Epithelioid angiosarcoma of the calf: a case report of an atypical imaging appearance

Angiosarcoma is an uncommon cause of soft tissue malignancy, accounting for approximately 2% of all soft tissue sarcomas. Of these, epithelioid angiosarcoma represents a morphologic subtype, where the malignant endothelial cells demonstrate a predominantly or exclusively epithelioid appearance. Overall, epithelioid angiosarcoma shares similar imaging characteristics to conventional angiosarcoma including a T1 hypointense to isointense and T2 hyperintense mass, which demonstrates avid enhancement, serpentine feeding vessels, and overlying skin thickening on MRI. The case herein describes a case of epithelioid angiosarcoma in a 65-year-old female presenting with an enlarging calf mass and lower extremity pain. Initial imaging features, particularly on MRI, were highly unusual for angiosarcoma which was thus not strongly considered in the initial differential diagnosis. However, once diagnosis of epithelioid angiosarcoma was confirmed following resection, pathologic correlates were utilized to account for the unusual imaging findings retrospectively. The goal of this study is to not only describe an atypical presentation of an uncommon diagnosis but also attempt to rationalize the unexpected imaging findings with gross and microscopic correlates. Further, the utility of radiology-pathology correlation demonstrated in this case may be useful to others when evaluating similar lesions with unexpected MRI characteristics.

Angiosarcoma of gallbladder, a literature review

BACKGROUND

Angiosarcoma of the gallbladder is a rare diagnostic entity rarely encountered by pathologists and has rarely been reported in literature. This review aimed to examine the clinicopathological features, immunohistochemistry, treatment, and outcomes of gallbladder angiosarcoma.

METHODS

A search of the PubMed, Science Direct and Google Scholar was done with the search terms ("angiosarcoma" OR "angiosarcomas") AND ("gallbladder" OR "gallbladders"). Based on inclusion and exclusion criteria, only case reports could be used for this review.

RESULT

8 case reports were chosen in the end for analysis. The mean age of the patients at presentation was 65 years. It was most frequently observed in males. Abdominal pain and palpable mass were the most commonly reported symptoms. Cholelithiasis and anemia were also reported. On histopathology morphologically epithelioid appearance of angiosarcoma was evident. Cytokeratin (CK) AE1/AE3, Von willebrand factor, Factor VIII antigen, Vimentin, CD31 were positive. Meanwhile, UEA, CD34, CD117, S-100, Keratin, EMA, and CEA showed negative outcome. Surgery was the preferred method of treatment and a mean 10-months follow-up was done.

CONCLUSION

Despite the unavailability of convincing data, histological and immunohistochemical analyses play a major role in the diagnosis of gallbladder angiosarcoma. Nevertheless, more comprehensive clinical studies are required to provide universal guidelines for the treatment and diagnosis of angiosarcoma of the gallbladder.

Primary epithelioid hemangioendotheliomas and angiosarcomas of the pleura: a clinicopathological and immunohistochemical analysis of 13 cases

Thirteen cases of primary epithelioid hemangioendotheliomas (EHE) and epithelioid angiosarcomas (EA) of the pleura are presented. The patients were 7 men and 6 women between the ages of 34 and 65 years (mean: 47 years). The patients presented with non-specific symptoms of cough, dyspnea, and chest pain. Diagnostic imaging revealed the presence of either diffuse pleural thickening or pleural nodules involving the serosal surfaces. Open surgical biopsies were obtained in all cases. Histologically, eight tumors were characterized by the presence of a cellular proliferation composed of medium-sized epithelioid cells embedded in a myxohyaline stroma and a variable spindle cell component. Cellular atypia was mild to moderate and mitotic activity ranged from 1 to 2 per 2 mm2. Immunohistochemical stains for vascular markers, including CAMTA1 were positive, confirming a diagnosis of EHE. Five cases of epithelioid angiosarcomas were characterized by a neoplastic cellular proliferation admixed with areas of necrosis and hemorrhage and characterized by medium-sized epithelioid to spindle-shaped cells with eosinophilic cytoplasm, round to oval nuclei and prominent nucleoli. In addition, marked cytologic atypia and a mitotic activity ranging from 3 to 5 per 2 mm2 were identified. Immunohistochemical studies demonstrated positive staining for vascular markers; however, CAMTA1 was negative. Clinical follow-up obtained in eleven cases showed that all patients had died within 30 months post diagnosis. The current study highlights that even though it may be important to histologically separate EHE from EA for academic purposes, primary pleural origin of these tumors appears to portent an aggressive clinical behavior.

Primary cerebral epithelioid angiosarcoma: a case report

BACKGROUND

Primary cerebral epithelioid angiosarcoma (PCEA) is a rare malignant tumor of the central nervous system. To the best of our knowledge, only three cases have been reported in the English language literature thus far.

CASE PRESENTATION

Here, we report a fourth case in a 73-year-old man admitted for headache. Radiological examination revealed a mass in the right occipital lobe, which was removed by right occipital craniotomy. Histopathological examination revealed epithelioid angiosarcoma. The patient received radiotherapy after resection but survived for only nine months due to recurrence of the tumor and his declining further surgery.

CONCLUSIONS

In this report, we add to the knowledge base on this exceedingly rare tumor, review the small number of relevant cases published previously, and analyze and summarize the clinical and pathological characteristics, treatment options and prognosis of this cancer.

Primary Cardiac Epithelioid Angiosarcoma with Sustained Remission following Surgical Resection: A Case Report

Epithelioid angiosarcoma is an extremely rare subtype of cardiac angiosarcoma that is highly aggressive and associated with poor prognosis. Due to its rare nature, the epidemiology and pathogenesis of this disease are not well-known. Thus, effective diagnostic and treatment modalities are limited. Here, we report a case of a primary epithelioid angiosarcoma in a patient who was treated successfully with surgical resection. A 45-year-old woman who initially presented with chronic systemic symptoms and severe anemia and subsequently developed new-onset atrial fibrillation with rapid ventricular rate was found to have a right-sided cardiac mass with a large pericardial effusion. Several years prior to presentation, she was treated for localized papillary thyroid cancer with Gc protein-derived macrophage-activating factor (Gc-MAF) therapy after declining thyroidectomy. After initial workup of her cardiac mass, including a transthoracic echocardiogram and cardiac MRI, she was transferred to an outside hospital where her mass was surgically resected. She was found to have stage IIIA high-grade epithelioid angiosarcoma involving the inferior vena cava, right atrium, and pericardium. She subsequently had complete resolution of her pericardial effusion and anemia and continues to have good performance status 16 months after her excellent surgical outcome without evidence of recurrence. This unique case contributes to our knowledge of epithelioid cardiac angiosarcoma, of which limited number of cases has been reported. It highlights a favorable outcome following surgical resection of a rare, life-threatening primary cardiac tumor.

Demonstration of Multiple Metastatic Sites by Positron Emission Tomography/Computed Tomography in a Rare Case of Epithelioid Angiosarcoma of the Scalp

Epithelioid angiosarcoma is a rare subtype of angiosarcoma, with metastases occurring in more than 50% of cases and the lung is the most organ which is involved. Whole-body fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) has demonstrated its clinical utility in the early detection of metastases in angiosarcoma. It is helpful to differentiate between benign lesions with low FDG uptake as compared to malignancies with high FDG avidity. Here, we present a rare case of a young man with epithelioid angiosarcoma, in which FDG PET/CT has demonstrated metastatic sites (especially lung metastases).

Epithelioid angiosarcoma of the duodenum: a case report

Background

Angiosarcomas are rare malignant tumors that arise from the endothelium of blood vessels. They occur most commonly in the skin and soft tissue, and less commonly in the breast, liver, bone, and spleen. Gastrointestinal angiosarcomas are extremely rare. Herein, we present a case of duodenal epithelioid angiosarcoma that was treated with surgical resection.

Case presentation

A 68-year-old man presented with a 1-month history of fatigue and hypotension. He visited the outpatient clinic for a routine follow-up. Laboratory examination revealed anemia. Esophagogastroduodenoscopy revealed multiple duodenal lesions with central ulceration. A biopsy showed a sheet-like arrangement of large round and spindle-shaped tumor cells that were positive for CD31. Based on the histological and immunohistochemical staining findings, an epithelioid angiosarcoma was diagnosed. Computed tomography (CT) and positron emission tomography–CT revealed no lymph node metastasis or distant metastasis. Radical subtotal stomach-preserving pancreatoduodenectomy with lymphadenectomy was performed. After removing the specimen, reconstruction was performed using the Child procedure. Grossly, two dark-red polypoid tumors were found in the second portion of the duodenum. Histological evaluation revealed proliferation of malignant round and polygonal cells arranged in sheets and spindle-like cells arranged in bundles. Vasoformative structures were recognized as slit-like spaces containing red blood cells. Immunohistochemical staining demonstrated that the tumor cells were positive for CD31. These findings confirmed the diagnosis of epithelioid angiosarcoma in the duodenum. The patient’s postoperative course was uneventful. The patient was discharged on postoperative day 19 without any complications. At a follow-up examination in the outpatient clinic at postoperative 4 months, no evidence of recurrence was detected.

Conclusion

The present report describes a case of duodenal epithelioid angiosarcoma. Duodenal angiosarcomas may cause anemia and gastrointestinal bleeding. Because angiosarcomas sometimes show epithelioid cytomorphology, immunohistochemical analysis is useful for confirming the diagnosis.

Primary epithelioid angiosarcoma originating from the mandibular gingiva: a case report of an extremely rare oral lesion

Background

Angiosarcoma occurs very rarely in the oral cavity, and the epithelioid type is even rarer. Here, we report a rare case involving an elderly man with a primary epithelioid angiosarcoma that originated from the mandibular gingiva and resembled a dentigerous cyst on radiographs.

Case presentation

A 66-year-old Japanese man visited our hospital with a chief complaint of gingival swelling in right mandibular third molar region. A panoramic radiograph showed bone resorption around the crown of right mandibular third molar, which was impacted. Incisional biopsy confirmed a diagnosis of epithelioid angiosarcoma. The lesion exhibited aggressive proliferation after biopsy resulting in uncontrolled bleeding and difficulty in closing the mouth. Mandibular segmental resection including the tumor was performed without reconstruction. Because of the aggressive preoperative course of the tumor, the patient received adjuvant chemotherapy. There were no signs of recurrence during a 2-year follow-up period.

Conclusions

A review of the literature yielded only four reported cases of epithelioid angiosarcoma in the jaw region, with the lesions occurring in the maxilla in three cases. To our knowledge, this is the second case of primary epithelioid angiosarcoma in the mandible.

Multifocal gastrointestinal epithelioid angiosarcomas diagnosed by endoscopic mucosal resection: A case report

BACKGROUND

Epithelioid angiosarcoma is a vascular neoplasm that is among the most aggressive subtypes of sarcomas. Its involvement in the gastrointestinal tract is rare. We here report a case of multifocal gastrointestinal epithelioid angiosarcomas presenting with gastrointestinal bleeding.

CASE SUMMARY

A 77-year-old woman was admitted because of melena and dizziness for three months. Gastroscopy and colonoscopy were performed, revealing a centrally ulcerated hemorrhagic polypoid lesion in the gastric body and multiple polypoid lesions with blood clots and hemorrhagic tendency in the colon. Histopathological examination of routine endoscopic biopsy samples showed inflammation in the gastric mucosa and tubular adenomas in the colon. The polypoid lesions were removed by endoscopic mucosal resection. Immunohistochemistry suggested a final diagnosis of epithelioid angiosarcomas. The patient refused chemotherapy and died after three months.

CONCLUSION

Epithelioid angiosarcomas are characterized by highly vascular nature and tendency to cause gastrointestinal bleeding. Efforts to obtain histological findings using endoscopic mucosal resection are of great importance.

Epithelioid angiosarcoma of the chest wall with atypical morphology: report of one case

Epithelioid angiosarcoma is a rare soft-tissue sarcoma, which originates from endothelial cells. Herein, we report a case of an uncommon morphology of epithelioid angiosarcoma in the chest wall with diffuse hemorrhage and necrosis. The 52-years-old man suffered from severe chest pain, hemoptysis, and fever. Contrast-enhanced chest CT scans showed a large space-occupying lesion in the right chest cavity. A right thoracotomy was performed for definite diagnosis and surgical resection. Microscopically, the specimen demonstrated extensive hemorrhage and necrosis, while few visible tumor cells were noted. These cells were round to polygonal and even had an epithelioid appearance, with abundant eosinophilic cytoplasm. Vesicular nuclei and prominent nucleoli were observed. Immunohistochemistry indicated that these abnormal cells were positive for cytokeratin, vimentin, CD31, ERG, and FLI-1. They were negative for D2-40, CK5/6, calretinin, WT-1, CK7, TTF-1, napsin A, and CEA. Moreover, Ki-67 with MIB-1 was about 40%. On the whole, histology and immunohistochemistry supported the diagnosis of epithelioid angiosarcoma.

"Man in Istanbul" Lesions of the Urinary Tract (Known Entities in an Unusual Context): Melanoma, Carcinoid Tumors, Epithelioid Angiosarcoma

Certain tumors are more difficult to recognize when they present in an unusual location. Within the urinary tract, primary melanomas, carcinoid tumors, or epithelioid angiosarcoma could present diagnostic challenges due to their infrequent occurrence. This article emphasizes the clinical and histopathologic features of these entities and their differential diagnoses including the immunophenotype and their prognoses.

Epithelioid angiosarcoma: A rare cause of pericarditis and pleural effusion

Angiosarcomas are rare cancers accounting for less than 2% of all soft tissue sarcomas. We report the case of an unusual presentation of pleural epithelioid angiosarcoma in a patient with constrictive pericarditis and recurrent pleural effusion. A 62 year old smoker presented with acute chest pain. ECG showed diffuse elevation of ST segments in the precordial leads. After extensive evaluation, he was diagnosed with viral pericarditis and treated with colchicine. Two weeks later the patient presented to the emergency department with a large right pleural effusion. Evaluation of the pleural fluid obtained from a thoracentesis revealed an exudative effusion with negative microbial studies and no evidence of malignant cells. His pleural effusion re-accumulated rapidly, requiring repeated thoracenteses over several weeks. Medical thoracoscopy was performed and pleural biopsy revealed primary pleural epithelioid angiosarcoma. Staging PET scan revealed malignant enhancement of right pleura, pericardium, right iliac bone and right shoulder. He died suddenly within 6 weeks of diagnosis, prior to initiating palliative chemotherapy. Pleural angiosarcoma should be considered in the differential diagnosis of recurrent pleural effusions of unknown etiology. Negative cytology does not rule out the diagnosis; excisional biopsy is required. Reported risk factors include asbestos exposure, prior chest radiation, active smoking and history of complicated pleural tuberculosis. Pleural epithelioid angiosarcomas carry a very poor prognosis, with the majority of patients dying within months of diagnosis.

Treatment of Epithelioid angiosarcoma with Topical ALA-PDT in the course of surgery

BACKGROUND

Epithelioid angiosarcoma is a high grade malignancy sarcoma of soft tissue, which is hard to diagnose and completely excise without causing functional and cosmetic problems. Moreover, the high rate of recurrence is hard to salvage. Photodynamic therapy is a novel treatment protocol which can selectively destroy tumor cell with good functional and cosmetic outcomes.

METHODS

This is a case about a 81 years old patient with Epithelioid angiosarcoma in the right medial angle of eye, which received surgery and ALA photodynamic therapy.

RESULTS

There is no recurrence in one year after treatment of surgery and photodynamic therapy in the course of surgery.

CONCLUSIONS

Excision combined with photodynamic therapy during operation is a promising strategy towards tumors which are hard to resect thoroughly and have a high risk of recurrence.

Epithelioid angiosarcoma of the thyroid gland without distant metastases at diagnosis: report of six cases with a long follow-up

We present six cases of epithelioid angiosarcomas (EAS) of the thyroid gland without distant metastases at diagnosis and with a long follow-up. We retrieved the six consecutive cases of thyroid EAS between 2005 and 2011. Gender was equally represented; median age was 60 years (range 53-68). One case was post-irradiation and another post-exposure to vinyl chloride. Median diameter was 6 cm (range 5-13). Regional nodal metastases were present at onset in two cases. All the cases expressed CD31 in a membranous pattern. CD34 was always negative. All the patients underwent complete surgical resection. Neoadjuvant chemotherapy was applied in one case and adjuvant chemotherapy in four cases with adjuvant radiation therapy in one case. Follow-up until June 2015 was available in five cases. Median follow-up was 59 months (range 9-82). Three patients relapsed. Two patients (the post-irradiation and post vinyl chloride exposure cases) died of disease after 36 and 9 months, after a local relapse soon followed by distant metastases. Three patients are alive and well after 59, 70, and 82 months, including a patient with a relapse treated with neoadjuvant chemotherapy and surgery. In conclusion, thyroid EAS without distant metastases at diagnosis are very rare tumors. They all expressed CD31, while CD34 was always negative. Distant metastases developed together with local relapse, rapidly followed by death. Inadequate surgery contributed to poor outcome. Cases with previous exposure to irradiation and vinyl chloride showed a particularly poor behavior.

Diagnostically Challenging Epithelioid Vascular Tumors

The diagnosis of vascular tumors is a challenging area in soft tissue pathology. Epithelioid vascular tumors pose a particular challenge. Due to the epithelioid morphology of the tumor cells, they can be misdiagnosed as a variety of other entities, including metastatic carcinoma or epithelioid sarcoma. Furthermore, it can be difficult to distinguish between different epithelioid vascular tumors. This review focuses on vascular tumors characterized by epithelioid endothelial cells, including epithelioid hemangioma, cutaneous epithelioid angiomatous nodule, epithelioid hemangioendothelioma, epithelioid sarcomalike hemangioendothelioma/pseudomyogenic hemangioendothelioma, and epithelioid angiosarcoma.

Epithelioid angiosarcoma: a clinicopathological study of 16 Chinese cases

AIMS

To review retrospectively 16 cases of epithelioid angiosarcomas (EAs) with emphasis on their clinical and pathological characteristics, treatment and possible prognostic factors.

METHODS AND RESULTS

All eligible cases were searched and acquired from archives of the pathology departments of two hospitals in Shanghai, The Fifth People's Hospital of Shanghai, Fudan University, and the Shanghai Cancer Center, Fudan University, China. The patients ranged in age from 19 to 77 years, and 5 patients were below 50 years of age. Microscopically, the tumors were mostly composed of large, round or polygonal epithelioid cells that were predominantly arranged in solid sheets or nests. The tumor cells had basophilic or eosinophilic cytoplasm, vesicular nuclei, and prominent nucleoli. Mitotic figures including abnormal mitoses were frequently encountered. In all 16 cases in our series, immunohistochemical studies showed positivity for CD31, and partial positivity for Fli-1, CD34 and factor VIII-related antigen. Of the 14 patients available for follow-up, 3 patients were alive with disease, 9 patients died as a result of the tumor, 1 died of local hemorrhage, and one died of unknown etiology. The median survival was 17.1 months.

CONCLUSIONS

EA is highly aggressive and carries a very poor prognosis. Therefore, the clinical recognition and correct diagnosis of EA are essential.

Epithelioid angiosarcoma of the ilium: a case report

Bone epithelioid angiosarcoma (EA) is rare and characterized by large, mildly to moderately pleomorphic epithelioid cells, with abundant eosinophilic cytoplasm, vesicular nuclei, and prominent nucleoli. The tumors may arise in various locations in bone and the patients may present with unifocal or multifocal osseous disease. We present a unifocal lesion case of EA of the ilium in a 62-year-old woman. A needle biopsy of the ilium was performed and first diagnosed poorly differentiated adenocarcinoma based on CKpan and CK18 immunopositivity. The tumor was treated initially with curettage followed by chemotherapy. The final diagnosis on the surgical specimen was epithelioid angiosarcoma.