Soft Tissue Special Issue: Perivascular and Vascular Tumors of the Head and Neck

New Insights into Cervicofacial Vascular Anomalies

Congenital cervicofacial vascular anomalies are extremely rare and present many difficulties in diagnosis and treatment requiring a multidisciplinary approach. Firstly, there is little consensus on this subject among head and neck specialists. There are two main types of vascular anomalies: vascular tumors and vascular malformations. Vascular malformations are also divided into malformations with slow blood flow (veins, lymphatics, capillaries or combined) and malformations with a fast blood flow (arteriovenous malformations and fistula). Vascular tumors like hemangiomas are known for their spontaneous involution with aging, while vascular malformations grow in dimensions with age. It is very important to choose the correct differential diagnosis between cervicofacial hemangiomas and vascular malformations for proper therapy management. Anamnesis and clinical exams help in raising suspicions about the real nature of a cervico-vascular anomaly. Furthermore, imaging brings in-depth details of the anomaly, ranging from ultrasound and contrast CT to MRI scanning and minimally invasive angiography. Angiography with selective embolization is rarely a curative procedure for arteriovenous malformations, being more suitable as a preliminary step before attempted surgical removal. Surgery is clearly necessary when there are aesthetic and functional deficits. Slow-flow vascular malformations present a reduced morbidity, and in cases without involution, the surgical ablation is reserved for the cases with aesthetic dysfunctions or psychological trauma. Lymphatic malformations must undergo surgical ablation when they are associated with mass effects and compression of great vessels or aerial viscera. The prognosis after surgical removal is good, with a low rate of recurrence or morbidity. Fast-flow vascular malformations require a combined approach, with embolization and excision in the next 48 h for safety reasons. Removal may be followed by reconstructive surgery depending on the location and dimensions of the malformation, with a possible secondary recovery of the normal microscopic vessels. Some of the masses may hinder the normal airflow and swallowing. Pathology is the gold standard for confirming the clinical and imaging diagnosis.

Ultrasound of Benign Cutaneous Tumors and Pseudotumors: The Key Lesions

Benign cutaneous tumors are commonly seen in daily practice. Most of these lesions are diagnosed based on clinical appearance, but in some cases, clinical findings are nonspecific. A diagnostic imaging exam is indicated to provide additional information, and the first choice for studying dermatologic lesions is a high-frequency color Doppler ultrasound, a noninvasive technique that can play a relevant role in all cases and give important anatomical information for final diagnosis and proper clinical management. This article aims to show the most common benign skin lesions emphasizing clinical-sonographic correlation and familiarizing radiologists with the sonographic appearance of the key benign cutaneous tumors.

Progressive vascular tumor in infant: A case report and literature review of PIK3CA vascular malformation

PURPOSE

Vascular anomalies are classified as either vascular tumors or vascular malformations. Vascular malformations can be difficult to diagnose and treat in the pediatric population and can masquerade as malignant processes. Understanding the genetics behind vascular malformations can lead to identification of specific mutations which can be treated with targeted immunotherapy.

METHODS

Our case presents a pediatric patient with progressively enlarging vascular malformation despite multiple surgical resections and systemic medical treatments who underwent genetic evaluation and was found to have PIK3CA mutation.

RESULTS

After identification of PIK3CA mutation, our patient was successfully treated with the p110ɑ-specific inhibitor, alpelisib, with both shrinkage of malformation on follow-up imaging as well as gains in her developmental milestones.

CONCLUSION

Progressive vascular malformations in the pediatric population can be hard to diagnose and treat and are thought to arise from somatic mutations. Our case highlights a patient with progressive malformation despite multiple surgical resections who was successfully treated with targeted immunotherapy after proper identification of genetic mutation.

Kaposiform Haemangioendothelioma of the Sublingual Gland in an Adult

Kaposiform haemangioendotheliomas (KHE) are extremely rare, borderline malignant, locally aggressive vascular tumours. KHE is usually found in the retroperitoneum, over the extremities, the soft tissues of the trunk, mediastinum and the head and neck regions. We present a very rare case of KHE of the sublingual gland in an adult, which was not associated with Kasabach-Merritt phenomenon and was resected completely without any recurrence. To the best of our knowledge, this is the first reported case in the literature of a KHE arising from the salivary glands in an adult.

Review of diagnosis, differential diagnosis, and management of retroperitoneal lymphangioma

Lymphatic malformation (LM) is the currently preferred term for what was previously known as lymphangioma. Retroperitoneal LMs are extremely rare, benign, cystic masses that arise from lymphatic vessels. They can be challenging to diagnose because they resemble other retroperitoneal cystic tumors. The development of treatment strategies for rare diseases, including retroperitoneal LM, requires the acquisition of new knowledge to enhance our understanding of the disease progression. Therefore, we present an update regarding fundamental and advanced issues associated with retroperitoneal LM. This review describes the epidemiology, histopathology, biomedicine, clinical manifestations, radiological features, differential diagnosis, and management of this lesion.

Primary intranasal perivascular wall tumors in 2 cats

Perivascular wall tumors (PWTs) are common well-known canine mesenchymal tumors. The term PWT has not yet been applied to cats; only 2 cases of feline soft tissue hemangiopericytomas (HEPs) are available. In human medicine, sinonasal HEP-like tumor/glomangiopericytoma (SHPCL/GP) and intranasal solitary fibrous tumor (SFT) are well-known mesenchymal tumors with staghorn vasculature and low malignant potential; however, these entities have not been described in small animals. We describe here the pathologic and immunohistochemical features of 2 cases of feline intranasal mesenchymal tumors consistent with PWTs and resembling human SHPCL/GP (case 1), and human intranasal SFT (case 2). Both cats developed intranasal, unilateral, polypoid, expansile neoplasms with a mostly patternless growth of spindle cells, minimal stroma, and prominent staghorn vessels. The stroma was PAS negative, which excludes a glomus tumor. Immunohistochemistry identified diffuse vimentin and PDGFRβ expression. Case 1 was α-SMA positive (as is human SHPCL/GP); case 2 was negative (as is human intranasal SFT). Both tumors were incompletely excised, leading to recurrence in case 1. Case 2 was lost to follow up. To our knowledge, intranasal PWTs have not been reported previously in cats. The frequency of the lesions is not known, but awareness of these entities may assist in their recognition and better characterization in the future.

Incidental superficial soft tissue epithelioid angioleiomyoma

Epithelioid angioleiomyoma is rare in the skin and subcutaneous tissues. To our knowledge, only two previous cases of this tumor have been reported. We document here the case of an 83-year-old woman who underwent complete removal of a squamous cell carcinoma of the retromolar trigone and lymph node dissection of the neck. An incidental epithelioid angioleiomyoma was observed in the adipose tissue. The tumor formed a unilocular, poorly-demarcated neoplasm measuring 0.3 cm., and showed cavernous angiomatous spaces with villiform growth of large epithelioid cells arranged in clusters. Besides the epithelioid cells of muscular origin, bundles of well-differentiated smooth muscle cells were observed. Epithelioid cells accounted for 70% of the total. The neoplasm originated in the wall of a medium-sized vein. Epithelioid and spindle cells were positive for alpha-smooth muscle actin, calponin, h-caldesmon, and muscle-specific actin. The endothelial cells lining the vascular spaces showed intense and diffuse positivity for CD31 and ERG. The main differential diagnosis includes metastatic carcinoma, melanoma, perivascular epithelioid cell neoplasm (PEComa), myopericytoma, glomangiomyoma, epithelioid glomus tumor, and epithelioid leiomyosarcoma. This report expands the morphological spectrum of the epithelioid angioleiomyoma. Awareness of this uncommon morphologic variant of angioleiomyoma and the use of adequate techniques can avoid misdiagnosis. This article is protected by copyright. All rights reserved.

[Abdominal soft tissue tumors]

Gastrointestinal stromal tumors are the most common mesenchymal tumors in the abdomen and occur in Germany with an incidence of 10 to 15 cases per million inhabitants. Clear identification and characterization are of major importance for the prognosis and therapy of patients. Similarly, they have to be differentiated from other mesenchymal neoplasias such as leiomyomatous, neurogenic, adipocytic, and fibroblastic tumors. Additionally, the number of translocation positive neoplasias is increasing, requiring the use of adequate molecular assays. The aim of this paper is to give practical advice for their identification. Reference pathology is one possibility to support the correct diagnosis.

MR Imaging of Vascular Malformations and Tumors of Head and Neck

Soft tissue vascular anomalies show a wide heterogeneity of clinical manifestations and imaging features. MR imaging has an important role in the diagnosis and management of vascular lesions of the head and neck. MR angiography is mandatory in cases of arteriovenous and combined malformations to assess the high-flow nature/component of the lesions and plan therapy. Infantile hemangiomas can be differentiated from congenital hemangiomas by clinical course. Reactive vascular tumors have nonspecific features similar to infantile hemangiomas. Locally malignant and malignant vascular tumors have irregular borders, infiltration of different tissue planes, and lower apparent diffusion coefficient values than benign vascular tumors.

Oral lymphatic malformations: A multicenter study of 208 cases and literature review

BACKGROUND

To evaluate the frequency and analyze demographic and clinical characteristics of individuals with a histopathological diagnosis of oral lymphatic malformations (OLMs).

METHODS

A multicenter study was performed, collecting biopsy record data from a consortium of Brazilian Oral and Maxillofacial Pathology Centers. A review was also conducted to compare this data with cases already available in the literature.

RESULTS

This study retrieved 208 cases of OLM in the multicenter study and 1035 cases in the literature review. In both, OLMs affected male and female individuals equally, with the most affected site being the tongue. Individuals ≥60 years of age were uncommonly affected. Symptomatic and larger lesions were more commonly reported in the literature review.

CONCLUSIONS

This study comprises the largest sample of OLMs to date. OLMs are rare conditions, without sex predilection. The elderly proved to be less frequently affected, and the tongue is the most commonly affected site.

EWSR1-The Most Common Rearranged Gene in Soft Tissue Lesions, Which Also Occurs in Different Bone Lesions: An Updated Review

EWSR1 belongs to the FET family of RNA-binding proteins including also Fused in Sarcoma (FUS), and TATA-box binding protein Associated Factor 15 (TAF15). As consequence of the multifunctional role of EWSR1 leading to a high frequency of transcription of the chromosomal region where the gene is located, EWSR1 is exposed to aberrations such as rearrangements. Consecutive binding to other genes leads to chimeric proteins inducing oncogenesis. The other TET family members are homologous. With the advent of widely used modern molecular techniques during the last decades, it has become obvious that EWSR1 is involved in the development of diverse benign and malignant tumors with mesenchymal, neuroectodermal, and epithelial/myoepithelial features. As oncogenic transformation mediated by EWSR1-fusion proteins leads to such diverse tumor types, there must be a selection on the multipotent stem cell level. In this review, we will focus on the wide variety of soft tissue and bone entities, including benign and malignant lesions, harboring EWSR1 rearrangement. Fusion gene analysis is the diagnostic gold standard in most of these tumors. We present clinicopathologic, immunohistochemical, and molecular features and discuss differential diagnoses.

Primary angiosarcoma of the oral cavity in a young adult

Angiosarcoma is a rare neoplasm, constituting only 2% of all the soft tissue tumors and most frequently involves the skin of the head and neck region in elderly males. They are extremely aggressive tumors with high rates of metastasis and poor outcomes. We report a unique case of angiosarcoma involving an unusual site – upper alveolus and maxilla in a young patient highlighting the diagnostic challenges in such a scenario. A 29 years old female presented with a non-healing wound of the oral cavity, which had progressed to the current maximum size of 6.4 cm within one month. Magnetic resonance imaging (MRI) scan revealed the involvement of maxilla up to the floor of the orbit and adjacent soft tissue. However, no distant metastasis was detected on Positron Emission Tomography (PET) scan. Biopsy of the lesion showed an irregular, highly pleomorphic, and mitotically active epithelioid soft tissue tumor conclusively diagnosed as angiosarcoma.

Frontoethmoidal Extranasopharyngeal Angiofibroma With Orbital Pyocele

Significance StatementExtranasopharyngeal angiofibromas (ENA) are rare vascular tumors that do not conform to the clinical characteristics of typical nasopharyngeal angiofibromas. We present the management of an angiofibroma in a rare site, within the frontal sinus with a concomitant orbital pyocele, which was completely excised via an endoscopic approach. ENAs should be considered as a differential diagnosis in patients with sinonasal mass and epistaxis. Awareness of this rare entity will avoid radical surgery thus decreasing postoperative morbidity.

Aggressive Intraosseous Myofibroma of the Maxilla: Report of a Rare Case and Literature Review

Myofibroma (MF) is a benign mesenchymal myofibroblast-derived tumor, which occurs most frequently in children, and rarely affects the maxilla. We reported a case of an aggressive intraosseous lesion found in the maxilla of a 9-year-old female child. Intraorally, the swelling extended from tooth 12 to 16, causing displacement of teeth 13, 14, and 15. Computed tomography revealed a large osteolytic lesion causing thinning and cortical erosion. Microscopically, the lesion showed a proliferation of spindle-shaped cells, with elongated nuclei and eosinophilic cytoplasm, arranged in interlaced fascicles. The immunohistochemical analysis revealed cytoplasmic positivity for α-SMA and HHF-35, and negativity for desmin, laminin, S-100, β-catenin, and CD34. Ki-67 was positive in 8% of tumor cells. The diagnosis was MF. Herein, we describe an additional case of central MF arising in the maxilla, including clinical, imaging, microscopical, and immunohistochemical features, as well as a review of the literature.