New Insights about Pulmonary Epithelioid Hemangioendothelioma: Review of the Literature and Two Case Reports

Imaging features and deep learning for prediction of pulmonary epithelioid hemangioendothelioma in CT images

Background

Pulmonary epithelioid hemangioendothelioma (PEH) is a rare vascular tumour, and its early diagnosis remains challenging. This study aims to comprehensively analyse the imaging features of PEH and develop a model for predicting PEH.

Methods

Retrospective and pooled analyses of imaging findings were performed in PEH patients at our center (n=25) and in published cases (n=71), respectively. Relevant computed tomography (CT) images were extracted and used to build a deep learning model for PEH identification and differentiation from other diseases.

Results

In this study, bilateral multiple nodules/masses (n=19) appeared to be more common with most nodules less than 2 cm. In addition to the common types and features, the pattern of mixed type (n=4) and isolated nodules (n=4), punctate calcifications (5/25) and lymph node enlargement were also observed (10/25). The presence of pleural effusion is associated with a poor prognosis in PEH. The deep learning model, with an area under the receiver operating characteristic curve (AUC) of 0.71 [95% confidence interval (CI): 0.69-0.72], has a differentiation accuracy of 100% and 74% for the training and test sets respectively.

Conclusions

This study confirmed the heterogeneity of the imaging findings in PEH and showed several previously undescribed types and features. The current deep learning model based on CT has potential for clinical application and needs to be further explored in the future.

Primary pulmonary epithelioid hemangioendothelioma

Pulmonary epithelioid hemangioendothelioma (PEH) is a rare tumour of vascular origin with low to intermediate malignancy. Typical radiological finding on CT is multiple small nodules in bilateral lungs, and some will have punctate calcifications and pleural thickening. The diagnosis of PEH is confirmed by histopathological findings and positive immunohistochemistry staining. We report a case of a woman in her 50s with a medical history of lung adenocarcinoma. Later, regular chest CT during a routine cancer follow-up revealed multiple small pulmonary nodules and increased sizes of these nodules on serial images, initially misdiagnosed as multiple lung metastases. The histopathological diagnosis was made on a pulmonary wedge resection. Finally, PEH was diagnosed on the basis of positive immunohistochemical staining for CD31, ERF and TFE3. In the current study, the clinicopathological features and review of the literature were investigated. Our case highlights the importance of a histological diagnosis to avoid misdiagnosis.

An extremely rare case of pulmonary epithelioid hemangioendothelioma

Epithelioid emangioendothelioma (EHE) is a rare tumor originating from vascular endothelial cells, which belongs to malignant vascular tumors with low to moderate differentiation and potential metastatic ability and its incidence rate is less than one in a million. We herein report a rare case of EHE of pulmonary origin and a review of the literature concerning the clinical and pathological features of this disease. The patient underwent left upper lobectomy to completely extirpate the lesion by video-assisted thoracic surgery. Our findings suggest the difficulty of making a diagnosis before surgery and that more cases need to be reported in order to facilitate the preoperative diagnosis of such a rare tumor.

Pleural Epithelioid Hemangioendothelioma (EHE): A Case Report

Pleural epithelioid hemangioendothelioma (EHE) is a rare malignancy of vascular origin. It can affect various organs; pleural involvement is rare and lack of suspicion leads to delay in diagnosis. We present a case of pleural EHE with metastasis to lung parenchyma that presents with chest pain and dyspnea. Chest imaging showed loculated pleural effusion, pleural thickening, mediastinal lymphadenopathy, and pulmonary nodules.

Delayed metastatic pulmonary epithelioid hemangioendothelioma of the femoral vessels: case report and literature review

Background

Epithelioid hemangioendothelioma (EHE) is a rare sarcoma of the blood vessels. We report a patient with vascular EHE with delayed pulmonary metastasis, of which there are no previously known case reports.

Case Description

A 40-year-old female presents with a painful right groin mass and swelling in the lower extremity. A 3.8 cm soft tissue mass was identified in the femoral sheath with the abutment of the femoral artery on a computerized tomography (CT) scan. Surgical resection of the femoral vein was performed, and the final pathology confirmed a diagnosis of EHE. A second en-bloc resection of the femoral artery with bypass grafting was performed with clear surgical margins. The patient did well post-operatively with annual surveillance of the right groin as well as chest X-rays. However, the patient developed a metastatic Epithelioid hemangioendothelioma (EHE) to the right lower lobe, 12 years after the initial EHE treatment. She underwent a pulmonary resection with clear margins. The patient remains disease-free after one year. EHE is a rare soft tissue sarcoma with unpredictable clinical behavior. While most commonly presenting in the lung and liver they can also originate from any vascular system. Delayed pulmonary metastasis from vascular EHE has not been reported.

Conclusions

Our case shows that indolent metastasis can occur in EHE, despite a prolonged disease-free interval. This case highlights the need for long-term surveillance with serial imaging of not only the primary site but pulmonary imaging beyond 5 years may be beneficial.

Watch the Mime Carefully! A Refractory Interstitial Lung Disease

Epithelioid hemangioendothelioma (EHE) is a rare neoplasm of a vascular origin which can arise in different locations such as the lungs, liver, soft tissue, and rarely, in the bones. In the lungs, pulmonary hemangioendothelioma (PEH) shows a variable clinical behavior, displaying a range from either an asymptomatic course to a highly aggressive progression with metastases. Based on radiological features, PEH differential diagnosis mainly includes primary or metastatic lymphangitic carcinomatosis, granulomatous infections, and diffuse interstitial lung diseases where ground glass pattern predominates. In this case, a transbronchial biopsy and subsequent histological and immunohistochemical analysis allowed for the attribution of the scenario to a pulmonary epithelioid hemangioendothelioma. Clinicians should always consider bronchoscopy as a useful and effective tool to better investigate indeterminate and questionable clinical pictures, sparing patients the morbidity and mortality associated with more invasive techniques such as surgical or thoracoscopic biopsy.

Epithelioid Haemangioma of Bone: A Case Series and Comprehensive Literature Review Reappraising the Diagnostic Classification of All Epithelioid Vascular Neoplasms of Bone

Epithelioid vascular neoplasms of the bone are classified by the World Health Organization (WHO) into only two tiers: low-grade epithelioid hemangioma (EH) and a more malignant category including both epithelioid hemangioendothelioma and epithelioid angiosarcoma. The World Health Organization defines bone EH as a locally aggressive neoplasm with no connotation of benign or intermediate malignancy. We reviewed three cases of EH in our lab archives with the perspective of appraising their histomorphological approach toward diagnosis. Patients were in the age range of 15-25 years. The site of the neoplasms ranged from the carpal bones to the metatarsal bones. Histomorphological examination of the lesions showed a nodular growth pattern of a vascular neoplasm without demonstrable vessel origin. The vasoformative area increased from the center to the periphery, with prominent epithelioid morphology of the endothelial cells at the periphery and an associated inflammatory infiltrate comprising eosinophils, lymphocytes, and plasma cells. The growth pattern was diffuse, with extension into the deeper dermis of overlying skin.

An unusual case of aggressive malignant spread of epithelioid hemangioendothelioma

Epithelioid hemangioendothelioma (EHE) is a rare vascular neoplasm which typically originates from liver, lung, or bone. Due to the low incidence of disease, the most effective treatment is not easily studied and much of the information known about EHE has been learned through case reports and case series. In this case, we will present an uncommon form of primary soft tissue EHE with local recurrence, bone metastasis, and lymphangitic spread to the lungs leading to respiratory failure. Imaging of the chest was atypical for EHE with intraseptal thickening and hilar lymphadenopathy. Respiratory failure was progressive despite aggressive multimodal treatment. This case highlights an unusually aggressive recurrence and metastasis of primary soft tissue EHE with atypical pulmonary imaging findings.

Epithelioid hemangioendothelioma: evaluation by 18F-FDG PET/CT

PURPOSE

The purpose of this study was to evaluate the imaging characteristics of epithelioid hemangioendothelioma (EHE) on staging ¹⁸F-FDG PET/CT.

MATERIALS AND METHODS

An IRB-approved retrospective review was conducted for patients with biopsy-proven EHE who underwent FDG PET/CT at our institution between 2005 and 2019. Patients with a history of surgery, chemotherapy, or radiotherapy prior to PET/CT were excluded. PET/CT exams were analyzed, noting metabolic activity, distribution of involvement, and CT morphologic features. PET/CT findings were correlated with comparative CT and MRI performed within three months.

RESULTS

There were 35 patients [21 females, 14 males; average age 55.1±16.9 years (range 15-82 years)]. 18/35 patients (52%) had more than one organ affected on PET/CT. The most common sites were liver [21/35 (60%)], lung [(19/35 (54%)], bone [5/35 (14%)], lymph nodes [4/35 (11%)], and vasculature [4/35 (11%)]. Most patients [30/35, (86%)] presented with multiple lesions. The average largest lesion dimension was 4.0±3.6 cm (range 0.6-15.0 cm). The average SUVmax of the most metabolically active lesion at any site was 5.3±3.3 (range 1.2-17.1), and for bone was 7.9±5.4 (range 3.5-17.1), liver was 5.1±2.1 (range 2.6-10.5), and lung was 3.0±1.9 (range 1.2-8.5). Of patients with pulmonary lesions, 9/19 (47%) showed calcification, and 4/19 (21%) had nodules that were either non FDG-avid or too small for accurate SUV assessment. Of patients with hepatic lesions, 11/21 (52%) demonstrated capsular retraction, and 12/21 (57%) were found to have additional hepatic lesions on contrast-enhanced CT or MRI that were occult on PET/CT.

CONCLUSION

EHE demonstrates variable, but most commonly moderate FDG activity on PET/CT. The most common sites of disease are the liver, lungs, and bones, and most patients present with multiple lesions and more than one organ involved. Given the intrinsic metabolic activity and multi-organ involvement, FDG PET/CT represents an attractive modality for EHE evaluation. However, it may be best used in combination with CT or MRI given that EHE pulmonary or hepatic lesions may be missed by PET/CT.

Multiple bilateral pulmonary epithelioid hemangioendothelioma mimicking metastatic lung cancer: case report and literature review

Pulmonary epithelioid hemangioendothelioma (PEH) is a rare tumor of low to intermediate malignancy, which originates from vascular endothelial cells. Most patients with PEH are asymptomatic and the tumor occurs most frequently in women. Typical radiologic images of patients with PEH are multiple irregular nodules with punctate calcification and pleural indentation. Here, we describe a 54-year-old woman who presented with multiple bilateral nodules of different sizes and well-defined borders, as well as lung markings, without punctate calcification or pleural indentation. These atypical computed tomography images resulted in misdiagnosis as metastatic lung cancer. Right upper lobe wedge resection was performed; intraoperative frozen pathologic examination suggested that the tumor was benign. However, immunohistochemical analysis revealed the presence of PEH. Subsequently, the patient chose watchful waiting, rather than chemotherapy. This rare case of PEH with atypical computed tomography findings, which was misdiagnosed as metastatic lung cancer, demonstrates that intraoperative frozen analysis is unreliable; thus, histopathological analysis is necessary.

Pleural epithelioid hemangioendothelioma mimicking pleural empyema: A case report

Malignant pleural effusion is an important and difficult differential diagnosis to pleural empyema. Epithelioid hemangioendothelioma is an uncommon vascular tumor, which typically occurs in liver, lung or bone. We present an extremely rare case of primary pleural epithelioid hemangioendothelioma mimicking pleural empyema. We conclude, that pleural epithelioid hemangioendothelioma should be kept in mind as a differential diagnosis in patients suspected of empyema.

CT-guided Biopsy for the Diagnosis of Pulmonary Epithelioid Hemangioendothelioma Mimicking Metastatic Lung Cancer

A 69-year-old male patient presented with multiple lung nodules revealed by chest-computed tomography (CT) during a preoperative examination for an appendiceal tumor. The nodule diameters ranged from 2-10 mm without either pleural thickening or effusions. A fluorine-18-labeled fluorodeoxyglucose (¹⁸F-FDG)-positron emission tomography (PET)/CT scan showed a high FDG uptake in the appendiceal tumor, but almost normal standardized uptake values in the bilateral lung nodules. A CT-guided biopsy led to a diagnosis of pulmonary epithelioid hemangioendothelioma, a rare vascular tumor with a radiological presentation similar to that of a metastatic lung tumor. The present case is the first to describe successful treatment using a CT-guided biopsy instead of more conventional methods.