Vascular and lymphatic tumors in infancy, childhood and adulthood: challenge of diagnosis and treatment

Cystic lymphangioma of spleen in adults

Splenic diseases are rare. Tumours of the spleen are classified as either benign or malignant. Primary benign tumours of the spleen are extremely rare, identified on surgery and autopsy, accounting for <0.007% of all splenic tumours. Splenic lymphangiomas are benign cystic tumours resulting from congenital malformations of the lymphatic system that appear as a single or multiple lesions of the spleen. It mainly affects children and is rarely manifested after the age of 20 years of age. We report a case of cystic lymphangioma of spleen in a 40-year-old woman admitted with a huge mass in the abdomen, which on imaging found to be a cystic mass arising from spleen. On laparotomy the spleen was found occupying a major part of the abdomen. Splenectomy was performed and histopathological examination revealed it to be a cystic lymphangioma of spleen. This case report emphasises on the rarity of the case at this age and the sheer size of the tumour, being largest until as per our knowledge.

Hemangioma: review of literature

Hemangiomas are tumors identifed by rapid endothelial cell proliferation in early infancy, followed by involution over time. All other abnormalities are malformations resulting from anomalous development of vascular plexuses. The malformations have a normal endothelial cell growth cycle that affects the veins, the capillaries or the lymphatics and they do not involute. Hemangiomas are the most common tumors of infancy and are characterized by a proliferating and involuting phase. They are seen more commonly in whites than in blacks, more in females than in males in a ratio of 3:1.

Primary mesenteric angiosarcoma in a child with associated lymphangiectasia: a case report

Angiosarcomas are rare tumors in children, usually occurring in soft tissue and liver. By contrast, angiosarcoma in adults usually occurs in the extremities in conjunction with lymphedema. Mesenteric angiosarcoma has only rarely been reported. When angiosarcomas arise in this location, they usually represent a 2nd malignancy following Hodgkin's lymphoma. We report a child who presented to the emergency room with an acute abdomen and underwent emergency surgery for a mesenteric angiosarcoma with associated lymphangiectasia of the bowel and mesentery. A brief review of the literature and the nomenclature of these unusual tumors are discussed.

The HIF-2alpha/VEGF pathway activation in cutaneous capillary haemangiomas

AIM

To investigate the pathogenesis of capillary haemangiomas, a common form of vascular malformation.

METHODS

Twenty-five cutaneous capillary haemangiomas, excised from patients under 14 years of age, were studied immunohistochemically for endothelial cells, the angiogenic factors thymidine phosphorylase (TP) and vascular endothelial growth factor (VEGF), the proliferation index Ki-67, and the hypoxia inducible factors-1alpha (HIF-1alpha) and -2alpha (HIF-2alpha).

RESULTS

Endothelial-lined channels reacted strongly with CD31 in all cases, clearly definining capillary spaces. Between 5 and 20% of the endothelial cells were Ki-67 positive, indicating an intense proliferative activity; more importantly, they consistently expressed VEGF and HIF-2alpha, and in many cases TP, but failed to react with HIF-1alpha.

CONCLUSION

It is suggested that the activation of the HIF-2alpha pathway and the consequent overexpression of VEGF by the endothelial cells are involved in the pathogenesis of cutaneous capillary haemangiomas.

Cardiac surgery in a child with sacral and intrasacral haemangioma

A 23-month-old female with giant sacral (S1-S5) and intrasacral (L4-S5) haemangioma, lipomyeloschisis and a tethered cord presented for correction of a sinus venosus atrial septal defect. Angiography revealed a large perisacral hypervascular mass with large veins and an intraspinal extension. The patient had a neurogenic bladder and left extremity weakness due to spinal cord compression. The potential for additional neurological injury secondary to bleeding, venous congestion, ischaemia and steal phenomenon during cardiopulmonary bypass is discussed.

A large arteriovenous malformation of the external ear in an adult: report of a case and approach to management

OBJECTIVES/HYPOTHESIS

Arteriovenous malformations involving the external ear are relatively uncommon in adults. Arteriovenous malformations in the head and neck can poses difficult therapeutic challenges.

STUDY DESIGN

Case report.

METHODS

We report a case of a large arteriovenous malformation in the external ear in a 41-year-old man.

RESULTS

Extensive enlargement of the previously latent and asymptomatic arteriovenous malformation was triggered by blunt trauma to the ear.

CONCLUSION

We discuss the definition, clinical findings, diagnostic approaches, and therapeutic management of arteriovenous malformations.

Intralesional corticosteroid therapy in proliferating head and neck hemangiomas: a review of 155 cases

PURPOSE

The purpose of this paper is to review the effect of intralesional corticosteroid therapy in the treatment of 155 head and neck hemangiomas.

METHODS

In the past 10 years, we have treated 155 proliferating head and neck hemangiomas with intralesional corticosteroid injections. Three to 6 injections of triamcinolone acetonide (10 mg/mL) in monthly intervals were given. Using slides and chart review, the results were assessed 1 month after completion of the treatment.

RESULTS

Eighty-five percent of the lesions showed greater than 50% reduction in volume. Varied treatment response was noted in different classes of hemangioma. Eighty percent of the superficial, 75% of the deep, and 60% of the combined hemangiomas show more than 50% reduction in volume. Further growth was not found after treatment. The postinjection complication rate was 6.4% in this series. There were 2 patients with cushingoid appearance, 5 with cutaneous atrophy, and 3 suffered from anaphylactic shock. We found that lesions showing less than 50% reduction in volume were located mostly in the perioral area.

CONCLUSIONS

Intralesional corticosteroid injections are safe and effective in arresting hemangioma proliferation. Superficial hemangiomas yield the best results.

Skeletal-extraskeletal angiomatosis. A clinicopathological study of fourteen patients and nosologic considerations

We reviewed the consultation files of the ARmed Forces Institute of Pathology for 1951 through 1989 and identified fourteen patients who had had skeletal-extraskeletal angiomatosis. Skeletal-extraskeletal angiomatosis was defined as a benign vascular proliferation involving the medullary cavity of bone and at least one other type of tissue. The age of the patients at the time of initial biopsy ranged from nine months to sixty-nine years (average, twenty-two years; median, ten years). Ten of the patients were male and four were female. The presenting signs and symptoms were highly variable; they included pain (four patients), a mass noted at birth (three patients), a painless mass that developed after birth (two patients), both pain and a mass (one patient), a localized deformity of the thoracic spine (one patient), and anemia associated with chronic bleeding of the gastrointestinal tract (one patient); in this last patient, skeletal lesions subsequently were found and biopsied. Skeletal-extraskeletal angiomatosis was an incidental finding in the remaining two patients. Multiple bones were involved in thirteen of the fourteen patients. Histologically, three patterns of lesion could be identified: cavernous lymphangioma (six patients), cavernous hemangioma (six patients), and arteriovenous hemangioma (two patients). Five of the patients died (three of sepsis associated with persistent lesions of angiomatosis and two of unrelated causes); eight of the patients survived but had residual disease, and one survived and had no evidence of residual disease.

Spinal cord arteriovenous malformation with an associated lymphatic anomaly. Case report

Spinal cord arteriovenous malformations (AVM's), like other vascular anomalies of the central nervous system, can be associated with similar vascular lesions of the skin and viscera. A 7-year-old girl, who presented with rapidly progressing paraplegia, was found to have a spinal cord AVM, cutaneous angioma, and a chylous malformation of the lymphatic system. She had previously undergone treatment for a posterior thoracic cutaneous angioma. At surgery, upon incision of the paravertebral muscle fascia, viscous pale fluid was encountered emanating from a foramen in the thoracic lamina. The spinal AVM was resected in spite of concern that the abnormality represented spinal osteomyelitis. Postoperatively, there was full return of function in the lower extremities, along with recurrent episodes of chylothorax, which slowly came under control with dietary manipulation. A review of the anatomy of the thoracic duct and nontraumatic causes of chylothorax is presented, and the association of cutaneous and central angiomas is discussed. Finally, the treatment of chylothorax is delineated.

Angiomatosis: a vascular malformation of infancy and childhood. Report of 17 cases

Angiomatosis is a complex vascular malformation of infancy and childhood consisting of proliferating blood vessels with accompanying mature fat and fibrous tissue, lymphatics and sometimes nerves, that may involve skin, subcutaneous tissue, skeletal muscle and occasionally bone; lesions are non-encapsulated with poorly defined infiltrative borders. Treatment is surgical, with local recurrence being common. We report 17 cases of angiomatosis presenting in children. Recurrences occurred in 10 patients, with multiple recurrences occurring in four. One child was treated with foot amputation followed two years later by mid-thigh amputation in an attempt to control local disease. Histology in all cases showed a mixture of small and medium-sized blood vessels, fat, connective tissue and lymphatics; nerves were increased in several cases. All lesions showed nests of proliferating capillaries, arranged in a lobular pattern, pushing into adjacent muscle and fat. This appearance was not seen in a large comparison group of vascular soft tissue lesions, and may serve as an indicator of angiomatosis with its associated risk of recurrence.

Splenic lymphangiomatosis: a rare cause of splenomegaly

A case of lymphangiomatosis of the spleen and adrenal in a 10-year-old girl is described. The patient had multiple recurrent lymphangiomata excised from her neck during the first 4 years of life. She presented with a recurrent cystic hygroma of the neck and was found to have an enlarged spleen. This increased in size during 5 months of observation, causing left upper quadrant discomfort, and was excised. The diagnosis, management, and prognosis of this rare disorder are discussed.

The pathology of head and neck tumors: vasoformative tumors, part 9A

Tumors originating from components of the vascular system vary widely in the degree of morbidity and mortality that they incur. They all have endothelial cells as integral components of their histologic appearance. Vasoformative tumors include hemangiomas, lymphangiomas, and pyogenic granulomas, which are relatively common, and hemangiopericytomas, glomus tumors, and angiosarcomas, which are relatively uncommon. For many vasoformative tumors, including lymphogenous lesions, the head and neck is an area of predilection, and, in some instances, location in the head and neck appears to modify biologic activity.