Acquired Benign and “Borderline” Vascular Lesions

Invited Review : Three New Vascular Tumors—Tufted Angioma, Kaposiform Infantile Hemangioendothelioma, and Proliferative Cutaneous Angiomatosis

The features of tufted angioma (Nakagawa), Kaposiform infantile hemangioendotheli oma, and proliferative cutaneous angiomatosis are reviewed. Tufted angioma, which usually appears before the age of ten years, is a large, poorly demarcated, macular, cutaneous and subcutaneous lesion most commonly located on the neck or trunk. Histologically, there is a "cannon ball" pattern of concentrically whorled lobules and tufts of endothelial and perithelial cells. Tufted angioma is difficult to excise and usually persists throughout life but causes no serious symptoms. Kaposiform infantile heman gioendothelioma is a rare, aggressive vascular tumor of the deep soft tissues, bone, and skin that presents during the first year of life and is often complicated by Kasabach- Merritt syndrome. Histologically, there is a Kaposiform pattern, but some cells may be arranged in nodules and tufts indistinguishable from tufted angioma. Kaposiform infantile hemangioendothelioma responds to interferon therapy. On the basis of the few cases so far recognized, proliferative cutaneous angiomatosis is a large, diffuse, mainly superficial angioma that grows insidiously and is biopsied in the second or third decade of life. Histologically, there are irregular, interconnecting cords and sheets of endothelial cells that form anastomosing spaces. Extravasated red cells and endothe lial hemosiderosis are prominent. The superficial location, older age, and the distinctive histology suggest that proliferative cutaneous angiomatosis differs from Kaposiform infantile hemangioendothelioma. Int J Surg Pathol 2(1):63-72, 1994

Successful treatment of angioma serpiginosum using a novel 532 nm potassium titanyl phosphate (KTP) laser

Angioma serpiginosum (AS) is a rare, benign, vascular disorder comprising non-blanchable punctate red to purple lesions in a gyrate or serpiginous configuration. We report a case of a 38-year-old woman with a red colored eruption on her chest which was present since puberty. A novel 532 nm potassium-titanyl phosphate (KTP) laser (Excel V, Cutera Inc., Brisbane, CA, USA) was applied which resulted in near complete resolution after two sessions of treatment.

Atypical angioma serpiginosum

Angioma serpiginosum is an uncommon, acquired vascular nevoid disorder with capillary dilation and proliferation in the papillary dermis. The eruptions are asymptomatic and characterized by grouped, erythematous to violaceous, serpiginous and punctate macules. The condition usually appears in females during adolescence on unilateral lower extremities and the buttocks. We report a rare case with a late onset and atypical distribution of lesions in a 48-year-old female patient who had groups of punctate lesions on her left foot for four to five years. Histopathological examination showed hyperkeratosis and multiple dilated and proliferated capillaries in the papillary dermis. Inflammation and extravasation of red blood cells were not found. According to the clinical and pathological findings, we established a diagnosis of angioma serpiginosum. She was treated with a pulsed dye laser, and the angiomatous lesions subsequently improved.

Vascular tumors of the skin: A selective review

Cutaneous vascular proliferations are a vast and complex spectrum. Many appear as hamartomas in infancy; others are acquired neoplasms. Some vascular proliferations are hyperplastic in nature, although they mimic hemangiomas, i.e., neoplasms. The vast majority of the vascular lesions are hemangiomas. Between the hemangiomas and frankly angiosarcomas, there is a group of neoplasms that are angiosarcomas, albeit ones of low grade histologically and, probably, biologically. The term "hemangioendothelioma" has been created to encompass these neoplasms. Vascular proliferations are, fundamentally, composed of endothelial cells. Some hemangiomas, however, contain also abundant pericytic, smooth muscle, or interstitial components, or a combination of them. These heterogeneous cellular components are present usually in hemangiomas. Some of the newly described vascular proliferations, however, are difficult to differentiate from some of the angiosarcomas. Others are markers, occasionally, of serious conditions such as Fabry's Disease (angiokeratoma) and POEM's syndrome (glomeruloid hemangioma). Kaposi's sarcoma continues to be an enigma. The demonstration of Herpes virus 8 in this condition raises doubt about its neoplastic nature. The demonstration of endothelial differentiation of its nodular lesions is tenuous and its true nature remains unresolved. While physicians have known about post-mastectomy angiosarcomas from the origin of the radical mastectomy, a new group of unusual vascular proliferations of the mammary skin are being defined. These lesions arise in the setting of breast-conserving surgical treatment with adjuvant radiation therapy. The incubation period is usually 3 to 5 years, in contrast with the 10, or more, in classical cases of post-mastectomy angiosarcoma. These lesions usually are subtle, both clinically and histologically, in contrast with the "classical," dramatic presentation of mammary angiosarcoma. The spectrum of findings ranges from "simple" lymphangiectasia-like vascular proliferations to unequivocal angiosarcomas. The pathogenesis of these lesions remains a mystery. There are very few clues that allow one to separate hemangiomas from angiosarcomas. The presence of heterologous cellular elements and, particularly, well-developed smooth muscle components tends to favor a hemangioma. Similarly, the presence of thrombosis usually supports hemangioma. Nevertheless, there are no unequivocal or reliable individual diagnostic criteria. A thorough knowledge of the different conditions and their differential diagnoses eventually leads to the proper diagnosis in most cases.

Rare vascular proliferations of the oral mucosa

Benign vascular lesions-malformative, reactive, and neoplastic-are fairly common in the oral soft tissues; nevertheless, extravascular papillary endothelial hyperplasia and sinusoidal hemangioma have not been reported in this location. To our knowledge, a single case of intraoral spindle cell hemangioma has appeared in the literature. This report deals with histopathological features of these rare vascular proliferations involving the oral mucosa.

Expression of the caveolins in dermal vascular tumors

INTRODUCTION

Histopathologic criteria are usually sufficient for the accurate distinction of benign from malignant dermal vascular tumors. A minority of cases, however, pose a vexing diagnostic dilemma. Recent studies suggest that caveolin, a scaffolding cell membrane protein, may prove helpful in predicting the biologic behavior of endothelial-derived neoplasms.

METHODS

We analyzed a series of 30 dermal vascular tumors including 12 lobular capillary hemangiomas (LCH), 4 cases of targetoid hemosiderotic hemangiomas (TH), 4 cases of tufted angioma (TA), 12 cases of Kaposi's sarcoma (KS), 4 epithelioid (EH) and 1 spindle cell hemangioendothelioma (SH), and 4 cases of angiosarcoma (AS). The distribution of immunoreactivity was analyzed by quantifying cell membrane staining in each case.

RESULTS

There was a statistically significant difference in the expression of caveolin between LCH (mean labeling index=91.6), TH (mean labeling index=89.7), and TA (mean labeling index=87.2) and the cases of KS (mean labeling index=21.6, EH mean labeling index= 23.1), and the AS (mean labeling index=6.3).

CONCLUSIONS

These results indicate that antibodies to caveolin may be useful in separating benign and malignant dermal vascular tumors and possibly implicates this peptide in their pathogenesis.

Spindle cell hemangioendothelioma of the spinal cord

An intradural extramedullary spinal cord hemangioendothelioma at T10, T11 recurred twice and was irradiated after the third resection. This first reported case prompted a review of the neuropathology and natural history of this unusual tumor.