Retiform hemangioendothelioma treated with Mohs micrographic surgery

Malignant Superficial Mesenchymal Tumors in Children

Malignant superficial mesenchymal tumors are a very diverse group of neoplasms with few clinical and radiological discriminatory factors. Hence, some of these cancers are rarely suspected based on clinical and radiological grounds, others may be easily misdiagnosed, and the histological analysis of a biopsy or resection is central in the diagnostic process. In children, the age at presentation is a major element of the differential diagnosis. Some tumors have a very distinct epidemiology, while others may be seen at any age. More recently, the advances in molecular biology have greatly improved the diagnosis of mesenchymal tumors and new entities are still being described. In the present review, we provide an overview of the diversity of malignant superficial mesenchymal tumors in children, including new and/or rare entities. We discuss the important diagnostic features, be they clinical, histological, or molecular. Special attention was given to the genetic features of these tumors, particularly when they were helpful for the diagnosis or treatment.

Retiform hemangioendothelioma: a case series and review of the literature

BACKGROUND

Retiform Hemangioendothelioma (RH) is an extremely rare vascular tumor of intermediate biological behavior, which is prone to local recurrence but rarely shows metastasis to distant sites. It may harbor areas resembling Dabska tumor in some cases and angiosarcoma, which in its well differentiated form may exhibit similar pathological appearance in some areas, making it problematic to rule out a possibility of a malignant diagnosis on a core biopsy. Therefore, complete surgical resection with negative margins is essential for accurate diagnosis and local control.

RESULTS

In our series, two of the three Pakistani cases were in females, with an age range between 18 and 50 years. Our first patient presented with symptoms of cardiac compromise and pulmonary hypertension. Her computed tomography scan showed multiple tumor masses within the mediastinum. The second patient presented with an ulcerated lesion on his scalp, at right temple. The third patient presented with a hard growth on her left 4th toe which was amputated. Histologically, all cases exhibited retiform arborizing vascular spaces lined by bland endothelial cells with hobnail nuclei, characteristic of retiform hemangioendothelioma. Immunohistochemical markers CD31, CD34 and ERG confirmed the vascular nature of the tumor. The first and the second patient are alive and healthy at 4 and 7 months follow up respectively, while the third patient is lost to follow up.

CONCLUSION

Owing to the rate of local recurrence, RH should always be considered in the differential diagnosis of vascular tumors showing arborizing blood vessels, as it may have an atypical presentation and it should be carefully differentiated from Dabska tumor and an angiosarcoma.

Vascular tumors

Vascular tumors are a rare subset of vascular anomalies. These are classified based on their malignant potential or local destruction potential. Classification has been historically difficult and treatment recommendations are based on case series. The purpose of this chapter is to review the presentation, pathologic and imaging characteristics. Treatment recommendations are summarized based on the current literature. Congenital and infantile hemangiomas are covered separately in a separate chapter in this issue.

Systematic review of Mohs micrographic surgery in children: Identifying challenges and practical considerations for successful application

BACKGROUND

Few data exist to guide the application of Mohs micrographic surgery (MMS) in the pediatric population.

OBJECTIVE

We sought to summarize the clinical characteristics of children undergoing MMS, identify challenges that limit the use of MMS in this population, and examine how these challenges can be overcome.

METHODS

A systematic review of PubMed and EMBASE, from inception of databases to November 2, 2019, identified all cases of pediatric skin lesions treated with MMS.

RESULTS

A total of 111 patients were included. The median patient age was 11 years (range 6 weeks to 17 years). The most commonly treated tumor was dermatofibrosarcoma protuberans (n = 62), followed by basal cell carcinoma (n = 30). The most common location was the head and neck (n = 34), followed by the trunk (n = 28) and the extremities (n = 23). The most commonly cited challenges in the application of MMS in children included patient cooperation, concerns for the safety of prolonged general anesthesia, availability of a MMS service in the pediatric setting, and access to a histopathology laboratory experienced in MMS sectioning.

LIMITATIONS

Many articles did not report specific patient characteristics.

CONCLUSION

Multiple obstacles limit the application of MMS in pediatric patients. This review describes practical methods to circumvent these obstacles to facilitate the appropriate use of MMS in children.

Mohs micrographic surgery for cutaneous malignancies: A focus review of its indications in pediatric age groups

Mohs micrographic surgery (MMS) is a highly specialized technique that has been successful in the treatment of a variety of skin tumors. The technique can be performed as an outpatient procedure and encompasses surgical excision and intraoperative assessment of tumor margins in one setting by the same physician. The process ensures precise margin control with maximal preservation of healthy tissues. Mohs micrographic surgery has been practiced worldwide, including in the United States, Europe (United Kingdom, Germany, Spain, Netherlands, Switzerland), and Australia. Although it is commonly performed in adults with greater success, it has been discussed less frequently in children. In this article, we describe several cutaneous tumors in children and the role of Mohs micrographic surgery in their management. A PubMed search was conducted to review the most common cutaneous tumors in children treated using Mohs micrographic surgery. In this review, we discuss indications for Mohs micrographic surgery and pertinent studies examining success rates in children. Mohs micrographic surgery has been used to treat several tumors in children and offers the advantage of high cure rates and tissue conservation. This report emphasizes the benefits of Mohs micrographic surgery in children and highlights several cutaneous tumors for which it has been used to treat successfully.

Retiform hemangioendothelioma treated with conservative therapy: report of a case and review of the literature

BACKGROUND

Retiform hemangioendothelioma (RH) is a locally aggressive vascular tumor. Wide surgical excision with tumor-free margins is the standard treatment strategy. However, surgical excision is not an option for lesions near critical anatomical structures, such as those on the face. We report the case of a patient with retiform hemangioendothelioma that responded to non-surgical treatments.

METHODS

We describe the case of a 72-year-old male patient with a retiform hemangioendothelioma on the face that responded to a combination of pulsed dye laser, local corticosteroid injection, and application of imiquimod cream. In addition, we reviewed past case reports of patients with retiform hemangioendothelioma.

RESULTS

Thirty-five cases that describe the management of RH, including the present case, have been reported. Review of the cases indicate a relatively low disease-free survival rate in cases that underwent surgical excision as the initial therapy for retiform hemangioendothelioma.

CONCLUSION

Surgical excision might not be the best therapeutic option. Local control with conservative therapy is an acceptable strategy for lesions in anatomical regions including the face.

Retiform hemangioendothelioma: an uncommon pediatric vascular neoplasm

Retiform hemangioendothelioma is considered as a low grade angiosarcoma, commonly seen in 2^nd-4^th decade of life. The youngest patient reported is of 9 years of age. A 9-year-old boy was presented with an asymptomatic red patch on the chest since 1 year. There was an erythematous patch with nodule of about 5 mm near the distal margin. Biopsy from the nodule revealed numerous thin-walled branching vessels in dermis resembling rete testis, suggestive of retiform hemangioendothelioma. We, hereby, report this case for its rarity and uncommon clinical presentation in childhood period.

RETIFORM HEMANGIOENDOTHELIOMA OF THE FINGER: A CASE REPORT

Retiform hemangioendothelioma is a rare, intermediate-grade, locally aggressive vascular tumour that involves the skin and soft tissues of the trunk and extremities (1–10). Macroscopically it appears as a plaque or an exophytic lesion. Involvement of the hand or upper extremity is rare, with only Three cases reported in the literature (2, 3, 9). Treatment usually involves surgical excision or amputation (2). We present the case of a middle-aged woman with a retiform hemangioendothelioma of the small finger, successfully treated with surgical excision with no signs of recurrence at 4 years of follow-up.