Epithelioid hemangioendothelioma of the common femoral vein: Case report and review of the literature

Epithelioid Hemangioendothelioma of the Lower Limb, Discovered by a Claudication

Epithelioid hemangioendothelioma (EHE) is a rare case of a tumor with different clinical behaviors and a difficult anatomopathological diagnosis. The diagnosis of EHE is usually confirmed by postoperative histopathologic examination. Actually, it is a challenge to put a correct diagnosis and to propose aggressive treatment. We report a case of an EHE of the left lower limb discovered in a 53-year-old claudicant woman. Surgical resection, arterial, and venous bypass were performed. The histology demonstrated EHE with a low mitotic index, emerging for the femoral vein.

A Rare Case of Hemangioendothelioma of Upper Thigh

Hemangioendothelioma is a rare tumor arising from the vascular endothelium of soft tissue, skin, bone, and viscera. The disease has an indolent course, with the potential for recurrence, and is often associated with multi-organ involvement. We present a rare case of subcutaneous tumor in the thigh, without systemic involvement in a middle-aged woman. The tumor was completely excised after ligation of the feeding vessels, and the histopathologic diagnosis was consistent with hemangioendothelioma. Regular follow-up is suggested due to the potential for recurrence.

Open surgical treatment for rare epithelioid hemangioendothelioma of the common femoral vein

Epithelioid hemangioendothelioma is a very rare disease affecting big blood vessels, especially veins. There have been very few articles describing the disease. We hereby present the case of a 56-year-old woman presenting with lower limb edema, who was initially being treated for residual thrombus in the common femoral vein but was eventually diagnosed with epithelioid hemangioendothelioma (EHE). The common femoral vein was resected and reconstructed using the external jugular vein. No additional therapy was administered. In this article, previous literature about EHE has been reviewed and oncologic principles have been discussed.

Epithelioid hemangioendothelioma of the thyroid: a case report

Background

Epithelioid hemangioendothelioma (EHE) of the thyroid is an extremely rare disease; only three cases have been reported in the English literature to date. Here, we describe a case involving a patient with thyroid EHE successfully treated with curative surgery.

Case presentation

A 74-year-old woman presented with a right thyroid mass. The nodule was approximately 2 cm in size and was diagnosed as an indeterminate lesion by fine needle aspiration cytology. She was treated with thyroid lobectomy. The histopathological and immunohistochemical findings indicated an EHE of the thyroid. At the latest follow-up, 3 years postoperatively, the patient showed no signs of recurrence.

Conclusion

There is currently no standard therapy for EHE; however, our case suggests that curative resection represents an effective treatment.

Epithelioid Hemangioendothelioma of the Maxillary Sinus

The clinical course and pathologic features of a 72 year old female who presented with epistaxis are presented. Radiographic findings were notable for a large, soft tissue lesion filling the maxillary sinus with significant bony erosion and expansion. The patient was ultimately diagnosed with epithelioid hemangioendothelioma (EHE) and underwent endoscopic resection. She has no evidence of local, regional or distant recurrence 14 months post-surgery. The rarity of this neoplasm, the unusual anatomic location and non-specific symptoms present diagnostic and management challenges. Epithelioid vascular tumors encompass a spectrum of benign and malignant tumors. EHE itself is thought to have an intermediate malignant behavior pattern, though cases with indolent behavior have been reported. Differentiation of EHE from other lesions has historically based on histopathology. Additionally, recent studies have described a recurrent genetic fusion WWTR1-CAMTA1 in EHE, involving t(1;3) (p36;q25). This represents the second reported case of EHE arising in a paranasal sinus. The histopathologic findings of this lesion are reviewed.

A rare case of intravascular epithelioid hemangioendothelioma of the cephalic vein treated with surgery and postoperative radiation therapy: a case report and review of the literature

INTRODUCTION

Epithelioid hemangioendothelioma (EHE) is a rare endothelial tumor with an intermediate grade of malignancy. Few cases of primary vascular hemangioendothelioma have been described in the literature. Surgery is the treatment of choice, but radiation therapy and chemotherapy should also be considered in particular cases.

CASE PRESENTATION

We present the case of a 44-year-old Caucasian woman affected by EHE of the cephalic vein, treated by complete surgical removal of the mass and postoperative local radiation therapy. At 5-year follow-up, our patient is alive, with no signs of local or distant relapse and with no late radiation-related effects.

CONCLUSIONS

Postoperative radiotherapy may play a role in cases in which tumor margins are close or cannot be assessed or when high-risk features are present.

Report of 2 Cases of Primary Epithelioid Hemangioendothelioma of the External Iliac Vein

The epithelioid hemangioendothelioma (EHE) is a rare type of endothelial neoplasm found mainly in soft tissues and visceral organs and in extraordinary cases in large veins like the iliac veins. Currently, there is an active discussion in which EHE behavior, classification, new diagnostic tools, and treatment procedures are proposed. Here, we present 2 cases of EHE and discuss our experience in diagnosis and treatment of this neoplasm.

Epithelioid hemangioendothelioma: occasionally encountered and potentially harmful

Epithelioid hemangioendothelioma (EH) is a rare neoplasm which can arise from any vascularised tissue and has the potential to metastasise. Correct diagnosis can be challenging as it has a variety of presentations and can mimic other pathology. We present a case arising from the brachial artery at the level of the antecubital fossa. Incision biopsies showed benign fatty tissue only; leading to delayed diagnosis, delayed excision and prolonged patient discomfort. This case shows the importance of exercising clinical judgement as negative incision biopsies were, with hindsight, not representative of the lesion.

A case of intravascular epithelioid hemangioendothelioma occurring 14 years after coil embolization for an extracranial internal carotid artery aneurysm

Epithelioid hemangioendothelioma (EHE) is a rare neoplasm originating from various organs. The clinical outcome mostly depends on surgical resectability. The authors report an EHE of the extracranial internal carotid artery developed in a 59-year-old male patient 14 years after the intravascular coil embolization for a carotid aneurysm at the same site. Because the lesion was initially diagnosed as regrowth of the thrombosed aneurysm, decision for radical resection was delayed, and the patient died from rapid tumor progression. Differential diagnosis of atypical vascular mass lesions should include neoplasm, because initial radical resection may be the key to achieve a better prognosis.

Malignant hepatic epithelioid hemangioendothelioma with abdominal pain due to rapid progression

Hepatic epithelioid hemangioendothelioma (HEH) is a rare tumor. We report on a patient who underwent hepatectomy for malignant HEH associated with abdominal pain due to rapid progression. An 83-year-old man was admitted to Nippon Medical School Hospital because of acute, severe upper abdominal pain. Seven months before admission, a hepatic tumor, 3 cm in diameter, had been detected in the left lateral sector. The diagnosis was hepatic cavernous hemangioma. Abdominal ultrasonography revealed a heterogeneous hyperechoic tumor with a smooth border, 6 cm in diameter, in the left lateral sector (segment 3). Contrast-enhanced computed tomography of the abdomen showed that the tumor was enhanced from the early to the late phase. Abdominal angiography revealed a cotton wool-like appearance of the tumor. The diagnosis was hepatic cavernous hemangioma. A malignancy could not be ruled out because of the tumor's rapid growth, which had caused abdominal pain. Left hepatectomy was performed. Histopathological examination showed necrosis throughout the tumor. Slightly pleomorphic neoplastic cells with rounded, spindle-like nuclei and scant cytoplasm were sporadically found in vascular channels. Intracytoplasmic lumina occasionally contained red cells. Neoplastic cells were positive for factor VIII-related antigen, CD31, and CD34. The Mib-1 index was high. The tumor was diagnosed as malignant HEH. The postsurgical course was uneventful, and the patient was discharged on postoperative day 11. After 3 months, multiple metastatic tumors appeared in right hepatic lobe. Transcatheter arterial chemoembolization was performed.

[Epithelioid hemangioendothelioma of the inferior vena cava]

Epithelioid hemangioendothelioma is a rare endothelial cell-derived tumor of intermediate grade malignancy. It has an unpredictable outcome, independently of the usual histoprognostic criteria. Thirty-three cases with intravascular localisation are described in the literature. We describe a case occurring in a 31-year-old male, which developed an inferior veina cava tumor, with recurrence after incomplete surgical resection and chemotherapy. He was operated on again under extracorporeal circulation and complete surgical resection was then performed. Histologic examination found an intravascular epithelioid hemangioendothelioma developing in the vascular lumen without vascular wall infiltration. This entity represents a challenge not only for the vascular surgeon, but also for the pathologist given its difficult diagnosis.

Epithelioid hemangioendothelioma as a rare cause of blue toe syndrome

Blue toe syndrome (BTS), is a well-known entity of toe gangrene and rest pain secondary to micro emboli lodged within the digital arteries. BTS among young patients should alert physicians to look for causes such as trauma, connective tissue disease, hypercoagulability state, and others. We hereby describe a 32-year-old female with right BTS. A mass obstructing 80% of the right popliteal artery lumen was the source of emboli. The histologic results of the replaced arterial segment revealed a thrombus on top of epithelioid hemangioendothelioma. This is the first description of the association between primary vascular tumor and BTS.

Epithelioid hemangioendothelioma mimicking a nerve sheath tumor clinically and on MR imaging

Epithelioid hemangioendothelioma is a tumor of the soft tissues arising from the vascular endothelium. It is considered an intermediate grade malignancy. A 42-year-old female patient presented with pain and tingling down her right arm and a mass at the right medial upper extremity. MRI revealed an oblong mass along the course of the neurovascular bundle. Given the clinical and MR findings, a nerve sheath tumor was suspected. At surgery, the mass was adherent to both the brachial artery medially and the median nerve posteriorly. Pathology revealed epithelioid hemangioendothelioma. The imaging characteristics of epithelioid hemangioendothelioma on ultrasound, CT, and MRI are reviewed. Epithelioid hemangioendothelioma can mimic a nerve sheath tumor clinically and radiologically and should be considered in the differential diagnosis of tumors involving or adjacent to a neurovascular bundle.

Results of limb-sparing surgery with vascular replacement for soft tissue sarcoma in the lower extremity

OBJECTIVE

To evaluate limb-salvage surgery with vascular resection for lower extremity soft tissue sarcomas (STS) in adult patients and to classify blood vessel involvement.

METHODS

Subjects were consecutive patients (median age, 56 years) who underwent vascular replacement during surgery of STS in the lower limb between January 1988 and December 2003. Blood vessel involvement by STS was classified as follows: type I, artery and vein; type II, artery only; type III, vein only; and type IV, neither artery nor vein (excluded from the analysis). Patient data were prospectively gathered in a computerized database.

RESULTS

Twenty-one (9.9%) of 213 patients underwent vascular resections for lower limb STS. Besides 17 type I tumors (81.0%), 3 (14.3%) type II and 1 (4.7%) type III STS were diagnosed. Arterial reconstruction was performed for all type I and II tumors. Venous replacement in type I and III tumors was performed in 66.7% of patients. Autologous vein (n = 8) and synthetic (Dacron and expanded polytetrafluoroethylene; n = 12) bypasses were used with comparable frequency for arterial repair, whereas expanded polytetrafluoroethylene prostheses were implanted in veins. Morbidity was 57.2% (hematoma, thrombosis, and infection), and mortality was 5% (embolism). At a median follow-up of 34 months, the primary and secondary patency rates of arterial (venous) reconstructions were 58.3% (54.9%) and 78.3% (54.9%). Limb salvage was achieved in 94.1% of all cases. The 5-year local control rate and survival rate were 80.4% and 52%, respectively. We observed a 5-year metastasis-free survival rate of 37.7% and found vessel infiltration and higher tumor grade (low-grade vs intermediate grade and high grade tumors) to be negative prognostic factors at univariate and multivariate analysis.

CONCLUSIONS

Long-term bypass patency rates, the high percentage of limb salvage, and the oncologic outcome underline the efficacy of en bloc resection of STS involving major vessels in the lower limb. Disease-specific morbidity must be anticipated. The classification of vascular involvement (type I to IV) is useful for surgical management.

Epithelioid hemangioendothelioma of the radial artery

Epithelioid hemangioendothelioma (EHE) is an extremely rare vascular tumor of intermediate malignancy. Generally it develops from the peripheral veins (usually the femoral vein). We report on a case of EHE of the radial artery, developed in a 26-year-old male patient, which presented as a solitary painless mass. He had a complete resection of the tumor and of the segment of radial artery involved. The histologic examination revealed an intravascular EHE, with low mitotic index and with insufficient histologic anormalities.

Ulcerated epithelioid hemangioendothelioma of the foot in childhood

Epithelioid hemangioendothelioma is an uncommon malignant vascular tumor usually involving soft tissue and, in rare cases, the skin. Histologically and biologically it is considered to be a borderline neoplasm between an angiolymphoid hyperplasia with eosinophilia and an epithelioid angiosarcoma. Here we describe an 11-year-old girl with a 1-year history of an isolated, spontaneously appearing, painful ulceration on the instep of the right foot. The histopathologic examination of a wedge biopsy specimen revealed epithelioid eosinophilic cells with intracytoplasmic vacuoles containing erythrocytes. Immunohistochemical staining was positive for the endothelial markers CD31, CD34, and factor VIII. On the basis of these findings the diagnosis of epithelioid hemangioendothelioma was made. Two weeks after complete excision of the tumor, a lymph node metastasis in the right groin was excised. Because of another inoperable lymph node metastasis on the proximal right femur, polychemotherapy was started. As our case report shows, in the event of a nonhealing cutaneous ulceration the possibility of a malignant tumor such as epithelioid hemangioendothelioma should be considered, even in children.

Malignant epithelioid hemangioendothelioma presenting as an aneurysm of the superficial palmar arch: a case report

A patient with a malignant epithelioid hemangioendothelioma that presented as an aneurysm of the superficial palmar arch and third common digital artery had complete excision of the aneurysm and vascular reanastomosis. After pathologic diagnosis and surgical staging she received local irradiation to the hand. This case suggests that an aneurysm in the hand may develop in the setting of an underlying malignancy of blood vessel. When aneurysms in the hand require surgical intervention, we recommend that resection be complete, pathologic examination undertaken, and marginal tissue well-labeled to allow precise pathologic examination.