Epithelioid Hemangioendothelioma: Incidence, Mortality, Prognostic Factors, and Survival Analysis Using the Surveillance, Epidemiology, and End Results Database

Background

Although epithelioid hemangioendothelioma (EHE) is a rare and aggressive vascular tumor, its demographic characteristics remain unclear. We used the surveillance, epidemiology, and end results (SEER) database to determine the clinical features, incidence, and prognostic factors associated with overall survival in patients with EHE.

Methods

The demographic and clinical data of patients with EHE were extracted from the SEER database (1975-2019) to calculate the incidence of EHE and survival rate in these patients. The Cox proportional hazards model and Kaplan-Meier method were used to analyze the prognostic factors of overall survival in these patients. A nomogram and time-dependent receiver operating characteristic (ROC) curve were employed to predict the 3- and 5-year survival rate.

Results

The overall incidence rate (IR) of EHE was 0.230 (95%confidence interval [CI] = 0.201–0.263) per 1,000,000 person-years. According to the age-stratified IR, the highest age-adjusted IR was observed in patients aged 60–79 years (0.524 per 1,000,000 person-years, 95%CI = 0.406–0.665). The majority (30.8%) of the tumors were located in the soft tissue and skin, followed by lesions in the abdomen (28%), respiratory system (19%), bone and joint (8.6%), and others. The 5-year overall survival rate was 55.6% (95%CI = 32.8–73.5%). Multiple Cox regression analysis revealed that age >80 years (hazard ratio [HR] = 8.57, 95%CI = 2.32–31.63, P < 0.001), African-American race (HR = 2.52, 95%CI = 1.31–4.85, P < 0.01), “American Indian/Alaska Native” or “Asian or Pacific Islander” (HR = 2.99, 95%CI = 1.5–5.96, P < 0.01) race, and respiratory tumors (HR = 2.55, 95%CI = 1.37–4.75, P < 0.01) were distinctly related to worse overall survival. The calibration plots demonstrated good consistency between nomogram-predicted and actual survival. The area under the time-dependent ROC curve was 0.721 (95%CI = 0.63–0.81) and 0.719 (95%CI = 0.63–0.81) for the 3- and 5-year survival, respectively. For the convenience of researchers and clinicians, we designed an online dynamics nomogram to predict the survival rate.

Conclusion

EHE is a relatively rare vascular tumor, which principally occurs in the soft tissue and skin. It most commonly occurs in patients aged 60–79 years and its incidence has increased in recent years. Age at diagnosis, race, and tumor location may affect the overall survival outcomes.

Malignant Vascular Tumors of the Head and Neck-Which Type of Therapy Works Best?

Simple Summary

Malignant vascular tumors are extremely rare tumors with variable clinical courses, and few data on their clinical management are available. Diagnosis is difficult due to their wide morphologic appearance. The intent of the present review is to demonstrate the current knowledge and management on malignant vascular tumors of the head and neck area. The mainstay of treatment for malignant vascular tumors is surgery, but radiotherapy and chemotherapy are also parts of the treatment concept especially in angiosarcomas. Targeted therapy, antiangiogenetic drugs and immunotherapy have been studied as new treatment options.

Abstract

Malignant vascular tumors of the head and neck are rare neoplasms with variable clinical presentation, wide age distribution, and variable clinical courses. The heterogeneous presentation of angiosarcomas and epithelioid hemangioendothelioma often leads to misdiagnosis and unsuitable treatment. While risk factors for angiosarcomas are previous radiation, chronic lymphedema, and exposure to arsenic, thorium oxide, or vinyl chloride, there are only limited and retrospective data available on prognostic factors in EHE. In both angiosarcomas and EHE, surgery is the mainstay of treatment. There is limited evidence regarding the role of radiotherapy in EHE, although EHE is considered relatively radiosensitive. In angiosarcomas, adjuvant radiotherapy is recommended according to retrospective case series. A standard medical therapy for metastasized malignant vascular tumors is lacking. Chemotherapy, which is effective in angiosarcoma, is mostly ineffective in EHE. Targeted therapy, antiangiogenetic drugs and immunotherapy have been studied as new treatment options. The goal of this review is to summarize the current data regarding malignant vascular tumors along with their diagnosis and management.

A primary solitary vascular tumor of calcaneum: case report and review of literature

Epithelioid hemangioendothelioma (EHE) is a rare vascular tumor with metastatic potential and estimated prevalence of less than one case per million. Among the musculoskeletal system, the long bones are commonly involved with approximately half patients experiencing multicentric involvement. Clinical course of EHE is often variable and nonspecific. Poorly demarcated osteolytic lesions are most commonly seen radiologically. Diagnostic confirmation is usually obtained by biopsy and histopathological exam, including immunostaining for endothelial markers. We present a rare case of unicentric EHE involving the calcaneum. Our patient had an indolent course of disease after surgical resection and no recurrence in seven years on clinical and radiological surveillance.

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.

Imaging characteristics and prognostic values of hepatic epithelioid hemangioendothelioma on 18F-FDG PET/CT

Hepatic epithelioid hemangioendothelioma (HEHE) is a low-to-intermediate-grade malignant mesenchymal tumor. The diagnostic and prognostic values of 2-[18F] fluoro-2-deoxy-D-glucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) to patients with HEHE have not been fully validated. Patient survival outcomes (including overall survival [OS] and progression-free survival [PFS]), lesions characteristics and semi-quantitative parameters, in terms of maximum standardized uptake value (SUV_max), peak SUV (SUV_peak), total lesion glycolysis (TLG) and metabolic tumor volume (MTV) on ¹⁸F-FDG PET/CT of 20 cases with HEHE were measured and analyzed. A total of 310 liver lesions were detected (excluding the diffuse-type lesions in 3 cases). Most lesions had higher SUV_max in delayed imaging than in early imaging (P = 0.013). Patients with multiple organs involved had higher death rate (P = 0.022), higher progression rate (P = 0.020), shorter OS (P = 0.011), larger lesion SUV_max (P = 0.048) and TLG (P = 0.033) than those with only liver involved. The area under curves (AUCs) from the receiver operating characteristic (ROC) curve analysis were 0.960, 0.949, 0.980 and 0.960 for SUV_max, SUV_peak, TLG and MTV, respectively, in predicting OS (P = 0.005, 0.008, 0.001 and 0.024, respectively). For predicting PFS, the AUCs were 0.791, 0.824, 0.857 and 0.813 (P = 0.036, 0.019, 0.010 and 0.024), respectively. Dual-time-point imaging may improve lesions detectability. Patients with multiple organ involved had worse prognosis. The higher SUV_max, SUV_peak, TLG and MTV of lesions, the worse prognosis of patients were found.

Hepatic hemangioendothelioma: CT, MR, and FDG-PET-CT in 67 patients-a bi-institutional comprehensive cancer center review

OBJECTIVE

To evaluate the imaging features of hepatic epithelioid hemangioendothelioma (HEH) on multiphasic CT, MR, and FDG-PET-CT.

METHODS

Bi-institutional review identified 67 adults (mean age, 47 years; 23 M/44 F) with pathologically proven HEH and pretreatment multiphasic CT (n = 67) and/or MR (n = 30) and/or FDG-PET-CT (n = 13).

RESULTS

HEHs were multifocal in 88% (59/67). Mean size of the dominant mass was 4.1 cm (range, 1.4-19 cm). The tumors were located in the peripheral, subcapsular regions of the liver in 96% (64/67). Capsular retraction was present in 81% (54/67 cases) and tumors were coalescent in 61% (41/67). HEH demonstrated peripheral ring enhancement on arterial phase imaging in 33% (21/64) and target appearance on the portal venous phase in 69% (46/67). Persistent peripheral enhancement on the delayed phase was seen in 49% (31/63). On MR, multilayered target appearance was seen on the T2-weighted sequences in 67% (20/30) and on the diffusion-weighted sequences in 61% (11/18). Target appearance on hepatobiliary phase of MRI was seen in 57% (4/7). On pre-therapy FDG-PET-CT, increased FDG uptake above the background liver parenchyma was seen in 62% (8/13).

CONCLUSION

HEHs typically manifest as multifocal, coalescent hepatic nodules in peripheral subcapsular location, with associated capsular retraction. Peripheral arterial ring enhancement and target appearance on portal venous phase are commonly seen on CT. Similarly, multilayered target appearance correlating with its histopathological composition is typically seen on multiple sequences of MR including T2-weighted, diffusion-weighted, and dynamic contrast-enhanced multiphasic MR.

KEY POINTS

• Hepatic epithelioid hemangioendotheliomas manifest on CT and MR as multifocal, coalescent hepatic nodules in peripheral subcapsular location, with associated capsular retraction. • Enhancement pattern on contrast-enhanced CT and MR can vary but peripheral ring enhancement on arterial phase and target appearance on portal venous phase are commonly seen. • Retrospective two-center study showed that cross-sectional imaging may help in the diagnosis.

Spontaneous Bilateral Hemothorax as a Case of Epithelioid Hemangioendothelioma (EHE)

Epithelioid hemangioendothelioma (EHE) is a rare tumor that is vascular in origin, arising from the endothelial or preendothelial cells. It can occur at different sites of the body, commonly in the liver, lungs, and bone. Pulmonary EHE is usually symptomatic, sometimes presenting with a cough, dyspnea, or chest pain. Rarely, it presents with pleural effusion. Here, we are presenting a case of pleural epithelioid hemangioendothelioma presenting as a case of spontaneous bilateral hemothorax.

Spectrum of appearances on CT and MRI of hepatic epithelioid hemangioendothelioma

Background

This study aims to analyze the computed tomography (CT) and magnetic resonance imaging(MRI) characteristics of hepatic epithelioid hemangioendothelioma (HEHE).

Methods

Eleven patients with histopathologically confirmed HEHE via surgical excision or biopsy were included. Imaging findings of these 11 patients were retrospectively analyzed (CT images obtained from all patients and MR images from five patients). Patterns of growth, characteristics of distribution, density/signal features, patterns of contrast enhancement, and changes of adjacent tissues were evaluated.

Results

HEHE is characterized by multiple lesions in the liver. HEHE could be further categorized as three types when considering patterns of growth: nodular type(5 cases), coalescent type(1 case) and mixed type(5 cases). In this study, a total of 312 lesions were detected, 214(74.3 %) of which were subcapsular. All lesions appeared as hypodense while round lower density were found within 10 lesions(<2 cm) on unenhanced CT images. On MRI, all lesions demonstrated low signal intensity on T1 weighted images and high heterogeneous signal intensity on T2 weighted images when compared to the normal liver parenchyma. Other imaging features included “lollipop sign”(6 cases) and capsular retraction(6 cases). On contrast-enhanced CT and MRI, lesions smaller than 2.0 cm mostly showed mild homogeneous enhancement (214/227, 94.3 %); lesions measuring 2.0–3.0 cm in diameter showed ring-like enhancement (16/53,30.2 %) and heterogeneous delayed enhancement (29/53,54.7 %); lesions larger than 3.0 cm demonstrated heterogeneous delayed enhancement (26/32, 81.3 %).

Conclusion

The imaging findings of HEHE showed some typical imaging features and size-dependent patterns with contrast enhancement on both CT and MR images, these features can be used for accurate imaging diagnosis of HEHE.

Malignant hepatic epithelioid hemangioendothelioma with abdominal pain due to rapid progression

Hepatic epithelioid hemangioendothelioma (HEH) is a rare tumor. We report on a patient who underwent hepatectomy for malignant HEH associated with abdominal pain due to rapid progression. An 83-year-old man was admitted to Nippon Medical School Hospital because of acute, severe upper abdominal pain. Seven months before admission, a hepatic tumor, 3 cm in diameter, had been detected in the left lateral sector. The diagnosis was hepatic cavernous hemangioma. Abdominal ultrasonography revealed a heterogeneous hyperechoic tumor with a smooth border, 6 cm in diameter, in the left lateral sector (segment 3). Contrast-enhanced computed tomography of the abdomen showed that the tumor was enhanced from the early to the late phase. Abdominal angiography revealed a cotton wool-like appearance of the tumor. The diagnosis was hepatic cavernous hemangioma. A malignancy could not be ruled out because of the tumor's rapid growth, which had caused abdominal pain. Left hepatectomy was performed. Histopathological examination showed necrosis throughout the tumor. Slightly pleomorphic neoplastic cells with rounded, spindle-like nuclei and scant cytoplasm were sporadically found in vascular channels. Intracytoplasmic lumina occasionally contained red cells. Neoplastic cells were positive for factor VIII-related antigen, CD31, and CD34. The Mib-1 index was high. The tumor was diagnosed as malignant HEH. The postsurgical course was uneventful, and the patient was discharged on postoperative day 11. After 3 months, multiple metastatic tumors appeared in right hepatic lobe. Transcatheter arterial chemoembolization was performed.

Clinical patterns and outcome in epithelioid hemangioendothelioma with or without pulmonary involvement: insights from an internet registry in the study of a rare cancer

BACKGROUND

Epithelioid hemangioendothelioma (EHE) is a rare vascular neoplasm of endothelial origin with clinical behavior intermediate between hemangioma and angiosarcoma. The natural history of EHE is highly variable. This study uses an Internet registry to identify clinical patterns with prognostic significance in EHE.

METHODS

Cases from the International Hemangioendothioma, Epithelioid Hemangioendothelioma, and Related Vascular Disorders (HEARD) Support Group were evaluated based on demographics, organ involvement, disease progression, presence or absence of pleural effusion, and treatment. Survival among various cohorts was compared using log-rank analysis of Kaplan-Meier plots.

RESULTS

Two hundred sixty-four patients were identified from April 2004 to November 2009. Fifty-eight cases were excluded because of inadequate information or wrong diagnosis. EHE was more common in female patients (61%). Male gender and age ≥ 55 years were associated with decreased survival. The most commonly affected organs were liver, lung, and bone. No specific organ or combination of organ involvement differentially affected survival, and survival was no different between patients with multiple vs single organ involvement. However, pattern B, defined as lesions without distinct borders (eg, pulmonary infiltrates, pleural effusion, ascites), hemoptysis, or involvement of more than two bones adversely affected survival in all cohorts.

CONCLUSION

A novel staging system with prognostic value for EHE is proposed. Pleural effusion or other signs of uncontained tumor growth, hemoptysis, and osseous involvement of more than two bones implied worse survival than did localized and discrete tumors, regardless of number of organs involved. A lay registry can provide useful insights into the clinical behavior of a rare cancer.

Pediatric liver transplantation for primary malignant liver tumors with a focus on hepatic epithelioid hemangioendothelioma: the UNOS experience

Treatment for HEH does not follow a standardized algorithm. From clinical experience, it is assumed that pediatric patients with HEH will fare as well as other common pediatric liver tumors post-OLT. The UNOS dataset was examined for patients with pediatric OLT between 1987 and 2007. Patients were grouped into non-tumors, HB, HCC, HEH, and rare liver tumors. COD analysis was calculated using Fisher's exact test. Patient, allograft, and recurrence-free survival were compared using Kaplan-Meier curves and log-rank tests. A total of 366 patients with pediatric OLT were identified with primary liver tumors (HB - 237, HCC - 58, HEH - 35, other - 36). HEH patient survival (five yr: 60.6%) was poorer than non-tumor OLTpatient survival (five yr: 84.4%). Survival was worse when compared to HB (five yr: 72%) and rare liver tumors (five yr: 78.9%), but better than HCC (five yr: 53.5%). Allograft survival in HEH (five yr: 50.1%) lies between HB (five yr: 63.6%) and HCC (five yr: 42.8%). COD analysis demonstrates recurrence as a major cause in HB and HCC, but not for HEH or other liver tumors. The data suggest that patient survival may not be as high as previously believed and further investigation is warranted.