Cutaneous angiosarcoma of the face: clinicopathologic and immunohistochemical study of a case resembling rosacea clinically

Atypical presentation of cutaneous angiosarcoma: Review of the literature

Cutaneous angiosarcoma is a quite aggressive tumor of vascular or lymphatic origin. Although relatively rare, it is important to be early recognized and treated. It typically arises on the head or neck as a bruise or raised purplish-red papule or plaque. Sometimes though, it can resemble a benign skin lesion leading to diagnosis delay and poor patient outcome. Angiosarcoma may be mistaken for inflammatory, auto-immune, or infectious disease, benign skin tumor or post-traumatic lesion. Herein we analyze the atypical clinical forms of this aggressive tumor.

Extensive Cutaneous Scalp Angiosarcoma

Angiosarcoma is a cancer that is derived from endothelial cells that line blood vessels and lymphatic channels. Cutaneous angiosarcoma can appear anywhere on the skin and the clinical presentation is highly variable. Most cases appear on the scalp and face de novo. Our case describes a 91-year-old female with cutaneous scalp angiosarcoma. Our case serves to remind physicians that an abnormal skin finding in older adults should raise their index of suspicion for angiosarcoma and an early biopsy should be performed.

Metastatic Angiosarcoma of Lower Extremity

Angiosarcoma (AS) is an uncommon malignant neoplasm characterized by rapidly proliferating, extensively infiltrating anaplastic cells derived from blood vessels. These are aggressive tumors and tend to recur locally, spread widely with high rate of lymph node and systemic metastases. They are more frequent in skin and soft tissue, head and neck being the most common sites. Here we report a case of metastatic AS affecting lower extremity in an elderly patient on a background of chronic lymphedema due to filariasis (Stewart–Treves syndrome).

A Novel Presentation of Cutaneous Angiosarcoma: A Case Report and Review

We report a case of a 70-year-old male, with slowly widening induration, ulceration, and oozing for 3 months on the scalp and face. The diagnosis of aggressive cutaneous angiosarcoma was made on histopathology and immunochemistry from the biopsy material from the involved area of the skin.

Cutaneous angiosarcoma of the foot: a case report and review of the literature

Primary Angiosarcoma of the skin of the foot is very rare. Angiosarcoma is typically treated with resection and wide-field postoperative radiation therapy. Chemotherapy and radiation therapy have also been used. Regardless of the treatment, the risk of local and distant relapse remains high for this disease. We present a case of an elderly patient who developed cutaneous angiosarcoma of the foot. It posed as a diagnostic dilemma at presentation. Chronic lymphedema was a possible predisposing factor. Given his age, preexisting renal dysfunction, refusal of surgery, and preference not to receive chemotherapy, the patient was ultimately treated with definitive radiotherapy. We present this case because of its rare site, unique presentation and delay in diagnosis of the condition, and attainment of an excellent response to radiation at the time of follow-up. We also review the current literature on this topic.

[Tumors of the scalp: special aspects of selected examples]

BACKGROUND

Tumors of the scalp display some clinical, histological and prognostic characteristics. Early recognition of tumors is hampered by dense hair growth which can result in delayed diagnosis.

MATERIAL AND METHODS

Taking current literature into consideration atypical fibroxanthoma, cutaneous angiosarcoma, melanoma of the scalp, some adnexal tumors including the proliferating trichilemmal tumor as well as cutaneous metastases from visceral malignancies will be discussed.

RESULTS

Based on the fact that early scalp tumors are clinically difficult to recognize, they are often diagnosed at a late stage. Angiosarcomas belong to the most aggressive skin tumors and show a rapid growth with unfavorable prognosis. Malignant melanoma on the head has a more serious prognosis in comparison to other locations of the body. Cutaneous metastases are mostly a sign of an advanced tumor stage with a fatal prognosis. The various types of adnexal tumors are mostly benign. In exceptional cases rapid growth and ulceration may be an indicator for the development of an adnexal carcinoma. On the scalp tumors with sweat gland differentiation are more frequent than tumors with follicular differentiation. This shows that the general view that adnexal tumors develop from local adnexal structures is wrong.

CONCLUSION

Scalp lesions in which the diagnosis is unclear should be biopsied or excised early. Based on the result of the histological examination further therapy can be determined.

Unusual clinical presentation of cutaneous angiosarcoma masquerading as eczema: a case report and review of the literature

An unusual case of cutaneous angiosarcoma clinically mimicking eczema is described. A 98-year-old Caucasian male presented with a 6-month history of a flesh-colored, subcutaneous nodule on his left forehead with contralateral facial erythema and scaling that had been previously diagnosed as eczema. Despite treatments with topical steroids and moisturizers, the condition did not resolve. At our clinic, excisional biopsy of the forehead lesion and scouting biopsies from the contralateral cheek were performed which revealed cutaneous angiosarcoma. The described case illustrates that dermatitis-like features should be considered as a rare clinical manifestation of cutaneous angiosarcoma. It also demonstrates that these lesions may respond well to radiotherapy as a single modality.

Cutaneous angiosarcoma of the head, neck, and face of the elderly in type 5 skin

Cutaneous angiosarcoma is a rare, highly malignant vascular tumor with three clinical types. It is predominantly seen in the white-skinned people and rarely dealt with among the colored races. Cutaneous angiosarcoma of head and neck of the elderly is a great mimicker with many clinical presentations. The condition needs to be differentiated from several other common conditions and the diagnosis may be extremely difficult in some cases. Herein, we report the case of a 65-year-old man with type 5 skin who presented with an unusual and extensive involvement of the scalp and face presenting a diagnostic challenge.

Sarcoidosis and molecular mimicry--important etiopathogenetic aspects: current state and future directions

Sarcoidosis is a disease of uncertainty in terms of its cause, presentation, and clinical course. The disease has a worldwide distribution and affects all ages, races, and both sex. Sarcoidosis of the skin may have an extremely heterogeneous clinical presentation, so that the definitions of 'great imitator' and 'clinical chameleon' have long been used. The factors that influence clinical picture and severity of the disease are probably linked to the etiopathogenesis of sarcoidosis, which continues to be shrouded in mystery. The current state of the art on the pathogenesis of sarcoidosis is that it is an immunological response in a genetically susceptible individual to an as-yet undefined antigenic stimulus. How exposure occurs in genetically predisposed patients is not completely clear, but the most likely explanation is that these agents or antigens are either inhaled into the lungs or enter through contact with the skin, as these are the common target organs that are constantly in contact with the environment. An autoimmune etiology of sarcoidosis could possibly occur through a process of molecular mimicry of infectious or other environmental antigens to host antigens. This could lead to a cross-mediated immune response and induction of autoimmune disease. This molecular mimicry may probably be responsible for the heterogeneous clinical presentations of the disease. Several investigations and studies have provided valuable evidence on the etiopathogenesis of sarcoidosis, which may lead to the future development of targeted and innovative treatment strategies. Nevertheless, we are still a long way from unravelling the underlying cause of this mysterious disease.

Angiosarcoma of the eyelid: a clinicopathologic comparison between isolated unilateral tumors and tumors demonstrating extrapalpebral involvement

Angiosarcomas involving the head and neck are malignant tumors which tend to involve multiple anatomical structures with an overall dismal prognosis. Reports of primary, isolated eyelid involvement are rare. We report 4 cases of angiosarcoma involving the eyelid as either an isolated tumor or as part of a more diffuse malignant process and compare the features of these 2 tumor types to cases reported in the literature. The mean age at which patients develop angiosarcoma involving the eyelid was 72. Patients with isolated tumors most often presented complaining of a discrete mass clinically resembling a stye. Patients with isolated eyelid involvement had better survival (100% at 3.2 years) compared with patients with diffuse disease (57% at 3.3 years). Those with isolated eyelid involvement have an average tumor size of 2.08 cm with no distant metastasis. Patients who have eyelid angiosarcoma with extrapalpebral involvement have tumors ranging between 5 and 10 cm on average and 21% develop metastases. True isolated angiosarcoma of the eyelid is rare. When extrapalpebral involvement is ruled out by clinical and radiographic examination, patients with isolated involvement seem to fare better compared with patients with eyelid involvement secondary to more regionally extensive tumors.

Primary gingival angiosarcoma successfully treated by radiotherapy with concurrent intra-arterial chemotherapy

The occurrence of angiosarcoma in the oral cavity is extremely rare, and optimal management of this tumor is undefined. These tumors are aggressive, with a high propensity for local recurrence. We present here a case of primary gingival angiosarcoma successfully treated by intra-arterial chemotherapy concurrent with radiation therapy. A 69-year-old female with a primary angiosarcoma in the right maxillary gingiva was admitted to our hospital. The diagnosis of angiosarcoma was established by immunohistochemistry. The patient refused surgical treatment, and so intra-arterial cisplatin and concurrent radiation were given. The gingival tumor disappeared after completion of the therapeutic regimen. However, the patient died 8 months after initial treatment because of multiple lung metastases. Locoregional control was achieved up to her death. To our knowledge, this is the first report of this treatment for angiosarcoma of the oral cavity.

Cutaneous epithelioid angiosarcoma: a neoplasm with potential pitfalls in diagnosis

Angiosarcoma (AS) is a rare neoplasm. Cutaneous AS is the most common form of AS. The epithelioid variant of the disease, however, is a rare entity. This subset can histologically mimic non-vascular neoplasms and impose serious challenges in reaching the correct diagnosis. We present five patients with cutaneous epithelioid angiosarcoma (EAS); in none, the clinical diagnosis included a vascular lesion. Three patients had history of breast conservation surgery with/without radiation therapy. Other patients had no previous radiation, and there was no lymphedema in any of the cases. The histopathological examination of the biopsy specimens by hematoxylin and eosin method was not suggestive of a malignant vascular neoplasm initially and the differential diagnoses included carcinoma, malignant melanoma and atypical lymphoid infiltrate. Only after performing immunohistochemical studies that included vascular markers, a definitive diagnosis was possible. Some cases showed unusual histopathological features. Cutaneous EAS is a rare variant of cutaneous AS that can mimic a variety of more common, non-vascular neoplasms, creating a major pitfall in the diagnosis. A careful and thorough histopathological examination and a high index of suspicion, along with appropriate immunohistochemical evaluation, can help reach a correct diagnosis and provide optimal patient care.

Successful radiotherapy of facial angiosarcoma

Cutaneous angiosarcoma of the face and scalp is a rare malignant vascular tumor that affects mostly Caucasian elderly males. At present, connections concerning the etiology of this neoplasm with radiation therapy, exposure to environmental carcinogens and chronic lymphedema have been described. Due to the difficult histologic evaluation, high local recurrence and tendency to early metastasing, angiosarcoma poses generally a very poor prognosis. We report the case of an 80-year-old patient who experienced successful removal of large, exophytic growing angiosarcoma of the face achieved with radiotherapy with long-term relapse-free survival.

Sinonasal tract angiosarcoma: a clinicopathologic and immunophenotypic study of 10 cases with a review of the literature

BACKGROUND

Primary sinonasal tract angiosarcoma are rare tumors that are frequently misclassified, resulting in inappropriate clinical management. There are only a few reported cases in the English literature.

MATERIALS AND METHODS

Ten patients with sinonasal tract angiosarcoma were retrospectively retrieved from the Otorhinolaryngic Registry of the Armed Forces Institute of Pathology.

RESULTS

Six males and four females, aged 13 to 81 years (mean, 46.7 years), presented with epistaxis and bloody discharge. Females were on average younger than their male counterparts (37.8 vs. 52.7 years, respectively). The tumors involved the nasal cavity alone (n = 8) or the maxillary sinus (n = 2), with a mean size of 4.3 cm; the average size was different between the genders: males: 2.8 cm; females: 6.4 cm. Histologically, all tumors had anastomosing vascular channels lined by remarkably atypical endothelial cells protruding into the lumen, neolumen formation, frequent atypical mitotic figures, necrosis, and hemorrhage. All cases tested (n = 6) demonstrated immunoreactivity with antibodies to Factor VIII-RA, CD34, CD31, and smooth muscle actin, while non-reactive with keratin and S-100 protein. The principle differential diagnosis includes granulation tissue, lobular capillary hemangioma (pyogenic granuloma), and Kaposi's sarcoma. All patients had surgery followed by post-operative radiation (n = 4 patients). Follow-up was available in all patients: Six patients died with disease (mean, 28.8 months); two patients had died without evidence of disease (mean, 267 months); and two are alive with no evidence of disease at last follow-up (mean, 254 months).

CONCLUSIONS

Sinonasal tract angiosarcoma is a rare tumor, frequently presenting in middle-aged patients as a large mass usually involving the nasal cavity with characteristic histomorphologic and immunophenotypic features. Sinonasal tract angiosarcoma will often have a poor prognosis making appropriate separation from other conditions important.

Pseudolymphomatous Cutaneous Angiosarcoma: A Rare Variant of Cutaneous Angiosarcoma Readily Mistaken for Cutaneous Lymphoma

Cutaneous angiosarcoma is probably the most malignant neoplasm involving the skin. Three clinical variants of cutaneous angiosarcoma are recognized, including angiosarcoma of the scalp and face of elderly patients, angiosarcoma associated with chronic lymphedema, and postirradiation angiosarcoma. Histopathologically, these three variants of angiosarcoma show similar features, which consist of poorly circumscribed, irregularly dilated, and anastomosing vascular channels lined by prominent endothelial cells that dissect through the dermis. Focally, neoplastic endothelial cells show large, hyperchromatic, and pleomorphic nuclei, protruding within vascular lumina and creating small papillations. Usually, inflammatory infiltrate is sparse and consists of a patchy, perivascular lymphoid infiltrate around the neoformed vessels. In rare instances, cutaneous angiosarcomas may exhibit prominent inflammatory infiltrate, and the neoplasm may be mistaken for an inflammatory process, both from clinical and histopathologic points of view. We describe four examples of cutaneous angiosarcomas with dense lymphocytic infiltrates involving the neoplasm. Immunohistochemically, lymphocytes expressed immunoreactivity for CD3, CD5, and CD45 markers, whereas the germinal centers were positive for CD20, CD79a, and Bcl-6. The neoplastic endothelial cells expressed immunoreactivity for the CD31, CD34, podoplanin, Prox-1, Lyve-1, and D2-40. We discuss the possible relationship between neoplastic endothelial lymphatic cells and reactive lymphocytes. Cutaneous angiosarcoma with prominent lymphocytic infiltrate may be readily mistaken for cutaneous follicle center cell lymphoma or cutaneous pseudolymphoma.

Cutaneous angiosarcoma of the face

Cutaneous angiosarcoma is a rare tumour of vascular origin, which has a poor prognosis because of its high potential for metastasis. We report the case of a 57-year-old man with an 8-month history of a progressively enlarging, asymptomatic red patch over the left periorbital region of the face, previously diagnosed as angiolupoid leishmaniasis, insect-bites, 'cellulitis' and treated with several topical antibiotic and steroid therapy, without any improvement. A skin biopsy of the lesion was performed and histological and immunohistochemical examination revealed a pattern of poorly differentiated angiosarcoma. The peculiarity of the localization at the periorbital area and the particular clinical presentation are emphasized.

Angiosarcoma of the face resembling rhinophyma

We report the case of a 69-year-old man who had a persistent lesion develop on his nose during a 1-year period of time that was diagnosed as rhinophyma. Despite laser treatment the lesion continued to grow. Histopathology and immunohistochemical studies were consistent with cutaneous angiosarcoma. Rhinophyma-like features should be considered as an unusual clinical manifestation of cutaneous angiosarcoma.

A case of angiosarcoma of the nose

A case of angiosarcoma arising from the nose of a 69-year-old man is presented in this report. The patient was treated with a combination of recombinant interleukin-2 (rIL-2, Celeuk), electron beam irradiation, and surgery. He died 27 months after diagnosis, but there was no apparent remote metastasis.

Angiosarcoma of the mandible: a case report and review of the literature

Angiosarcoma is a rare malignancy that is characterized by endothelial cell differentiation. In the head and neck area, most of these lesions arise in the scalps of elderly individuals. Less commonly, angiosarcomas can be found within bone. The purpose of this report is to describe an example of angiosarcoma involving the floor of the mouth and right body of the mandible. The histopathologic and immunopathologic features of these lesions are also reviewed.