Epithelioid angiomyolipoma of the liver: a case report

Epithelioid angiomyolipoma of the liver in a patient with Li-Fraumeni syndrome: a case report

BACKGROUND

Epithelioid angiomyolipoma (EAML) is a rare variant of angiomyolipoma that predominantly consists of epithelioid cells and belongs to the perivascular epithelioid cell neoplasm (PEComa) family. The majority of EAMLs arise in the kidneys, and primary hepatic EAML appears to be much less common than renal EAML. Most PEComas arise sporadically, but may be associated with tuberous sclerosis complex (TSC), an autosomal dominant genetic disorder characterized by germline mutations in the TSC1 or TSC2 genes. However, PEComas have previously been reported in five patients with Li-Fraumeni syndrome (LFS), which is an inherited cancer susceptibility disorder resulting from germline mutations in the TP53 tumor suppressor gene.

CASE PRESENTATION

We report a 49-year-old female patient with hepatic EAML and pancreatic cancer. Because she had previously been diagnosed with bilateral breast cancer at the age of 30, we performed a comprehensive genetic analysis to identify genetic alterations associated with any cancer predisposition syndrome. Whole-exome sequencing of a blood sample identified a heterozygous germline variant of TP53 (NM_000546.5):c.708C>A, and targeted next-generation sequencing of liver EAML and pancreatic cancer tissue samples demonstrated the same TP53 (NM_000546.5):c.708C>A variant in both. This, plus the patient's history of early-onset breast cancer, met the 2015 version of the Chompret criteria for diagnosis of LFS.

CONCLUSIONS

There have been very few case reports regarding the presence of PEComa in LFS, and to the best of our knowledge, this is the first report of EAML of the liver in a patient with LFS.

Epithelioid hepatic angiomyolipoma in pregnancy: A case report

INTRODUCTION AND IMPORTANCE

Epithelioid hepatic angiomyolipoma (HAML) is a rare benign tumor predominantly found in women. Its occurrence during pregnancy is extremely rare. Accurate diagnosis of HAML is challenging due to its radiological resemblance to other hepatic neoplasms. We present a case of epithelioid HAML in a pregnant patient, highlighting the diagnostic and management challenges encountered.

CASE PRESENTATION

A 24-year-old pregnant female, in her fifth month of pregnancy, presented with right hypochondrium pain and nausea. Radiological imaging suggested the possibility of a hepatic adenoma. The patient opted to continue the pregnancy with regular monitoring of the mass as well as fetal health. After delivering a healthy baby, the patient underwent successful mass excision and cholecystectomy. Histopathology of the liver mass confirmed the diagnosis of epithelioid HAML.

CLINICAL DISCUSSION

Epithelioid HAML is a rare tumor often misdiagnosed. It is more aggressive and frequently associated with tuberous sclerosis complex (TSC) compared to other subtypes. The diagnosis of HAML can be challenging due to its resemblance to Hepatocellular Carcinoma and other hepatic neoplasms on radiological imaging. Immunohistochemistry plays a crucial role in confirming the diagnosis. Surgical excision is the recommended treatment, with complete removal to minimize the risk of recurrence.

CONCLUSION

This case report highlights the rarity of epithelioid HAML during pregnancy and emphasizes the importance of a multidisciplinary approach in managing hepatic neoplasms. Close monitoring is crucial, considering the potential risks to the mother and fetus. Accurate diagnosis through histopathological evaluation, immunohistochemistry and a multidisciplinary approach are essential for appropriate management.

Hepatic epithelioid angiomyolipoma: magnetic resonance imaging characteristics

PURPOSE

The aim of the study was to analyze MR imaging features of hepatic epithelioid angiomyolipoma (HEAML).

METHODS

This study included 113 patients with 122 pathologically confirmed HEAML who underwent enhanced MRI scanning before partial hepatectomy. MR images were retrospectively reviewed and correlated with pathological findings.

RESULTS

The mean age of 113 patients was 48.12 ± 11.77 years old, and the male to female ratio was 1:3.35 with 87 females (76.99%). 107 (94.69%) patients presented as single tumor, and 96 patients (84.96%) were asymptomatic. 122 HEAML lesions were diagnosed pathologically in 113 patients, with the average of 4.47 ± 3.26 cm. 109 lesions (89.34%) and 108 lesions (88.52%) showed regular and well-defined boundary. On T1WI, 121 lesions (99.18%) mainly presented hypointensity. On T2WI, 118 lesions (96.72%) and 109 lesions (89.34%) mainly showed hyperintensity and heterogeneous signals. Most of the lesions (97.46%) showed hyperintensity on DWI. 118 lesions (96.72%) manifested as severe hyperenhancement and 106 lesions (86.89%) showed heterogeneity during the arterial phase. As for the lesion enhancement pattern, 73 lesions (59.84%) presented as persistent enhancement, 37 lesions (30.33%) as wash out, 8 lesions (6.56%) as degressive enhancement, and 4 lesions (3.28%) as poor blood supply. Additionally, 96 lesions (78.69%) with intra-tumor vessels and 85 lesions (69.67%) with outer rim were confirmed during the delayed phase.

CONCLUSION

At enhanced MRI, hypointensity on T1WI, hyperintensity and heterogeneous signals on T2WI, hyperintensity on DWI, little or no fat component, heterogenous hyperenhancement, persistent enhancement, intra-tumor vessels, and outer rim would be helpful to diagnose HEAML.

Hepatic epithelioid angiomyolipoma is scattered and unsuitable for surgery: a case report

Hepatic epithelioid angiomyolipoma (HEAML) is a rare tumour of mesenchymal tissue with a malignant tendency. Occurring most frequently in women, the relative incidence in men and women, according to incomplete statistics, is approximately 1:5. In rare cases, disease occurrence and development is hidden. Lesions are generally discovered as chance findings by patients; abdominal pain is the first symptom, and imaging has no specificity in diagnosing the disease. Therefore, great difficulties exist in the diagnosis and treatment of HEAML. Here, the case of a 51-year-old female patient with a history of hepatitis B, and abdominal pain over 8 months as the initial symptom, is described. The patient was found to have multiple intrahepatic angiomyolipoma. Due to the small and scattered foci, complete resection was impossible, and because of her history of hepatitis B, conservative treatment was undertaken, with the patient undergoing regular follow-up. When hepatic cell carcinoma could not be excluded, the patient was treated with transcatheter arterial chemoembolization. No tumour neogenesis or metastasis was detected at the 1-year follow-up.

Hepatic angiomyolipoma: A case report and literature review

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HAML is a rare mesenchymal liver tumour which belongs to the family of perivascular epithelioid cell tumours.

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HAML is typically composed of blood vessels, smooth muscle, and adipose cells.

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HAML is characteristically positive for HMB-45.

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In patients with symptoms, uncertain diagnosis, or tumour growth, surgical resection should be performed.

Introduction

Hepatic angiomyolipoma (HAML) is a rare mesenchymal liver tumour which belongs to the family of perivascular epithelioid cell tumours (PEComas). It is typically composed of blood vessels, smooth muscle, and adipose cells, and shows strong immunoreactivity for HMB-45.

Presentation of the case

A 57-year-old woman was referred to our hospital with an unclear liver lesion. A fine needle biopsy revealed a suspicion of hepatic angiomyolipoma with extramedullary haematopoiesis. Preoperative imaging revealed a tumour 17 cm in diameter in the left liver lobe segments II and III. A lobectomy of the left lobe segments II and III was performed. The pathological diagnosis of hepatic angiomyolipoma was obtained.

Discussion

Variations in the predominance of the tissue components in HAML impedes diagnosis based on imaging alone. The most promising evidence of HAML is the histological identification of lipomatous, myomatous, and angiomatous tissue combined with immunohistochemical positivity for HMB-45. Although the tumour is considered benign, some cases have been described with malignant behaviour. Surgical resection should be considered in case of symptoms, inconclusive biopsy, or growth in follow-up. Other surgical indications may include aggressive patterns such as vascular invasion, p53 immunoreactivity, or rapidly proliferating tumour cells.

Conclusion

HAML is a rare liver tumour. In patients with symptoms, uncertain diagnosis, or tumour growth, surgical resection should be performed according to oncological criteria.

Partial nephrectomy can be a successful treatment option for renal epithelioid angiomyolipoma: a case report and literature review

Background

Renal epithelioid angiomyolipoma is a rare tumour which involves kidneys in most cases. It is known for its aggressive behaviour as a significant number of cases have been associated with metastatic epithelioid angiomyolipoma. Usually, radical treatment with systemic therapy is recommended. Only a small number of cases of epithelioid angiomyolipomas have been reported with the standard treatment being radical or partial nephrectomy. We present a  case report showing that partial nephrectomy can be a successful treatment option for renal epithelioid angiomyolipoma. This is the first case of this nature in Lithuania.

Case presentation

In this case, a 40-year-old male with epithelioid angiomyolipoma of the left kidney is presented. In 2012, a cystic left renal mass 40 × 41 mm in size was diagnosed incidentally while performing ultrasound and later confirmed by MRI. Due to the size of the tumour and the possibility of renal cell carcinoma, surgery was scheduled. Left partial nephrectomy was performed successfully. Final pathology report came back with the diagnosis of renal epithelioid angiomyolipoma. The patient had yearly follow-up for six years by CT scan, and neither recurrence nor progression were observed.

Conclusions

Early detection and diagnosis are crucial for treatment as the tumour tends to have malignancy potential. With early diagnosis, partial nephrectomy can be performed with yearly follow-up and no systemic treatment required.

Hepatic epithelioid angiomyolipoma: contribution of a new case

In relation to the article published by Ortiz S et al. (1), we have recently seen a 37-year-old female who presented to the Emergency Department with pain in right hypochondrium and a mild increase in transaminase levels. An ultrasound was performed that showed a large 13-cm tumor in the right hepatic lobe, which was heterogeneous with hyperechogenic and anechoic areas.

[Hepatic epithelioid angiomyolipoma/PEComa and focal nodular hyperplasia in a patient with a previous history of cutaneous melanoma]

Hepatic perivascular epithelioid cell tumors (PEComas) are uncommon mesenchymal neoplasms. PEComas concurrent with other hepatic lesions is a very rare occurrence, with only two previously reported cases. We report a primary hepatic PEComa associated with focal nodular hyperplasia in a patient with a previous history of cutaneous melanoma. Diagnostic imaging studies suggested a hepatic adenoma and the patient underwent a segmentectomy. The tumor was mainly composed of epithelioid cells, adipose tissue and smooth muscle fibers intermixed with blood vessels. The neoplastic cells were diffusely immunoreactive for HMB-45, Melan-A and smooth muscle actin, but not for Hepatocyte, S100, MITF or BRAF. Molecular studies were negative for BRAFV600 mutation. The final diagnosis was hepatic epithelioid angiomyolipoma/PEComa. The differential diagnosis of hepatic PEComa is discussed.

Two case reports and literature review for hepatic epithelioid angiomyolipoma: Pitfall of misdiagnosis

BACKGROUND

Hepatic epithelioid angiomyolipoma (HEAML) is a rare liver disease and is easily misdiagnosed. Enhanced recognition of HEAML is beneficial to the differential diagnosis of rare liver diseases.

CASE SUMMARY

We presented two cases of HEAML in Changzheng Hospital, Naval Medical University, and then collected and analyzed all reports about HEAML recorded in PubMed, MEDLINE, China Science Periodical Database, and VIP database from January 2000 to March 2018. A total of 409 cases of HEAML in 97 reports were collected, with a ratio of men to women of 1:4.84 and an age range from 12 years to 80 years (median 44 years). Among the patients with clinical symptoms mentioned, 61.93% (205/331) were asymptomatic, 34.74% (115/331) showed upper or right upper quadrant abdomen discomfort, while a few of them showed abdominal mass, gastrointestinal symptoms, low fever, or weight loss. The misdiagnosis rate of HEAML was as high as 40.34% (165/409) due to its nonspecific imaging findings. Most of the tumors were solitary and round in morphology, with clear boundaries. Ultrasound scan indicated low echo with internal nonuniformity and rich blood supply in most cases. Computer tomography/magnetic resonance imaging enhanced scan showed varied characteristics. The ratio of fast wash-in and fast wash-out, fast wash-in and slow wash-out, and delayed enhancement was roughly 4:5:1. A definite diagnosis of HEAML depended on the pathological findings of the epithelioid cells in lesions and the expression of human melanoma black 45, smooth muscle actin, melanoma antigen, and actin by immunohistochemical staining. HEAML had a relatively low malignant rate of 3.91%. However, surgical resection was the main treatment for HEAML, due to the difficulty diagnosing before operation.

CONCLUSION

HEAML is a rare and easily misdiagnosed disease, and it should be diagnosed carefully, taking into account clinical course, imaging, pathological ,and immunohistochemical findings.

Comparison of MRI Features of Epithelioid Hepatic Angiomyolipoma and Hepatocellular Carcinoma: Imaging Data From Two Centers

Introduction: Epithelioid hepatic angiomyolipoma (Epi-HAML) can easily be misdiagnosed as a malignant tumor such as hepatocellular carcinoma (HCC) because of the low-fat content on imaging. We analyzed and compared the magnetic resonance imaging (MRI) features of Epi-HAML and HCC, which would aid in disease diagnosis.

Methods: We included 30 pathologically confirmed patients with Epi-HAML and 80 with HCC, who underwent both MRI unenhanced scan and three-phase contrast-enhanced MRI scan. The clinical and MRI features of the two groups were summarized and analyzed.

Results: Epi-HAML showed significant differences compared to HCC group in terms of clinical features such as sex preference, age, concomitant diseases (hepatitis B and cirrhosis), and elevated plasma alpha-fetoprotein (AFP) (P < 0.001). In addition, there were statistically significant differences between both tumor types with regard to conventional MRI findings such as a solitary tumor (100 vs. 83.8%, P = 0.018), well-defined (93.3 vs. 71.3%, P = 0.027), mild hyperintensity (40.0 vs. 3.7%, P < 0.001) on DWI with high b-value, fat within the tumor (43.3 vs. 8.8%, P < 0.001), and rare necrosis (3.3 vs. 26.3%, P = 0.016). Besides, Epi-HAML displayed significant differences compared to HCC in terms of contrast-enhanced MRI characteristics such as draining hepatic vein (30.0 vs. 3.8%, P < 0.001), portal vein tumor thrombus (0 vs. 13.8%, P = 0.033), hypointensity at delayed phase (70.0 vs. 95%, P = 0.001), intra-tumor vessel at delayed phase (36.7 vs. 10.0%, P = 0.003), pseudocapsule (20.0 vs. 78.8%, P < 0.001), and prolonged enhancement (56.7 vs. 1.2%, P < 0.001).

Conclusion: Epi-HAML frequently occurs in middle-aged women and usually lacks characteristic clinical symptoms. Typically, Epi-HAML presents as an isolated and well-defined tumor with rich vasculature. Specific MRI features such as intra-tumor fat, intra-tumor vessel, draining hepatic vein, prolonged enhancement, and lack of capsule may contribute to a more confident diagnosis of Epi-HAML.

Hepatic epithelioid angiomyolipoma with renal metastasis: radiologic-pathologic correlation

Epithelioid angiomyolipoma (EAML) is a rare subtype of angiomyolipomas. Unlike the conventional angiomyolipomas, EAML often contains minimal fat which usually precludes prospective diagnosis on imaging. The imaging findings of EAML may overlap with other benign and malignant hepatic neoplasms. We report a hepatic epithelioid angiomyolipoma in a 47-year-old female which metastasized to the right kidney and recurred after resection in the liver. We analyze the imaging findings of EAML on ultrasound, computed tomography, positron emission tomography and magnetic resonance imaging. Correlation between the imaging and histopathologic findings is made. The estimated annual growth and doubling time of the primary hepatic EAML are calculated. To the best of our knowledge, this is the first published report of positron emission tomography–computed tomography findings and annual growth rate for hepatic EAML.

Hepatic epithelioid angiomyolipoma: a report of two cases and review of the literature

Hepatic epithelioid angiomyolipoma (EAML) is an uncommon mesenchymal tumor with malignant potential, which is clinically susceptible to being misdiagnosed as hepatocellular carcinoma. Therefore, accurate diagnosis of hepatic EAML and treatment is necessary. We report two cases of hepatic EAML that were identified by abdominal computed tomography (CT). The first case presented in a 37-year-old woman and was an oval-shaped liver mass, measuring 4.5×4.2×4.9 cm. The second case presented in a 51-year-old woman and was a round-shaped mass measuring 4×3.5×3.7 cm. Both patients underwent laparoscopic resection. Microscopically, we detected epithelioid and spindle-shaped cells with adipocytes. After the analysis of biomarkers, we found that both cases were positive for HMB45 and Melan-A, which helped to confirm the diagnosis. Hepatic EAML is a rare clinical tumor, which has a high rate of misdiagnosis and the final diagnosis depends on histopathologic and immunohistochemical features. Laparoscopic resection remains the recommended choice for hepatic EAML. Partial hepatic EAML has a tendency become malignant and thus long-term follow-up is needed.

Imaging appearance of renal epithelioid angiomyolipoma: A case report and literature review

RATIONALE

Epithelioid angiomyolipoma (EAML) is an extremely rare disease. It commonly occurs in middle-aged females and mainly involves the kidney. Histological and immunohistochemical examination play important roles in differentiating EAML from renal cell carcinoma (RCC) and poor-fat angiomyolipoma (AML).

PATIENT CONCERNS

Here, We report the imaging phenotype, as well as the pathological findings of a case of EAML in a 39-year-old female.

DIAGNOSES

Preoperative noncontrast computed tomography (CT) scan revealed a 6.0 × 5.2 × 7.0 cm soft tissue mass with necrosis, located in the left kidney. On contrast-enhanced CT images, aprogressive enhancement pattern was observed. CT angiography did not show any enlarged vessels or vascular malformation. Abdominal MRI showed a well-circumscribed solid mass with a heterogeneous signal on T1-weighted and T2-weighted images. Ultrasonography of the abdomen demonstrated a hypoechoic mass with abundant blood flow. This patient underwent radical nephrectomy. The pathologic diagnosis was EAML.

INTERVENTIONS

This patient underwent operative resection of the tumor. The resection margins were negative for the neoplastic proliferation and no distant metastases were found. The patient did not receive advanced radiotherapy or chemotherapy.

OUTCOMES

Four months after surgery, the follow-up CT scan did not reveal any local recurrence or distant metastases.

LESSONS

This case adds to the experience with EAML by summarizing its imaging characteristics as well as reviewing the literature. Additionally, we described the state-of-the-art management of the management of this rare tumor.