Cutaneous CD30-Positive Epithelioid Angiosarcoma Following Breast-Conserving Therapy and Irradiation: A Potential Diagnostic Pitfall

A review of CD30 expression in cutaneous neoplasms

BACKGROUND

The surface protein CD30 is a therapeutic target of monoclonal antibody therapy. Knowledge of the frequency of CD30 expression and its prognostic relevance is therefore interesting, not only in lymphoproliferative disorders (LPD) but also in solid tumors of the skin.

METHODS

A review was completed in PubMed for all published reports of CD30 expression in cutaneous lymphomas, mastocytosis, epithelial tumors and sarcomas from 1982 to April 2019. Only accessible articles in English and German were considered. Entities with an expected CD30 expression, such as CD30-positive LPD, were not evaluated.

RESULTS

The electronic research identified 1091 articles and a further 34 articles were obtained from manual bibliographic reference. Overall 91 articles were included that examined CD30 expression in various entities of cutaneous neoplasms and matched the inclusion criteria.

CONCLUSION

Apart from cutaneous CD30-positive LPD, the best-studied group for CD30 expression was mycosis fungoides (MF). CD30 positivity was found in 32% of classical (patch and plaque stage) and in 59.4% cases of transformed MF. CD30 was also frequently expressed in cutaneous mastocytosis (96.5%). In solid tumors, some single reports describe CD30 expression by tumor cells, but CD30-reactive lymphocytes were frequently observed in the tumor microenvironment (TME), especially in keratoacanthoma (KA).

Radiogenic angiosarcoma of the breast: case report and systematic review of the literature

BACKGROUND

Radiogenic angiosarcoma of the breast (RASB) is a rare late sequela of local irradiation of the breast or chest wall after breast cancer. The prognosis of women with RASB is poor and there is no standardized therapy for this type of malignancy.

CASE PRESENTATION

We present the case of a 54 year old woman with RASB (poorly differentiated angiosarcoma of the left breast; pT1, pNX, M0, L0, V0) and a history of invasive-ductal cancer of the left breast (pT1b, G2, pN0, ER positive, PR positive, HER-2/neu negative) treated in July 2012 with breast-conserving surgery, adjuvant chemotherapy with 6 cycles of epirubicin and cyclophosphamide, adjuvant irradiation of the left breast with 50 Gray, and adjuvant endocrine therapy with an aromatase inhibitor. In August 2016, a bilateral salpingo-oophorectomy was performed to remove a tumor of the left ovary, which was diagnosed as breast cancer recurrence. At the same time, a small, purple skin lesion of 1.2 cm in diameter was noted in the inner upper quadrant of the right breast. RASB was diagnosed by punch biopsy and the tumor was excised with clear margins. Imaging studies showed no evidence of further metastases. A systemic chemotherapy with 6 cycles of liposomal doxorubicin was initiated. Five months later, a local recurrence of RASB was diagnosed and mastectomy was performed. Six months later, the patient is alive with no evidence of disease. Three hundred seven cases of RASB were identified. The pooled incidence rate of RASB was 1/3754 women. The most common treatment of RASB was mastectomy in 83% of cases. Adjuvant radiotherapy or chemotherapy were rarely used with 6 and 4%, respectively, whereas in case of recurrence, chemotherapy was the mainstay of treatment, used in 58% of cases. Radiotherapy and repeated surgery were also common with 30 and 33% of cases, respectively. Overall, the prognosis of women with RASB was poor and the recurrence-free survival was short with a mean of 15.9 months. Mean overall survival was 27.4 months.

CONCLUSION

RASB is a rare late complication of breast irradiation. The prognosis of women with RASB is poor. Surgery is the mainstay of treatment for localized disease while systemic chemotherapy and re-irradiation are appropriate for women with disseminated or recurrent RASB.

Cutaneous angiosarcoma: a current update

Cutaneous angiosarcoma (cAS) is a rare malignant neoplasm with variable clinical presentation. Although a distinct vascular tumour, cAS shares many overlapping histopathological features with other vasoformative and epithelioid tumours or 'mimickers'. cAS shows aggressive behaviour and carries a grave prognosis, thus early diagnosis is of paramount importance to achieve the best possible outcomes. Recently, several genetic studies were conducted leading to the identification of novel molecular targets in the treatment of cAS. Herein, we present a comprehensive review of cAS with discussion of its clinical, histopathological and molecular aspects, the differential diagnosis, as well as current therapies including ongoing clinical trials.

Potential application and prevalence of the CD30 (Ki-1) antigen among solid tumors: A focus review of the literature

BACKGROUND

CD30 (Ki-1) is a cell membrane protein derived from the tumor necrosis factor (TNF) receptor family. The CD30 antigen has been associated primarily with Hodgkin lymphoma (HL) and systemic anaplastic large cell lymphoma (sALCL). Brentuximab vedotin (BV) is an antibody-drug conjugate targeting the CD30 antigen. FDA approval for BV includes relapsed and refractory HL and sALCL. The CD30 antigen also has been identified in many solid tumors, predominantly of germ cell origins and early clinical data is promising.

OBJECTIVE

Perform a focus literature review evaluating the prevalence of the CD30 antigen among nonlymphomatous tumors with a potential correlate for CD30 targeted therapy.

ELIGIBILITY CRITERIA

Inclusion criteria: all retrospective reviews and case reports citing CD30 positivity or negativity in non-lymphomatous malignancies in which data were presented based on location.

EXCLUSION CRITERIA

studies with hematopoetic malignancies, cutaneous malignancies, non-human populations, and non-english publications.

INCLUDED STUDIES

A total of 119 articles met these criteria and are summarized in this manuscript.

CONCLUSION

The CD30 antigen has shown variable prevalence among non-hematopoetic tumors, most notably among germ cell tumors and mesothelioma. With additional, preclinical and properly powered clinical studies, CD30 targeted therapy such as that of BV, alone or in combination with other agents may prove to be a strong candidate in the treatment of various CD30⁺ malignancies.

Primary Breast Angiosarcoma: A Retrospective Study of 36 Cases from a Single Chinese Medical Institute with Clinicopathologic and Radiologic Correlations

The aim of this study was to present our experience with primary breast angiosarcoma (PBA) by describing a large series of cases with an emphasis on clinicopathologic and radiologic correlations. Thirty-six cases of PBA diagnosed at our institution between 2006 and 2014 were retrospectively evaluated. All but one case occurred in women with a median age of 35.5 years. The majority of patients presented with a deeply located painless mass, whereas a minority manifested as diffuse enlargement or swelling of the breast. Magnetic resonance imaging showed poorly demarcated lesions with low signal intensity on T1-weighted images, markedly high intensity on T2-weighted images, and prolongation of enhancement upon dynamic study. Histologically, 19 cases (52.8%) were low grade, 12 cases (33.3%) were intermediate grade, and 5 cases (13.9%) were high grade. Follow-up information was available for 27 patients and revealed local recurrence and/or metastasis in 16 patients (59.3%). Five patients (18.5%) died of the disease at a median interval of 20 months. Univariate analysis showed that tumor differentiation had effect on disease-free survival (DFS) (p = 0.005) but failed to predict overall survival (OS) (p = 0.645). The treatment modality was related to OS (p = 0.042) but not DFS (p = 0.131). The Cox proportional hazards regression model suggested that tumor differentiation was an independent predictor of DFS (p = 0.015). We hypothesize that tumor differentiation may be used as a prognostic factor for this rare malignancy. Clinicopathologic and radiologic correlation may help pathologists to arrive at the correct diagnosis of PBA.

Brentuximab vedotin for treatment of non-Hodgkin lymphomas: A systematic review

BACKGROUND

Brentuximab vedotin (BV) is an antibody-drug conjucate (ADC) comprising a CD30-directed antibody, conjugated to the microtubule-disrupting agent MMAE via a protease cleavable linker. BV is FDA approved for use in relapsed classical Hodgkin lymphoma (HL) and relapsed systemic anaplastic large cell lymphoma (sALCL). There are multiple publications for its utility in other malignancies such as diffuse large B-cell lymphoma (DLBCL), mycosis fungoides (MF), Sézary syndrome (SS), T-cell lymphomas (TCL), primary mediastinal lymphoma (PMBL), and post-transplant lymphoproliferative disorders (PTLD). We believe that BV could potentially provide a strong additional treatment option for patients suffering from NHL.

OBJECTIVE

Perform a systematic review on the use of BV in non-Hodgkin lymphoma (NHL) and other CD30⁺ malignancies in humans.

DATA SOURCES

We searched various databases including PubMed (1946-2015), EMBASE (1947-2015), and Cochrane Central Register of Controlled Trials (1898-2015).

ELIGIBILITY CRITERIA

Inclusion criteria specified all studies and case reports of NHLs in which BV therapy was administered.

INCLUDED STUDIES

A total of 28 articles met these criteria and are summarized in this manuscript.

CONCLUSION

Our findings indicate that BV induces a variety of responses, largely positive in nature and variable between NHL subtypes. With additional, properly powered prospective studies, BV may prove to be a strong candidate in the treatment of various CD30⁺ malignancies.

CD30 expression in malignant vascular tumors and its diagnostic and clinical implications: a study of 146 cases

Angiosarcoma (AS) is a rare malignant vascular tumor, whereas epithelioid hemangioendothelioma (EHE) is a vascular tumor of low-grade malignancy. CD30 is a member of the tumor necrosis factor receptor superfamily, member 8 (TNFRSF8). Although the expression of CD30 is most commonly associated with lymphoid malignancies or germ cell tumors, occasional ASs have been reported as CD30 positive. However, there are limited data to evaluate its role definitively in malignant vascular tumors. In this study, we evaluated 91 ASs, 30 EHEs from various sites, and 25 Kaposi sarcomas. Overall, CD30 was expressed in 31/91 cases (34%) of AS, in 7/30 cases (30%) of EHE, but in none of the Kaposi sarcomas. CD30 was expressed in a membranous staining pattern and positivity in tumor cells varied from focal to diffuse. The positive ASs included vasoformative more differentiated tumors and also solid, undifferentiated, lymphoma-like examples, one of which was classified as lymphoma before the era of immunohistochemistry. The CD30 expression was seen in >50% of tumor cells in a majority of ASs but only in 7% of EHEs. None of the 55 ASs studied were immunohistochemically positive for TIA-1 or Granzyme B, antigens used as more specific markers for anaplastic large-cell lymphoma. Compared with AS, normal vascular endothelia of capillaries and muscular vessels showed variable positivity. Among hemangiomas, cavernous and spindle cell hemangiomas showed most frequent endothelial CD30 positivity, whereas in most other hemangiomas, CD30 positivity was scant. In conclusion, CD30 expression occurs in a significant subset of ASs and EHEs and needs to be included in the differential diagnosis with other CD30-positive malignancies to avoid a diagnostic pitfall. It remains to be determined whether patients with strongly CD30-positive ASs could be candidates for targeted therapy using the recently introduced CD30 antibody drug conjugates.

Epithelioid angiosarcoma of the kidney: A case report and literature review

Epithelioid angiosarcoma (EAS) is a rare disease which presents a great diagnostic challenge. The present study reports a case of EAS in the kidney in a 75-year-old male who presented with gross hematuria. An abdominal computed tomography scan revealed space-occupying lesions of the right kidney and renal cell carcinoma was suspected. Histological examination of the resected specimens showed pleomorphic epithelioid cells with vesicular nuclei, prominent nucleoli and eosinophilic cytoplasm that lined irregular vascular spaces. Immunohistochemical staining revealed that the tumor cells were positive for AE1/AE3, cytokeratin (CK) 7, vimentin, cluster of differentiation (CD) 31 and E-cadherin, but showed no staining for CD10, CD34, factor VIII, CK20, carcinoembryonic antigen or desmin. Based on the histopathological and immunohistochemical findings, the patient was diagnosed with epithelioid angiosarcoma. Postoperative radiation therapy was administered and no recurrence was observed six months after surgery.

Aberrant expression of neuroendocrine markers in angiosarcoma: a potential diagnostic pitfall

Angiosarcomas (AS) are uncommon endothelial malignancies, usually arising from sun-damaged skin in older adults. Although most AS are readily diagnosed by light microscopy alone, immunohistochemistry (IHC) for endothelial markers such as CD31, CD34, FLI1, and ERG plays a valuable adjunctive role. However, IHC studies of AS must be interpreted with caution, as aberrant expression of markers such as cytokeratins, CD30, and CD117 may be seen. We report 3 cases of AS showing aberrant expression of the neuroendocrine markers synaptophysin and/or chromogranin A, previously unreported phenomena. Cases presented as metastatic lesions in the lung of a 48-year-old woman and as primary tumors of the kidney and neck in a 29-year-old and a 51-year-old woman, respectively. All cases expressed synaptophysin and/or chromogranin A, and various neuroendocrine/endocrine neoplasms were strongly considered as diagnoses by the initial evaluating pathologists. Additional morphological study and confirmatory IHC for CD31, FLI1, and ERG established the diagnosis of AS in all cases. Coexpression of synaptophysin and chromogranin A in 1 case suggests that at least some AS show true neuroendocrine differentiation. Awareness of this potential diagnostic pitfall is important for correct diagnosis and treatment of this rare subset of AS.

Epithelioid angiosarcoma: a brief diagnostic review and differential diagnosis

Epithelioid angiosarcoma is a highly aggressive endothelial cell malignancy, most commonly arising in the deep soft tissues, but a variety of primary sites, including the adrenals, thyroid, skin, and bone, are encountered. On hematoxylin-eosin-stained sections, the pathologist encounters sheets of large, mildly to moderately pleomorphic epithelioid cells, with abundant eosinophilic cytoplasm, vesicular nuclei, and prominent nucleoli. Obvious vasoformative foci may not be present, creating confusion with metastatic carcinomas, malignant mesothelioma, melanoma, anaplastic lymphoma, epithelioid peripheral nerve sheath malignancies, and epithelioid sarcoma. Moreover, malignancies with apparent vascular differentiation must be distinguished from less aggressive vascular neoplasms, including epithelioid hemangioendothelioma. Given the range of clinical presentation, the diversity of primary sites, and the nonspecific initial histopathologic appearance, here we review the histologic findings and immunohistochemical profiles of epithelioid angiosarcoma and neoplasms in its differential diagnosis.

Epithelioid angiosarcoma: a neoplasm with potential diagnostic challenges

Epithelioid angiosarcomas are extremely rare tumors associated with poor prognosis and early metastases. Its epithelioid cytomorphology and limited vasoformation make it difficult to distinguish from more common malignancies, such as, carcinoma. This can be a potential diagnostic pitfall for the cytopathologist. In this report, the patient is a 24-year-old man presenting with testicular pain, a pelvic mass, and innumerable liver nodules. Immediate interpretation of the needle core biopsies of the pelvic mass and liver lesions initially favored a poorly differentiated adenocarcinoma. Unusual positive immunohistochemical stains for CD30 and CK7 ultimately led the investigation toward a tumor of mesenchymal origin. Further, immunohistochemical evaluation demonstrated positive CD31 and Factor VIII staining and established the final diagnosis of epithelioid angiosarcoma. The tumor cells were negative for CD34, CK20, alpha-fetoprotein, placental-like alkaline phosphatase, hepatocyte paraffin 1, polyclonal carcinoembryonic antigen, CD10, CA-125, prostate-specific antigen, and prostatic acid phosphatase. This case is reported to illustrate the importance of considering the diagnosis of epithelioid angiosarcoma when encountering an "epithelioid" neoplasm particularly with unusual immunoreactivity for CK7 and CD30.