Use of immunohistochemical procedures in diagnosing angiosarcoma. Evaluation of 98 cases

Case Report: A Rare Case of Primary Angiosarcoma of the Cervix with a Literature Review

Primary angiosarcomas are a rare type of soft-tissue sarcomas that originate from endothelial cells. These sarcomas can develop in any part of the body and have a poor prognosis. However, they are commonly found in the skin of elderly white men, particularly on the scalp and head region. Primary angiosarcoma of the cervix is exceptionally rare. To date, only two cases of this disease have been reported worldwide. The diagnosis of the disease is difficult microscopically, requiring immunohistochemistry and genetic testing to distinguish. We report a recent case, in which the lesion was preoperatively considered a high-grade endometrial stromal sarcoma. A 35-year-old woman presented with vaginal bleeding and cervical erosions. A high-grade endometrial stromal sarcoma involving the cervix was considered and a modified radical hysterectomy was performed with bilateral salpingo-oophorectomy and sentinel lymph nodes resection. The gene diagnosis performed by fluorescence in situ hybridization for YWHAE translocation fusion was negative excluding a YWHAE-translocated high-grade endometrial stromal sarcoma. A primary angiosarcoma of the cervix was finally diagnosed. Primary angiosarcoma of the cervix is rare, and gynecologic pathologists do not know it well, so it is easy to be wrongly considered. Immunohistochemistry and genetic testing help confirm the diagnosis.

Dual unifocal primary Epithelioid Angiosarcoma: A case report and review of the literature unveiling a rare genre of neoplasia

INTRODUCTION AND IMPORTANCE

Angiosarcomas are an exceedingly rare and malignant form of soft tissue sarcoma that are derived from endothelial cells. Overall, they comprise <1 % of the total number of soft tissue sarcomas. Due to nonspecific and misleading symptoms, the subsequent clinical presentations can easily result in misdiagnosis. This leads to life-threatening complications for patients. Contemplating this tumor as a differential diagnosis during the preoperative phase allows for essential time-sensitive therapeutic interventions to be accomplished.

CASE PRESENTATION

Herein, we present the seldom precedented case of a 66-year-old Middle Eastern male who came to our surgical clinic chiefly complaining of an exacerbation of chronic left hypochondriac pain accompanied by gradual inexplicable abdominal distention. Our diagnostic radiological evaluation demonstrated two isolated abdominal mass formations.

CLINICAL DISCUSSION

Sheer excision of the neoplastic masses with safety margins was successfully executed via open surgery. The stemming histopathological examination through Hematoxylin and Eosin and immunohistochemical staining established the definitive diagnosis of an Epithelioid Angiosarcoma.

CONCLUSION

Epithelioid Angiosarcomas belong to the category of profoundly rare tumors. The available published literature conveys this rarity through the scarcity of epidemiological parameters and studies. It necessitates being borne in mind when facing similar clinical scenarios so that apt therapeutic interventions can be achieved. Structured diagnostic methods, timely surgical interventions and proper techniques, and comprehensive follow-up patient surveillance protocols are, therefore, merited. After thorough review of the published literature, we reckon herewith that ours is the first documented case from our country of an Epithelioid Angiosarcoma.

Hemangiosarcoma in dogs as a potential non-rodent animal model for drug discovery research of angiosarcoma in humans

Since the domestication of dogs 10,000 years ago, they have shared their living environment with humans and have co-evolved. The breeding process that dogs have undergone in only a few centuries has led to a significant accumulation of specific genetic alterations that could induce particular diseases in certain breeds. These canine diseases are similar to what is found in humans with several differences; therefore, comparing such diseases occurring in humans and dogs can help discover novel disease mechanisms, pathways, and causal genetic factors. Human angiosarcoma (AS) and canine hemangiosarcoma (HSA), which are sarcomas originating from endothelium, are examples of diseases shared between humans and dogs. They exhibit similar characteristics and clinical behaviors, although with some critical differences resulting from evolution. In this review, we will describe the similarities and differences in terms of clinical and molecular characteristics between human AS and canine HSA, and discuss how these similarities and differences can be applied to advance the treatment of these diseases.

Current understanding of angiosarcoma: disease biology and evolving treatment

Angiosarcoma is a very rare soft tissue sarcoma that originates from endothelial cells and typically has a poor prognosis. It is most commonly found in elderly white men and can occur anywhere in the body, particularly in the head, neck, and scalp. Patients who have undergone previous radiation treatment or who have chronic lymphedema also face an elevated risk of this condition. Various genetic changes are suspected to contribute to the development of angiosarcoma, and these changes have been identified as potential targets for treatment. For localized disease, wide surgical resection is often the prudent course of action. A multidisciplinary approach, which may include surgery, radiotherapy, systemic chemotherapy, or immunotherapy, is typically the most effective way to achieve favorable outcomes. In this review, we discuss the general understanding of angiosarcoma and its management, with a particular focus on the current evolving treatments for the disease.

Cutaneous vascular tumors: an updated review

Cutaneous vascular tumors constitute a heterogeneous group of entities that share overlapping morphologic and immunohistochemical features, which can be diagnostically challenging for pathologists and dermatopathologists. Our understanding and knowledge of vascular neoplasms have improved over time, resulting in both a refinement of their classification by the International Society for the Study of Vascular Anomalies (ISSVA) and an improvement in the accurate diagnosis and clinical management of vascular neoplasms. This review article aims to summarize the updated clinical, histopathological, and immunohistochemical characteristics of cutaneous vascular tumors, as well as to highlight their associated genetic mutations. Such entities include infantile hemangioma, congenital hemangioma, tufted angioma, spindle cell hemangioma, epithelioid hemangioma, pyogenic granuloma, Kaposiform hemangioendothelioma, retiform hemangioendothelioma, pseudomyogenic hemangioendothelioma, Kaposi sarcoma, angiosarcoma, and epithelioid hemangioendothelioma.

Naturally occurring canine sarcomas: Bridging the gap from mouse models to human patients through cross-disciplinary research partnerships

Fueled by support from the National Cancer Institute's "Cancer Moonshot" program, the past few years have witnessed a renewed interest in the canine spontaneous cancer model as an invaluable resource in translational oncology research. Increasingly, there is awareness that pet dogs with cancer provide an accessible bridge to improving the efficiency of cancer drug discovery and clinical therapeutic development. Canine tumors share many biological, genetic, and histologic features with their human tumor counterparts, and most importantly, retain the complexities of naturally occurring drug resistance, metastasis, and tumor-host immune interactions, all of which are difficult to recapitulate in induced or genetically engineered murine tumor models. The utility of canine models has been particularly apparent in sarcoma research, where the increased incidence of sarcomas in dogs as compared to people has facilitated comparative research resulting in treatment advances benefitting both species. Although there is an increasing awareness of the advantages in using spontaneous canine sarcoma models for research, these models remain underutilized, in part due to a lack of more permanent institutional and cross-institutional infrastructure to support partnerships between veterinary and human clinician-scientists. In this review, we provide an updated overview of historical and current applications of spontaneously occurring canine tumor models in sarcoma research, with particular attention to knowledge gaps, limitations, and growth opportunities within these applications. Furthermore, we propose considerations for working within existing veterinary translational and comparative oncology research infrastructures to maximize the benefit of partnerships between veterinary and human biomedical researchers within and across institutions to improve the utility and application of spontaneous canine sarcomas in translational oncology research.

Magnetic resonance findings of Stewart-Treves Syndrome in primary limb lymphedema compared with pathology: A retrospective single-center study

Background

Stewart-Treves Syndrome in Primary Limb Lymphedema (STS-PLE) is an extremely rare malignant tumor. A retrospective analysis was conducted to elucidate the relationship between magnetic resonance imaging (MRI) findings and signs compared to pathology.

Methods

Seven patients with STS-PLE were enrolled at Beijing Shijitan Hospital, Capital Medical University, from June 2008 to March 2022. All cases were examined by MRI. The surgical specimens were subjected to histopathological and immunohistochemical staining for CD31, CD34, D2-40, and Ki-67.

Results

There were two different types of MRI findings. One was mass shape (STS-PLE I type) in three male patients, and the other was the "trash ice" d sign (STS-PLE II type) observed in four female patients. The average duration of lymphedema (DL) of STS-PLE I type (18 months) was shorter than that of STS-PLE II type (31 months). The prognosis for the STS-PLE I type was worse than that for the STS-PLE II type. Regarding overall survival (OS), the STS-PLE I type (17.3 months) was three times shorter than that of the STS-PLE II type (54.5 months). For STS-PLE I type, the older the STS-PLE onset, the shorter the OS. However, there was no significant correlation in STS-PLE II type. MRI was compared to histological results to provide an explanation for the differences in MR signal changes, especially on T2WI. Against a background of dense tumor cells, the richer the lumen of immature vessels and clefts, the higher the T2WI MRI signal (taking muscle signal as the internal reference standard) and the worse the prognosis, and vice versa. We also found that younger patients with a lower Ki-67 index (<16%) had better OS, especially for the STS-PLE I type. Those with stronger positive expression of CD31 or CD34 had shorter OS. However, the expression of D2-40 was positive in nearly all cases, and seemed not to be associated with prognosis.

Conclusions

In lymphedema, the richer the lumen of immature vessels and clefts based on dense tumor cells, the higher the T2WI signal on the MRI. In adolescent patients, the tumor often showed a "trash ice" sign (STS-PLE II-type) and prognosis was better than for the STS-PLE I type. While in middle-aged and older patients, tumors showed a mass shape (STS-PLE I type). The expression of immunohistochemical indicators (CD31, CD34, and KI-67) correlated with clinical prognosis, especially decreased Ki-67 expression. In this study, we determined it was possible to predict prognosis comparing MRI findings with pathological results.

Differences in potential key genes and pathways between primary and radiation-associated angiosarcoma of the breast

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Angiosarcoma of the breast is a high-grade malignant soft tissue tumor, it can be divided into primary and secondary.

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The differences between primary and secondary angiosarcomas in terms of pathogenesis, clinical behavior, early diagnosis biomarkers, genetic abnormalities, and therapeutic targets remain to be fully elucidated.

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Due to its rarity, most of the current information relating to angiosarcoma is provided by case reports and single-institution retrospective cohort studies and the research with large-scale genomic studies published to date are very limited.

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We identified the differentially expressed genes (DEGs) between primary and second breast angiosarcomas and identified the hub genes as well as predicted novel biomarkers, pathways, and potential therapeutic targets for primary and secondary breast angiosarcomas.

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We aimed to identify novel biomarkers, pathways, and potential therapeutic targets for primary and secondary breast angiosarcomas to facilitate future research.

Background

Angiosarcoma of the breast is a high-grade malignant soft tissue tumor, it can be divided into primary and radiation-associated angiosarcoma(secondary). However, the differences between primary and secondary angiosarcomas in terms of pathogenesis, clinical behavior, early diagnosis biomarkers, genetic abnormalities, and therapeutic targets remain to be fully elucidated. At the same time, due to its rarity, most of current information relating to angiosarcoma is provided by case reports. Therefore, exploring the mechanisms of primary and secondary breast angiosarcoma have important value for the discovery of new biomarkers and research into potential therapeutic targets.

Methods

The differentially expressed genes (DEGs) between 36 cases of primary angiosarcoma and 54 cases of secondary angiosarcoma were screened. Then, the DEGs were used to gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis. Then, a protein-protein interaction (PPI) network was constructed using the STRING database.

Results

A total of 18 DEGs were identified, of which 13 were upregulated and 5 were downregulated in secondary breast angiosarcoma. The GO enrichment analysis showed that the DEGs were most enriched in metabolism, energy pathways, and protein metabolism in biological processes. The enriched signaling pathways of DEGs were the transforming growth factor-β (TGF-β), Wnt, Hippo and PI3K-Akt signaling pathways. Then, the PPI network was conducted and hub genes were identified and they were involved in thyroid hormone, Hippo and other signaling pathways.

Conclusion

This study lay the foundation for the discovery of effective and reliable molecular biomarkers and essential therapeutic targets for these malignancies.

A case of malignant glomus tumor (glomangiosarcoma) of the nasal cavity

Glomus tumors are rare and usually benign. The malignant form (glomangiosarcoma) comprises <1% of all glomus tumors. There are limited reports that describe glomus tumors in the nasal cavity. However, to the best of our knowledge, glomangiosarcoma of the nasal cavity was never reported in humans. We report on the first case of nasal cavity glomangiosarcoma in a 59-year-old male who presented with a bleeding mass in his right nostril. We completely excised the lesion with a 0.7-mm free margin, and the histopathologic examination was consistent with glomangiosarcoma. A 6-month follow-up illustrated no evidence of recurrence or distant metastasis. Although it is rare, glomus tumors should be in the differential diagnosis of nasal cavity tumors. Histopathologic examination is essential for glomangiosarcoma diagnosis. Treatment requires complete excision with free margin, alongside careful clinical and radiological follow-up.

Angiosarcoma secondary to postirradiation and chronic lymphedema: Case reports

INTRODUCTION

Angiosarcoma secondary to post-irradiation and lymphedema is rare, but it is aggressive with a poor prognosis. It is essential to understand these patients' clinical features and distinguish them from benign diseases or other malignant tumors.

PATIENT CONCERNS

Three patients who had radiotherapy for cancer treatment and chronic lymphedema admitted to the hospital with specific skin lesions at upper or lower extremities.

DIAGNOSIS

Excisional biopsies revealed prominent, highly atypical cells with a vasoformative area, composed of atypical, large epithelioid cells with vesicular nuclei, prominent nucleoli, and mitoses. Immunohistochemistry revealed diffuse expression of endothelial cell markers suggestive of angiosarcoma.

INTERVENTIONS

One patient had shoulder disarticulation with wide excision with adjuvant radiotherapy and chemotherapy and other 2 discontinued the treatment.

OUTCOMES

After the treatment, one patient was transferred to rehabilitation department for shoulder disarticulation prosthesis fitting without recurrence sign for 1 year. Two patient refused further treatment and was lost to follow-up.

CONCLUSION

In cases of patients with irratiation and chronic lymphedema, clinical findings suggestive of angiosarcoma, biopsy and imaging studies should be performed as soon as possible.

Radical radiotherapy for localized cutaneous angiosarcoma of the scalp

Angiosarcoma is a rare but highly aggressive sarcoma of mesenchymal origin with a high mortality rate. Due to its rarity, there are very limited reports on the clinical outcomes of angiosarcoma treated with radical radiotherapy. The aim of the present study was to evaluate the efficacy and feasibility of treating patients with radiotherapy for cutaneous angiosarcoma localized to the scalp at The University of Tokyo Hospital (Tokyo, Japan). The present study analyzed 15 consecutive patients treated for cutaneous angiosarcoma of the scalp with radiotherapy between June 2008 and January 2020. All patients were treated with 70 Gy of irradiation split into 35 fractions, focused on the lesion, including 9 patients who received total scalp radiotherapy. The median follow-up period in all patients was 9.7 months. The median overall survival (OS) time was 20.7 months, and the 1-, 2- and 5-year OS rates were 56.2, 28.1 and 9.4%, respectively. At the time of analysis, 13 patients (86.7%) developed recurrence. Among these 13 patients, the first site of recurrence was the scalp as local recurrence in 7 patients (46.7%), parotid recurrence in 2 patients (13%) and distant metastasis in 4 patients (26.7%). No patient exhibited grade 3-5 radiation-induced late toxicity. Therefore, the present study revealed the clinical outcomes of radical radiotherapy for cutaneous angiosarcoma of the scalp.

Angiosarcoma of the Face: A Case Study and Literature Review of Local and Metastatic Angiosarcoma

Angiosarcomas are vascular malignancies with a tendency to spread extensively both locally and systemically. We report a case of cutaneous angiosarcoma of the face in a 53-year-old man that was originally misdiagnosed as an abscess. Initially small, the lesion enlarged over a four-to-six-month period and began to bleed. Two shave biopsies were performed that returned a diagnosis of angiosarcoma. The patient underwent radical resection and lymph node dissection, which revealed positive margins and ten of forty-six positive lymph nodes. The patient was treated with paclitaxel and concurrent radiation therapy (RT). Restaging scans showed a new sclerotic lesion of the T10 vertebra, three hepatic lesions, and an adrenal lesion, all concerning for metastasis. Biopsy of one of the hepatic lesions was consistent with metastatic angiosarcoma. In this review, we discuss the presentation of cutaneous angiosarcoma, the importance of early diagnosis, and the treatment options available for metastatic disease that has failed first-line chemotherapy.

Angiosarcoma in arteriovenous fistula after kidney transplantation

Angiosarcoma is a rare complication of both functioning and nonfunctioning fistulas. It is an aggressive soft tissue sarcoma arising from vascular or lymphatic endothelial cells. We report a case of angiosarcoma from a nonfunctional fistula in a kidney transplantation patient receiving immunosuppressive drugs. The patient had presented with arm pain mimicking a thrombosed arteriovenous fistula.

[Cutaneous angiosarcoma : Radiochemotherapy with liposomal pegylated doxorubicin]

BACKGROUND

Whilst cutaneous angiosarcoma is rare tumour which primarily affects elderly patients, its management presents a significant therapeutic challenge. Indeed, complete surgical excision is often not possible due to the location and the diffuse and extensive nature of the tumour. Therefore, current treatment strategies often include chemo- and/or radiotherapy.

METHODS

We report our experience of combined chemo- and radiotherapy in the clinical course of 6 patients with cutaneous angiosarcoma who were treated between 2007 and 2018.

RESULTS

All patients presented non-resectable tumours and were treated with radiotherapy in combination with the administration of liposomal, pegylated doxrubicin (25 mg/m² every 2 weeks). The mean duration of progression-free survival was 8 months (5-14 months), corresponding to an overall survival of 13 months (13-34 months). A partial response was seen in 4 patients and 1 patient developed progressive disease. One patient abandoned therapy after one administration. Two patients developed severe adverse events which led to termination of therapy after 1.5 months and 7 months, i.e. after 4 and 15 cycles respectively.

DISCUSSION

Combined radio- and chemotherapy with liposomal, pegylated doxorubicin is a useful therapeutic option in the management of cutaneous angiosarcoma. Given the short-lived response rate, new treatment options are urgently required.

Intravascular Papillary Endothelial Hyperplasia of the Maxillary Sinus in Patient with Tricuspid Atresia

Intravascular papillary endothelial hyperplasia (IPEH) is a benign, highly vascularized, endothelial growth that can be mischaracterized as a malignancy. While hundreds of IPEH cases are reported, only four occurred in the maxillary sinus. We present the case of a 28-year-old male who underwent surgical resection of IPEH of the right maxillary sinus. An additional consideration was the patient's condition of univentricular tricuspid atresia which contributed to chronic hypoxemia and polycythemia. After complete resection from the maxillary sinus, post-operational workup determined the lesion to be IPEH. Given the potential for misdiagnosis of IPEH, careful histopathologic evaluation is required in order to avoid improper treatment.

Immunohistochemistry in Dermatopathology and its Relevance in Clinical Practice

Immunohistochemistry (IHC) is an important diagnostic tool in histopathology. Dermatopathology is a rapidly developing subspecialty of histopathology. Although IHC is not widely used in routine dermatopathology practice, its application is gradually increasing. IHC is used to differentiate two conditions with similar morphology, to confirm a diagnosis as well as to assess prognosis. It is more commonly used for neoplastic conditions like melanocytic, hematolymphoid, and spindle cell tumors, although uses can be very wide. Although IHC can aid in diagnosis, sometimes interpretation can be difficult as there may be overlapping findings. Thus, IHC should not be interpreted in isolation and should be done in the context of clinical and histological findings. In this review, we have discussed the uses of various immunohistochemical markers in dermatopathology in the light of current literature and their clinical relevance.

Metastatic Angiosarcoma of Lower Extremity

Angiosarcoma (AS) is an uncommon malignant neoplasm characterized by rapidly proliferating, extensively infiltrating anaplastic cells derived from blood vessels. These are aggressive tumors and tend to recur locally, spread widely with high rate of lymph node and systemic metastases. They are more frequent in skin and soft tissue, head and neck being the most common sites. Here we report a case of metastatic AS affecting lower extremity in an elderly patient on a background of chronic lymphedema due to filariasis (Stewart–Treves syndrome).

Primary Small Intestinal Angiosarcoma: Epidemiology, Diagnosis and Treatment

Angiosarcoma is an aggressive mesenchymal sarcoma of endothelial cell origin with high mortality. Its occurrence in the small intestine is exceedingly low. In addition to the rarity of small intestine angiosarcoma, the nonspecific early clinical symptoms obscure the suspicion of such tumors and thereby delay the diagnosis. In a hope to improve the knowledge of this rare but fatal neoplasm, we report one case of angiosarcoma of duodenum and jejunum in a 73-year-old man. Furthermore, we summarize and analyze the common clinical features, tumor markers, treatment, and survival of previous reported cases of this malignancy. Small bowel angiosarcoma occurs more often in men than women (1.6:1). The median age at diagnosis is 68.5 years. The overall median survival time is 150 days; the median survival time in female (300 days) is longer than that of male patients (120 days). Von Willebrand factor (vWF), CD31, CD34, vimentin, and Ulex europaeus agglutinin 1 appear to be the most useful markers for the diagnosis. The majority of the patients underwent surgical resection alone or surgery with subsequent chemotherapy. The patients treated with surgery plus chemotherapy survive longer than those underwent surgical resection only (median 420 days, n = 7 vs. 96.5 days, n = 26, respectively; P = 0.0275). Further studies of more cases are needed for a better understanding of this rare entity, as well as the development of effective strategies for prevention, early diagnosis, and treatment.

Cutaneous Angiosarcoma: The Possibility of New Treatment Options Especially for Patients with Large Primary Tumor

The most widely accepted treatment for cutaneous angiosarcoma (CAS) is wide local excision and postoperative radiation to decrease the risk of recurrence. Positive surgical margins and large tumors (T2, >5 cm) are known to be associated with poor prognosis. Moreover, T2 tumors are known to be associated with positive surgical margins. According to previous reports, the majority of CAS patients in Japan had T2 tumors, whereas less than half of the patients in the studies from western countries did so. Consequently, the reported 5-year overall survival of Japanese CAS patients without distant metastasis was only 9%, lower than that for stage-IV melanoma. For patients with T2 tumors, management of subclinical metastasis should be considered when planning the initial treatment. Several attempts to control subclinical metastasis have been reported, such as using adjuvant/neoadjuvant chemotherapy in addition to conventional surgery plus radiation. Unfortunately, those attempts did not show any clinical benefit. Besides surgery, new chemotherapeutic approaches for advanced CAS have been introduced in the past couple of decades, such as paclitaxel and docetaxel. We proposed the use of chemoradiotherapy (CRT) using taxanes instead of surgery plus radiation for patients with T2 tumors without distant metastasis and showed a high response ratio with prolonged survival. However, this prolonged survival was seen only in patients who received maintenance chemotherapy after CRT, indicating that continuous chemotherapy is mandatory to control subclinical residual tumors. With the recent development of targeted drugs for cancer, many potential drugs for CAS are now available. Given that CAS expresses a high level of vascular endothelial growth factor (VEGF) receptor, drugs that target VEGF signaling pathways such as anti-VEGF monoclonal antibody and tyrosine kinase inhibitors are also promising, and several successful treatments have been reported. Besides targeted drugs, several new cytotoxic anticancer drugs such as eribulin or trabectedin have also been shown to be effective for advanced sarcoma. However, most of the clinical trials did not include a sufficient number of CAS patients. Therefore, clinical trials focusing only on CAS should be performed to evaluate the effectiveness of these new drugs.

Stewart-Treves syndrome: Magnetic resonance imaging data compared with pathological results from a single center

The aim of the present study was to evaluate the magnetic resonance imaging (MRI) data of patients with Stewart-Treves Syndrome (STS), and to compare them with the corresponding pathological data. A total of 4,289 cases of secondary upper limb lymphedema (LE) from a single center, including 5 female cases of STS who underwent modified-radical post mastectomy, were included in the study. All cases were diagnosed pathologically, and by conventional and contrast-enhanced (ce)MRI scans. A total of 43 tumor nodules (Φ ≥4 mm) were examined. According to the immunohistochemical results, the 5 cases of STS were divided into 2 types; 4 patients exhibited STS type I [angiosarcoma (AS)] and 1 patient exhibited STS type 2 [mixed lymphangiosarcoma (mLAS)]. The MRI signal intensity (SI) of all the nodules was compared with the pathological results. In the T1WI sequences, all nodules showed isointensity compared with normal muscle tissues in the same image. However, in the T2WI sequences, there were the visually recognizable differences in the SI compared with the LE tissues in the two STS types. The SI of mLAS was more markedly decreased compared with that of AS. The SI of mLAS was closer to that of normal muscle tissues compared with the SI of AS. In the ceMRI, the SI of the tumor nodules was markedly increased in the two STS types, compared with non-enhancement imaging. Overall, MRI is a useful tool for the evaluation and diagnosis of STS. A chronic case of LE, in which MRI examination demonstrates nodules within the LE, may suggest a diagnosis of STS.

Immunohistochemical Expression of CD31 (PECAM-1) in Nonendothelial Tumors of Dogs

CD31 immunoreactivity has been reported in human nonendothelial tumors of both epithelial and mesenchymal origin. This study examined CD31 immunoreactivity of 347 formalin-fixed, paraffin-embedded normal, nonneoplastic, and neoplastic canine tissues. CD31 expression was considered positive if at least 10% of the cell population had membranous reactivity. Labeling with the CD31 antibody (clone JC/70A) was observed in 16 samples of normal organs (liver, kidney, lymph node), 6 of 6 specimens of hepatic nodular hyperplasia, 3 of 3 hepatic regenerative nodules, 1 of 4 anal sac carcinomas, 6 of 6 hemangiosarcomas, 18 of 20 hepatocellular carcinomas, 1 of 6 mammary carcinomas, 3 of 5 plasmacytomas, 18 of 53 renal cell carcinomas, and 1 of 5 cutaneous histiocytomas. CD31 expression did not correlate with case outcome in hepatocellular or renal cell carcinomas. Although distinguishing hemangiosarcoma from other neoplasms is typically straightforward, pathologists should be aware of potential cross-reactivity when relying on CD31 immunohistochemistry for diagnosis, particularly in small biopsy samples or when faced with an epithelioid or poorly differentiated vascular neoplasm.

Surgical Treatment of a Giant Primary Cardiac Angiosarcoma

Primary cardiac angiosarcoma is a rare tumor, and surgical resection is often required to relieve its symptoms. A 54-year-old male with a large primary cardiac angiosarcoma is described in this case report. The tumor was located in the right atrium and right ventricle. The bulk was resected with the right coronary artery (RCA), and partial right atrium and partial right ventricle resections were performed during cardiopulmonary bypass. The resected tumor measured 15 x 10 x 8 cm, and the histopathological diagnosis was well differentiated primary cardiac angiosarcoma. In the postoperative period, the patient was followed up for 22 months, and radiotherapy and chemotherapy were performed for metastases. The optimal therapy for cardiac angiosarcoma is still controversial, but combined treatment including surgical resection should be considered.

Angiosarcoma of the Prostate Gland following Brachytherapy for Prostatic Adenocarcinoma

Prostatic adenocarcinoma is the most common cancer in men, but only a handful of cases of prostatic angiosarcoma have been reported in the literature. Prior radiation therapy for prostatic adenocarcinoma has been hypothesized to be a risk factor for angiosarcoma. The increasing practice of prostate cancer screening and the use of radiation therapy for management of prostatic adenocarcinoma will likely lead to more cases of prostatic angiosarcoma. Diagnosis is made by tissue sampling. Optimal management of these aggressive tumors remains to be defined and outcomes are poor with a high 1-year mortality. Primary care physicians and urologists should be aware of this rare entity and refer these patients to specialist centers where they can be managed by a multidisciplinary team. We report a case of angiosarcoma of the prostate gland diagnosed in a male presenting with lower urinary tract symptoms 5 years after brachytherapy for prostate adenocarcinoma.

Diagnostic Immunohistochemistry in Cutaneous Neoplasia: An Update

Immunohistochemistry (IHC) is an important adjunct in the diagnosis of neoplastic skin diseases. In addition to the many established IHC markers currently in use, new markers continue to emerge, although their general acceptance and routine application requires robust validation. Here, we summarize the most well-established and commonly used biomarkers along with an array of newer ones reported in the past several decades that either demonstrate or hold high clinical promise in the field of cutaneous pathology. We also highlight recent applications of novel IHC markers in melanoma diagnosis including genetic mutation status markers [e.g. BRAF (v-raf murine sarcoma viral oncogene homolog B) and NRAS (neuroblastoma RAS viral oncogene homolog)] and an epigenetic alteration marker (e.g. 5-hydroxymethylcytosine). We specifically focus on the role of IHC in the differential diagnosis of cutaneous lesions that fall under the following categories: melanoma, epidermal tumors with an intraepidermal epitheliomatous pattern, spindle cell lesions of the dermis, small round blue cell tumors of the dermis, and cutaneous adnexal tumors. While IHC is a valuable tool in diagnostic dermatopathology, marker selection and interpretation must be highly informed by clinical context and the histologic differential diagnosis. With rapid progress in our understanding of the genetic and epigenetic mechanisms of tumorigenesis, new IHC markers will continue to emerge in the field of diagnostic dermatopathology.

Obscure gastrointestinal bleeding due to multifocal intestinal angiosarcoma

INTRODUCTION

Intestinal angiosarcomas are an extremely rare and aggressive vascular tumors, with a few cases reported in the literature.

PRESENTATION OF CASE

A 45 years-old male arrived to our hospital with intermittent gastrointestinal bleeding presenting melena and weight loss, he has antecedent of pelvic radiotherapy ten years before admission for an unknown pelvic tumor. Emergency surgery was required because of uncontrolled bleeding and hemodynamic instability. Histopathological findings revealed a multifocal high-grade epithelioid angiosarcoma, with cells reactive for CD31, keratins CKAE 1/AE3 and factor VIII.

DISCUSSION

Angiosarcomas are aggressive tumors with a high rate of lymph node metastasis and peripheral organs. The diagnosis is difficult because it present nonspecific clinical presentation, radiological and histopathological findings. There are few reports of angiosarcoma involving the small intestine and the most common presentation are abdominal pain and gastrointestinal bleeding. There is not enough information for intestinal angiosarcoma secondary to radiation therapy, but there have been proposed criteria for diagnosis: no microscopic or clinical evidence of antecedent malignant lesion, angiosarcoma presented in the field of irradiation, long latency period between radiation and angiosarcoma and histological confirmation. We suspect our patient course with a secondary form of angiosarcoma. Therapy for bleeding angiosarcoma consists in control of bleeding and medical management to stabilize the patient. Once accomplished surgical resection is required.

CONCLUSION

We should keep in mind this tumors as a cause of obscure intestinal bleeding in patients with medical history of radiation therapy.

Long-term survival of a patient with scalp angiosarcoma and multiple metastases treated using combination therapy: A case report

Angiosarcoma is a rare and deadly malignancy originating from the vascular endothelial cells. Surgery is the most effective method to cure this disease, but for metastatic angiosarcoma, a chemotherapy-based treatment is the main therapeutic choice. However, there is currently no standard chemotherapy regimen. The current study reports the case of a 66-year-old male with post-operative scalp angiosarcoma recurrence and multiple metastases. The patient obtained a complete response to first-line combination chemotherapy consisting of cyclophosphamide, epirubicin, vincristine and dacarbazine, with a progression-free survival time of eight months. After benefitting from subsequent comprehensive treatment including, cyclophosphamide, epirubicin, vincristine, dacarbazine, docetaxel, cisplatin, gemcitabine and radiotherapy and anti-angiogenic therapy, the patient obtained an overall survival time of 38 months following initial diagnosis.

The utility of ERG, CD31 and CD34 in the cytological diagnosis of angiosarcoma: an analysis of 25 cases

AIMS

Erythroblast transformation specific related gene (ERG), a proto-oncogene member of the erythroblast transformation specific transcription factor family, is a sensitive marker of endothelial differentiation and is expressed in vascular tumours, including angiosarcomas (AS). Immunohistochemistry is necessary for the diagnosis of AS in fine needle aspirates where low cellularity and lack of preserved tissue architecture impedes diagnosis. The aim of this study was to assess the utility of an ERG-enriched immunohistochemistry panel in the cytological diagnosis of AS.

METHODS

25 AS diagnosed on fine needle aspirates were stained for ERG, CD31, CD34, and AE1/AE3. Staining intensity and percentage tumour cell positivity were evaluated. Spearman's correlation was assessed for significant correlations between antibodies.

RESULTS

Sensitivities for ERG, CD31, CD34 and AE1/AE3 were 100%, 100%, 60% and 21%, respectively. Spearman's analysis revealed that ERG and CD31 staining correlated significantly; there was no significant correlation between CD31 and CD34 staining.

CONCLUSIONS

With equal sensitivity to, and strong correlation with CD31, ERG staining is highly suitable for the cytological diagnosis of AS. ERG and CD31 are more sensitive vascular markers than CD34. ERG, a nuclear stain, complements the cytoplasmic/membranous staining of CD31. Used in conjunction with CD31, ERG can corroborate the diagnosis of AS.

Modeling human endothelial cell transformation in vascular neoplasias

Endothelial cell (EC)-derived neoplasias range from benign hemangioma to aggressive metastatic angiosarcoma, which responds poorly to current treatments and has a very high mortality rate. The development of treatments that are more effective for these disorders will be expedited by insight into the processes that promote abnormal proliferation and malignant transformation of human ECs. The study of primary endothelial malignancy has been limited by the rarity of the disease; however, there is potential for carefully characterized EC lines and animal models to play a central role in the discovery, development and testing of molecular targeted therapies for vascular neoplasias. This review describes molecular alterations that have been identified in EC-derived neoplasias, as well as the processes that underpin the immortalization and tumorigenic conversion of ECs. Human EC lines, established through the introduction of defined genetic elements or by culture of primary tumor tissue, are catalogued and discussed in relation to their relevance as models of vascular neoplasia.

Lymphangiosarcoma of the scalp

BACKGROUND

Lymphangiosarcoma is a rare, aggressive malignancy that originates from the endothelial cells lining lymphatic vessels and carries an extremely poor prognosis. Its clinical and histologic features are often indistinguishable from angiosarcoma.

OBJECTIVE

We sought to better characterize the clinical and histologic features of lymphangiosarcoma.

METHODS

Case report and review of the literature.

RESULTS

A number of immunohistochemical markers, including Von Willebrand factor, Ulex europaeus agglutinin 1, CD31, VEGFR-3, D2-40, Prox-1, can be used to help differentiate lymphatic from vascular tissue.

CONCLUSIONS

Recent characterization of several new biologic markers has allowed greater differentiation between these tumors and may provide new therapeutic targets for treatment.

Loss of autocrine endothelial-derived VEGF significantly reduces hemangiosarcoma development in conditional p53-deficient mice

Malignant transformation of the endothelium is rare, and hemangiosarcomas comprise only 1% of all sarcomas. For this reason and due to the lack of appropriate mouse models, the genetic mechanisms of malignant endothelial transformation are poorly understood. Here, we describe a hemangiosarcoma mouse model generated by deleting p53 specifically in the endothelial and hematopoietic lineages. This strategy led to a high incidence of hemangiosarcoma, with an average latency of 25 weeks. To study the in vivo roles of autocrine or endothelial cell autonomous VEGF signaling in the initiation and/or progression of hemangiosarcomas, we genetically deleted autocrine endothelial sources of VEGF in this mouse model. We found that loss of even a single conditional VEGF allele results in substantial rescue from endothelial cell transformation. These findings highlight the important role of threshold levels of autocrine VEGF signaling in endothelial malignancies and suggest a new approach for hemangiosarcoma treatment using targeted autocrine VEGF inhibition.

Ovarian angiosarcoma: a case report and review of the literature

Introduction

Sarcomas of the ovary can either be histologically pure or can represent components of a more complex tumor. Ovarian angiosarcomas are rare, and probably arise from carcinosarcomas, teratomas or the rich ovarian vasculature. To date, only two small case series have been published, one with four cases and the other with seven.

Case presentation

A 41-year-old Saudi woman presented to our gynecological clinic with abnormal vaginal bleeding. The initial clinical diagnosis was left ovarian cyst. The results of the remainder of her abdominopelvic examination were normal. Peri-operatively, the left ovarian mass resembled a hemorrhagic solid tumor. It was sent for frozen sectioning, which revealed it was an undifferentiated neoplasm. The final histopathological examination showed a vascular neoplasm showing vasoformative arborizing channels of variable sizes and shapes lined by atypical endothelial cells with intact capsule. Areas of necrosis were seen, along with fused anastomosing solid vascular area. She was diagnosed as having an angiosarcoma of intermediate grade, International Federation of Gynecology and Obstetrics stage IA.

Conclusions

Patients with ovarian angiosarcomas most commonly present with abdominal pain, however some patients present with distant metastases, often in the lungs. Spread beyond the ovary is present at the time of diagnosis in most reported cases, with disease progression within less than a year after diagnosis. Cases of advanced stage disease behave aggressively and demonstrate poor response to surgery and chemotherapy, with an overall poor prognosis. They have a tendency for local recurrence and metastases, and prognosis is hence poor; the reported five-year survival rate is 10 percent to 35 percent, however, cases confined to the ovary have survived up to nine years.

Clinical management of secondary angiosarcoma after breast conservation therapy

AIM

The aim of this paper is to summarize the treatment outputs of secondary angiosarcoma after breast conservation therapy at St. Eizabeth Cancer Centre, Slovakia.

BACKGROUND

Angiosarcoma of the breast is a rare but very aggressive malignant tumor of the vascular endothelium, characterized by rapidly proliferating and extensively infiltrating growth. Breast angiosarcoma may occur de novo, or as a complication of radiation therapy, or chronic lymphedema secondary to axillary lymph node dissection for mammary carcinoma. Radiotherapy in the treatment of breast cancer is associated with an increased risk of subsequent sarcoma.

MATERIALS AND METHODS

Retrospective study of medical records from the cancer databases was done in order to analyze the secondary breast angiosarcoma. This disease is an iatrogenic condition that warrants close follow-up and judicial use of radiotherapy in breast conserving therapy. Therefore, it is more prevalent in cases treated with radiotherapy, occurring especially in or adjacent to the radiation field. Clinical histories and follow-up data of identified patients after breast conservation therapy of invasive breast cancer were reviewed. In addition, a comprehensive literature review on diagnosis and treatment procedures was done in order to summarize state-of-the-art clinical approach.

RESULTS AND DISCUSSIONS

Three cases of secondary angiosarcoma after breast conservation therapy (BCT) were identified among 4600 patients treated at St. Elizabeth Cancer Institute during previous 16 years (1995-2011). Secondary breast angiosarcoma was diagnosed in a median period of 11 years following primary radiotherapy, median age at the time of diagnosis was 75 years. Surgical treatment consisted of radical mastectomy. The first patient, a 56-year-old woman received neoadjuvant chemotherapy (docetaxel + gemcitabin), second one (75 year) was treated by radiotherapy (TD 26 Gy, 2 Gy per fraction), since chemotherapy was not indicated. The last patient (80 year) got adjuvant chemotherapy (paclitaxel). Average follow up of the patients was 31 months. As of 31 July 2012, our patients were doing well without evidence of recurrent disease after treatment.

CONCLUSIONS

Angiosarcoma remains a difficult management problem with poor loco-regional and distal control. In our study, an overall incidence rate of secondary breast angiosarcoma is 0.065%. Although the prognosis for this disease is poor (typical survival period is 14.5-34 months with a 5-year survival rate of approximately 15%), all the three patients treated at our institute are alive and disease-free at the end of reported period. Finally, it is assumed that the use of breast conserving therapy will increase the incidence of post-irradiation angiosarcoma but the small difference in risk of subsequent sarcoma of the breast cancer patients receiving radiotherapy does not suppress its benefit.

Soft tissue sarcomas--new approaches to diagnosis and classification

The study of sarcoma pathology is a rapidly evolving field. The continued refinement of classic diagnostic techniques in conjunction with the molecular diagnostics has resulted in an abundance of data regarding this diverse and rare group of tumors. We anticipate that cutting edge technology including next generation sequencing will continue to further our understanding of saromagenesis and enable more precise classification and diagnosis of sarcomas in the future.

Expression of angiopoietin-TIE system components in angiosarcoma

Angiosarcoma is an aggressive malignancy of endothelial differentiation. Potential roles of the endothelial angiopoietin-tunica interna endothelial cell kinase (ANGPT-TIE) system in angiosarcoma diagnosis, pathogenesis, prognosis and treatment are undefined. To examine the expression and prognostic significance of angiopoietin-1, angiopoietin-2, TIE1 and TEK (TIE2) proteins in angiosarcoma, we immunohistochemically evaluated clinically annotated human angiosarcoma samples. Correlations of protein expression with overall survival and pathological features were explored. The cohort included 51 patients diagnosed with angiosarcoma at the age of 30-86 years (median 67). The 5-year overall survival was 45% with a median of 26 months. Moderate to strong expression of angiopoietin-1, TIE1 and TEK (TIE2) was identified in the majority of angiosarcomas and moderate to strong expression of angiopoietin-2 was observed in 42% of angiosarcomas. Increased angiopoietin-1 expression correlated with improved survival. Non-significant trends toward longer survival were also observed with increased TIE1 and TEK (TIE2) expression. Increased expression of angiopoietin-2, TIE1 and TEK (TIE2) was associated with vasoformative architecture. No differences in expression of these proteins were observed when patients were segregated by age, gender, presence or absence of metastases at diagnosis, primary tumor location, radiation association or the presence of necrosis. We conclude that components of the ANGPT-TIE system are commonly expressed in angiosarcomas. Reduced expression of these proteins is associated with non-vasoformative and clinically more aggressive lesions.

Angiosarcoma: a tissue microarray study with diagnostic implications

BACKGROUND

Angiosarcoma (AS) is a rare soft tissue sarcoma showing endothelial differentiation as indicated by morphology and expression of CD31 (blood), D2-40 (lymphatic), factor VIII, and CD34 (both). We sought to examine the pattern of immunohistochemical markers of differentiation in AS and correlate these with outcome.

DESIGN

An AS tissue microarray (n = 70 specimens) was constructed for immunohistochemical analysis of CD31, CD34, factor VIII, D2-40, and pan-cytokeratin. Samples on this array were linked to clinicopathologic and outcome data for these patients. Univariate analyses were used to explore disease-specific survival (DSS) factors.

RESULTS

Nine metastatic, 23 localized, and 4 recurrent cases were included. Information about the tissue status (ie, primary or metastasis) was unavailable in 4 patients. Primary sites for the tumor included bone (n = 1), breast parenchyma (n = 11), breast skin (n = 4), heart (n = 5), skin (n = 8), soft tissue (n = 7), and unknown (n = 3). Three patients presented with multifocal disease (primary sites in these patients included breast, skin, and soft tissue). Metastatic sites included lung, bone, lymph nodes, brain, liver, and parotid. Of the 40 cases, 8 (20%) showed a pure or predominant epithelioid histology. Of the biomarkers evaluated by tissue microarray, 92% of tumors expressed at least one endothelial marker (factor VIII = 83%, CD31 = 80%, CD34 = 63%, and D2-40 = 43%) with 88% expressing 2 or more markers. Eighty-eight percent of tumors expressing D2-40 coexpressed CD31, an unusual combination in normal vessels. No endothelial marker clearly associated with disease-specific survival. Fifty percent (4/8) of epithelioid cases and 9% (3/32) of nonepithelioid cases showed keratin expression.

CONCLUSIONS

Unusual patterns and loss of endothelial markers are common in AS, suggesting use of multiple markers in challenging cases and perhaps indicating important biologic characteristics.

Prostate angiosarcoma: is there any association with previous radiation therapy?

What's known on the subject? and What does the study add? Angiosarcomas are histological subtype of sarcomas and rarely involve the prostate gland. Only ten cases of prostate angiosarcoma have been reported in the literature to date. Occurrence of post-irradiation prostate angiosarcoma is rare considering the frequency of radiotherapy used for treatment of prostate adenocarcinoma. We provide a brief review of all cases of prostate angiosarcoma and describe the epidemiology, etiology, clinical presentation, histopathology, prognostic factors and current treatment options for prostate angiosarcoma. For the current review a literature search was carried out using Pubmed, EmBase, and Cochrane databases. All cases of prostate angioscaroma reported to date and observational studies evaluating the radiation associated cancer occurrence were reviewed. Despite the rarity, prostate angiosarcomas display remarkable clinical and pathological heterogeneity, and a treatment challenge. We found the association of prostate angiosarcoma with radiation therapy to be weak based upon the results from observational studies and case reports. Although radiation exposure has been suggested etiology of prostate angiosarcomas, assumption of such association is not supported by the current literature.

Immunohistochemical endothelial markers: a review

A relatively large number of new endothelial markers that can assist in the diagnosis and classification of endothelial and vascular neoplasms have become available over the past few years. The expression of these markers, however, differs considerably among the various tumors. A selection of markers that have potential diagnostic utility or are of current interest among pathologists are reviewed and compared with some of the more traditional markers that have been employed in diagnostic pathology.

High-Grade Breast Epithelioid Angiosarcoma Secondary to Radiotherapy Metastasizing to the Contralateral Lymph Node: Unusual Presentation and Potential Pitfall

BACKGROUND: Breast angiosarcoma is a rare disease occurring as primary tumour or secondary to lymphoedema or radiotherapy. The more frequent use of breast-conserving therapy and radiotherapy for breast carcinoma explains the increasing diagnosis of these tumours. CASE REPORT: We report a case of a breast epithelioid angiosarcoma which metastasized to the contralateral axillary lymph node, occurring 4 years after breast-conserving therapy with axillary lymph node dissection and radiotherapy. The patient presented skin lesions and an axillary lump (clinically diagnosed as carcinoma relapse and lymph node metastasis). Fine-needle cytology on both lesions and a core needle biopsy of the axillary lump were carried out. Differential diagnosis included carcinoma, malignant melanoma, and angiosarcoma. Immunohistochemistry confirmed the diagnosis of angiosarcoma. CONCLUSIONS: Breast angiosarcoma is a challenge - clinically, radiologically and pathologically - and requires a high index of suspicion in susceptible patients.

Malignancies confined to disused arteriovenous fistulae in renal transplant patients: an important differential diagnosis

BACKGROUND

Swelling in an arteriovenous fistula (AVF) is commonly caused by thrombosis, aneurysm and infection. However, due to the increased risk of malignancy after transplantation, this should also be considered.

PATIENTS

We discuss 4 patients with malignancy confined to an AVF after renal transplantation presenting in a 2-year period. Angiosarcoma was diagnosed in 3 patients and the other had post-transplant lymphoproliferative disorder (PTLD). Angiosarcoma behaves aggressively and 2 of our patients died within 6 months of diagnosis. There are 6 previous cases and 5 died within 16 months of diagnosis. PTLD at AVFs has not been documented previously.

CONCLUSION

Malignancy at an AVF is a rare but important differential that can impact significantly on patient morbidity and mortality. Predilection for malignancy at an AVF is not understood. We review the literature and discuss possible aetiologies.

Orbital metastatic angiosarcoma

We report a case of a 48-year-old man who developed metastatic angiosarcoma in her left orbit. A 48-year-old man was first sent to us for a check up of proptosis of the left eye. A left orbital tumor was recognized on orbital computed tomography scans. The open biopsy showed angiosarcoma. Chest X-ray films and thoracic computed tomography showed an abnormal mass in the left inferior lung field. Angiosarcoma was confirmed by transbronchial lung biopsy. In summary, we believed that the orbital tumour was an initial symptom of the metastasis ensuing from the lung angiosarcoma.