of the literature

Epithelioid hemangioendothelioma (EHE) is a rare and heterogeneous malignant vascular tumor. Decision making on a treatment strategy is difficult and a standard of care does not exist. EHE shows a wide age distribution but is rare in children. It can appear anywhere in the body, although lung and liver involvement are most common. There is a female predominance for visceral lesions and several case reports in which EHE developed during or after pregnancy are described in literature, hinting towards a putative role of sex hormones in the course of the disease. We present a case of a 32-year-old woman diagnosed with symptomatic pulmonary metastatic hepatic EHE (HEHE) 8 days postpartum, while the patient was completely asymptomatic before. A wait and see policy was chosen and the patient became asymptomatic in the months following the diagnosis. Although no expression of estrogen and progesterone receptors was found in the diagnostic liver biopsy specimen, we presume that the increased level of sex hormones during pregnancy may have triggered disease progression. The clinical behaviour of the disease in this case report reinforces the suspicion of female hormonal involvement in this type of malignancy and hints toward the potential role of other pregnancy-related factors, e.g. placental growth factor (PlGF), in the development of the disease.

Clinical characteristics and CT features of hepatic epithelioid haemangioendothelioma and comparison with those of liver metastases

BACKGROUND

To analyse clinical characteristics and computer tomography (CT) findings of hepatic epithelioid haemangioendothelioma (HEH) and to determine differential features compared with liver metastasis (LM).

METHODS

This retrospective study included 80 patients with histopathologically confirmed HEH (n = 20) and LM (n = 60) of different primary tumours who underwent dynamic contrast-enhanced CT scans. CT findings included the location, contour, size, number, margin, and density of lesions, the patterns and degree of contrast enhancement of lesions, vascular invasion and changes in other organs. The enhancement ratio (ER) and tumour-to-normal parenchyma ratio (TNR) were calculated. Receiver operating characteristic curves (ROCs) were used to determine areas under the curve (AUCs).

RESULTS

About 65% of HEH lesions were located in submarginal areas. Significant differences were observed between HEH and LM patients in age, sex, and tumour marker positivity (p < 0.05). HEH showed minimal to slight enhancement, thin ring-like enhancement in arterial phase, and slight, homogeneous, progressive enhancement in the portal phase. HEH presented capsule retraction, and the "target" sign and the "lollipop" sign were significantly more frequent than in LM (p < 0.05). The ER and TNR in the arterial phase of HEH were lower than those of LM (p < 0.05). AUCs of ER and TNR in the arterial phase were 0.74 and 0.73, respectively.

CONCLUSION

Lesions in subcapsular locations, capsular retraction, slight and thin ring-like enhancement, "target" and "lollipop" signs and lower ER and TNR in the arterial phase may represent important features of HEH compared with LM.

Laparoscopic repeat liver resection for hepatic epithelioid hemangioendothelioma

BACKGROUND

Optimal treatment for patients with hepatic epithelioid hemangioendothelioma (HEHE) remains unclear. Laparoscopic repeat liver resection (LR) is a minimally invasive and potentially effective surgical option for multiple HEHEs.

CASE PRESENTATION

A 42-year-old woman with no relevant history was admitted for multiple liver tumors. Six tumors were observed on T2-weighted magnetic resonance imaging (MRI) including one in S2, two in S3, two in S7, and one in S8. Pathological evaluation of percutaneous tumor biopsy tissue suggested a diagnosis of HEHE and laparoscopic LR was planned. The procedure began with partial resection of S7 and partial resection of S8 and left lateral sectionectomy were performed. Another tumor was found intraoperatively on the surface of S6, necessitating removal by partial resection. Pathological evaluation of the resected tumor tissue from all seven tumors concurred with that of the preoperative biopsy. The patient was discharged on postoperative day 6 without any complications. A follow-up MRI 15 months after the primary surgery revealed one tumor each in S4, S6, and S8. Laparoscopic repeat LR was performed. The patient was discharged on postoperative day 5 without any complications. All three recurrent tumors were pathologically confirmed as HEHEs.

CONCLUSIONS

We successfully treated primary and recurrent HEHEs with laparoscopic LR, which is a reasonable minimally invasive procedure considering the possibility of multiple courses of liver surgery in patients with HEHE.

Hepatic epithelioid hemangioendothelioma: Update on diagnosis and therapy

With an estimated incidence of only 1-2 cases in every 1 million people, hepatic epithelioid hemangioendothelioma (HEHE) is a rare vascular endothelial cell tumor occurring in the liver and consisting of epithelioid and histiocyte-like vascular endothelial cells in mucus or a fibrotic matrix. HEHE is characterized as a low-to-moderate grade malignant tumor and is classified into three types: solitary, multiple, and diffuse. Both the etiology and characteristic clinical manifestations of HEHE are unclear. However, HEHE has a characteristic appearance on imaging including ultrasound, magnetic resonance imaging, and positron emission tomography/computerized tomography. Still, its diagnosis depends mainly on pathological findings, with immunohistochemical detection of endothelial markers cluster of differentiation 31 (CD31), CD34, CD10, vimentin, and factor VIII antigen as the basis of diagnosis. Hepatectomy and/or liver transplantation are the first choice for treatment, but various chemotherapeutic drugs are reportedly effective, providing a promising treatment option. In this review, we summarize the literature related to the diagnosis and treatment of HEHE, which provides future perspectives for the clinical management of HEHE.

Hepatic hemangioendothelioma: CT, MR, and FDG-PET-CT in 67 patients-a bi-institutional comprehensive cancer center review

OBJECTIVE

To evaluate the imaging features of hepatic epithelioid hemangioendothelioma (HEH) on multiphasic CT, MR, and FDG-PET-CT.

METHODS

Bi-institutional review identified 67 adults (mean age, 47 years; 23 M/44 F) with pathologically proven HEH and pretreatment multiphasic CT (n = 67) and/or MR (n = 30) and/or FDG-PET-CT (n = 13).

RESULTS

HEHs were multifocal in 88% (59/67). Mean size of the dominant mass was 4.1 cm (range, 1.4-19 cm). The tumors were located in the peripheral, subcapsular regions of the liver in 96% (64/67). Capsular retraction was present in 81% (54/67 cases) and tumors were coalescent in 61% (41/67). HEH demonstrated peripheral ring enhancement on arterial phase imaging in 33% (21/64) and target appearance on the portal venous phase in 69% (46/67). Persistent peripheral enhancement on the delayed phase was seen in 49% (31/63). On MR, multilayered target appearance was seen on the T2-weighted sequences in 67% (20/30) and on the diffusion-weighted sequences in 61% (11/18). Target appearance on hepatobiliary phase of MRI was seen in 57% (4/7). On pre-therapy FDG-PET-CT, increased FDG uptake above the background liver parenchyma was seen in 62% (8/13).

CONCLUSION

HEHs typically manifest as multifocal, coalescent hepatic nodules in peripheral subcapsular location, with associated capsular retraction. Peripheral arterial ring enhancement and target appearance on portal venous phase are commonly seen on CT. Similarly, multilayered target appearance correlating with its histopathological composition is typically seen on multiple sequences of MR including T2-weighted, diffusion-weighted, and dynamic contrast-enhanced multiphasic MR.

KEY POINTS

• Hepatic epithelioid hemangioendotheliomas manifest on CT and MR as multifocal, coalescent hepatic nodules in peripheral subcapsular location, with associated capsular retraction. • Enhancement pattern on contrast-enhanced CT and MR can vary but peripheral ring enhancement on arterial phase and target appearance on portal venous phase are commonly seen. • Retrospective two-center study showed that cross-sectional imaging may help in the diagnosis.

Liver transplantation for unresectable malignancies: Beyond hepatocellular carcinoma

Indications for liver transplantation have expanded over the past few decades owing to improved outcomes and better understanding of underlying pathologies. In particular, there has been a growing interest in the field of transplant oncology in recent years that has led to considerable developments which have pushed the boundaries of malignant indications for liver transplantation beyond hepatocellular carcinoma (HCC). In this article, we review and summarise the published evidence for liver transplantation in non-HCC primary and metastatic liver malignancies and highlight ongoing clinical trials that address unresolved questions therein. We also examine the current technical, immunological and oncological challenges that face liver transplantation in this growing field and explore potential approaches to overcome these barriers.

Malignant hepatic vascular tumors in adults: Characteristics, diagnostic difficulties and current management

Malignant vascular tumors of the liver include rare primary hepatic mesenchymal tumors developed in the background of a normal liver parenchyma. Most of them are detected incidentally by the increased use of performing imaging techniques. Their diagnosis is challenging, involving clinical and imaging criteria, with final confirmation by histology and immunohistochemistry. Surgery represents the mainstay of treatment. Liver transplantation (LT) has improved substantially the prognosis of hepatic epithelioid hemangioendothelioma (HEHE), with 5-year patient survival rates of up to 81%, based on the European Liver Intestine Transplantation Association-European Liver Transplant Registry study. Unfortunately, the results of surgery and LT are dismal in cases of hepatic angiosarcoma (HAS). Due to the disappointing results of very short survival periods of approximately 6-7 mo after LT, because of tumor recurrence and rapid progression of the disease, HAS is considered an absolute contraindication to LT. Recurrences after surgical resection are high in cases of HEHE and invariably present in cases of HAS. The discovery of reliable prognostic markers and the elaboration of prognostic scores following LT are needed to provide the best therapeutic choice for each patient. Studies on a few patients have demonstrated the stabilization of the disease in a proportion of patients with hepatic vascular tumors using novel targeted antiangiogenic agents, cytokines or immunotherapy. These new approaches, alone or in combination with other therapeutic modalities, such as surgery and classical chemotherapy, need further investigation to assess their role in prolonging patient survival. Personalized therapeutic algorithms according to the histopathological features, behavior, molecular biology and genetics of the tumors should be elaborated in the near future for the management of patients diagnosed with primary malignant vascular tumors of the liver.

68Ga-DOTA-E-[c(RGDfK)]2 positron emission tomography-computed tomography in the evaluation of hepatic hemangioendothelioma epithelioid

Hemangioendothelioma epithelioid is a rare tumor that originates in soft tissues. Imaging evaluation with conventional modalities (tomography and magnetic resonance) is difficult. Novel radiotracers which capably evaluate angiogenesis may have a higher impact on the therapeutic decisions. A 45-year-old man underwent workup for thrombosis and was diagnosed with hemangioendothelioma epithelioid based on the results of liver pathology and immunohistochemistry. The decision of the multidisciplinary board was to begin with thalidomide. After 4 months, progression of disease was documented and right hepatectomy was performed. A ⁶⁸Ga-DOTA-E-[c(RGDfK)]2 positron emission tomography–computed tomography scan showed residual lesions. After documented angiogenesis by ⁶⁸Ga-DOTA-E-[c(RGDfK)]2 positron emission tomography–computed tomography, nintedanib was administrated. And 1 year later, progression of the disease was documented by positron emission tomography–computed tomography. Ipilimumab plus nivolumab was started and partial response and excellent clinical response were documented. Molecular imaging with ⁶⁸Ga-DOTA-E-[c(RGDfK)]2 positron emission tomography–computed tomography is a good biomarker of the response of hemangioendothelioma epithelioid, and ipilimumab plus nivolumab therapy demonstrated a good response.

Spontaneous rupture of a splenic artery aneurysm with splenic epithelioid hemangioendothelioma: a case report

Spontaneous rupture of a splenic artery aneurysm with splenic epithelioid hemangioendothelioma is a rare condition. Splenic artery aneurysm can be complicated by rupture resulting in hypovolemic shock, which can be fatal if not treat properly. We report a case of a 50-year-old man who presented with sudden onset of left upper quadrant pain and shock. This patient underwent splenectomy with distal pancreatectomy. His pathological diagnosis showed splenic epithelioid hemangioendothelioma.

Hepatic Epithelioid Hemangioendothelioma - a Rare Tumor and Diagnostic Dilemma

BACKGROUND/AIM

Hepatic epithelioid haemangio-endothelioma (HEHE) is a very rare malignant tumor of vascular origin and uncertain biological behaviour that is difficult to diagnose using preoperative radiology diagnostic techniques.

PATIENTS AND METHODS

The authors present here two patients with HEHE of different extent. The first patient had a generalised form of disease, with involvement of the liver, lungs and bones and was treated with a combination of bevacizumab and capecitabine. The second patient had a localised form of disease involving the liver and this was resolved using a combination of liver resection and radiofrequency ablation. In both patients, the radiology work-up before surgery was non-specific and metastases of another malignant process were considered. The definitive histological diagnosis was made by the pathologist on the basis of immunohistochemical analysis that demonstrated the presence of CD31, CD34 and calmodulin-binding transcription activator 1 (CAMTA 1).

RESULTS

Both patients remain in an overall good condition 27 and 5 months respectively following treatment for HEHE.

CONCLUSION

Preoperative radiological diagnosis of HEHE is difficult and immunohistochemical examination of the tumor tissue sample remains the key diagnostic tool. Radical surgical resection or liver transplantation is the method of choice in patients with localised liver involvement.

Spontaneous rupture of hepatic epithelioid hemangioendothelioma: A case report

Hepatic epithelioid hemangioendothelioma (HEH) is a rare tumor of vascular endothelial origin. Spontaneous rupture of HEH is a life-threatening complication and is extremely rare. HEH has variable malignant potential, and the clinical diagnosis remains challenging. Here we report a case of HEH with spontaneous rupture. A 44-year-old man presented with constant cutting pains over the right upper abdomen after eating. He had hemoptysis 11 d previously. Diagnostic abdominal puncture demonstrated active bleeding. Chest and abdominal computer tomography scan showed multiple ground-glass nodules over the lungs, multiple low-density intrahepatic nodules and massive hemorrhage. Transcatheter arterial embolization and exploratory laparotomy were performed and subsequent immunohistochemical examination confirmed a diagnosis of HEH.

Aggressive primary hepatic epithelioid hemangioendothelioma: a case report and literature review

A new case of epithelioid hemangioendothelioma is reported to have occurred to a 67-year-old patient who consulted for right-sided chest pain. The work-up showed multiple right pulmonary lesions associated with bilateral moderate pleural effusion and left-sided pleural thickening and three hypodense nodules in the right lobe of the liver, peritoneal thickening, ascites, and multiple vertebral lytic lesions. The diagnosis of an epithelioid hemangioendothelioma was concluded through a histological examination of a computed tomography scan guided biopsy of the liver. The patient received a primary mono-chemotherapy with Adriamycin (75 mg/m² every three weeks) and intravenous bisphosphonates without response and general status impairment. The patient died after 16 months of follow-up.

Hepatic epithelioid hemangioendothelioma: Dilemma and challenges in the preoperative diagnosis

Hepatic epithelioid hemangioendothelioma (HEHE) is a rare category of vascular tumor with uncertain malignant potential. It commonly presents nonspecific and variable clinical manifestations, ranging from asymptomatic to hepatic failure. In addition, laboratory measurements and imaging features also lack specificity in the diagnosis of HEHE. The aim of the present study is to highlight the dilemma and challenges in the preoperative diagnosis of HEHE, and to enhance awareness of the range of hepatobiliary surgery available in patients with multiple hepatic nodular lesions on imaging. In these patients, HEHE should at least be considered in the differential diagnosis.

Typical CT and MRI signs of hepatic epithelioid hemangioendothelioma

To investigate the typical magnetic resonance imaging (MRI) and computed tomography (CT) features of hepatic epithelioid hemangioendothelioma (HEH), the CT and MRI findings of 14 histopathologically confirmed cases of HEH were retrospectively analyzed. Non-contrast and dynamic contrast-enhanced scans were conducted in all cases. A total of 229 lesions were detected in the 14 cases. All cases were classified as one of three types: (i) Solitary nodular type (1 case, 7%); (ii) multifocal nodular type (11 cases, 79%); or (iii) diffuse type (2 cases, 14%). The diameter of the lesions ranged from 5 to 105 mm. For the first two types (solitary and multifocal nodular types), the CT findings included low density lesions with clear margins on non-contrast scans, centripetal enhancement in arterial phase, and homogeneous enhancement in the portal venous and delay phases. The findings of non-contrast MRI scans for these two types included low signal intensity on T1-weighted images, heterogeneous high signal intensity on T2-weighted images, and heterogeneous high signal intensity on diffusion-weighted images. The lesions were predominantly located in submarginal areas. On contrast-enhanced MRI, the findings for the first two types included peripheral ring-like enhancement with a central low signal intensity (‘black target-like’ sign) and a central enhanced core surrounded by a low signal intensity halo (‘white target-like’ sign). The findings for the third HEH type (diffuse type) on CT and MRI scans included low density or heterogeneous signal intensity lesions involving regions of part or the whole liver, coalescent lesions (‘strip-like’ sign), and gradual enhancement along central vessels (‘lollipop’ sign). Collectively, these findings indicate that the ‘white target-like’ sign, ‘black target-like’ sign, ‘lollipop’ sign and ‘strip-like’ sign, in addition to capsular contraction and submarginal location, on CT and MRI imaging may have implications for the diagnosis of HEH. Furthermore, a variety of MRI sequences may provide additional information for the differential diagnosis of HEH.

Multiple hemorrhagic intraparenchymal tumors presenting with fatal intracranial hypertension: A rare manifestation of systemic epithelioid hemangioendothelioma

BACKGROUND

Epithelioid hemangioendotheliomas (EHE) is an extremely rare tumor that can arise not only intracranially but also systemically. Its radiological characteristics and the mechanism underlying the multiple organ involvement in EHE are poorly understood.

CASE DESCRIPTION

A 24-year-old woman with a 7-month history of coughing and blood-stained sputum complained of visual disturbance in the right eye that had persisted for 1-month. Magnetic resonance (MR) imaging revealed multiple intraparenchymal masses with low-intensity on MR susceptibility-weighted images with minimal enhancement with gadolinium. Systemic computed tomography revealed multiple nodules in both lungs and the liver. Because her neurological status rapidly deteriorated, brain biopsy of the right frontal mass was performed. The pathological diagnosis was EHE. Over the following 3 months, the patient gradually developed disturbance of consciousness. She died at 4 months after admission because of significant intracranial hypertension.

CONCLUSION

Although intracranial EHEs are extremely rare, they should be included in the differential diagnoses of multiple small-sized masses with low-intensity on MR susceptibility-weighted images. We also emphasize that the systemic involvement of this tumor was more compatible with multicentric development than metastasis.

Combination capecitabine and bevacizumab in the treatment of metastatic hepatic epithelioid hemangioendothelioma

Hepatic epithelioid hemangioendothelioma (HEHE) is a rare, often misdiagnosed vascular neoplasm with clinical behaviors that range from indolent to highly aggressive. Even when the appropriate diagnosis is achieved, the best treatment for HEHE has not been defined or standardized, further complicating the care of these patients. We present a diagnostically challenging case of HEHE where we utilized capecitabine and bevacizumab as another novel treatment option.

Epithelioid hemangioendothelioma of the liver as a rare indication for liver transplantation

AIM: To investigate the indications and outcomes of liver transplantation for hepatic epithelioid hemangioendothelioma (HEHE).

METHODS: Between 1989 and August 2013, in the Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, 1306 orthotopic liver transplantations (OLTx) were performed, including 72 retransplantations. Unresectable HEHE was an indication for OLTx in 10 patients (0.8% of primary OLTx), the mean age of the patients was 40.5 ± 13.3 years (range 23-65 years), and the male-to-female ratio was 2:8. Kaplan-Meier survival analysis in HEHE, hepatocellular carcinoma (HCC), and other OLTx recipients groups was performed. The differences in mortality were compared using the χ² test. A P-value < 0.05 indicated statistical significance.

RESULTS: No concomitant liver disease was found in any patient. There was no neoadjuvant chemotherapy or radiotherapy. Liver function test results were normal in most of the patients. The levels of alpha-fetoprotein, carcinoembryonic antigen, and carbohydrate antigen 19-9 were normal. In immunohistochemical staining, the neoplastic cells were positive for factor VIII-related antigen, CD31, and CD34, which are endothelial cell markers, and negative for cytokeratin 19, cytokeratin 7, and HepPar-1. Nine patients were alive without tumor recurrence. One patient died 2 mo after OLTx due to septic complications. No morbidity was observed. Maximum follow-up was 11.4 years, with a minimum of 1 mo. The cumulative survival rate at the end of follow-up in HEHE patients was 87.5% compared with 54.3% in the HCC group and 76.3% in the other OLTx recipients group (χ² test = 1.784, df = 2, P = 0.409).

CONCLUSION: Unresectable HEHE, without extrahepatic metastases is an excellent indication for liver transplantation. Long-term survival is very good and much better than in HCC patients and the entire group of OLTx patients.

Consumptive coagulopathy in angiosarcoma: a recurrent phenomenon?

Objectives. To report the prevalence of consumptive coagulopathy in angiosarcoma patients seen at a single center. Methods. We retrospectively reviewed case records of 42 patients diagnosed with angiosarcoma at Mount Sinai Hospital between 2000 and 2013. Results. Seven patients (17%) met clinical criteria for disseminated intravascular coagulation (DIC) in absence of concomitant clinical states known to cause coagulopathy or myelosuppression. In all patients who received systemic antineoplastic therapy with resultant disease response or stability, DIC resolved in tandem with clinical improvement. DIC recurred at time of disease progression in all cases. Two patients had bulky disease, defined as diameter of largest single or contiguous tumor mass measuring 5 cm or more. All patients demonstrated an aggressive clinical course with short duration of disease control and demise within 1 year. In contrast, evaluation over the same period of 17 epithelioid hemangioendothelioma patients serving as a clinical control group revealed no evidence of DIC. Conclusion. Angiosarcomas can be associated with a consumptive coagulopathy arising in tandem with disease activity. Vigilance for this complication will be needed in the course of often aggressive multimodality therapy. The potential utility of coagulopathy as a prognostic biomarker will need to be explored in future studies.