Primary De Novo Angiosarcoma of the Pleura

Pleural angiosarcoma presenting with spontaneous hemothorax

Angiosarcomas (ASs) are very rare and constitute 1-2% of soft tissue malignancies. Primary pleural AS (PPAS) is a very rare neoplasm, with only 50 cases reported in the literatüre, and is a tumor with a high tendency for local recurrence and metastasis, with an aggressive course and a generally poor prognosis unless diagnosed early. It originates from the endothelial cells of small blood vessels and therefore can affect many organs. The etiology and definitive method in the treatment is still unclear. Patients usually present with nonspecific symptoms such as cough, dyspnea, chest pain, and hemoptysis. Recurrent exudative or hemorrhagic pleural effusion may develop due to its pleural location. The diagnosis can be made by histopathological and immunohistochemical examinations of excisional biopsy specimens. The effectiveness of chemotherapy and radiotherapy is weak and can be applied for palliative purposes. Surgical approach can be used for diagnostic and palliative purposes. Due to the high degree of malignancy and insidious course of PPAS, patients usually die within months after diagnosis. In these patients, surgical exploration is important for the diagnosis and palliative/definitive treatment of the disease. We present a 61-year-old male patient who presented with dyspnea, chest pain, and massive pleural effusion findings in the left hemithorax and was diagnosed with PPAS as a result of pleural biopsy.

Primary epithelioid hemangioendotheliomas and angiosarcomas of the pleura: a clinicopathological and immunohistochemical analysis of 13 cases

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.

Characteristics and outcomes of primary pleural angiosarcoma: A retrospective study of 43 published cases

Primary pleural angiosarcoma (PPA) is an extremely rare malignancy for which there is no consensus on treatment. The clinical course of PPA is usually quickly fatal, regardless of the treatment used.We summarized and evaluated a relatively large population of published PPA cases to assess prognostic factors, diagnostic approaches, treatment methods and clinical outcomes. Using the CNKI, Embase, and PubMed databases, literature published in English and Chinese from 1988 through 2020 was searched using the terms "primary pleural angiosarcoma," "pleural angiosarcoma," and "pleuropulmonary angiosarcoma."A total of 43 patients with PPA were identified in retrospective case series and case reports. The median age at diagnosis was 64 years (range 24-87 years), and the median overall survival was 4 months (range 0.1-180 months). Approximately 80% of patients died from PPA within 10 months of diagnosis, and the 2-year survival rate was approximately 4.4%. In univariate analyses, the presence of pleural effusion and hemothorax were significant predictors of decreased survival, with hazard ratios (HRs) of 2.7 (P = .04) and 3.3 (P = .006), respectively. Sixteen patients received no therapy, and their prognosis was worse than patients who did receive therapy (P = .019). Radiation therapy improved survival more than no radiation therapy (P = .007). Patients appeared to derive clinical benefit from chemotherapy (P = .048). However, tumor resection did not seem to provide a survival benefit (P = .051). In multivariate analysis, tumor resection, and radiation were independent, statistically significant, positive predictors of better survival, with HRs of 0.3 (P = .017) and 0.1 (P = .006), respectively. The presence of hemothorax was an independent predictor of worse prognosis (P = .006).Primary angiosarcoma of the pleura is a rare, poorly understood malignancy with a poor prognosis; hence, the clinical spectrum of PPA is not completely defined. By multivariate analysis, this retrospective study showed a survival benefit of tumor resection or radiation therapy, and the presence of hemothorax was a significant prognostic factor for poor outcomes.

Primary pleural epithelioid angiosarcoma treated successfully with anti-PD-1 therapy: A rare case report

RATIONALE

Primary pleural angiosarcoma (PPA) is an extremely rare malignancy for which there is no consensus on treatment. The clinical course of PPA is usually quickly fatal, regardless of the treatment used.

PATIENT CONCERNS

We describe the rare case of a 52-year-old man who presented initially with hemoptysis and received emergency surgery for the primary.

DIAGNOSES

He received a confirmed diagnosis of primary pleural angiosarcoma (PPA) by postoperative pathology and was subsequently treated with radiotherapy and chemotherapy, but had failed and was intolerant to chemotherapy.

INTERVENTIONS

The patient had 5% tumor PD-L1 positivity with 22C3 pharmDx and received pembrolizumab (200 mg every 21 days) for 13 cycles.

OUTCOMES

The disease remained well controlled according to the RECIST 1.1. criteria. He is currently under observation and waiting to start the next cycle of immunotherapy.

LESSON

Our case report suggests that the use of anti-PD-1 therapy does show efficacy in the treatment of PPA and may provide a viable treatment option for patients.

Primary pleural epithelioid angiosarcoma manifesting as a loculated hemothorax: A case report and literature review focusing on CT findings

Primary pleural angiosarcoma (PPA) is an extremely rare and clinically aggressive tumor. We report the case of a 66-year-old man having PPA with chest computed tomography (CT) scan showing a large oval-shaped, nonenhancing high attenuation cystic mass in the left hemithorax. Morphological and immunohistochemical findings supported the diagnosis of epithelioid angiosarcoma. Pleural angiosarcoma should be considered in the differential diagnosis of spontaneous hemothorax manifesting as high attenuation loculated pleural fluid on CT.

Primary pleural angiosarcoma: Case report and literature review

Primary pleural angiosarcoma is an exceptionally rare malignancy of pleura originating from the vascular endothelial cells. Here, we present a 70-year-old African-American female who presented with 1-month history of dyspnea on exertion, loss of appetite, and loss of weight along with left-sided pleuritic chest pain. Evaluation revealed hemorrhagic pleural effusion in the left pleural cavity. Computed tomography of the chest performed after therapeutic thoracocentesis revealed left upper lobe lung mass along with multiple nodules in right lung. Mass was biopsied at video-assisted thoracoscopy. Histopathology was consistent with high-grade angiosarcoma. Endothelial origin of the tumor cells was confirmed with positive immunohistochemical staining with CD31 antibodies. Our patient was diagnosed with primary pleural angiosarcoma metastatic to the lung. She opted for palliative care and had a rapidly declining clinical course and expired within 5 weeks of the diagnosis. Here, we present a case report and review the relevant literature.

Primary epitheloid angiosarcoma of the pleura: an exceptional tumor location

Primary angiosarcoma of the pleura is an extremely rare tumour arising from arterial or venous pulmonary vessels of various size. It is characterized by an aggressive course and a poor prognosis. The early diagnosis is challenging due to diverse clinical and radiological manifestations. We report a case of a 70 year old male with primary right pleural epitheloid angiosarcoma. The patient had a history of a two week's progressive dyspnea. CT-scan showed a prominent thikening of the right pleura associated with pleural effusion and atelectasis. CT-scan guided by biopsy was performed and histological examination showed a tumor proliferation consisting of sheets of polygonal and epitheloid cells showing rudimentary vascular differentiation. Immunohistochemically, tumor cells were strongly positive for CD31 and Factor VIII-related antigen, negative for CD34, weakly and focally positive for EMA and Cytokeratine. The overall pathological and immunohistochemical features of the pleural specimens supported the diagnosis of epitheloid angiosarcma. The patient died after a week of discharge by pulsless ventricular tachycardia arrest. In addition, we also present a brief litterature review on pleural angiosarcoma. Our experience with this case suggests that comprehensive and sufficient sample collection and meticulous histological examination aided with immunohistochemical stains, particulary the endothelial markers, are required for accurate diagnosis of this rare malignancy.

Primary pleural angiosarcoma in a 63-year-old gentleman

Primary pleural angiosarcomas are extremely rare. As of 2010, only around 50 case reports have been documented in the literature. Herein, we report the case of a 63-year-old gentleman who presented with a 3-month history of right-sided chest pain, dyspnea, and hemoptysis. Chest X-ray showed bilateral pleural effusion with partial bibasilar atelectasis. Ultrasound-guided thoracocentesis showed bloody and exudative pleural fluid. Cytologic examination was negative for malignant cells. An abdominal contrast-enhanced computed tomography (CT) scan showed two right diaphragmatic pleural masses. Whole-body positron emission tomography/computed tomography (PET/CT) scan showed two hypermetabolic fluorodeoxyglucose- (FDG-) avid lesions involving the right diaphragmatic pleura. CT-guided needle-core biopsy was performed and histopathological examination showed neoplastic cells growing mainly in sheets with focal areas suggestive of vascular spaces lined by cytologically malignant epithelioid cells. Immunohistochemical analysis showed strong positivity for vimentin, CD31, CD68, and Fli-1 markers. The overall pathological and immunohistochemical features supported the diagnosis of epithelioid angiosarcoma. The patient was scheduled for surgery in three weeks. Unfortunately, the patient died after one week after discharge secondary to pulseless ventricular tachycardia arrest followed by asystole. Moreover, we also present a brief literature review on pleural angiosarcoma.

Rare pleural tumors

Primary pleural tumors other than mesothelioma account for fewer than 1% of all lung cancers, and consequently they pose diagnostic and management challenges. Their treatment must be targeted toward the specific tumor type and is often quite different from the treatment for mesothelioma or metastases. Despite the best efforts at diagnosing and treating these tumors, the prognosis associated with some of the benign and many of the malignant variants of these tumors remains poor. In this review, we describe the radiologic and pathologic features of the less common primary pleural tumors and propose a diagnostic approach to their evaluation.