Retiform hemangioendothelioma: presentation of a case expressing D2-40

Retiform hemangioendothelioma of the breast in a man with 18F-flurodeoxyglucose accumulation on positron emission tomography: a case report

BACKGROUND

Retiform hemangioendothelioma (RH) is a rare, intermediate-grade vascular tumor that often arises in the trunk and extremities. The clinical and radiological features of RH remain largely unknown.

CASE PRESENTATION

A male patient in his 70s presented with shortness of breath on exertion, and computed tomography incidentally revealed a tumor in his right breast. Positron emission tomography (PET) revealed moderate ¹⁸F-fluorodeoxyglucose (FDG) uptake in the tumor. RH was observed in the resected specimens. Three months after surgery, the patient was free of local recurrence and distant metastasis.

CONCLUSIONS

RH was found in the male breast and was accompanied by FDG uptake on PET. PET may be useful in diagnosing RH. Although metastasis is rare in RH, local recurrence may occur, and careful follow-up is required.

Retiform hemangioendothelioma: a rare lesion of the vulva

Retiform hemangioendothelioma (RH) is a rare borderline-malignant vascular tumor with specific histological characteristics, usually occurring in the limbs and trunk. We report the case of a 63-year-old woman who presented with a painless, oval nodule that had been growing slowly on her left vulva for 3 years. Magnetic resonance imaging of the pelvic cavity revealed a 4.4- × 2.7- × 1.8-cm cystic lesion in the subcutaneous fat of the left vulva. Resection beyond the macroscopic border was performed. Pathology revealed vascular structures with elongated and narrow arborizing vascular channels that were arranged in a retiform pattern resembling rete testis tissue. Immunohistochemical endothelial staining was positive for CD31, CD34, and Friend leukemia integration-1 (FLI-1). The above features confirmed a diagnosis of RH. There was no local recurrence or metastasis during the 26-month follow-up. RH of the vulva is rare, and its diagnosis is supported by specific histological characteristics and immunohistochemical staining for CD31, CD34, and FLI-1. Wide surgical resection with tumor-free margins is important for a favorable prognosis.

Retiform hemangioendothelioma: An uncommon vascular neoplasm

Retiform hemangioendothelioma is a rare vascular neoplasm of intermediate grade, the diagnosis of which can be challenging. We report a case of 35-year-old man with swelling in the postauricular region. He had undergone FNAC which had revealed blood only. Microscopic examination showed narrow, arborizing, vascular channels resembling normal rete testis. Evidence of mitoses or cytological atypia were lacking. Immunohistochemistry showed diffuse and strong staining for CD34 along with CD31 positivity. Immunostains for D240 and GLUT1 were negative. A diagnosis of retiform hemangioendothelioma was made. Histologically, it should be distinguished from Kaposiform hemangioendothelioma, Dabska tumor, epithelioid hemangioendothelioma, and angiosarcoma.

Vascular tumors of the mediastinum

Vascular tumors represent only a sliver of all tumors affecting the mediastinum, but they pose diagnostic challenges due to significant overlap among entities, ever-evolving classification schemes, and the exquisite rarity of some of the entities not only in the mediastinum but in pathology practice as a whole. Most of the vascular tumors are better known to the practice of soft tissue pathology, from which some of the knowledge of clinical behavior can be extrapolated. For example, the stratification of epithelioid hemangioendothelioma (EHE) into two biologically separate categories has effectively translated from the somatic soft tissues to the thorax. For other entities, the effective validation of soft tissue parameters is hindered by the small numbers of reported mediastinal cases. Many of the treatment modalities have also transferred over, with the key differences resting on the difficulty in achieving complete surgical resection for mediastinal tumors as opposed to those in the somatic soft tissues. Accordingly, systemic drug therapies have emerged as attractive options for some of the mediastinal vascular tumors, such as kaposiform hemangioendothelioma (KHE) and Kaposi sarcoma (KS). The categories presented herein mirror the classification scheme set forth by the 5th Edition WHO Classification of Soft Tissue and Bone Tumors. This review focuses on the biologically aggressive vascular neoplasms while limiting discussion of the benign entities to relevant comparisons in the differential diagnoses. While distinguishing among the benign entities has academic importance, in practice, the stakes are far higher for diagnosing the biologically aggressive tumors given their marked heterogeneity in clinical outcomes. Practical advice for problem areas in pathology will be reviewed alongside tumor pathobiology, including the latest in molecular diagnostics.

Nonepithelial Tumors and Tumor-like Lesions of the Skin and Subcutis in Children

This overview of mesenchymal tumors presenting in the skin and/or subcutis in children brings together the range of neoplasms and hamartomas which are seen in this age-group. It is not surprising from the perspective of the pediatric or general surgical pathologist that vascular anomalies, including true neoplasms and vascular malformations, are the common phenotypic category. Since there is considerable morphologic overlap among these lesions, clinicopathologic correlation may be more important than for many of the other mesenchymal tumors. The skin and subcutis are the most common sites of clinical presentation for the infantile myofibroma which is the most common of fibrous mesenchymal tumors in children. Several of the other mesenchymal tumors are more common adults-like dermatofibrosarcoma protuberans, but nonetheless have an important presence in children, even as a congenital neoplasm. A lipomatous tumor in a young child should be considered as a possible manifestation of an overgrowth syndrome.

Retiform hemangioendothelioma in the infratemporal fossa and buccal area: a case report and literature review

We report a case of retiform hemangioendothelioma (RH) located in the infratemporal fossa and buccal area in a 13-year-old Korean boy. The tumor originated from the sphenoid bone of the infratemporal fossa area and spread into the cavernous sinus, orbital apex, and retro-nasal area with bone destruction of the pterygoid process. Tumor resection was conducted via Le Fort I osteotomy and partial maxillectomy to approach the infratemporal fossa and retro-nasal area. The diagnosis of RH was confirmed after surgery. In the presented patient, surgical excision was incomplete, and close follow-up was performed. There was no evidence of expansion or metastasis of the residual tumor in the 8 years after surgery. In cases of residual RH with low likelihood of expansion and metastasis, even though RH is an intermediate malignancy, close follow-up can be the appropriate treatment choice over additional aggressive therapy. To date, 29 papers and 48 RH cases have been reported, including this case. This case is the second reported RH case presenting as primary bone tumor and the first case originating in the oromaxillofacial area.

Atypical retiform hemangioendothelioma arising in a patient with Milroy disease: a case report and review of the literature

Retiform hemangioendothelioma (RH) is a rare vascular neoplasm with a high rate of local recurrence and low metastatic potential. We describe an unusual case of RH in a 45-year-old patient with Milroy disease, with a prominent solid component diffusely involving a chronic lymphedematous leg. This case is consistent with the postulated relationship between lymphedema and vascular neoplasms developing as a result of local immune dysfunction, and highlights the need to closely monitor patients with Milroy disease for pathologic changes. Our case highlights a unique example of RH with atypical features. There are several noteworthy unusual clinical and histologic findings including diffuse involvement of an entire limb, solid component with cytologic atypia, D2-40 expression, and first-time-reported association with Milroy disease. Given the atypical histologic presentation of cytologic atypia, solid areas and atypical immunohistochemical profile with D2-40 positivity, this case could cause diagnostic difficulty, especially in the setting of such a broad clinical differential.

A case report of retiform hemangioendothelioma as pleural nodules with literature review

Retiform hemangioendothelioma (RH) is a rare low-grade variant of angiosarcoma mostly reported on dermis or subcutaneously. A 30-year-old woman suffering from dry cough, dyspnea and pleural effusion has been described. Distinctive symptoms and lesions on high resolution computed tomography (HRCT) scan and common histological, immunological feature are discussed. Diagnosis was made by thoracoscopy as RH.

Retiform hemangioendothelioma treated with conservative therapy: report of a case and review of the literature

BACKGROUND

Retiform hemangioendothelioma (RH) is a locally aggressive vascular tumor. Wide surgical excision with tumor-free margins is the standard treatment strategy. However, surgical excision is not an option for lesions near critical anatomical structures, such as those on the face. We report the case of a patient with retiform hemangioendothelioma that responded to non-surgical treatments.

METHODS

We describe the case of a 72-year-old male patient with a retiform hemangioendothelioma on the face that responded to a combination of pulsed dye laser, local corticosteroid injection, and application of imiquimod cream. In addition, we reviewed past case reports of patients with retiform hemangioendothelioma.

RESULTS

Thirty-five cases that describe the management of RH, including the present case, have been reported. Review of the cases indicate a relatively low disease-free survival rate in cases that underwent surgical excision as the initial therapy for retiform hemangioendothelioma.

CONCLUSION

Surgical excision might not be the best therapeutic option. Local control with conservative therapy is an acceptable strategy for lesions in anatomical regions including the face.

Clinical, dermoscopic and histopathologic findings of retiform hemangioendothelioma

Retiform hemangioendothelioma (RH) is an uncommon vascular neoplasm of borderline malignancy that clinically develops as a solitary, gradually enlarging exophytic mass, nodule or plaque, most often on the lower limbs, upper limbs and trunk. Clinical recognition of RH is troublesome because of its non-specific appearance, with differential diagnosis comprising a variety of benign and malignant tumors clinically presenting as reddish nodules. In this article we describe the clinical, dermoscopic and histopathologic findings in a case of RH developing on the flank of a 26-year-old woman, and discuss the possible role of dermoscopy in facilitating the clinical recognition of this rare tumor.

Hemangioendothelioma

Hemangioendothelioma is the term used to name those vascular neoplasms that show a borderline biological behavior, intermediate between entirely benign hemangiomas and highly malignant angiosarcomas. Although originally spindle cell hemangioendothelioma was proposed as a specific clinicopathologic variant of hemangioendothelioma, currently, it is considered as an entirely benign lesion, and thus, the name spindle cell hemangioma seems to be the most accurate for this lesion. Authentic hemangioendotheliomas involving the skin and soft tissues include papillary intralymphatic angioendothelioma (also known as Dabska tumor), retiform hemangioendothelioma, kaposiform hemangioendothelioma, epithelioid hemangioendothelioma, pseudomyogenic hemangioendothelioma (also known as epithelioid sarcoma-like hemangioendothelioma), and composite hemangioendothelioma. Each of these neoplasms exhibit characteristic histopathologic features. The most characteristic finding of papillary intralymphatic hemangioendothelioma consists of papillary tufts, with a central hyaline core lined by hobnail-like endothelial cells protruding into the lumina. Retiform hemangioendothelioma is an infiltrative neoplasm composed of elongated arborizing vessels, arranged in an anastomosing pattern that resembles that of the rete testis, and lined by a single layer of hobnail-like endothelial cells that protrude within the narrow lumina. Kaposiform hemangioendothelioma is composed of several solid poorly circumscribed nodules, and each nodule is composed of a mixture of small capillaries and solid lobules of endothelial cells arranged in a glomeruloid pattern. A frequent finding consists of the presence of areas of lymphangiomatosis adjacent to the solid nodules. Epithelioid hemangioendothelioma is composed of cords, strands, and solid aggregates of round, oval, and polygonal cells, with abundant pale eosinophilic cytoplasm, vesicular nuclei, and inconspicuous nucleoli, embedded in a fibromyxoid or sclerotic stroma. Many neoplastic cells exhibit prominent cytoplasmic vacuolization as an expression of primitive vascular differentiation. Pseudomyogenic hemangioendothelioma is a poorly circumscribed, fascicular lesion with infiltrative borders composed of round or oval neoplastic cells, with vesicular nuclei and inconspicuous nucleoli, and ample homogeneous eosinophilic cytoplasm, giving them a rhabdomyoblastic appearance. Finally, composite hemangioendothelioma is the term used to name locally aggressive vascular neoplasms of low-grade malignancy showing varying combinations of benign, low-grade malignant, and high-grade malignant vascular components. From the immunohistochemical point of view, proliferating cells of all hemangioendotheliomas express a lymphatic endothelial cell immunophenotype. Most hemangioendotheliomas are low-grade vascular neoplasms, with a tendency to recur locally and a low metastatic potential, mostly to regional lymph nodes. Epithelioid hemangioendothelioma, especially large lesions and those located in deep soft tissues, seems to have a more aggressive biological behavior.

Retiform hemangioendothelioma developed on the site of an earlier cystic lymphangioma in a six-year-old girl

Retiform hemangioendothelioma (RH) is a rare low-grade malignancy angiosarcoma, with a high rate of local recurrence and a low metastatic risk. A 6 year-old girl with a large cervical cystic lymphangioma diagnosed by ultrasound and Doppler ultrasound, which showed a large multiloculated anechoic cyst with no flow. The lymphangioma was treated with injections of Picibanil (OK-432). The tumor regressed, but after a year, she developed a poorly limited infiltrated plaque spreading out regularly over her chest, back, and shoulder. The biopsy showed a poorly limited dermal and subcutaneous vascular proliferation composed of elongated arborising vessels lined with ovoid endothelial cells in a hobnail pattern. In addition, the deep part of the lesion showed typical features of a papillary intralymphatic angioendothelioma pattern (PILA) or Dabska tumor. The endothelial cells strongly expressed podoplanin (D2-40). A diagnosis of RH with focal areas of PILA was reached. The girl died 8 months after surgery of hypovolemic shock in a context of diffuse lymphangiomatosis with pulmonary localization. To our knowledge, RH has hardly ever been described in children. This entity exhibits a continuum with the PILA, sharing not only morphological and immunohistochemical similarities but also its ability to develop in a context of a vascular anomaly, particularly a lymphangioma. The role of Picibanil in the development of this tumor can be discussed.

A cutaneous vascular neoplasm with hobnail microscopic morphology and unusual gross features

Vascular tumors are categorized into benign hemangiomas, frankly malignant angiosarcomas and tumors with intermediate biological behavior (hemangioendotheliomas). The latter group includes hemangioendotheliomas of the epithelioid, kaposiform, retiform and composite subtypes. Furthermore, a heterogeneous group of both benign and intermediate vascular tumors exhibits a peculiar hobnail cell morphology. This heterogeneous group encompasses hobnail hemangioma, retiform hemangioendothelioma, papillary intralymphatic angioendothelioma and a subset of angiosarcoma. We herein present a case of a cutaneous vascular neoplasm with hobnail morphology and unusual gross features.