Early diagnosis and straight forward surgery of an asymptomatic primary angiosarcoma of the kidney led to long-term survival

Primary vascular tumours of the kidney

Primary vascular tumours of the kidney are rare and may pose diagnostic difficulties because of their similar clinical, morphological, and immunohistochemical features. This article summarizes the clinical and pathological features of primary renal angiosarcoma and anastomosing haemangioma of the kidney including epidemiology, genetics, and prognosis. Renal anastomosing haemangiomas are benign neoplasms characterized by anastomosing capillary-sized vascular channels. These tumours are rare, with about 75 cases reported in the literature. Most anastomosing haemangiomas are found incidentally on ultrasound, computed tomography, or magnetic resonance imaging. Common symptoms include abdominal pain, haematuria, and abdominal mass. Renal anastomosing haemangiomas are characterized by recurrent mutations in GNAQ and GNA14 genes. The prognosis of anastomosing haemangioma is excellent. Primary renal angiosarcomas are malignant tumours showing endothelial differentiation. To date, 76 cases have been described in the literature. Primary renal angiosarcomas are frequently symptomatic. The clinical features of renal angiosarcomas are similar to those of renal anastomosing haemangiomas, including abdominal pain, haematuria, and abdominal mass. Angiogenesis-related genes and vascular-specific receptor tyrosine kinases such as KDR, TIE1, SNRK, TEK, and FLT1 are upregulated in angiosarcomas. Primary renal angiosarcomas are highly aggressive neoplasms with a poor prognosis despite surgical treatment, chemotherapy, radiotherapy, or targeted therapy.

Primary renal angiosarcoma: A case report and a short review of literature

Primary renal angiosarcomas (AS) are uncommon tumors with poor prognosis. Aetiology is unknown but some unproven risk factors have been described. It is difficult to discriminate these masses from renal cell carcinomas or other renal masses with imaging modalities. Immunohistochemistry plays an important role in the diagnosis. Main treatment protocol for primary renal AS is still controversial and nephrectomy with chemotherapy and/or radiotherapy seems the only treatment option. We state a primary renal angiosarcoma case for its rareness and contribution to literature.

Primary Angiosarcoma of the Kidney: Case Report and Comprehensive Literature Review

PURPOSE

Angiosarcoma (AS) is an aggressive malignant tumour of endothelial origin, most frequently compelling the skin. The kidney is a rare site of primary occurrence of AS with a quite challenging diagnosis and poor prognosis, mainly due to its raw metastasising power. We described our first case of AS treatment. A comprehensive literature review in this field is also carried out.

PATIENTS AND METHODS

We report the case of a 56-years-old man with radiological appearance of an 11 cm poor vascularised left renal mass. The pre-operative imaging ruled out distant metastases and inferior vena cava thrombosis. Thus, after radioembolization, we performed a transperitoneal open radical nephrectomy with regional lymphadenectomy with the removal of the middle portion of the ileo-psoas muscle, followed by two lines of adjuvant chemotherapy. We analysed all the papers concerning primary kidney AS until December 2018.

RESULTS

Estimated intraoperative blood loss was 200 mL with an operative time of 100 minutes. No postoperative complications were recorded, with the patient discharge in the 8th postoperative day. The pathological assessment showed a pT3a N0, M0 tumour compatible with AS of the kidney. An immune-histochemical study showed a vascular positive for CD31, CD34, Fli-1 with a Ki-67/Mib 1 of 50%. One month after surgery the patient began adjuvant chemotherapy with gemcitabine. After 45 days from surgery, a Computed Tomography scan showed lung and liver metastases with disease relapse in the left kidney lodge. The response to the first-line treatment was excellent, unlike the second-line, encountering a chemo-refractory disease. The cancer-specific survival was of 15 months. We included 66 cases in our review.

CONCLUSION

This is the first case of treatment of kidney AS performed at our Institute. Our findings added new information about the unclear biology and progression of this subset of tumours, demonstrating an abysmal prognosis.

Primary Renal Angiosarcoma Mimicking Renal Cell Carcinoma: A Case Report

Primary renal angiosarcoma is an exceedingly rare malignancy of the kidney. It usually presents in the elderly with metastatic disease and dismal prognosis. Treatment protocols are not standardized for this very rare renal malignancy. We report the case of a young man who was incidentally diagnosed with primary renal angiosarcoma. Preoperative imaging was suggestive of renal cell carcinoma; however, postoperative histopathological examination confirmed it to be an angiosarcoma. The patient was treated with surgical excision followed by adjuvant chemotherapy and is doing well at one-year follow-up.

Primary renal angiosarcoma: a diagnostic and therapeutic challenge

Primary renal angiosarcoma is an exceedingly rare and aggressive neoplasm. Although it may occur in youth, this tumour is frequently reported in the sixth and seventh decades of life. The clinical presentation is frequently varied. Pathogenesis remains largely unknown and it has overlapping features with other tumours of the kidney. Current treatment options include variable combinations of surgery, chemotherapy and radiotherapy. Reports regarding the disease prognosis and natural history are limited. In this article, we chronicle the case of a patient with primary renal angiosarcoma presenting at an advanced stage as a widely metastasised tumour. Additionally, we undertake here a brief literature review highlighting the rarity and aggressiveness of this condition, its poor prognosis, and the lack of specific management guidelines.

Primary angiosarcoma arising in an angiomyolipoma of the kidney: case report and literature review

BACKGROUND

Primary angiosarcoma of the kidney is a rare and aggressive malignant tumor presenting with a recognizable vascular differentiation. Its prognosis is fatal and the pathogenesis remains unclear. Renal angiomyolipoma is a relatively infrequent renal cortical neoplasm and is composed of variable proportions of adipose tissue, spindle cells, epithelioid smooth muscle cells and abnormal thick-walled blood vessels.

CASE PRESENTATION

Here, we reported a case in which a 64-year-old woman presenting with the chief complaint of a progressively enlarged mass in the left abdomen. Abdominal computed tomography confirmed presence of a tumor measuring 18 cm × 11 cm in the left posterior renal fascia. Microscopic examination and immunohistochemical staining confirmed co-existence of angiomyolipoma and angiosarcoma. Furthermore, the two components interspersed with each other and there were transitional zones between them.

CONCLUSIONS

In this case, we described for the first time a primary renal angiosarcoma possibly arising in a pre-existing angiomyolipoma of the kidney.

Clinical and Pathologic Features of Primary Angiosarcoma of the Kidney

PURPOSE OF REVIEW

Primary angiosarcoma of the kidney is extremely rare; hence, relatively little is known regarding its clinicopathologic features and prognosis. Herein, we review the literature on primary renal angiosarcoma with emphasis on the clinical and pathologic features.

RECENT FINDINGS

Approximately 64 cases have been reported in the literature, and most cases occur in the 6th-7th decade with a strong male predominance. The aetiology is unknown. Patients present with flank pain, haematuria, abdominal mass and weight loss. A considerable number of patients develop metastatic disease at diagnosis or shortly afterwards. Grossly, the tumour comprises ill-defined haemorrhagic spongy masses often with necrosis. Microscopically, the tumour is composed of anastomosing capillary-sized vessels which are lined by malignant endothelial cells. The mainstay of treatment is surgery followed by radiation therapy with or without chemotherapy. Renal angiosarcomas are highly aggressive tumours with dismal outcome, and they must be distinguished from morphologically similar lesions of the kidney.

Epithelioid angiosarcoma arising in schwannoma of the kidney: report of the first case and review of the literature

Background

Schwannoma and angiosarcoma are infrequent pathologies that have been rarely reported in the kidney. Angiosarcoma is an uncommon malignant tumor presenting a recognizable vascular differentiation. It can develop in any site but the most common locations include the skin, soft tissues, breast, bone, liver, and spleen while renal localization has been very rarely reported in the literature. Schwannoma is a benign peripheral nerve sheath tumor composed of cells with the immunophenotype and ultrastructural features of differentiated Schwann cells. It has a wide anatomical distribution but the most frequent locations include subcutaneous tissues of the extremities and the head and neck region and the retroperitoneal and mediastinal soft tissues. The occurrence of an angiosarcoma in a pre-existing schwannoma is an extremely rare event with <20 cases reported in worldwide literature. In the present study, a renal case of angiosarcoma arising in schwannoma is presented with a detailed review of the pertinent literature.

Case Presentation

A 56-year-old man was admitted with a few days history of lower back pain and hematuria. Abdominal ultrasound showed a mass inside the left renal medulla. Subsequent imaging investigations with computed tomography and magnetic resonance confirmed the presence of the lesion and showed a pulmonary metastasis.

Conclusions

The final histopathological examination led to the diagnosis of epithelioid angiosarcoma arising in a schwannoma. The patient came to death a few months later due to a massive hemothorax. To the best of our knowledge, the present is the first case of an angiosarcoma arising in a schwannoma of the kidney.

Clinicopathological features of primary angiosarcoma of the kidney: a review of 62 cases

Angiosarcoma (AS) is a malignant tumor occurring in less than 2% of soft tissue sarcomas. Primary involvement of the kidney is rare, its pathogenesis remains largely unknown and it has overlapping features with other tumors of the kidney. The objective of this paper is to review the case reports of primary AS of the kidney in the literature. The search terms were primary AS of the kidney, primary renal AS and primary renal hemangiosarcoma. The total cohort of the cases reviewed was 62. The mean age of presentation was 61 years old with a predilection for the male sex. Metastatic disease at the time of diagnosis accounted for 44.9% (22/49) of the cases reported and 44.4% (12/27) of patients with non-metastatic disease at diagnosis, subsequently developed metastasis. Primary AS of the kidney is a rare malignant tumor with a poor prognosis. Local recurrence and distant metastasis is common. Primary AS of the kidney shares similar clinical presentation with other renal tumors and imaging does not allow for tumor specific diagnosis. Histopathological examination and immunohistochemistry is very important for the confirmation of the diagnosis. Current treatment options include a variable combination of surgery, radiotherapy and chemotherapy.

Primary renal angiosarcoma with progressive clinical course despite surgical and adjuvant treatment: A case report

Angiosarcoma is an extremely rare, high-grade malignancy, which accounts for <2% of all soft-tissue sarcomas. Cases of primary renal angiosarcoma represent 1% of these. Angiosarcomas involving the kidney usually originate from metastatic skin lesions or primary visceral lesions and most often occur in the sixth and seventh decades of life. The present study describes a case of primary renal angiosarcoma that presented as a large right-sided renal mass with symptoms of flank pain. Despite surgical removal of the tumor, recurrent disease with associated lung metastases was identified at the surgical site following adjuvant chemotherapy. The patient succumbed to the disease 13 months after the diagnosis.

Primary renal angiosarcoma

Primary angiosarcoma of the kidney is a rare tumor with only a few case reports in the literature. Management is not standardized and the prognosis is poor. However, clinicians need to be aware of this uncommon entity.

Primary Renal Angiosarcoma: Radiologic-Pathologic Correlation and Literature Review

We present a case of primary renal angiosarcoma. We focus on the characteristic striated pattern of the tumor on T2-w MR sequence as well as on other radiological features and correlate them with the pathologic findings. A review of the imaging characteristics of cases published in the literature was subsequently performed.

Primary vascular tumors and tumor-like lesions of the kidney: a clinicopathologic analysis of 25 cases

Vascular tumors of the kidney are distinctly rare, and to date no large series have been reported. We analyzed a series of primary vascular tumors of the kidney to further delineate their clinicopathologic features and identify organ-specific morphologic features, if present. Twenty-five renal cases previously coded as "arteriovenous malformation," "hemangioma," and "angiosarcoma" were retrieved from the archives of 4 collaborating institutions and were reevaluated histologically. Tumors were classified according to the 2002 World Health Organization classification of tumors of soft tissue and bone. There were 18 males and 7 females (M:F=2.6:1) ranging from 21 to 95 years (mean 56.7 y). Lesions ranged from "microscopic" to 30 cm (mean 6.0 cm) and were tan-brown, cystic, and hemorrhagic. On re-review, cases were classified as arteriovenous malformation (n=3), capillary hemangioma (n=14), and angiosarcoma (n=8). Arteriovenous malformations were identical to their somatic soft tissue counterparts. Renal capillary hemangiomas often lacked a well-formed lobular pattern and 5 cases showed a "sieve-like" arrangement reminiscent of splenic sinusoids, a pattern previously noted by others (anastomosing hemangioma). All hemangiomas were noninfiltrative and lacked cytologic atypia and mitotic activity. GLUT-1, D2-40, and CD8 were performed in 3 anastomosing hemangiomas and were all negative. Angiosarcomas were diffusely infiltrative with extensive parenchymal destruction; all showed at least small areas of conventional vasoformative growth, but were frequently dominated by spindled and epithelioid histology. All cases were positive for some combination of vascular tumor-associated markers (CD31, CD34, and FLI-1). Cytokeratin expression was absent in all angiosarcomas. Follow-up was available for 15 cases: all patients with arteriovenous malformation and hemangioma with follow-up were disease free after complete excision; 4 cases of angiosarcoma died of the disease at 1, 1, 6, and 11 months. Our review shows that many capillary hemangiomas of the kidney are morphologically distinctive tumors, which often show "spleen-like" or "anastomosing" features. Angiosarcomas of the kidney are highly aggressive tumors with poor outcome and may have morphologic features (spindling and epithelioid change), which could result in confusion with sarcomatoid carcinomas and other renal mesenchymal tumors.

A case of primary renal angiosarcoma

A 78-year old man was diagnosed with a left bleeding renal cyst from CT scan results. Serial CT scans revealed the left kidney mass to be increasing in size and a new lesion in the liver. Renal cell carcinoma with liver metastasis was diagnosed and a radical nephrectomy performed. The initial pathological diagnosis was a benign chronic hematoma. However, the liver mass increased in size and multiplied, while another mass emerged in the twelfth thoracic vertebra with spinal paralysis and was immediately removed. Pathological findings for that specimen showed malignancy of stromal cell origin but low atypia. The renal specimen was re-evaluated using whole cross-section analysis and immunohistochemistry, and diagnosed as a primary renal angiosarcoma. Recombinant interleukin-2 therapy was started immediately; however, the patient died of metastatic disease 13 months after the initial operation. Although contrast imaging depicted the primary lesion as a non-specific hematoma with little focal pooling, and low-grade cytological atypia was shown pathologically, the angiosarcoma was extremely aggressive.

Anastomosing hemangioma of the genitourinary tract: a lesion mimicking angiosarcoma

BACKGROUND

We describe 6 cases of a poorly recognized vascular neoplasm that can simulate angiosarcoma.

DESIGN

Cases of a rare vascular tumor with a proclivity for the genitourinary tract encountered in our consultation material were prospectively collected between the year 1999 and 2008. Follow-up information was obtained when possible.

RESULTS

There were 6 tumors from 4 men (66%) and 2 women, ranging in age from 49 to 75 years (median, 59.5) involving the kidney and renal hilum (4, 66%) and testis (2). Tumors ranged from 1.3 to 1.7 cm (median, 1.6 cm) and were grossly well-marginated with a hemorrhagic mahogany spongy appearance. Microscopically, at low power they had a loosely lobulated architecture and were associated with a medium-caliber vessel (5/6, 83%). Most kidney (3/4, 75%) tumors showed minor extensions into adjacent adipose tissue. At higher magnification, the tumors consisted of anastomosing sinusoidal capillary-sized vessels with scattered hobnail endothelial cells within a framework of nonendothelial supporting cells. There was a minimal inflammatory backdrop consisting of lymphocytes but not plasma cells or acute inflammation. Mitoses were absent (5/6, 83%) or rare (1 case; in supporting cells). There was mild cytologic atypia in one of the cases but no multilayering of endothelial cells in any case. Vascular thrombi were typical (5/6, 83%) and the lesions had zones of central sclerosis with focal necrosis (5/6, 83%). Two (33%) tumors featured prominent extra-medullary hematopoiesis and 2 tumors (33%) had striking hyaline globules reminiscent of those seen in Kaposi's sarcoma. Immunohistochemistry was available on some cases and the lesions stained with CD34, CD31, and FVIII but not human herpes virus type 8, keratin AE1/3, epithelial membrane antigen, HMB45, placental alkaline phosphatase, or human chorionic gonadotropin. In all but one submitted consultation, the possibility of angiosarcoma had been raised based on the anastomosing vascular pattern. On follow-up, there were no recurrences or metastases in 5 cases (range: 8 to 36 mo; median 12 mo, mean 15 mo), and 1 patient was lost to follow-up.

CONCLUSIONS

Anastomosing hemangioma of the genitourinary tract is a rare neoplasm displaying some overlapping features of both sinusoidal hemangioma and hobnail hemangioma of soft tissue and skin. However, in our opinion, it is a unique neoplasm with a proclivity for the kidney. Its anastomosing appearance can lead to concern for angiosarcoma but, despite small numbers and limited follow-up in our series, evidence to date supports that the lesion is benign.

Angiosarcoma of the kidney with minute clear cell carcinomas: a case report

A case of renal angiosarcoma with minute clear cell carcinomas in a 61-year-old male is described. The tumor was clinically considered a renal cell carcinoma. The lesion, removed by nephrectomy, was an unencapsulated hemorrhagic mass measuring 8.0cm in diameter. The tumor was histologically characterized by anastomosing vascular channels lined by cytologically atypical endothelial cells. The tumor cells reacted positively with CD31, factor-VIII related antigen, and CD34. A few minute clear cell carcinomas measuring less than 1mm were observed in the periphery of the angiosarcoma. There was no transition between angiosarcoma and renal cell carcinoma. The patient died of a widespread disease 13 months after surgery. This tumor is considered a primary renal angiosarcoma with clear cell carcinomas and not a sarcomatoid carcinoma.