Resection of the largest reported hepatic small vessel neoplasm

Incidental Vascular Lesion in Explanted Liver: A Rare Case Report and Review of the Literature

Hepatic small vessel neoplasm (HSVN) is a rare vascular hepatic lesion that is usually an asymptomatic incidental finding. Here we present a case of a 66-year-old male with HSVN who was discovered to have a lesion presenting as a small nodule in an explanted liver. HSVN is a recently described hepatic vascular lesion that has been previously underdiagnosed. It has an uncertain long-term malignant potential, so close follow-up is recommended.

Hepatic small vessel neoplasm: not totally benign, not yet malignant

Hepatic small vessel neoplasm (HSVN) is a rare vascular tumor with few reports in the literature. While imaging findings may show characteristic enhancement patterns, limited available literature may not reveal the full potential for image-based diagnosis. Histologically, HSVN mimics other entities, though certain morphologic and immunohistochemical findings provide clues for diagnosis. However, HSVN still provides diagnostic challenges, especially on core biopsies with limited material for morphologic and molecular evaluation. While current recommendations are surgical resection and close observation, the long-term course of the tumor is unknown. We report a case of HSVN in a liver with additional feature of organized lymphoid aggregates necessitating additional hematopathology consultation and workup to rule out concurrent entities.

Hepatic Small Vessel Neoplasm: A Case Report and Review of the Literature

Hepatic small vessel neoplasm (HSVN) is a recently described vascular neoplasm of the liver. It demonstrates an infiltrative growth pattern and lacks cytologic atypia and mitotic activity. So far, no cases of metastasis or disease recurrence after excision have been reported in the literature. In this report, we present the case of a 31-year-old woman with a lesion in segments VII-VIII of the liver who was referred to our surgical department due to right lumbar pain. She underwent an atypical wedge hepatectomy (segments VII, VIII) and cholecystectomy. The histopathology of the resected specimen confirmed a 40mm HSVN. The patient did not receive any adjuvant therapy and is scheduled for follow-up with serial magnetic resonance imaging (MRI) scans over the next five years due to the unknown malignant potential of the tumor.

Multifocal hepatic small vessel neoplasm with spleen dissemination

Among liver vascular tumours, hepatic small vessel neoplasm (HSVN) has been recently identified as a rare infiltrative vascular neoplasm whose malignant potential is yet to be fully ascertained. About 30 cases of HSVN have been described so far. The most common clinical presentation is an asymptomatic solitary liver lesion. Multifocal disease has been described in literature; however, to date, there are no reports of disease dissemination to other organs. Here we report a case of multifocal HSVN with synchronous spleen secondary lesions.

Hepatic small vessel neoplasm - A systematic review

Background

Hepatic small vessel neoplasm (HSVN) is a recently described vascular neoplasm of the liver that can mimic hepatic angiosarcoma (AS) because of its infiltrative nature but is considered biologically less aggressive. We carried out a systematic review of the literature after previously coming across a case of HSVN [1] to guide our surveillance.

Methods

We conducted a systematic review for all cases using PubMed, EMBASE, Cochrane Central Register of Controlled Trials, case report journals and Google Scholar according to the PRISMA guidelines using the terms “hepatic small vessel neoplasm” or “hepatic small vessel neoplasia” with no language restrictions. The review was registered with Research Registry (UIN: reviewregistry1127) [2].

Results

We identified 69 articles, of which 6 articles were eligible after screening. A total of 23 cases were identified. Median age was 58 (range 24–83 years) with a male preponderance (17 M:6F). Mean tumour size was 2.8 cm (range 0.2–15.9 cm). Mean follow-up was 7 months (range 1–24 months) with no reported evidence of recurrence in both patient groups with no residual disease or with positive margins after resection.

Discussion

HSVN appears to demonstrate a benign clinical course with no reported recurrences or metastatic disease. Long-term follow-up data will further supplement our understanding of these tumours and guide future management.

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HSVN is a recently described neoplasm with uncertain long-term malignant potential.

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23 cases have been identified, mean follow-up was 7 months (range 1–24 months).

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There is no reported evidence of recurrence in patients with no residual disease.

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There is no reported evidence of recurrence in patients with residual disease.

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Follow-up is limited in reported cases.

A Novel Entity Among Vascular Liver Tumors: The First Reported Liver Transplantation. Is It Feasible?

Liver transplant could be considered for certain tumors even if there is still dubious indication, as in the case of hepatic small vessels neoplasms that pose a difficult differential diagnosis with liver angiosarcoma. Liver transplant could be the best choice for patients with stable or slow-progressing tumors, for young patients with impaired quality of life, and when it would use organs that would be otherwise discarded but are capable of affording a good function. Vascular tumors are very heterogeneous cancers and our case represents the first description of a new histologic lesion that cannot be included in any of the pre-existing diagnostic categories. In our paper we want to present our decision to transplant a patient in whom the diagnosis was hepatic small vessels neoplasms (but was still in doubt for angiosarcoma as suggested by pathologists form other institutions). Furthermore, we want to highlight that after liver transplant, a new lesion never described before resulted from the specimen analysis that does not fit any of the pathologic diagnostic categories. This finding could open a scenario for additional improvement in molecular analysis in order to differentiate liver vascular tumors or even single lesion histotypes. This article emphasizes how little we know about the real behavior of liver vascular tumors and their clinical and therapeutic outcomes; we want to raise a question about the possibility for liver transplant in the setting of tumors not yet fully known and in which, in cases of diagnostic doubts, this option has been traditionally excluded, possibly bypassing ethical implications by using marginal donors.

Hepatic small vessel neoplasm case report: A surveillance conundrum

INTRODUCTION

Hepatic small vessel neoplasm (HSVN) is a recently described vascular neoplasm of the liver that can mimic hepatic angiosarcoma (AS) because of its infiltrative nature but is considered benign or, at most, low-grade. HSVN appears to demonstrate a benign clinical course with no reported recurrences or metastatic disease, although its long-term malignant potential is uncertain.

CASE PRESENTATION

We present a 57-year-old man with an incidentally growing segment VII lesion that displayed features concerning for a neoplasm. He underwent a posterior sectionectomy and final histopathology confirmed a 27 mm HSVN. As the long-term malignant potential of HSVN is uncertain, he will be followed up with serial MRI scans over the next 5 years.

DISCUSSION

HSVN is a recently described entity, it is uncertain what the long-term malignant potential of HSVN can be. Reported cases have not shown any evidence of disease progression.

CONCLUSION

There are no clear guidelines established on the duration of the follow-up of HSVN. More research needs to be done to determine further the natural history of these tumours and possible radiological criteria.

Frequent GNAQ and GNA14 Mutations in Hepatic Small Vessel Neoplasm

Hepatic small vessel neoplasm (HSVN) is a recently described infiltrative vascular neoplasm of the liver, composed of small vessels. Although the infiltrative nature can mimic angiosarcoma, HSVN are thought to be benign or low-grade neoplasms because they lack cytologic atypia and increased proliferation. To characterize the molecular pathogenesis of HSVN, we performed both targeted panel sequencing and exome sequencing on 18 benign or low-grade vascular neoplasms in the liver including 8 HSVN, 6 classic cavernous hemangioma (CH), and 4 variant lesions (VL) with overlapping features between HSVN and CH. All 18 lesions had simple genomes without copy number alterations. In total, 75% (6/8) of HSVN demonstrated known activating hotspot mutations in GNAQ (2/8, p.Q209H) or GNA14 (4/8, p.Q205L), and the remaining 2 had the same missense mutation in GNAQ, p.G48L, which has not been previously described. 25% (1/4) of VL had a hotspot GNAQ p.Q209H mutation and another VL had a GNAQ p.G48L mutation. Known pathogenic mutations were not identified in any of the 6 CH. These data suggest that HSVN share a similar molecular biology to several other vascular lesions (congenital hemangioma, tufted angioma, anastomosing hemangioma, lobular capillary hemangioma, and kaposiform hemangioendothelioma) recently reported to have GNAQ, GNA11, or GNA14 mutations.

Anastomosing hemangioma of liver

Anastomosing hemangiomas are a rare subtype of benign vascular hemangioma which most commonly arise in the genitourinary tract and retroperitoneum. In only a small number of reports has this entity been shown originating within the liver parenchyma. Despite their benign behavior, on contrast-enhanced computer tomography and magnetic resonance imaging studies anastomosing hemangiomas can demonstrate enhancement characteristics similar to primary and metastatic liver lesions. This case report highlights the imaging features of this entity and provides a brief review of the limited literature that exists on this rare hepatic lesion.

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.

Targeting SPINK1 in the damaged tumour microenvironment alleviates therapeutic resistance

Chemotherapy and radiation not only trigger cancer cell apoptosis but also damage stromal cells in the tumour microenvironment (TME), inducing a senescence-associated secretory phenotype (SASP) characterized by chronic secretion of diverse soluble factors. Here we report serine protease inhibitor Kazal type I (SPINK1), a SASP factor produced in human stromal cells after genotoxic treatment. DNA damage causes SPINK1 expression by engaging NF-κB and C/EBP, while paracrine SPINK1 promotes cancer cell aggressiveness particularly chemoresistance. Strikingly, SPINK1 reprograms the expression profile of cancer cells, causing prominent epithelial-endothelial transition (EET), a phenotypic switch mediated by EGFR signaling but hitherto rarely reported for a SASP factor. In vivo, SPINK1 is expressed in the stroma of solid tumours and is routinely detectable in peripheral blood of cancer patients after chemotherapy. Our study substantiates SPINK1 as both a targetable SASP factor and a novel noninvasive biomarker of therapeutically damaged TME for disease control and clinical surveillance.

Vascular tumours of the liver: a particular story

Vascular tumours of the liver represent an underrated chapter of medical and surgical hepatology. These tumours cover a wide spectrum ranging from the frequent and most benign hepatic haemangioma (HH), via the rare and intermediately aggressive hepatic epithelioid haemangioendothelioma (HEHE) to the rare and most malignant hepatic haemangiosarcoma (HHS). In contrast to the treatment algorithms for hepatocellular and cholangiocellular cancer, the diagnostic and therapeutic approaches to HEHE and HHS are not well developed. The related uncertainty is explained by their rare occurrence and their protean clinical, morphological (imaging) and histopathological presentation and behaviour. This article gives an update about these particular tumours based on the analysis of the recent literature and of the studies on vascular tumours published by the European Liver Intestine Transplantation Association (ELITA)-European Liver Transplant Registry (ELTR). It focuses also on the place of liver transplantation (LT) in the respective therapeutic algorithms. The differential diagnosis between these vascular and other tumour types may be very difficult. Correct diagnosis is of utmost importance and is based on a high index of clinical suspicion and on the integration of clinical, radiological, histological [including immunohistochemistry (IHC) and molecular biology findings]. Surgery, be it partial or total hepatectomy (LT), should be proposed whenever possible, because it is the therapeutic mainstay. In HEHE, LT provides excellent results, with long-term disease-free survivals (DFS) reaching 75%. Good results can be obtained even in case of (frequent) extrahepatic spread. Based on the extensive ELITA-ELTR study a HEHE-LT prognostic score has been proposed in order to estimate the risk of recurrence after LT. In contrast, results of surgery and LT are extremely poor for HHS, for the almost invariably rapid recurrence (within 6 months) and related death within 2 years. LT remains a contraindication for HHS. Due to the still important recurrence rate after surgical resection (25% in HEHE and almost 100% in HHS), there is an urgent need to develop pharmacological treatments targeting angiogenic and non-VEGF angiogenic pathways. To date, some prospective pilot studies and case reports have shown some short-term stabilisation of the disease in small groups of patients. In order to make progress, combination of surgery, anti-angiogenic and immunotherapy seems worthwhile. To complete the panel of vascular liver tumours, infantile haemangioendothelioma, haemangiopericytoma, nodular regenerative hyperplasia (NRH) and hepatic small vessel neoplasms (HSVN) are also discussed.