Histiocytoid hemangioma: A disease spectrum

Angiolymphoid hyperplasia with eosinophilia involving the common digital artery of the hand: A case report and classification of upper limb lesions

INTRODUCTION

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a rare benign reactive inflammatory lesion. The usual presentation is a single or multiple skin nodules of the head and neck. Involvement of the hand is very rare and there have been no comprehensive reviews on ALHE of the upper limb. In this paper, we report on a case involving the common digital artery of the hand. We also review the literature and offer two classification systems for upper limb lesions: One according to the primary structure involved, and the other according to the presentation with either single or multiple lesions.

PRESENTATION OF CASE

A 32-year old female presented with a slowly growing subcutaneous mass at the second web space of the left hand. The mass was neither tender or mobile. An MRI showed a tri-lobed soft tissue lesion. At the time of surgery, the lesion was found to be within the common digital artery of the second web space. Complete excision was done. Histopathology confirmed the diagnosis of ALHE There has been no recurrence or cold tolerance at final follow-up 1year later.

DISCUSSION

We offer two classification systems for upper limb lesions: One according to the primary structure involved, and the other according to the presentation with either a single or multiple lesions.

CONCLUSION

A rare case of ALHE of the hand is presented. The literature is reviewed and two classification systems for upper limb lesions are offered and their implications are discussed.

The Disappearing Phalanx: A Case Report of a Vascular Tumor of the Toe

We report a unique case of an epithelioid hemangioma of the third middle phalanx in which the lesion replaced the phalanx, became symptomatic, and then required resection, bone grafting, and joint arthroplasty. To the best of our knowledge, this is the first report of an epithelioid hemangioma in the toe that was treated using this approach.

Epithelioid Hemangioma of Bone: A Potentially Metastasizing Tumor?

The case of a 15-year-old boy with a severe swelling of the 2nd toe in the left foot and a large swelling of the left inguinofemoral region is described. Histologic examination of the foot lesion showed a typical epithelioid hemangioma of bone that extended into the soft tissues, with a secondary location in the groin, suggestive of lymph node involvement. Subsequently, imaging also revealed swelling of iliac and para-aortic lymph nodes, which probably indicates further lymph node spread.. Besides the fact that epithelioid hemangioma of the toe has not been reported yet, our case showed a noncontinuous localization, most likely in draining lymph nodes. This finding suggests metastatic disease, an event that is extremely rare for epithelioid hemangioma. As such, epithelioid hemangioma might be comparable to another benign vascular tumor, the retiform hemangioendothelioma, which occasionally metastasizes to the lymph nodes without systemic spread.

Epidemiology and treatment of angiolymphoid hyperplasia with eosinophilia (ALHE): A systematic review

BACKGROUND

Current knowledge of angiolymphoid hyperplasia with eosinophilia (ALHE) derives from retrospective reports and case series, leading to a nonevidence-based treatment approach.

OBJECTIVE

We sought to systematically review the literature relating to cutaneous ALHE to estimate its epidemiology and treatment outcomes.

METHODS

A literature search of PubMed, EMBASE, Web of Science, and Google Scholar was conducted. Articles detailing cases of histologically confirmed cutaneous ALHE were included.

RESULTS

In all, 416 studies were included in the review, representing 908 patients. There was no sex predominance among patients with ALHE. Mean age at presentation was 37.6 years. There was a significant association between presence of multiple lesions and pruritus, along with bleeding. Surgical excision was the most commonly reported treatment for ALHE. Treatment failure was lowest for excision and pulsed dye laser. Mean disease-free survival after excision was 4.2 years. There were higher rates of recurrence postexcision with earlier age of onset, longer duration of disease, multiple lesions, bilateral lesions, pruritus, pain, and bleeding.

LIMITATIONS

Potential for publication bias is a limitation.

CONCLUSIONS

Surgical excision appears to be the most effective treatment for ALHE, albeit suboptimal. Pulsed dye and other lasers may be effective treatment options. More studies are needed to improve the treatment of ALHE.

Epithelioid hemangioma of the distal humerus with pathologic fracture

Epithelioid hemangioma is a rare tumor that can have bone involvement. Its clinically and radiographically aggressive appearance mimics a malignant neoplasm. Although epitheliod hemangioma has been described as having an aggressive appearance on magnetic resonance imaging (MRI) and plain radiographs, this is the first reported case of pathologic fracture associated with this lesion to our knowledge. This article describes a case of epithelioid hemangioma involving the distal humerus, which initially presented with progressive pain and fracture of the lateral condyle. The aggressive appearance on plain radiographs and MRI suggested a malignant bone tumor. This preliminary diagnosis was confirmed due to the presence of local lymph node spread on positron emission tomography/computed tomography. After a core needle biopsy revealed nondiagnostic tissue, rather than performing a wide resection based on a presumptive malignant diagnosis, we followed the standard diagnostic algorithm and performed an open biopsy with temporary internal stabilization. The tissue sample was adequate and revealed a diagnosis of epithelioid hemangioma. Based on this finding, we were able to proceed with surgical management, including curettage of the lesion, placement of a bone graft, and internal fixation, rather than a wide resection with elbow joint replacement. This article emphasizes the need for careful adherence to the diagnostic algorithm for musculoskeletal tumors. In doing so, a definitive diagnosis was reached, and our patient was able to resume his occupation as a laborer without the restrictions that would have accompanied elbow arthroplasty.

Epithelioid hemangioma of bone revisited: a study of 50 cases

The clinical and pathologic features of 50 epithelioid hemangiomas of bone are analyzed. There were 29 males and 21 females who ranged in age from 10 to 75 (mean 35) years. The tumors arose in long tubular bones (40%), short tubular bones of the distal lower extremity (18%), flat bones (18%), vertebrae (16%), and small bones of the hands (8%). Nine patients (18%) had involvement of more than 1 bone. Radiographically, the lesions were lucent and well marginated. Microscopically, the neoplasms had a lobular architecture and were composed of epithelioid endothelial cells that formed obvious vascular lumina or grew in solid sheets. No hyalinized or solid appearing extracellular myxoid matrix was present. Thirty-five patients were treated with curettage, 13 patients had a local resection and 2 patients only had a biopsy. One patient had local lymph node involvement. Three patients were treated with surgery and radiation therapy. Follow-up information revealed that 4 patients experienced a local recurrence; and 1 patient developed limited involvement of a regional lymph node. Epithelioid hemangioma of bone is a benign lesion that may be multifocal and affect separate tissue and is successfully treated with curettage or marginal en bloc excision.

Angiolymphoid hyperplasia with eosinophilia affecting the nail bed and underlying bone

A 69-year-old Japanese woman had a dark red, 1-cm nodule located in the nail bed of the middle toe of her right foot. An X-ray examination revealed an osteolytic lesion of the distal phalanx of the right middle toe. Histopathology showed a proliferation of blood vessels surrounded by epithelioid cells and an infiltration of many eosinophils and some inflammatory cells. There has been no recurrence after surgical excision of the skin lesion and the distal phalanx of the right middle toe.

Spontaneous regression of a rare tumour in a child: angiolymphoid hyperplasia with eosinophilia of the hand: case report and review of the literature

Angiolymphoid hyperplasia with eosinophilia (ALHE) is an uncommon benign, idiopathic vasculoproliferative condition manifested by multiple or solitary subcutaneous nodules, usually in the head and neck region of young adults. It is very rare in the extremities especially in the hands. Although recurrence is common, surgical excision is still regarded as the treatment of choice. We report an 11-year-old girl with histologically confirmed ALHE on the dorsum of her left hand, which underwent complete spontaneous regression within 10 weeks. Angiolymphoid hyperplasia is a benign disease and it is important to recognise this condition so that early superficial lesions can be observed for 3-6 months pending spontaneous regression.

Angiolymphoid hyperplasia with eosinophilia of the nail bed and bone: successful treatment with radiation therapy

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a rare entity characterized by the presence of one or several papules or nodules in the skin. Histopathology of ALHE shows a marked proliferation of blood vessels with distinctive large endothelial cells and variable inflammatory infiltrates with eosinophils. We report a 32-year-old Caucasian woman with multiple nodules involving the skin, subcutaneous tissue and bone of the distal phalanx of the fingers that were treated successfully with orthovoltage radiation therapy (40 Gy/20 fractions) and without any side-effects after 9 years of follow-up.

Angiolymphoid hyperplasia with eosinophilia of the parapharyngeal space

Angiolymphoid hyperplasia with eosinophilia (ALHE) is an uncommon benign condition characterized by cutaneous nodules with a predeliction for the head and neck region. Extracutaneous involvement is rare. We report a 44-year-old woman who had a large submucosal ALHE tumour in the parapharyngeal space. Our patient is of interest because of the unusual, and as far as we are aware from the literature, unique site and presentation of her lesion.

Kimura's disease and angiolymphoid hyperplasia with eosinophilia: clinical and histopathologic differences

BACKGROUND

There has been considerable controversy about the relation between Kimura's disease and angiolymphoid hyperplasia with eosinophilia (ALHE).

OBJECTIVE

We describe the clinical and histopathologic differences between the two diseases.

METHODS

We reviewed clinical findings and histopathologic changes in two cases of Kimura's disease and three cases of ALHE.

RESULTS

Kimura's disease shows typical lymphoid follicles. It is associated with lymphadenopathy and is always accompanied by peripheral eosinophilia. ALHE shows typical changes in endothelial cells. It is characterized by superficial papules or nodules with no lymphadenopathy and is less frequently accompanied by peripheral eosinophilia.

CONCLUSION

Kimura's disease and ALHE are separate entities.