Epithelioid hemangioendothelioma of spleen with intrasplenic metastasis: ultrasound and computed-tomography appearance

A review of hepatic epithelioid hemangioendothelioma-Analyzing patient characteristics and treatment strategies

BACKGROUND

Hepatic epithelioid hemangioendothelioma (HEH) is a rare vascular tumor of unknown etiology and unpredictable natural history. To date, no large-scale studies have been published evaluating this disease due to its rare occurrence.

METHODS

The National Cancer Database was reviewed between 2004 and 2016 to identify patients with HEH. Univariate analysis with overall survival (OS) was performed by Cox proportional hazards model. Kaplan-Meier method was used to create OS curves and compared using the log-rank test.

RESULTS

We identified 229 patients with HEH. The majority of patients were female (61.1%), white (84.3%), and had a Charlson-Deyo score of 0 (75%). Chemotherapeutic intervention was seen in 26% of the patients while 33% received surgical intervention in the form of wedge/segmental liver resection (n = 27), hepatectomy lobectomy/extended lobectomy (n = 18), and liver transplant (n = 22). Five-year survival in surgical patients was 90.5%, 66.5% and 81%, respectively (p = 0.485). Age greater than 55 years (hazard ratio [HR], 2.78; p < 0.001), Asian ethnicity compared to white (HR, 2.84; p = 0.012), and a higher Charlson-Deyo score (score 1: HR, 2.28; p < 0.001 and score ≥2: HR, 2.76; p = 0.011) were associated with worse OS.

CONCLUSION

Treatment for HEH remains variable with only a third of the patients undergoing surgery. International collaboration is necessary to determine the optimal treatment for this rare disease.

MicroRNA profile of hepatic epithelioid hemangioendothelioma: A case report

A 72-year-old female was referred for further evaluation of epigastralgia. Abdominal contrast computed tomography revealed numerous tumors in the two lobes of the liver. Liver biopsy and immunohistochemical staining revealed that the tumor cells were positive for factor VIII-associated antigen, platelet endothelial cell adhesion molecule 1 and human hematopoietic progenitor cell antigen, concordant with a diagnosis of hepatic epithelioid hemangioendothelioma (HEH). To elucidate the etiology of HEH, particularly the microRNA (miRNA) profiles, tissue samples obtained from normal and tumor tissues were analyzed using a miRNA array system. A total of 14 miRNAs were significantly upregulated and 93 miRNAs were downregulated in the tumor tissues (P<0.01). Additionally, unsupervised hierarchical clustering analysis using Pearson's correlation revealed that the tumor tissues clustered separately from the normal tissues. The miRNA expression profile was analyzed in HEH and compared with angiosarcoma, which exhibits histology similar to HEH. Out of a total of 107 miRNAs, only miR-122-5p and miR-1290 demonstrated a differential expression pattern in angiosarcoma. Therefore, these miRNAs may be novel biological markers for the determination of a diagnosis of HEH in primary mesenchymal tumors of the liver. To the best of our knowledge, this study is the first report of a miRNA microarray analysis in HEH.

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.

Hepatic epithelioid hemangioendothelioma and the danger of misdiagnosis: report of a case

Malignant hepatic epithelioid hemangioendothelioma (HEHE) is a rare malignant tumor of vascular origin. Nonspecific symptoms and the absence of experience of surgeons, radiologists, and histopathologists due to the rarity of HEHE make the diagnosis of this entity very challenging. Misdiagnosis is not a rare event, and the consequences of such an event are catastrophic. We report a case of a patient suffering from HEHE in which the initial diagnosis was hepatocellular carcinoma (HCC). The presence of normal laboratory values, liver function tests, tumor markers along with the absence of a chronic liver disease, or any other predisposing factors for HCC, was in contrast with the diagnosis of HCC. Clinical suspicion drove us to the repetition of a liver biopsy and the reevaluation of the sample by a more experience histopathology department in liver tumors. The last biopsy confirmed the diagnosis of HEHE, and the patient escaped any unnecessary treatment for a nonexisting HCC.

Liver transplantation for hepatic epithelioid hemangioendothelioma: the Canadian multicentre experience

INTRODUCTION

Hepatic epithelioid hemangioendothelioma (HEHE) is a rare entity. At the present time, there is no standardized effective therapy. Liver transplantation (LT) has emerged as a treatment for this rare tumour.

OBJECTIVE

To evaluate the outcome of liver transplantation for HEHE at eight centres across Canada.

METHODS

The charts of patients who were transplanted for HEHE at eight centres across Canada were reviewed.

RESULTS

A total of 11 individuals (eight women and three men) received a LT for HEHE. All LTs were performed between 1991 and 2005. The mean (+/- SD) age at LT was 38.7+/-13 years. One patient had one large liver lesion (17 cm x 14 cm x 13 cm), one had three lesions, one had four lesions and eight had extensive (five or more) liver lesions. One patient had spleen involvement and two had involved lymph nodes at the time of transplantation. The mean duration of follow-up was 78+/-63 months (median 81 months). Four patients (36.4%) developed recurrence of HEHE with a mean time to recurrence of 25+/-25 months (median 15.6 months) following LT. The calculated survival rate following LT for HEHE was 82% at five years.

CONCLUSIONS

The results of LT for HEHE are encouraging, with a recurrence rate of 36.4% and a five-year survival rate of 82%. Further studies are needed to help identify patients who would benefit most from LT for this rare tumour.

Solitary splenic lesions

Solitary splenic lesions are unusual. A differential diagnosis can be organized around their basic imaging appearance as either predominantly cystic or solid. Other imaging characteristics, including vascular enhancement and activity on Tc-99m sulfur colloid scan, as well as clinical history may narrow the diagnostic possibilities. Cystic lesions include post-traumatic, inflammatory and infectious pseudocysts, congenital cysts, lymphangiomas and cystic metastasis. Solid lesions include both nonneoplastic lesions such as splenic hamartoma, benign tumors such as hemangioma and malignant masses including lymphoma and angiosarcoma. Percutaneous biopsy may be used for histologic diagnosis when required.

Primary malignant hepatic epithelioid hemangioendothelioma: a comprehensive review of the literature with emphasis on the surgical therapy

Malignant hepatic epithelioid hemangioendothelioma (HEH) is a rare malignant tumor of vascular origin with unknown etiology and a variable natural course. The authors present a comprehensive review of the literature on HEH with a focus on clinical outcome after different therapeutic strategies. All published series on patients with HEH (n = 434 patients) were analyzed from the first description in 1984 to the current literature. The reviewed parameters included demographic data, clinical manifestations, therapeutic modalities, and clinical outcome. The mean age of patients with HEH was 41.7 years, and the male-to-female ratio was 2:3. The most common clinical manifestations were right upper quadrant pain, hepatomegaly, and weight loss. Most patients presented with multifocal tumor that involved both lobes of the liver. Lung, peritoneum, lymph nodes, and bone were the most common sites of extrahepatic involvement at the time of diagnosis. The most common management has been liver transplantation (LTx) (44.8% of patients), followed by no treatment (24.8% of patients), chemotherapy or radiotherapy (21% of patients), and liver resection (LRx) (9.4% of patients). The 1-year and 5-year patient survival rates were 96% and 54.5%, respectively, after LTx; 39.3% and 4.5%, respectively, after no treatment, 73.3% and 30%, respectively, after chemotherapy or radiotherapy; and 100% and 75%, respectively, after LRx. LRx has been the treatment of choice in patients with resectable HEH. However, LTx has been proposed as the treatment of choice because of the hepatic multicentricity of HEH. In addition, LTx is an acceptable option for patients who have HEH with extrahepatic manifestation. Highly selected patients may be able to undergo living-donor LTx, preserving the donor pool. The role of different adjuvant therapies for patients with HEH remains to be determined.

Angiosarcoma of the spleen: imaging characteristics in 12 patients

PURPOSE

To retrospectively review clinical, pathologic, and imaging features of angiosarcoma of the spleen in 12 patients.

MATERIALS AND METHODS

Institutional review board approval was obtained, and informed consent was not required. Records of 12 cases of proved angiosarcoma of the spleen were accessed from the files of the Armed Forces Institute of Pathology. Clinical, pathologic, and imaging findings were reviewed. Presenting signs and symptoms were recorded, and the pathologist confirmed the diagnosis and determined gross and microscopic morphologic findings in each spleen. Radiologists reviewed available images to determine the size of the spleen and mass, amount of splenic involvement by the tumor (if enhanced at computed tomography [CT] and magnetic resonance [MR] imaging), and amount of nonviable tumor determined as decreased echogenicity at ultrasonography (US) and lack of enhancement at CT and MR imaging. Imaging and pathologic findings were compared. Five US, 10 CT, three MR, and two angiographic images were reviewed by two experienced abdominal radiologists.

RESULTS

There were seven men and five women (age range, 36-86 years; mean, 55 years). The most common symptom was upper abdominal pain in eight (67%) patients: Pain was acute for 24 hours prior to admission in one patient and chronic (range, 1-6 months) in seven patients. At imaging, the spleen was enlarged (>12 cm in length) in nine patients. The most common finding, seen in seven (58%) patients, was a complex mass or masses in an enlarged spleen. Four of these patients had evidence of metastases and one had intraperitoneal hemorrhage. Two patients had solitary hypervascular tumors and liver metastases. One patient had a normal-sized spleen with multiple lesions that ranged 2-3 cm in size, as well as metastases to the spine. The 11th patient had two small lesions, with small calcifications in the periphery of one lesion. The 12th patient had intraabdominal hemorrhage around the spleen and no obvious mass at CT. Tumor necrosis was confirmed at histologic evaluation in nine patients.

CONCLUSION

The most common clinical finding was upper abdominal pain. Angiosarcoma of the spleen could be suggested in the majority of cases (83%) by using the imaging features of splenic mass with evidence of metastatic disease.

Splenic vascular tumors

Splenic vascular tumors are uncommon and are more typically encountered as benign incidental findings. By contrast, splenic angiosarcoma may present acutely and dramatically and typically pursues a very aggressive clinical course. Vascular tumors in the spleen may show conventional endothelial, specialized endothelial (sinusoidal/littoral cell) or lymphatic differentiation and there is morphologic overlap between some of the currently defined diagnostic categories, within which benign, intermediate, and malignant subsets are recognized. The greatest problem in trying to better define and analyze these tumors is the availability of only relatively small case numbers. This overview describes the diagnosis and differential diagnosis of splenic vascular tumors as presently understood.

Hemangioendothelioma of the spleen: imaging findings at color Doppler, US, and CT

The ultrasonographic, color Doppler, and computed tomography findings of an unusual vascular primary tumor of the spleen are reported. A brief clinical and histopathological analysis of this entity is discussed and the differential diagnosis of other primary lesions of the spleen is attempted.

Case report: successful palliative treatment with intraperitoneal OK-432 injection for epithelioid haemangioendothelioma presenting with intractable ascites

Epithelioid haemangioendothelioma is an unusual type of endothelium-derived vascular tumour of borderline malignancy, which has high variability in clinical presentations, depending on the primary site of involvement. We report on a 20-year-old woman who presented with progressive abdominal fullness for 6 months. Multiple lung and liver nodules with pleural effusion and profuse ascites were found. The diagnosis of epithelioid haemangioendothelioma was made after wedge biopsy of the liver. The ascites was intractable and refractory to strong diuretic therapy and repeated paracentesis. Therefore, six courses of intraperitoneal injection of OK-432 were administered. The ascites subsided to a minimal amount after treatment and the patient remained symptom-free for approximately 8 months. The ascites recurred later and another three courses of intraperitoneal injection of OK-432 were administered. The ascites disappeared again. The patient has remained symptom-free since the end of the second period of treatment.

Epithelioid hemangioendothelioma of the liver. A rare hepatic tumor

BACKGROUND

Epithelioid hemangioendothelioma (EH) is a rare neoplasm of vascular origin that may develop at different sites, such as in soft tissue, the lungs, or the liver. It usually affects adult females, and its unpredictable malignant potential has a range between benign hemangioma and clearly malignant hemangioendotheliosarcoma.

METHODS

In the current study, the authors describe 2 patients with primary EH of the liver and review 127 previously published cases found in the literature.

RESULTS

Most patients presented with nonspecific symptoms, such as right upper quadrant abdominal pain or weight loss. The tumors usually presented as multiple nodular lesions involving both lobes of the liver. Overall metastasis rate was 45.1%, with preferential involvement of the lungs and bones. In general, the key to diagnosis was the demonstration of cells containing factor-VIII-related antigen.

CONCLUSIONS

EH of the liver is a very rare clinical entity. The primary treatments of choice are radical hepatic resection or orthotopic liver transplantation. The 5-year survival of 55.5% is significantly better than for other hepatic malignancies.