Angiosarcomas arising in edematous extremities: immunostaining for factor VIII-related antigen and ultrastructural features

Clinical update on cutaneous and subcutaneous sarcomas

BACKGROUND

Cutaneous sarcomas are uncommon cancers that can have a wide range of clinical symptoms and lead to considerable cutaneous as well as systemic morbidity.

AIM

The objective of this review article is to discuss epidemiology, clinical features, diagnosis, and therapy of different types of cutaneous sarcomas.

MATERIAL AND METHODS

Literature was screened to retrieve articles from PubMed/Medline and Google Scholar and related websites. Cross-references from the relevant articles were also considered for review. Review articles, clinical studies, systematic reviews, meta-analyses, and relevant information from selected websites were included.

RESULTS AND DISCUSSION

Cutaneous sarcomas have a negative effect on the quality of life. In their diagnosis, clinical presentation and histological evaluation are crucial. Complete surgical removal is the solution for more or less all cutaneous and subcutaneous sarcomas. The prognosis for cutaneous sarcomas is generally favorable since they tend to recur locally with distant metastases only on rare occasions. Patients having advanced disease should be treated in the setting of clinical trials if possible; choices include radiation therapy and systemic medicines. The value of innovative immunotherapy cannot be determined decisively at this time due to a paucity of relevant trials.

CONCLUSION

As cutaneous sarcomas are rarely diagnosed based on clinical findings, histology plays an important role in the diagnosis. They have a relatively favorable prognosis if treated properly. Patients should be treated at specialized centres.

Lymphangiosarcoma of the scalp

BACKGROUND

Lymphangiosarcoma is a rare, aggressive malignancy that originates from the endothelial cells lining lymphatic vessels and carries an extremely poor prognosis. Its clinical and histologic features are often indistinguishable from angiosarcoma.

OBJECTIVE

We sought to better characterize the clinical and histologic features of lymphangiosarcoma.

METHODS

Case report and review of the literature.

RESULTS

A number of immunohistochemical markers, including Von Willebrand factor, Ulex europaeus agglutinin 1, CD31, VEGFR-3, D2-40, Prox-1, can be used to help differentiate lymphatic from vascular tissue.

CONCLUSIONS

Recent characterization of several new biologic markers has allowed greater differentiation between these tumors and may provide new therapeutic targets for treatment.

Endothelial stomatal and fenestral diaphragms in normal vessels and angiogenesis

Vascular endothelium lines the entire cardiovascular system where performs a series of vital functions including the control of microvascular permeability, coagulation inflammation, vascular tone as well as the formation of new vessels via vasculogenesis and angiogenesis in normal and disease states. Normal endothelium consists of heterogeneous populations of cells differentiated according to the vascular bed and segment of the vascular tree where they occur. One of the cardinal features is the expression of specific subcellular structures such as plas-malemmal vesicles or caveolae, transendothelial channels, vesiculo-vacuolar organelles, endothelial pockets and fenestrae, whose presence define several endothelial morphological types. A less explored observation is the differential expression of such structures in diverse settings of angiogenesis. This review will focus on the latest developments on the components, structure and function of these specific endothelial structures in normal endothelium as well as in diverse settings of angiogenesis.

[Syntopical and synchronous leiomyosarcoma and papillary carcinoma of the female breast]

A 61 years old female was treated by total lumpectomy due to a palpable and radiologically demonstrable tumor measuring 22 cm in diameter in the left breast. Two different but directly neighboured malignant tumours were found: a poorly differentiated leiomyosarcoma and a well differentiated invasive papillary carcinoma of the breast. The latter had metastasized in 4 axillary lymph nodes. Three months after surgery the patient died. Post-mortem studies showed many metastases of the leiomyosarcoma in both lungs, the heart, the liver, the left kidney and both adrenals. Cause of death were relapsing pulmonary thrombembolisms. Case reports of leiomyosarcomas following radiotherapy of the breast cancer are published but coincidental occurrence of both metastasizing tumors are so far not known from the literature.

Role of surgery in the management of postmastectomy extremity angiosarcoma (Stewart-Treves syndrome)

Stewart-Treves syndrome (STS) is the rare occurrence of angiosarcoma in a setting of postmastectomy upper extremity lymphedema. A collective comparison of outcomes following various initial treatment options in STS has not previously been reported. We reviewed 160 cases of STS reported in the literature since 1966. We analyzed the relationship between initial treatment and survival in all 92 of these patients for whom detailed treatment and outcome data had been reported. There was no significant difference in survival comparing those initially treated with wide excision (n = 16) and those treated with amputation (n = 45) (P = 0.40). Even in the setting of initial surgical treatment, overall long-term survival was poor (<40%). There have been even fewer long-term survivors among those treated initially with regional chemotherapy (n = 7) or radiation therapy (n = 24). An update on STS and a discussion of recent advances in the understanding of its molecular pathogenesis that may result in future treatment improvements are presented.

Cutaneous vascular proliferations. Part III. Malignant neoplasms, other cutaneous neoplasms with significant vascular component, and disorders erroneously considered as vascular neoplasms

In this third and last part of our review of cutaneous vascular proliferations we include malignant vascular neoplasms and a group of heterogeneous cutaneous neoplasms characterized by a significant vascular component. We also review some disorders that, in our opinion, have been erroneously considered as vascular neoplasms. We review the epidemiologic, histogenetic, clinical, and histopathologic aspects of Kaposi's sarcoma in its four distinctive variants (classic, African-endemic, immunosuppressive drug-associated, and AIDS-associated Kaposi's sarcoma). There is still controversy about whether Kaposi's sarcoma represents a reactive vascular proliferation or a true neoplastic proliferation. In any event, most authors believe that Kaposi's sarcoma does not produce metastatic disease, but rather develops in multifocal fashion. However, Kaposi's sarcoma may cause death, especially in immunosuppressed patients. Epithelioid hemangioendothelioma, Dabska's tumor, and retiform hemangioendothelioma are examples of low-grade angiosarcoma. In contrast, cutaneous angiosarcomas, including the clinical variants of angiosarcoma of face and scalp in elderly patients, angiosarcoma associated with lymphedema, and radiation-induced angiosarcoma are highly aggressive neoplasms with poor prognosis and most patients die within a short period after presentation. A group of benign and relatively frequent cutaneous neoplasms, including multinucleate cell angiohistiocytoma, angiofibroma, angioleiomyoma, angiolipoma, cutaneous angiolipoleiomyoma, and cutaneous angiomyxoma are here covered because of their significant vascular component. Finally, we review briefly a series of cutaneous disorders that have been erroneously considered as vascular neoplasms. Kimura's disease is an inflammatory reactive condition of unknown origin, "benign" angioendotheliomatosis is a reactive intravascular proliferation of endothelial cells that occurs in the skin as a response to a variety of stimuli, "malignant" angioendotheliomatosis is an intravascular lymphoma, and acral pseudolymphomatous angiokeratoma of children (APACHE) is better interpreted as a pseudolymphoma.

Low susceptibility of the spontaneously hypertensive rat (SHR) to quinoline-induction of hepatic hemangioendothelial sarcomas

Effects of quinoline and captafol, both of which are hemangiocarcinogenic agents, were investigated in spontaneously hypertensive rats (SHR). Male SHR and Wistar Kyoto rats (WKY), the parent strain of SHR, were administered quinoline (0.2%) or captafol (0.15%) supplemented in the diet for 32 weeks. Resultant incidences of hepatic hemangioendothelial sarcomas were in animals receiving quinoline 93% for WKY and only 7% for SHR. A few hepatocellular nodules were also induced in both strains. No histopathological lesions were observed in the other organs. Thus, the SHR proved unexpectedly less susceptible to vascular carcinogenicity than its WKY counterpart.

Use of immunohistochemical procedures in diagnosing angiosarcoma. Evaluation of 98 cases

BACKGROUND

Differential diagnosis of angiosarcoma, predominantly showing a non- or poorly vasoformative proliferation from other types of sarcomas, poorly differentiated carcinomas, and amelanotic melanoma, is often problematic.

METHODS

The use of antibodies directed against Factor VIII-related antigen (FVIIIRA), Ulex europaeus lectin type 1 (UEA-1), CD31, and vascular endothelial growth factor (VEGF) in the diagnosis of angiosarcoma was examined in 98 cases of autopsy-proven angiosarcoma diagnosed during 1974-1990 in a survey of 178 Japanese hospitals. Reactivity of angiosarcoma cells for epithelial membrane antigen, cytokeratin, and melanoma cell antigen (HMB45) also was examined.

RESULTS

Histologic specimens were formed exclusively by vasoformative areas in 32 cases and combined vasoformative and varying extents of non- or poorly vasoformative areas in another 66 cases. In vasoformative areas, the proliferating cells showed a diffuse positive reaction in the cytoplasm and/or cell surface for anti-FVII-IRA in 82 (84%) of 98 cases, for anti-CD31 in 78 (80%), and for UEA-1 in 69 (70%). In non- or poorly vasoformative areas, the positivity rate for FVIIIRA, CD31, and UEA-1 was 29%, 62%, and 46%, respectively. A positive reaction was found for either one of three endothelial markers in the non- or poorly vasoformative areas of 57 cases (86%). Epithelial membrane antigen and anticytokeratin antibody were positive in 4 and 11 cases, respectively, in the vasoformative areas and in 3 and 14 cases, respectively, in non- or poorly vasoformative areas with a simultaneous positive reaction for either one of three endothelial cell markers. None of the proliferating cells showed a positive reactivity for HMB45. The positivity rates of the angiosarcoma cells for each marker were different according to the primary tumor sites. The angiosarcoma cells in non- or poorly vasoformative areas showed the lowest positivity rate for anti-FVIIIRA in the heart (9%) and for anti-CD31 in the extremities (17%) and the highest positivity rate for anticytokeratin in the trunk (60%). Ulex europaeus lectin type 1 had almost the same reactivity rate (30-56%) in every organ. Angiosarcoma cells in 13 (36%) of 36 biopsy specimens and 8 (14%) of 56 autopsy specimens were positive for the anti-VEGF antibody.

CONCLUSION

These findings suggest that the combined use of endothelial cell markers including FVIIIRA, UEA-1, and CD31 is useful in the diagnosis of angiosarcoma, especially in cases exclusively with a non- or poorly vasoformative pattern.

Immunohistochemical evaluation of vascular neoplasms

Immunohistochemistry is of proven value in the evaluation of cutaneous vascular neoplasms. Nonetheless, the lack of sensitivity and specificity demonstrated by some endothelial markers requires that a panel of antibodies to other lineage-related determinants be applied in this context. Compared with electron microscopy, enzyme-linked antibody techniques can be applied in a cost-effective manner, with a satisfactory diagnostic result in most cases. The efficacy of these methods will likely improve as more sensitive and specific markers of endothelial differentiation are characterized. For the time being, the exclusion of non-endothelial proliferations remains an important aspect of the differential diagnosis of vascular tumors.

The effect of radiation therapy on von Willebrand factor in patients with angiosarcoma

Radiation damages endothelial cells (EC) of malignant and normal tissues. Shortly after radiation injury platelet thrombi cause small vessel obstruction. Radiation doses of 20 Gy or higher release von Willebrand factor (VWF) from cultured human umbilical vein EC. Angiosarcoma (AS) is a vascular tumor with abnormal appearing EC which have detectable cytoplasmic VWF. We examined the effect of radiation therapy on VWF in three patients with AS. Each patient's malignant tissue was demonstrated to have cytoplasmic VWF present. Venous blood samples were drawn immediately before and at weekly intervals during treatment. Patient 1 received 80 Gy over 6 weeks and had no alterations in the VWF. Patient 2 received 64 Gy over 6 weeks and was noted to have loss of the high molecular weight multimers of VWF without loss of FVIII:C, VW: RIST, or von Willebrand antigen activity (VW:Ag). Patient 3 was treated with 64.4 Gy over 9 weeks and had a disproportionate increase of the VW: Ag and VW: RIST to FVIII: C. This returned to normal after completion of therapy. These changes were minimal and might be explained by either limited local release or no increased release of VWF from the irradiated tissue. The minimally abnormal multimeric pattern in patient 2 may be due to the release of an abnormal VWF in normal amounts or small amounts of proteolysis. The alteration in the VW: RIST and VW: Ag to FVIII: C ratio can be explained by activated coagulation secondary to radiation injury.

Ultrastructural and immunocytochemical observations on angiosarcomas

Forty-seven angiosarcomas have been studied by light and electron microscopy. Neoplastic endothelial cells do not consistently display specific ultrastructural features, but certain aspects of the fine structure of the cells and their arrangement can be useful to establish or confirm the diagnosis. Experience with the common endothelial cell markers as diagnostic aids is briefly reviewed.

Factor VIII-related antigen in canine endothelial neoplasms: an immunohistochemical study

Canine vascular tumors (47 hemangiomas, 36 hemangiosarcomas) were investigated for the endothelial cell marker factor VIII-related antigen (F VIII RAg). The primary antibody was a commercial rabbit anti-human (r/h) F VIII RAg antiserum. All (100%) hemangiomas and 32 (89%) of 36 hemangiosarcomas stained for F VIII RAg. One hemangiosarcoma (3%) was negative, and three tumors (8%) were equivocal in staining. Rarely, the interpretation of stained immature endothelial cells was difficult. The r/h F VIII RAg antibody was a positive marker of normal, reactive, and neoplastic endothelial cells in the dog.

Immunomorphological analysis of the role of blood vessel endothelium in the morphogenesis of cutaneous Kaposi's sarcoma: a study of 57 cases

In this study we report the histopathological features in a series of 88 biopsies from patients with cutaneous Kaposi's sarcoma; immunohistochemical examination for Factor VIII related antigen has been carried out on frozen and paraffin-embedded sections. The patient groups comprised 50 elderly patients, seven of whom were immuno-compromised, six patients with AIDS and one patient who had received a renal allograft. The findings were similar in these three groups. Histological staging was carried out with subdivision into stage I--patches characterized by angiomatoid and glomeruloid structures; stage II--plaques characterized by confluence of angiomatoid and glomeruloid structures and with spindle cells; and stage III--nodules in which the spindle cells were proliferative and frankly sarcomatous. Factor VIII related antigen was demonstrated in the central vessels of glomeruloid lesions whilst the surrounding vascular network contained both antigen-negative and antigen-positive vessels; in stage II and III lesions the spindle cells were consistently positive only in frozen section material. The findings were similar in the three patient groups. Our results suggest that Kaposi's sarcoma evolves from stage I through to stage III, that both blood vessels and lymphatic vessels are involved in the vascular proliferation and that the spindle cells are derived from vascular endothelium.

Lymphatic distribution of the stomach in normal, inflammatory, hyperplastic, and neoplastic tissue

Prompted by the lack of knowledge of the distribution of gastric lymphatics and the discrepancy between the incidence of lymph node metastases from intramucosal gastric carcinoma versus intramucosal colonic carcinoma, we undertook a study of the distribution of lymphatics in normal, abnormal non-neoplastic, and neoplastic gastric mucosas. The study involved the histologic, immunocytochemical, and electron microscopic evaluation of a total of 47 gastric biopsy, polypectomy, and resection specimens and showed that the gastric lymphatics normally begin as a plexus of vessels immediately superficial to, within, and below the muscularis mucosae. The upper two-thirds of the gastric lamina propria is normally devoid of lymphatics. This distribution is maintained throughout the cardia, fundus, and antrum and is also maintained in hyperplastic and neoplastic tissues. However, in patients with severe atrophic gastritis in which the overall height of the gastric mucosa is markedly decreased, lymphatic capillaries may be found near the surface epithelium. The relevance of these findings to the behavior of early gastric cancer is discussed.

Lymphatic endothelial cell line (CH3) from a recurrent retroperitoneal lymphangioma

An endothelial cell line derived from a massive recurrent chyle-containing retroperitoneal lymphangioma was isolated in monolayer culture. Scanning and transmission electron microscopy and immunohistochemistry confirmed a close resemblance to blood vascular endothelium with typical cobblestone morphology, positive immunofluorescence staining for endothelial marker Factor VIII-associated antigen and fibronectin, and prominent Weibel-Palade bodies. The endothelial cells also exhibited other ultrastructural features characteristic of lymphatic endothelium, including sparse microvillous surface projections, overlapping intercellular junctions, and abundant intermediate filaments. This endothelial cell line represents a new source of proliferating lymphatic endothelium for future study, including structural and functional comparison to blood vascular endothelium.

Staining for factor VIII related antigen and Ulex europaeus agglutinin I (UEA-I) in 230 tumours. An assessment of their specificity for angiosarcoma and Kaposi's sarcoma

In this study we examined the staining reactivity of commercially available antisera to factor VIII related antigen (F VIII RAg) and Ulex europaeus agglutinin I (UEA-I) on sections from 230 formalin fixed paraffin embedded tumours. These included 196 sarcomas, 20 carcinomas and 14 angiomas. All angiomas showed positive staining for F VIII RAg; all carcinomas showed negative staining; the vasoformative areas of all angiosarcomas stained positively but only four of six angiosarcomas showed positive staining of their solid areas; of seven Kaposi's sarcomas, all showed positive staining of vessels and six showed positive staining of the spindle cell component. In the remaining 181 non-vascular sarcomas there was a false positive result in four tumours (2.2%), three of which had a history of irradiation. Pre-radiotherapy biopsies of these three tumours stained negatively with anti-F VIII RAg. UEA-I was demonstrated in all the angiomas studied, in all angiosarcomas (including the solid components) and in well-formed vessels of all Kaposi's sarcomas, but only in the spindle cell component of 3/6. However, there was an unacceptably high rate of false positive staining amongst the carcinomas and non-vascular sarcomas. In conclusion, F VIII RAg is a specific but not a sensitive marker of angiosarcomas; UEA-I is a sensitive but not a specific marker of angiosarcomas.