Primary angiosarcoma of bone: a retrospective analysis of 60 patients from 2 institutions

Clinical recommendations for treatment of localized angiosarcoma: A consensus paper by the Italian Sarcoma Group

Angiosarcoma (AS) represents a rare and aggressive vascular sarcoma, posing distinct challenges in clinical management compared to other sarcomas. While the current European Society of Medical Oncology (ESMO) clinical practice guidelines for sarcoma treatment are applicable to AS, its unique aggressiveness and diverse tumor presentations necessitate dedicated and detailed clinical recommendations, which are currently lacking. Notably, considerations regarding surgical extent, radiation therapy (RT), and neoadjuvant/adjuvant chemotherapy vary significantly in localized disease, depending on each different site of onset. Indeed, AS are one of the sarcoma types most sensitive to cytotoxic chemotherapy. Despite this, uncertainties persist regarding optimal management across different clinical presentations, highlighting the need for further investigation through clinical trials. The Italian Sarcoma Group (ISG) organized a consensus meeting on April 1st, 2023, in Castel San Pietro, Italy, bringing together Italian sarcoma experts from several disciplines and patient representatives from "Sofia nel Cuore Onlus" and the ISG patient advocacy working group. The objective was to develop specific clinical recommendations for managing localized AS within the existing framework of sarcoma clinical practice guidelines, accounting for potential practice variations among ISG institutions. The aim was to try to standardize and harmonize clinical practices, or at least highlight the open questions in the local management of the disease, to define the best evidence-based practice for the optimal approach of localized AS and generate the recommendations presented herein.

Primary vascular tumors of bone: A comprehensive literature review on classification, diagnosis and treatment

Primary vascular tumors of bone are a heterogeneous group of neoplasms, ranging from benign hemangiomas to frankly malignant epithelioid hemangioendotheliomas and angiosarcomas. Over the years, their classification has been a matter of discussion, due to morphologic similarities and uncertainty regarding biologic behavior. Over the past decade, with the development of next-generation sequencing, there has been a significant improvement in the molecular characterization of these lesions. The integration of their morphologic, immunohistochemical and molecular features has led to a better stratification, with important prognostic and therapeutic implications. Nevertheless, primary vascular bone tumors still represent a challenge for medical oncologists. Given their rarity and heterogeneity, in the last few years, there has been no significant progress in medical treatment options, so further research is needed. Here we present a review of the current knowledge regarding primary vascular tumors of the bone, correlating clinicopathologic features with tumor behavior and therapeutic approaches.

Multicentric Epithelioid Angiosarcoma of Bones Showing Angiotropic Spread: A Case Report

Epithelioid angiosarcoma is a rare variant of angiosarcoma characterized by an epithelioid morphology that mimics carcinoma. Therefore, multicentric epithelioid angiosarcoma is easily misdiagnosed as bone metastasis from carcinoma and has an aggressive clinical course. Here, we present a rare case of a 61-year-old male with multicentric epithelioid angiosarcoma of the bone. Plain radiography, CT, and MRI revealed multiple osteolytic lesions in both femurs; some lesions showed soft tissue extension with cortical bone destruction. Interestingly, PET-CT revealed that the lesions were only distributed along the bones of the lower extremities, including the pelvic bones, femurs, and tibiae. Despite histological analysis initially suggesting metastatic carcinoma, after additional immunohistological staining, including that for vascular markers (CD31 and ERG), the final diagnosis was epithelioid angiosarcoma. A better understanding of the clinicoradiological features of this disease may help eliminate diagnostic confusion and provide better management.

Establishment and validation of prognostic nomograms to predict the overall and cancer-specific survival in patients with hepatic malignant vascular tumors

OBJECTIVE

To characterize the clinicopathologic features and to investigate the prognostic nomograms for overall survival (OS) and cancer-specific survival (CSS) in patients with Hepatic malignant vascular tumors (HMVT).

METHOD

Patients diagnosed with HMVT between 1973 and 2015 were screened from the Surveillance, Epidemiology, and End Results (SEER) database. The Kaplan-Meier (KM) was used for survival analysis. The univariate and multivariate Cox analyses were performed to identify independent predictors. Furthermore, the prognostic nomograms were established and evaluated.

RESULTS

A total of 510 HMVT patients were collected, and randomly divided into HMVT-training (N=308) and validation cohort (N=202) groups. The 3- and 5-year OS for overall HMVT were 21.3% and 19.8%, and the corresponding CSS was 29.8% and 27.7% respectively. Age at diagnosis, grade, tumor size, and histological type were identified as prognostic factors for OS and CSS in patients with HMVT. However, sex was just for predicting CSS, and T stage was only an indicator of OS. These factors were further utilized to construct the nomograms for OS and CSS in the HMVT-training cohort showing credible performance with the C-index of 0.763 and 0.762, respectively. Moreover, the AUC value for 1-, 3-, 5-year OS was 0.873, 0.905 and 0.898, and the corresponding value for CSS was 0.808, 0.794 and 0.788 respectively. Additionally, the calibration curves demonstrated a favorable agreement between the predicted and actual 1-, 3- and 5-year survival rates both in the training and validated cohorts.

CONCLUSION

This was the largest population-based study to describe the clinicopathologic characteristics in patients with HMVT. Moreover, we established and validated prognostic nomograms that indicated an accurate prediction for 1-, 3- and 5-year of OS and CSS.

Primary Angiosarcoma of the Adrenal Gland: Report of 2 Cases and Review of the Literature

Primary adrenal angiosarcoma is a rare, malignant, vascular neoplasm. These neoplasms typically arise in middle age (median age of 60 years) and are more common in males (65%) than in females. Although rare, these neoplasms are aggressive with a propensity for local recurrence and metastasis and a median survival of 18 months. We present 2 cases of primary adrenal angiosarcoma with synchronous, ipsilateral adrenocortical adenomas. We review the cases of adrenal angiosarcoma reported since 1988 and discuss their clinical and histopathologic characteristics.

Primary Angiosarcoma of Humerus - A Case Report and Literature Review

INTRODUCTION

Osseous angiosarcoma is a very rare tumor of bone with aggressive behavior, propensity for recurrences, and distant metastasis. The etiology of osseous angiosarcoma is uncertain; however, specific risk factors have been recognized. The diagnosis of angiosarcoma of bone demands multimodality imaging in conjunction with histopathological and vascular marker evaluation to aptly differentiate them from other vascular tumors. Treatment of osseous angiosarcoma remains controversial.

CASE REPORT

A 53-year-old male presented with pain and swelling of the right upper 1/3rd of the arm following heaviness while lifting weight for 3 months. He had a history of significant weight loss and appetite with no history of inciting trauma or irradiation in the past. On examination, a diffuse swelling was noted in the right shoulder and right scapular aspect with varied consistency and ill-defined borders and margins. The skin over the swelling was stretched and shiny with dilated engorged veins over it. The plain radiograph of the right shoulder with humerus revealed a large expansile lytic soft-tissue mass in the right proximal humerus with a wide zone of transition without sclerotic margins. Magnetic resonance imaging showed T1 hypointense, T2/PDFS hyperintense large well-defined expansile lytic lesion with multi-loculated cysts, and multiple blood-fluid levels involving right proximal humerus. The patient underwent an incisional biopsy which exhibited angiosarcoma of the humerus. The patient was treated with six cycles of chemotherapy with a mesna, doxorubicin, ifosfamide, and dacarbazine regimen. The patient was still under follow-up.

CONCLUSION

Being a rare clinical entity, controversy exists in angiosarcoma of humerus regarding its etiology and recommended management protocols. Histopathology and immunohistochemistry remain the gold standard in differentiating osseous angiosarcoma from other osseous vascular tumors. The treatment protocol has to be standardized to decrease morbidity and to improve the functional quality of life of the patient.

Clinical pathological characteristics of pelvic bone tumors

Introduction: Bone tumors are rare neoplasms whose therapy depends on the location. Pelvic bones represent a special anatomical entity diagnosis and therapy of pelvic tumors in addition to the pathohistological type largely depends on the anatomical specifics of that region. Aim: The aim of this study was to show the frequency, as well as clinical and pathological characteristics of primary and secondary tumors of the pelvic bones. Material and methods: The research as a descriptive study in the period from January 1, to December 31, 2019 at the Institute of Pathology of the Medical Faculty of the University of Belgrade and includes 33 patients. Demographic, clinical and radiological data were obtained from the Bone Tumor Registry. Statistical processing and analysis were done in the Statistical Package for Social Science SPSS Windows version 22 (IBM Chicago, Ilinois, USA). Results: Out of 33 patients, 55% had secondary pelvic tumors, primarily cancer metastases (37%). In 21% of cases, primary malignant bone tumor as diagnosed, and in 12%, primary benign bone tumor. Hematopoietic neoplasms were verified in 12%. Conclusion: Pelvic bone tumors are not common, but these neoplasms, in orthopedic oncology, represents their malignant biological behavior are of great importance. The most common primary malignant tumor in adults is chondrosarcoma, and in children Ewing sarcoma. Highest frequency for pelvic bone metastases has lung cancer. Plasmacytoma in adults, Langerhans cellular histiocytosis in children are hematological neoplasms seen at this site.

Metastatic angiosarcoma of unknown primary site misdiagnosed as tuberculosis

Tuberculosis in endemic areas is likely to be overdiagnosed in patients with atypical clinical and imaging findings mimicking tuberculosis, as in our case of angiosarcoma. Detailed history, physical examination, imaging, and histopathology avert diagnosis of tumors as tuberculosis in resource-limited settings, where countless diseases have common clinical and imaging presentations.

A Clinical Model of Bone Angiosarcoma Patients: A Population-based Analysis of Epidemiology, Prognosis, and Treatment

Objective

To investigate the epidemiological data, prognostic factors, and treatment outcomes of bone angiosarcoma (BA).

Methods

This retrospective study was based on the Surveillance, Epidemiology, and End Results (SEER) database. The medical records of BA patients were selected from the SEER database from 1975 to 2016. Variables including patients' baseline demographics (age, sex, marital status, and year of diagnosis), tumor characteristics (tumor size, grade, and SEER Historic Stage A), and treatment (surgery and radiotherapy) were selected for further analysis. The research endpoints were overall survival (OS) and cancer‐specific survival (CSS). The optimal cutoff values of continuous variables including age, year of diagnosis, and tumor size were identified using the X‐tail program. Univariate Cox regression was used to identify potential prognostic factors and multivariate Cox regression was used to identify independent prognostic factors. All prognostic factors were included to predict the survival time compared to the median OS and CSS times via the novel nomograms. To validate the internal validation of nomograms, we analyzed the concordance indices (C‐index).

Results

This study enrolled a total of 271 patients with malignant vascular bone tumors among residents of the United States between 1975 and 2016. After applying the exclusion criteria (one case without active follow‐up), this study included 152 patients with BA. The median survival time of BA was significantly shorter than that of malignant vascular bone tumors for OS (9 months vs 27 months, P < 0.001). Age, year of diagnosis, tumor size, grade, stage, and surgery were identified as potential prognostic factors for OS or CSS in univariate Cox regression. However, only age (P < 0.001, P < 0.001), stage (P = 0.002, P < 0.001), and surgery (P = 0.001, P = 0.002) were independent prognostic factors for CSS and OS, respectively, in the multivariate analysis. Younger patients less than 54 years have significantly better prognosis for CSS/OS than patients between 54 and 67 years (Hazard ratios [HRs]: 1.651 [1.763–3.575], 2.557 [1.395–4.687]) and more than 67 years (HRs: 4.404 [2.237–8.670], 5.113 [2.923–8.942]). For CSS/OS, the survival time of patients with localized stage was significantly longer than that of patients with regional stage (HRs: 1.530 [0.725–3.228], 1.548 [0.834–2.873]) and that of patients with distant stage (HRs: 1.706 [0.899–3.237], 2.101 [1.254–3.520]). Patients with surgery had more survival time than patients without surgery for CSS/OS (HRs: 2.861 [1.542–5.310], 2.103 [1.308–3.379]). All factors were further included to generate nomograms for CSS and OS. The C‐indexes for the internal validation of OS and CSS prediction were 0.787 (95% confidence interval [CI]: 0.738–0.836) and 0.768 (95% CI: 0.717–0.819), respectively.

Conclusions

Age, stage, and surgery were closely associated with prognosis in patients with BA, and this clinical model was a favorable tool to evaluate survival possibilities.

Angiosarcoma of bone: a retrospective study of the European Musculoskeletal Oncology Society (EMSOS)

Angiosarcoma of bone (B-AS) is a rare malignant tumor of vascular origin. The aim of this retrospective study is to report on treatments and prognosis. Data were collected from the EMSOS website. 80 patients in 9 centers included: 51 male/29 female; median age 54 years (range 17 to 92); 56% with localized disease, 44% metastatic. Primary tumor surgery: 76% (30% amputation, 26% intralesional margins); radiotherapy (RT): 41%; chemotherapy (CT): 47% (56% in metastatic, 41% in localized cases). With a median follow-up of 31 months (range 40 to 309), 5-year overall survival (OS) was 27% (95%CI 16–30): 41% (95%CI 25–56) for localized patients, and 8% (95%CI 0–20) for metastatic (p = 0.002). In metastatic patients, 1 year OS was significantly influenced by chemotherapy response: 67% (95CI% 29–100) for those who responded or had stable disease (n = 7), and 18% (95CI% 0–41) for patients with progressive disease (n = 11), p 0.002. The surgical complete remission (SCR) status was pivotal in localized patients (5-year OS 45% for SCR, 17% no SCR, p = 0.03); also 5-year OS was significantly influenced by age and site of the tumor. After multivariate analysis, the addition of radiotherapy to surgery significantly influenced the disease-free survival (DFS) rate, whereas the use of chemotherapy lost the significance showed at the univariate analysis. Overall, patients with metastatic B-AS have a dismal prognosis, with a prolonged survival in case with a response to chemotherapy. Experimental trials with more active systemic treatment regimens are needed. In patients with localized disease, the patient’s age and site of the tumor are prognostic factors and any effort must be made to achieve an SCR status. No definitive conclusions can be drawn from our data on the use of adjuvant chemotherapy, while the use of adjuvant radiotherapy might improve DSF in patients surgically free of disease.

The incidence of skip metastases on whole bone MRI in high-grade bone sarcomas

INTRODUCTION

Skip metastases have been described with osteosarcoma, Ewing sarcoma and rarely chondrosarcoma. The aim of this study was to determine the incidence of skip metastases on whole bone MRI in all primary high-grade sarcomas of the major long bones.

MATERIALS AND METHOD

Retrospective review of patients from April 2007 to April 2019 with high-grade primary bone sarcomas of the humerus, radius, ulna, femur, tibia or fibula who had whole bone MRI at initial staging. Data collected included age, sex, tumour type, presence and location of skip metastases based on whole bone MRI and presence of distant metastases (the skeleton and lung).

RESULTS

The study included 216 males and 171 females with mean age 30.6 years (range 4-92 years). Tumour types were as follows: High-grade osteosarcoma n = 202, Ewing sarcoma n = 68, high-grade chondrosarcoma n = 44, dedifferentiated chondrosarcoma n = 37, high-grade spindle cell sarcoma n = 29 and angiosarcoma n = 7. Skip lesions were identified in 63 (16.3%). However, after taking into account the presence of distant skeletal (n = 11) and pulmonary (n = 33) metastases, the overall incidence of skip metastases was 6.5%, occurring in 15 (7.5%) high-grade osteosarcomas, 3 (4.5%) Ewing sarcoma, 1 (2.8%) high-grade chondrosarcoma, 4 (10.8%) dedifferentiated chondrosarcomas, and 2 (6.9%) high-grade spindle cell sarcomas. A false positive MRI diagnosis of skip metastasis was made in 4 cases, 3 enchondromata and one focal nodular marrow hyperplasia.

CONCLUSION

The current study has documented the incidence of skip metastases in common types of high-grade primary bone sarcoma. The possibility of false positive skip metastases has also been highlighted.

Epidemiology, tumor characteristics and survival in patients with angiosarcoma in the United States: a population-based study of 4537 cases

OBJECTIVE

Limited by sample size, angiosarcoma was rarely studied. We aimed to investigate the characteristics and prognosis of angiosarcoma in the National Cancer Institute's Surveillance, Epidemiology and End Results database.

METHODS

Patients who were diagnosed with primary angiosarcoma from 1973 to 2014 were extracted from the Surveillance, Epidemiology and End Results database. Kaplan-Meier analysis was used to estimate the overall survival, and the difference between groups was tested by the log-rank test. Multivariate Cox regression analyses were employed to identify prognostic factors for primary angiosarcoma.

RESULTS

A total of 4537 patients with angiosarcoma were included with the median age of 69 years. The median overall survival was 82.1 (95% confidence interval: 76.5-87.7) months. Overall 1-, 2- and 5-year survival rates were 55.2 ± 0.7, 41.0 ± 0.7 and 26.3 ± 0.7%, respectively. In the univariate analysis, age, gender, marital status, race, primary site, tumor grade, tumor size, Surveillance, Epidemiology and End Results historic stage and the surgery of primary site were significantly associated with overall survival. Multivariate Cox regression showed that factors including the patients older than 69 years, male, unmarried status, other primary sites, grades (III and IV), tumor size ≥ 5 cm, regional and distant stage and non-surgery were independently associated with poor survival. The results were consistent after excluding the patients in IV stages.

CONCLUSIONS

This large population-based study comprehensively described the survival rate and prognostic factors for angiosarcoma in the United States. Age, gender, marital status, primary sites, tumor grade and size and historic stage were determinants of survival, and surgery can improve the prognosis of patients with angiosarcoma.

Survival Analysis of Patients with Osseous Malignant Vascular Tumors: Results of the Surveillance, Epidemiology, and End Results (SEER) Database from 1973 to 2015

Background

Osseous malignant vascular tumors (OMVTs) are rare lesions. Moreover, the prognostic determinants of OMVTs have not been reported. This study aimed to present epidemiological data and analyze the prognostic factors of survival in OMVT patients.

Material/Methods

OMVT patients who were diagnosed between 1973 and 2015 were screened using the Surveillance, Epidemiology, and End Results (SEER) program database, with special attention paid to osseous hemangiosarcoma (OAS) and osseous hemangioendothelioma (OHE). We assessed the prognostic values of cancer-specific survival (CSS) and overall survival (OS) rates with a Cox proportional hazards regression model and univariate and multivariate analyses. OS and CSS curves were obtained using the Kaplan-Meier method.

Results

A total of 202 cases were selected from the SEER database. The specific histopathological diagnoses were osseous hemangiosarcoma (n=127) and osseous hemangioendothelioma (n=75). Among OMVT patients, histology was an important factor in determining survival. Using multivariate analysis, old age, distant tumor stage, surgery, and low tumor grade were predictors of OS for OAS patients. Old age, surgery, and low tumor grade were predictors of CSS. Using multivariate analysis, old age and surgery were predictors of OS and CSS for OHE patients.

Conclusions

This study is the largest population-based study to show the demographic characteristics and analyze the prognosis of OMVT patients. Independent predictors of OS for patients with AS included old age, distant tumor stage, low tumor grade, and surgery. Old age, surgery, and low tumor grade were also predictors of CSS for patients with OAS. Independent predictors of CSS and OS for patients with OHE included old age and surgery.

Solitary Primary Intraosseous Angiosarcoma of the Mandible

Angiosarcoma is a malignant vascular tumor derived from the mesenchymal cells which have undergone an angioblastic differentiation. About half of the angiosarcomas are reported to localize in the skin and soft tissues of the head and neck, i.e., found predominantly to arise from the scalp and face. Angiosarcomas rarely involve the skeletal system, wherein they generally have a tendency for multicentricity. Primary bony angiosarcoma accounts for about 6% of all the angiosarcomas and about 1.4% of all the primary bony sarcomas. A majority of angiosarcomas are reported to occur in the elderly males; its occurrence in the pediatric population is extraordinarily rare. We report a rare case of a solitary primary intraosseous mandibular angiosarcoma in a 7-year-old male child. The unique clinical presentation, the histopathological features along with the management challenges of this fascinating yet aggressive tumor is discussed.

Malignant bone tumors (other than Ewing's): clinical practice guidelines for diagnosis, treatment and follow-up by Spanish Group for Research on Sarcomas (GEIS)

Primary malignant bone tumors are uncommon and heterogeneous malignancies. This document is a guideline developed by the Spanish Group for Research on Sarcoma with the participation of different specialists involved in the diagnosis and treatment of bone sarcomas. The aim is to provide practical recommendations with the intention of helping in the clinical decision-making process. The diagnosis and treatment of bone tumors requires a multidisciplinary approach, involving as a minimum pathologists, radiologists, surgeons, and radiation and medical oncologists. Early referral to a specialist center could improve patients' survival. The multidisciplinary management of osteosarcoma, chondrosarcoma, chordoma, giant cell tumor of bone and other rare bone tumors is reviewed in this guideline. Ewing's sarcoma will be the focus of a separate guideline because of its specific biological, clinical and therapeutic features. Each statement has been accompanied by the level of evidence and grade of recommendation on the basis of the available data. Surgical excision is the mainstay of treatment of a localized bone tumor, with various techniques available depending on the histologic type, grade and location of the tumor. Chemotherapy plays an important role in some chemosensitive subtypes (such as high-grade osteosarcoma). In other subtypes, historically considered chemoresistant (such as chordoma or giant cell tumor of bone), new targeted therapies have emerged recently, with a very significant efficacy in the case of denosumab. Radiation therapy is usually necessary in the treatment of chordoma and sometimes of other bone tumors.

Multicentric Primary Angiosarcoma of Bone Mimicking Metastasis on (18)F-FDG PET/CT in a Patient with a History of Sigmoid Colon Cancer: a Case Report

Primary angiosarcoma of the bone (PAB) is a rare and fatal high-grade malignant vascular bone tumor. We report a rare case of multicentric PAB mimicking bone metastasis in a 59-year-old female patient with a history of sigmoid colon cancer. This patient complained of lower back and pelvic pain and presented with multiple osteolytic bone lesions on plain radiography and pelvic computed tomography. First, bone metastasis of sigmoid colon cancer was suspected. However, on the (18)F-fluorodeoxyglucose ((18)F-FDG) positron emission tomography/computed tomography (PET/CT) scan, the patient presented unusual multiple hypermetabolic osteolytic bone lesions involving contiguous bones of the lower half of the body. After bone biopsy, these lesions were confirmed to be multicentric PAB. To the best of our knowledge, this is the first case report of an (18)F-FDG PET/CT scan in a patient with multicentric primary bone angiosarcoma.

Epithelioid angiosarcoma of the ilium: a case report

Bone epithelioid angiosarcoma (EA) is rare and characterized by large, mildly to moderately pleomorphic epithelioid cells, with abundant eosinophilic cytoplasm, vesicular nuclei, and prominent nucleoli. The tumors may arise in various locations in bone and the patients may present with unifocal or multifocal osseous disease. We present a unifocal lesion case of EA of the ilium in a 62-year-old woman. A needle biopsy of the ilium was performed and first diagnosed poorly differentiated adenocarcinoma based on CKpan and CK18 immunopositivity. The tumor was treated initially with curettage followed by chemotherapy. The final diagnosis on the surgical specimen was epithelioid angiosarcoma.

Primary multicentric angiosarcoma of bone: true entity or metastases from an unknown primary? Value of comparative genomic hybridization on paraffin embedded tissues

Multicentric primary angiosarcoma of bone has been described as a distinct entity from bone metastases from angiosarcoma. Bone angiosarcoma accounts for less than 1% of sarcomas. It has dismal prognosis overall, but the multicentric expression does not confer worse prognosis. We describe the case of an old male with bone angiosarcoma of the extremities with multicentric presentation. He soon after had soft tissue angiosarcoma of the head and neck. Histology and immunohistochemistry were consistent with the diagnosis of high-grade angiosarcoma. Comparative genomic hybridization on paraffin-embedded samples of the bone and head and neck samples suggested additional abnormalities in the bone fragment, thus suggesting than bone lesions were indeed metastatic from his head and neck angiosarcoma; although these preliminary analyses warrant confirmation in other similar rare cases. The patient died after 3 years of relapsed acute leukemia with progressive angiosarcoma.