Cytologic findings of epithelioid angiosarcoma of the thyroid. A case report

Cytopathology of mesenchymal tumors of the thyroid gland: analysis of 12 cases from multinational institutions with review of the literature

INTRODUCTION

Mesenchymal tumors of the thyroid gland are extremely rare. We report the cytomorphologic characteristics of 12 mesenchymal tumors occurring in the thyroid gland and highlight the diagnostic difficulties encountered in their cytologic evaluation.

MATERIALS AND METHODS

The cytopathology and surgical pathology archives from 5 large institutions were searched for thyroid mesenchymal tumors that had an FNA available for review. Clinicopathologic and cytomorphologic characteristics for each case were evaluated.

RESULTS

Twelve cases of mesenchymal tumors occurring in the thyroid were identified in our search. Patient age ranged from 28 to 84 years (median, 60 years). The cases occurred in 7 women and 5 men. The tumor size ranged from 1.4 to 14 cm (median, 3.3 cm). The tumors were as follows: hemangioma (n = 4; 33.3%), angiosarcoma (n = 2; 16.7%), schwannoma (n = 2; 16.7%), solitary fibrous tumor (n = 2, 16.7%), metastatic synovial sarcoma (n = 1, 8.3%) and metastatic pleomorphic rhabdomyosarcoma (n = 1, 8.3%). The cytomorphologic features of the tumors were similar to those of their counterparts occurring in different sites. An accurate diagnosis was achieved in six primary thyroid mesenchymal cases (60%). Five patients (41.7%) underwent total thyroidectomy, and 3 patients received partial thyroidectomy (25%). Three patients (25%) did not receive a thyroidectomy and subsequent surgical information was not available in 1 case (8.3%).

CONCLUSIONS

Mesenchymal tumors of the thyroid are extremely uncommon. Cytologic diagnosis of these tumors is often challenging due to the morphologic overlap with diverse epithelial and non-epithelial thyroid lesions. Ancillary studies such as immunohistochemistry and molecular studies are essential for accurate diagnosis.

Cytologic and histological features of rare nonepithelial and nonlymphoid tumors of the thyroid

Thyroid tumors can be classified into epithelial, nonepithelial, and nonprimary lesions. Nonepithelial thyroid tumors are rare. They can be of primary origin within the thyroid gland, arise secondary to contiguous growth from adjacent tissues, or represent metastatic disease. The incidence of nonepithelial tumors of the thyroid is only 1% to 2%, most of which are lymphomas; the remainder includes mesenchymal and histiocytic tumors. This review examines the cytohistological features of various nonepithelial and nonlymphoid tumors of the thyroid, including vascular lesions, neural tumors (including granular cell tumor and paraganglioma), smooth muscle tumors, solitary fibrous tumor, histiocytic neoplasms (eg, Langerhans cell histiocytosis and Rosai-Dorfman disease), and follicular dendritic cell sarcoma. Their differential diagnosis is discussed, including recommendations to prevent the pitfall of mistaking these rare tumors for more common epithelial thyroid neoplasms.

Primary Angiosarcoma of the Thyroid in an Asian Woman: A Case Report with Review of the Literature

Primary thyroid angiosarcoma is a rare malignant tumor and characterized by its prevalence in Alpine regions of Central Europe, close relation to longstanding goiter, and aggressive clinical course with dismal prognosis. We describe the case of an 83-year-old Chinese female who lives in the coastal area of Taiwan. She came to our hospital due to a progressively enlarged mass at her anterior neck. The sonography of the thyroid revealed a well-circumscribed mass in the left lobe. She underwent left hemithyroidectomy. The diagnosis of angiosarcoma of the thyroid was made and further confirmed at a different institution. To the best of our knowledge, this is the first case of primary thyroid angiosarcoma reported from Taiwan and the sixth Asian afflicted with primary thyroid angiosarcomas in the English literatures. The literature search in the PubMed database identified 58 cases who had histologically proven primary thyroid angiosarcomas. A preliminary analysis of epidemiological presentation, clinical features, immunohistochemical characters, and prognosis of primary thyroid angiosarcoma was proposed. The prognosis of this rare neoplasm is surprisingly favorable in comparison with that of its morphological similar, the anaplastic thyroid carcinoma. The use of a comprehensive panel of immunohistochemical stains, including at least two endothelial markers (especially CD31 and ERG) and PAX-8, in combination with thorough light microscopic examination may assist in the discrimination between these two tumors.

Cytopathologic characteristics of epithelioid vascular malignancies

OBJECTIVES

Epithelioid hemangioendothelioma (EHE) and epithelioid angiosarcoma (EAS) are rare vascular neoplasms that share many morphological characteristics on histology but demonstrate different clinical behavior. Given the many reported clinical and morphological features shared between EAS and EHE, we examined all cases of EAS and EHE diagnosed primarily on fine needle aspiration (FNA) at our three institutions that were confirmed by a tissue diagnosis.

STUDY DESIGN

A total of 29 cases from 25 patients were identified: 15 EHE from 11 patients and 14 EAS from 14 patients.

RESULTS

Many cytomorphological features existed on a spectrum that overlapped considerably between EAS and EHE cases. Common features between the two entities include epithelioid morphology and eccentrically placed nucleus. Intracytoplasmic lumens (ICL), a morphological feature that may suggest vascular origin, can be found in both entities but are not always present.

CONCLUSIONS

Given the general absence of vascular cytomorphological features, such as ICL, the proper classification of these tumors depends on the successful use of immunoperoxidase markers such as factor VIII-related antigen, ERG, or CD31 as well as a high index of suspicion. The distinction between EAS and EHE on FNA alone is treacherous at best.

Angiosarcoma of the thyroid: a case report with review of the literature

Angiosarcoma is a rare and aggressive tumor of the thyroid gland, mainly seen in the Alpine regions. We present such a case with literature review. We present the case of a 60-year-old man with cough, dyspnea, and hemoptysis along with slow increase in the size of his long-standing goiter. Computed tomography of the neck showed a large thyroid mass and chest imaging revealed multiple pulmonary nodules. Fine needle aspiration cytology and tru-cut biopsy of the thyroid were notable for poorly differentiated malignant cells. Diagnosis of angiosarcoma of the thyroid was made after total thyroidectomy. Patient died of continued hemoptysis and respiratory failure 3 weeks after admission. We searched the literature for previous case reports using Pubmed and Ovid. Forty-seven reported cases were identified and our case was added to make a database of 48 cases. Demographic and tumor characteristics were analyzed. Angiosarcoma was found to be more common in females and at age of 60 or above. Results were consistent with previously reported series of 14 and 17 cases from Austria. This review provides information on various characteristics angiosarcoma of the thyroid which can be used as baseline data for future reference and research studies for this cancer.

Primary angiosarcoma of the thyroid gland in an young Iranian woman

Angiosarcoma of the thyroid gland is a rare and aggressive primary malignant tumour of the thyroid, originally reported in patient from Swiss Alpine region. Here, the authors describe a case of primary angiosarcoma of the thyroid in an 21-year-old Iranian woman who presented with a rapidly enlarging neck mass associated with compressive symptoms.

Epithelioid angiosarcoma of the kidney: a diagnostic dilemma in fine-needle aspiration cytology

Epithelioid angiosarcomas (EAS) of kidney are rare and aggressive tumors with noncharacteristic imaging features that overlap with those of inflammatory conditions and renal cell carcinoma (RCC). We report the fine-needle aspiration (FNA) cytology findings of a case of EAS that involved the left kidney of an 83-year-old male. The smears and cell block sections showed pleomorphic epithelioid cells with ample cytoplasm, eccentric nuclei, occasional cytoplasmic hyaline globules, and rare intracytoplasmic lumina. Immunohistochemical stains performed on cellblock sections showed that the tumor cells were positive for vimentin, CD31, CD34, Factor VIII, and CD10, but showed no staining for cytokeratins AE1/AE3 and 8/18, HMB45, CD45, smooth muscle actin, and S100. The morphological and immunohistochemical distinction between EAS, primary tumors of the kidney, and other epithelioid and rhabdoid neoplasms is discussed.

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.

Fine-needle aspiration of metastatic radiation-induced cutaneous epithelioid angiosarcoma of the breast to the liver: A diagnostic dilemma

Radiation therapy is a significant risk factor for the development of angiosarcoma. With the increase in breast conservation treatment, the incidence of cutaneous radiation-induced angiosarcoma of the breast is rising. If the angiosarcoma demonstrates epithelioid features, the tumor cells may present a diagnostic dilemma on fine-needle aspiration cytology. We present a case of metastatic radiation-induced cutaneous epithelioid angiosarcoma of the breast to the liver and a review of the literature.

Primary angiosarcoma of the thyroid gland with recurrence diagnosed by fine needle aspiration: a case report

Angiosarcoma of the thyroid is a rare and aggressive primary malignant tumor of the thyroid originally reported in patients from the Swiss Alpine region. Diagnosis of this tumor rests mainly on characteristic histopathological features of a malignant vascular tumor supported by immunopositivity for vascular markers e.g., CD31, Factor VIII, and CD34. Its cytological features, however, are not well-defined. We describe a case of primary angiosarcoma of the thyroid in a 48-year-old female, who presented with a rapidly enlarging neck mass associated with compressive symptoms. She had a history of hypothyroidism. The initial fine needle aspiration cytology of the neck mass was negative. She then underwent left hemithyroidectomy. Histologically, the tumor showed poorly differentiated malignant cells with eccentrically-placed nuclei, prominent nucleoli, and intracytoplasmic vacuoles admixed with mixed inflammatory cells. These showed immunopositivity for CD31 but were negative for CD34, Factor VIII, CK5/6, EMA, TTF-1, Thyroglobulin, Calcitonin, Melan A, and Calretinin. A diagnosis of poorly differentiated malignant tumor consistent with angiosarcoma was made. The patient was treated with radiation therapy but developed recurrence of the tumor. Second aspiration cytology of the recurrent tumor yielded hypocellular smears containing singularly dispersed atypical cells having eccentrically-placed nuclei with prominent macronucleoli and intracytoplasmic vacuoles within a background of inflammatory cells, consistent with recurrent angiosarcoma. Chemotherapy was started but she succumbed to the disease 7 months after diagnosis. The cytological, histopathological, immunohistochemical findings, and the clinical course are discussed.

Angiosarcoma of the thyroid

Hemangiosarcoma of the thyroid gland is a very rare entity. The therapy of this tumor is difficult because of its locally aggressive and destructive behavior with a high recurrence rate. We report a case of 60-year-old man with history of 1 month rapidly enlarging neck mass in the thyroid region. Ultrasound examination and CT scan showed resistance arising from the left thyroid lobe. FNAC revealed necrotic tumor mass without any cytological specification. Because of the clinical findings, a total thyroidectomy was indicated. The surgery was complicated by invasion of the tumor mass into the surrounding tissues. Therefore, only left side hemithyroidectomy was performed. Histopathology including histochemistry proved positive staining for Factor VIII, Fasciin, and CD31 in tumor cells. In this case, adjuvant oncological treatment was planned, but the patient died because of massive bleeding from the tumor mass. The histological diagnosis of thyroid hemangiosarcoma is mostly difficult. The treatment of the first choice is radical surgery. If the tumor cannot be treated by surgery, then radiotherapy, eventually chemotherapy is indicated. The prognosis is not favorable.

Angiosarcoma after breast-conserving therapy: Fine-needle aspiration biopsy, immunocytochemistry, and clinicopathologic correlates

BACKGROUND

Angiosarcoma that arises after breast-conserving therapy can present clinically as a cutaneous and/or subcutaneous breast lump, which is misinterpreted easily as a recurrence of carcinoma. To the authors' knowledge, the role of fine-needle aspiration (FNA) cytology in the early diagnosis of this life-threatening complication of breast carcinoma therapy has not been established fully.

METHODS

The authors studied three new patients with this type of secondary angiosarcoma diagnosed by FNA biopsy and immunocytochemistry, reviewed the literature on the topic, and examined relevant differential diagnostic issues.

RESULTS

Patients presented with a discrete skin lump that had arisen several years after breast-conservative therapy for early-stage breast carcinoma near the scar from the previous surgery. The lesions were interpreted clinically as recurrent carcinoma. FNA yielded moderately cellular to highly cellular samples with variable patterns of cellular aggregation. Cells were epithelioid and spindle-shaped. Angioformative changes were subtle, and the overall picture suggested an epithelial malignancy, possibly a metaplastic carcinoma. Immunostaining of smears, however, provided conclusive evidence of the endothelial differentiation of tumor cells, and an FNA diagnosis of angiosarcoma was rendered in all patients. The histopathology of all surgically excised tumors confirmed the diagnosis of high-grade angiosarcoma.

CONCLUSIONS

Based on the authors' experience, the FNA cytologic appearance of angiosarcoma that presented as a breast skin nodule in a breast carcinoma survivor easily could have been misinterpreted as carcinoma. A correct diagnosis of this tumor relies on the proper evaluation of clinical findings and, as also shown by a review of the literature, requires immunocytochemical evidence of endothelial differentiation.

Fine-needle aspiration cytology of epithelioid angiosarcoma: A diagnostic dilemma

A 28-year-old woman with a 2-yr history of unilateral chronic leg swelling, initially thought to be secondary to deep vein thrombosis, later thought to be due to congenital venous malformation, eventually developed a pelvic mass, which was biopsied by fine-needle aspiration. On the basis of cytologic features on smears, high-grade sarcoma was reported. The patient underwent surgery to resect the pelvic mass, which showed anastomosing vascular channels arising from external iliac vein in histology. However, the tumor cells unexpectedly showed strong and diffuse immunohistochemical expression of cytokeratin and epithelial membrane antigen. The case was sent for expert consultation, and the expert's opinion was epithelioid angiosarcoma. The expert's diagnosis was confirmed 2 yr later by local recurrence. The clinical presentation, cytology, histology, and immunohistochemistry of the current case and 15 other cases of epithelioid angiosarcoma found in the cytology literature are summarized. This case illustrates that morphology with clinicopathologic correlation tends to be a better guide than available special techniques.

Mixed tumors of the vagina: an immunohistochemical study of 13 cases with emphasis on the cell of origin and potential aid in differential diagnosis

Mixed tumors of the vagina (MTsV) are rare benign neoplasms characterized by an admixture of well-differentiated epithelial cells and stromal-type cells in various proportions. In contrast to mixed tumors in other anatomic sites, the histogenesis of the vaginal tumors is unclear. We studied the immunohistochemical profile of 13 examples to explore their histogenesis and determine whether their immunohistochemical profile might be useful in the differential diagnosis. The panel of antibodies used and the number of cases studied were: AE1/3 (12), cytokeratin 7 (CK7) (13), cytokeratin 20 (CK20) (13), epithelial membrane antigen (EMA) (13), muscle actin (MA) (12), desmin (11), h-Caldesmon (13), CD10 (13), CD34 (11), CD99 (8), and S-100 (7). Eight out of 12 tumors were positive for AE1/3, 7/13 for CK7, 2/13 for CK20, and 6/13 for EMA. MA was positive in 11/12 mixed tumors, desmin in 10/11 tumors and h-Caldesmon in 5/13. All tumors were extensively positive for CD10; CD34 was positive in 7/11; and none out of eight tumors showed membranous CD99 staining. Focal S-100 immunoreactivity was seen in 1/7 tumors. These results show that MTsV coexpress epithelial and mesenchymal markers. The expression of muscle actin (usually extensive), and focal desmin and h-Caldesmon positivity suggests the presence of a smooth muscle or myoepithelial component; however, the S-100 negativity and diffuse CD10 expression argue against it. Positivity for muscle markers does not help distinguish MTsV from smooth muscle or skeletal muscle tumors. The frequent expression of CD10 negates its use in the differential diagnosis with endometrial stromal tumors, and the CD10 and CD34 expression suggests that mixed tumors may arise from a primitive pluripotential cell. MTsV are positive for h-Caldesmon and CD10, two markers that have been used in gynecologic pathology primarily to aid in establishing the smooth muscle or endometrial stromal phenotype of a neoplasm.

Cytological features of epithelioid mesenchymal neoplasms: A study of 21 cases

Epithelioid mesenchymal neoplasms (EMNs) are rare tumors that share cytological, histological, and immunohistochemical features with epithelial tumors. It is important to distinguish EMNs from epithelial tumors in cytology specimens due to their different clinical management and prognosis. The cytomorphological features of histologically confirmed EMN were reviewed. Twenty-one cytological specimens of EMN were evaluated and characterized by polygonal cells with moderate to abundant dense cytoplasm, prominent nucleoli, and pleomorphism. Additional findings included the presence of a distinct population of spindle cells, hemosiderin-containing cells, multinucleated cells, and granuloma-like structures in selected cases. Cytokeratin immunoreactivity was seen in two cases and was negative in one case. This study shows that the cytological features of EMNs and epithelial tumors overlap; nonetheless, some features are more helpful in suggesting EMN. A panel of immunocytochemical studies must include specific mesenchymal markers to avoid a misdiagnosis of carcinoma in cases of cytokeratin-positive EMN.

Cytohistologic correlations in angiosarcoma including classic and epithelioid variants: Institut Curie's experience

To characterize the cytological features of angiosarcomas, we reviewed the fine-needle aspiration material and corresponding histologic sections of 29 tumors in 23 patients. Histologically, 24 tumors were of the classic type, and 5 were epithelioid angiosarcomas. The original corresponding cytologic diagnoses were as follows: angiosarcoma, 17 cases; sarcoma not otherwise specified, 8 cases; and rhabdomyosarcoma, 1 case. Three samples were cell-poor and were considered suspicious of malignancy. The review of cytology samples showed that smears were cell-rich in 17 tumors and cell-poor in 12 tumors. A hemorrhagic background was present in 9 cases. Tumor cells were polymorphous, including spindle-shaped, round to oval, and polygonal epithelioid cells and giant cells in different proportions. Erythrophagocytosis was seen in 12 tumors. Smears of classic angiosarcomas were polymorphous and lacking specific characteristics, whereas smears of epithelioid tumors were morphologically similar and composed of round to oval and polygonal, epithelial cells frequently arranged in clusters, and showing erythrophagocytosis. The wide spectrum of cellular components of angiosarcomas accounts for the difficulty in establishing accurate tumor typing, particularly with cell-poor samples and low-grade classic angiosarcoma. Entities to consider in the differential diagnosis are carcinoma, epithelioid sarcoma, pleomorphic rhabdomyosarcoma, and malignant melanoma.