Vascular tumors of the liver: A brief review

Vascular tumors of the liver are mesenchymal lesions from endothelial cells. They range from common benign lesions such as haemangioma, intermediate tumors like Kaposi sarcoma, and perivascular epithelioid cell tumor to malignant tumors such as hepatic epithelioid hemangioendothelioma and hepatic angiosarcoma in adults. Pediatric vascular tumors of the liver also include benign, locally aggressive, borderline, and malignant masses with haemangiomas being the most common benign tumors and epithelioid hemangioendothelioma being an uncommon pediatric malignancy. The list of these lesions is completed by nodular regenerative hyperplasia, solitary fibrous tumour, and hepatic small vessel neoplasms (HSVN). Some of these tumors are uncommon and rare. This review article aimed to enumerate hepatic vascular tumors along with their imaging, histopathology, molecular findings for accurate diagnosis that can result in better management.

Equine conjunctival haemangiosarcoma: Clinical presentation, management, and outcome of seven cases in the United Kingdom

Background

Only 27 cases of equine conjunctival haemangiosarcoma have been reported in the literature over the past 37 years. Out of these, 22% of cases were lost to follow-up, 52% were euthanized, and 26% survived. A scarcity of cases and information is available for this rarely seen conjunctival tumour.

Aim

To describe the clinical features, management, and outcome of conjunctival hemangiosarcoma in seven horses in the UK.

Methods

Optivet medical records were reviewed for equine cases seen or advised on with a histopathological diagnosis of conjunctival haemangiosarcoma between January 2013 and March 2023. Medical records were accessed for details of signalment, history, management, and follow-up. Histopathology was used to confirm the diagnosis of haemangiosarcoma and assess the surgical margins. Immunohistochemistry was performed in a minority of cases with poorly differentiated solid tumours to support vascular lineage.

Results

Seven eyes from seven horses (five geldings and two mares) with a mean age of 16 years and median of 18 years (range 10-21 years) met the criteria. Serosanguinous discharge was seen in six eyes. All eyes were managed surgically; 4 by exenteration and 3 by conjunctivectomy/keratectomy. Adjunctive cryotherapy was performed in two eyes. Metastatic disease in the ipsilateral parotid salivary gland, confirmed with histopathology, was seen in one horse. Surgical margins were clear in all but one eye. Solar elastosis was noted in five eyes. All horses were healthy at the last follow-up (0.2-5 years, mean 2.9 years, and median 2 years).

Conclusion

Equine conjunctival haemangiosarcoma is rare. Serosanguinous ocular discharge is a common clinical sign. Early surgical excision is highly effective. Solar elastosis is a common histopathological feature, suggesting a role for UV-light in the pathogenesis.

CT angiography and MRI of hand vascular lesions: technical considerations and spectrum of imaging findings

Vascular lesions of the hand are common and are distinct from vascular lesions elsewhere because of the terminal vascular network in this region, the frequent hand exposure to trauma and microtrauma, and the superficial location of the lesions. Vascular lesions in the hand may be secondary to local pathology, a proximal source of emboli, or systemic diseases with vascular compromise. In most cases, ischaemic conditions are investigated with Doppler ultrasonography. However, computed tomography angiography (CTA) or dynamic contrast-enhanced magnetic resonance angiography (MRA) is often necessary for treatment planning. MR imaging is frequently performed with MRA to distinguish between vascular malformations, vascular tumours, and perivascular tumours. Some vascular tumours preferentially affect the hand, such as pyogenic granulomas or spindle cell haemangiomas associated with Maffucci syndrome. Glomus tumours are the most frequent perivascular tumours of the hand. The purpose of this article is to describe the state-of-the-art acquisition protocols and illustrate the different patterns of vascular lesions and perivascular tumours of the hand.

An integrated multidisciplinary team approach to the management of vascular anomalies: challenges and benefits

BACKGROUND

Vascular anomalies comprise highly variable pathophysiology and commonly pose diagnostic and management dilemmas. Consequently, patients often benefit from input from multiple specialists. This study describes the inception of a multidisciplinary team (MDT) Vascular Anomaly Clinic (VAC) in a tertiary paediatric centre, and the subsequent experience managing this complex patient group.

METHODS

This was a retrospective study of paediatric patients (< 18 years old) attending an MDT VAC from its inception in October 2012 until November 2019. Patient demographics, presentation, diagnosis and management were reviewed.

RESULTS

One hundred and thirty-three paediatric patients were seen over 7 years with a median age of 9.8 years. Vascular malformations were the most common diagnosis (88%), with venous malformations predominating (27%). The most common symptoms were pain (46%) and swelling (34%). Patients often required ≥ 2 investigations, with Doppler ultrasound (86%) and magnetic-resonance imaging (61%) being most common. Management included surgery (27%), sclerotherapy (26%), compression garments (23%), analgesia (12%), laser (15%), embolisation (5%) and sirolimus (3%).

CONCLUSIONS

The complex nature of vascular anomalies and high proportion of patients requiring multi-specialty management justified the establishment of an MDT VAC in our centre. Our experience demonstrates the success of an efficient one-stop MDT environment in the management of these challenging conditions.

LEVEL OF EVIDENCE

IV.

TFE3 rearranged epithelioid hemangioendothelioma of bone: A clinicopathological, immunohistochemical and molecular study of two cases

Epithelioid hemangioendothelioma (EHE) is a rare malignant angiocentric vascular neoplasm. Around 90% of classic EHE has a t(1;3)(p36;q25) that results in a WWTR1-CAMTA1 fusion gene, a histologically distinctive subset of EHE has been recently shown to have a t(10;14)(p13;q42)that results in a different fusion gene, YAP1-TFE3. Twenty-one cases of TFE3 Rearranged Epithelioid Hemangioendothelioma have been reported in the literature, and only two cases occurred in bone. In the report, we report additional two cases occurred in the femur and skull and review the related literature.

Recurrent upper limb neuropathies secondary to an epithelioid haemangioendothelioma - A rare mimic of nerve tumours

Epithelioid haemangioendothelioma (EHE) is an uncommon type of vascular tumour with intermediate malignant potential, classified as a sarcoma which occasionally involves neurovascular structures and can mimic nerve sheath tumours. EHE is difficult to distinguish from other nerve sheath tumours based on imaging, including MRI, and biopsy is often required for diagnosis. Diagnosis of EHE from biopsy often requires the use of vascular immunohistochemical stains. We present a case of left upper limb neurovascular bundle EHE presenting with proximal ulnar nerve neuropathy and subsequent median nerve neuropathy and liver, lungs and bone metastases. The tumour had been identified 20 years prior with a similar presentation of upper limb weakness and sensory disturbance, yet following surgical excision it was misdiagnosed as inflammatory fibrous tissue. Treatment with propranolol has resulted in disease stability and surgical debulking resulted in improved upper limb function. The use of beta-adrenergic receptor antagonists in EHE and other sarcomas have been shown to increase T-cell infiltration and decrease immunosuppressive PD-1 expression in neoplastic cells.

Inferior vena cava leiomyosarcoma in an octogenerian

Inferior Vena Cava (IVC) leiomyosarcoma (LM) is a rare malignancy of mesenchymal origin with an incidence of 1/100,000. We present an 82-year-old lady with a past history of open cholecystectomy who presented with a large indeterminate mass on abdominal imaging. Open resection of the mass was performed and histology with immunohistochemical staining revealed leiomyosarcoma. She received adjuvant radiotherapy and remained disease free 4 years after.

The use of rapamycin to treat vascular tumours and malformations: A single-centre experience

Objectives

To assess the safety and efficacy of rapamycin in treating children with vascular tumours and malformations.

Study design

We performed a retrospective review at a large tertiary care paediatric centre to assess the efficacy and safety of using rapamycin to treat vascular tumours and malformations. Response to therapy was defined by patient-reported symptom improvement, radiological reduction in size of lesions, and/or improvement of laboratory parameters.

Results

Forty-two patients (7 with vascular tumours and 35 with vascular malformations) have been treated with rapamycin. Despite 33 of 42 patients being diagnosed in the first year of life, the median age of initiating rapamycin was 11 years. Of the 38 children treated for a minimum of 4 months, 29 (76%) exhibited a clinical response. Twenty-one patients had follow-up imaging studies and of these, 16 (76%) had radiographic decrease in lesion size. Median time to demonstration of response was 49 days. All five children with vascular tumours and all three children with vascular malformations under the age of 4 years showed a clinical response. Response rate was lower for children ≥ 4 years of age (0/2, 0% for vascular tumours; 21/28, 75% for vascular malformations). No patient experienced an infection directly related to rapamycin or discontinued rapamycin due to toxicity.

Conclusions

Rapamycin is safe and efficacious in most children with select vascular tumours and malformations. Young children appear to respond better, suggesting that early initiation of rapamycin should be considered.

Case Series of Pre-Operative Endovascular Embolization of Nasopharyngeal Angiofibroma Using Polyvinyl Alcohol Foam Particle: A Single Centre Experience

BACKGROUND

Nasopharyngeal Angiofibroma is a rare neoplasm in the sphenopalatine foramen. This tumour is histologically benign, but clinically malignant because it can erode the bone and surrounding structures, such as the pterygopalatine fossa, paranasal sinuses, and nasal cavity. It is a highly vascular tumour, sometimes from multiple Feeding arteries, and tends to bleed easily.

CASE PRESENTATION

In these cases, series, we reported four cases of nasopharyngeal angiofibroma in children and one case in an elderly patient. The diagnosis was made by history taking, physical examination and Cerebral MSCT Angiography, as well as Digital Subtraction Angiography (DSA). After identification of the Feeding artery, we performed transarterial embolisation using polyvinyl alcohol (PVA) foam particles.

CONCLUSION

Preoperative embolisation in the highly vascular tumour, such as nasopharyngeal angiofibroma, is very useful to reduce peri-operative complication of surgery. This procedure can reduce blood loss during resection of the tumour and gives better outcomes.

Up-to-date imaging review of paediatric soft tissue vascular masses, focusing on sonography

The purpose of this article is to provide an up-to-date overview on imaging of paediatric vascular soft tissue masses, including both neoplastic and non-neoplastic lesions. We describe the-often challenging-imaging diagnosis-mainly performed by ultrasound (and secondarily by MRI) and differential diagnosis of vascular soft tissue lesions in children. We underline how important it is to determine whether a vascular anomaly has a regional vascular origin, or if there are other entities, ranging from benign to malignant lesions, which have flow-signal or blood degradation products. Even though clinical examination and patient's history are the first and indispensable steps in the initial diagnosis, the role of imaging is crucial, not only to determine whether a mass represents a true tumour/pseudo-tumour, but also to achieve a more correct diagnosis and determine the extension of the tumour/pseudo-tumour and its relation with the nearby anatomic structures.

Cutaneous epithelioid angiomatous nodule: a report of a series including a case with moderate cytologic atypia and immunosuppression

BACKGROUND

Cutaneous epithelioid angiomatous nodule (CEAN) is a very rare and relatively recently recognized vascular proliferation characterized usually by minimal cytological atypia and accompanying mitotic activity. As such, CEAN represents an important diagnostic pitfall, which could lead to significant misdiagnosis and unnecessary treatment.

METHODS

The clinicopathologic findings of 5 cases of CEAN were reviewed including a unique case with typical findings but also moderate cytologic atypia and brisk mitotic activity in a patient on immunosuppression.

RESULTS

The cases were in 3 women and 2 men ranging in age from 18 to 61 years with lesions in the neck (2 cases), upper arm, back and shoulder. In 4 of the cases, the patients did not have any relevant potentially contributory clinical history, and in 1 case the patient was on immunosuppressive treatment. All 5 cases were superficially located within the dermis, well-circumscribed and similarly composed of epithelioid cells displaying minimal (in 4 cases) and moderate (1 case) atypia. The mitotic count ranged from 1 to 3 per 10 high power fields (HPF) in 4 cases and up to 9 per 10 HPF in the immunosuppressed patient. Atypical mitoses were not encountered in any of the cases. Two lesions that were incompletely excised recurred, but none of the patients showed distant metastases.

CONCLUSION

While cytologically alarming, CEAN has a characteristic microscopic appearance and if completely excised follows an indolent course.

Clinical and Pathologic Features of Primary Angiosarcoma of the Kidney

PURPOSE OF REVIEW

Primary angiosarcoma of the kidney is extremely rare; hence, relatively little is known regarding its clinicopathologic features and prognosis. Herein, we review the literature on primary renal angiosarcoma with emphasis on the clinical and pathologic features.

RECENT FINDINGS

Approximately 64 cases have been reported in the literature, and most cases occur in the 6th-7th decade with a strong male predominance. The aetiology is unknown. Patients present with flank pain, haematuria, abdominal mass and weight loss. A considerable number of patients develop metastatic disease at diagnosis or shortly afterwards. Grossly, the tumour comprises ill-defined haemorrhagic spongy masses often with necrosis. Microscopically, the tumour is composed of anastomosing capillary-sized vessels which are lined by malignant endothelial cells. The mainstay of treatment is surgery followed by radiation therapy with or without chemotherapy. Renal angiosarcomas are highly aggressive tumours with dismal outcome, and they must be distinguished from morphologically similar lesions of the kidney.

[Epithelioid hemangioendothelioma of the spine: A case report]. Cancer Radiother. 2017;21:222-225. [PMID: 28478891 DOI: 10.1016/j.canrad.2016.11.006]

with intensity modulation. During the follow-up, a second inoperable spinal location necessitated a new sequence of radiotherapy in modulation of intensity with integrated boost. The patient was alive at 24 months of follow-up without evidence of local relapse or distance. This observation is followed by a discussion with review of the literature on other epithelioid hemangioendothelioma cases treated with radiation.

Extra Nasopharyngeal Angiofibroma Simulating a Mucocele: A New Location for the Rare Entity

Angiofibromas are rare, benign, but locally aggressive vascular tumours which account for 0.05-0.5% of all head and neck neoplasms. The common variant of angiofibromas of head and neck region is Juvenile Nasopharyngeal Angiofibroma (JNAF) which is well published in the literature. Incidence of Extranasopharygeal Angiofibromas (ENAF) is relatively rare and most of the published literature favours maxillary sinus as the most common site. We report a rare clinical entity of ENAF involving the upper lip which is first of its kind in the light of literature review owing to its anatomical location. The present article not only complements a new location of angiofibroma (in the upper lip) but also concretely reinforces the inclusion of angiofibromas in the spectrum of differential diagnosis of soft tissue lesions pertaining to oral cavity.

Composite Hemangioendothelioma: Report of a Rare Case

Composite Hemangioendothelioma (CHE) is a new entity classified under the Heman gioendothelioma (HE) group of tumours. It is an extremely rare vascular neoplasm of low to moderate malignancy. Very few cases have been described in the literature. We herein report a case of CHE arising in a 31-year-old male who presented with a history of painless slow growing swelling on upper back since 1year. Clinically, the surface of firm and mobile swelling of 1.5x1.5cm showed focal ulcerations. The histopathological findings were consistent with the diagnosis of composite hemangioendothelioma. The patient underwent wide local excision and at the end of five months of follow up there were no features of local recurrence or metastasis. To the best of our knowledge, this is the first reported case of CHE from India.

Risk factors and morbidity of infantile haemangioma: preterm birth promotes ulceration

AIM

We identified the characteristics of an infantile haemangioma (IH) that predispose children to complications, interventions and long-term morbidity and examined perinatal risk factors for IH.

METHODS

We studied children with IHs admitted to Helsinki University Hospital's paediatric vascular anomaly clinic in Finland in 2004-2007 and registered perinatal records, IH characteristics, complications and interventions. These patients received a questionnaire on perinatal data and long-term morbidity resulting from IH. We analysed factors related to complications, interventions and morbidity and compared our cohort's perinatal data to the Finnish Medical Birth Register (FMBR) figures.

RESULTS

We approached 185 families, of which 136 replied to the questionnaire. Children with facial, segmental and indeterminate IHs showed more complications, interventions and higher long-term morbidity. Preterm birth predisposed infants to ulceration of IHs, with a 95% confidence interval (CI) of 1.02-5.14 and odds ratio (OR) of 2.29. In addition to earlier known risks, maternal gestational diabetes mellitus rate was higher in our IH cohort than the rate in the FMBR (95% CI 1.39-4.95, OR 2.62).

CONCLUSION

Physicians treating IHs should consider the elevated ulceration risk in preterm infants. The association between gestational diabetes mellitus and child's risk for an IH is uncertain and requires further research.

Capillary Hemangioma of the Fallopian Tube

Neoplastic lesions of the fallopian tube are rarely seen by surgical pathologists. Haemangioma of the fallopian tube is an extremely rare benign neoplasm. A 30-year-old lady with polymenorrhea and dysmenorrhea underwent hysterectomy and bilateral salpingo-oophorectomy. Her left fallopian tube showed a 2mm sized solid nodule in the wall. Histopathological examination revealed a well-defined vascular lesion in the left fallopian tube, consistent with capillary haemangioma. The vascular endothelium was highlighted by CD34 immunostaining. Our literature review has identified 10 cases of cavernous haemangioma of the fallopian tube. To the best of our knowledge, we report the first ever case of capillary haemangioma of the fallopian tube. This is also the smallest detected haemangioma in the fallopian tube.

Giant Placental Chorangioma: A Rare Case Report

Chorangioma is a nontrophoblastic benign vascular tumour of the placenta, arising from the primitive chorionic mesenchyme. The clinical significance is related to the size of the tumours. Small chorangiomas, with a frequency of about 1%, are often asymptomatic. On the contrary, giant chorangiomas, greater than 5 cm in diameter, are rare tumours, with prevalence ranging from 1:9,000 to 1:50,000, and often associated with a variety of pregnancy complications and a poor perinatal outcome. We report a case of 26-year-old female who presented to us at 36 weeks of gestation with pain in the lower abdomen. Ultrasonograpy revealed polyhydramnios and a vascular tumour on the surface of placenta. Proper conservative antenatal management was done and a full term healthy baby was delievered. Histopathological examination of the extracted mass confirmed the diagnosis of chorangioma. The novelty of this report lies in the presence of large nontrophoblastic vascular placental tumour and the absence of any fetal complications. We emphasise the need of regular and timely antenatal management to diagnose and treat the complications of chorangioma at an early stage.

Juvenile Nasopharyngeal Angiofibroma Extending into the Oral Cavity: A Rare Entity

Juvenile nasopharyngeal angiofibroma (JNA) is a rare vascular tumour which is benign but locally aggressive and occurs invariably in young and adolescent males. It seldom involves the oral cavity but has the tendency to invade the adjacent structures. Its characteristic features include slow progression, aggressive growth & an increased rate of persistence and recurrence due to its location in inaccessible areas. In literature, very few cases of JNA have been reported with extension into the oral cavity. Here, a case of JNA with extension into the oral cavity has been discussed who reported to our institute.

Capillary Haemangioma: A Rare Vascular Tumour of the External Auditory Canal

Haemangiomas are relatively common in the head and neck region, but cases in the temporal bone are rare. Hemangioma of the external auditory canal (EAC) is a rare otologic entity. Up till now (till 2013), only 18 cases of hemangioma EAC have been reported in the English literature. It is commonly classified as capillary or cavernous hemangioma. According to the literature, this case represents the fourth patient with capillary hemangioma of the EAC. A 22-year-old male presented to our department with a 3 years history of right-sided aural fullness, mild pain and decreased hearing. There was no history of ear discharge, pulsatile tinnitus, vertigo and local trauma. Oto-microscopic and otoendoscopic examination revealed a smooth surface, reddish pulsatile mass arising from the right postero-superior portion of bony canal wall, which measured about 1 cm in diameter, obstructing 2/3rd of the EAC. The tympanic membrane was not seen. No facial nerve dysfunction was observed. Patient had moderate conductive hearing loss in right ear on audiology. HRCT temporal bone showed soft tissue mass involving the right EAC and middle ear. The lesion was excised via a postaural approach under general anesthesia. The tumor was a reddish, soft mass and measured 1.6 × 1.7 × 2.8 cm. The histopathologic assessment indicated a capillary hemangioma.

The 'pantie' tumour

We present a case of radiation-associated angiosarcoma. A 67-year-old Thai woman was diagnosed with endometrium carcinoma stage IC and was treated with surgery and radiations. Ten years later, she presented with a gradually enlarging mass on the pubic area, in the shape of a pair of panties. Skin biopsy of lesions confirmed angiosarcoma. The diagnosis was radiation-associated angiosarcoma. She was treated with chemotherapy due to unresectable tumour. The chemotherapy was started with paclitaxel 70 mg/m² every 2 weeks. After completing the fifth cycle of paclitaxel, the lesion was markedly decreased in size and the symptoms previously described were also completely resolved.

A glomus tumour arising from the flexor aspect of the forearm: a case report with review of the literature

A 45 year old male patient presented with the complaint of a purplish nodular painful swelling on the flexor aspect of the left forearm of five years duration. A radiological examination of the lesion was not done prior to its excision. A biopsy was done and it was sent for a histopathological examination. The biopsied tissue was single, irregular, firm and globular, it measured 0.5 x 0.5cm in size and it was processed in two halves Its microscopic examination showed a well circumscribed area which comprised of sheets and nodules of monomorphic round cells with slightly vesicular, round nuclei and an acidophilic cytoplasm, amongst which were interspersed numerous blood vessels, many of which were dilated and congested, along with numerous lymphatic channels which were filled with lymph. Immunohistochemistry for SMA, CEA and CD 34 was advised, out of which only SMA turned out to be strongly positive and a final diagnosis of a Glomus tumour was made.

Capillary haemangioma of the middle ear: a rare lesion difficult to evaluate

Haemangiomas are benign vascular tumours relatively common in the head and neck district but very rare in the temporal bone. Depending on its clinical presentation, haemangioma can be mistaken for other vascular masses such as glomus tumour or other lesions of the middle ear. Unfortunately, clinical and radiological evaluation may be insufficient to make a pre-operative diagnosis and the diagnosis is often based upon intra-operative biopsy specimen findings.