Primary malignant hepatic epithelioid hemangioendothelioma: a comprehensive review of the literature with emphasis on the surgical therapy

Hepatic epithelioid hemangioendothelioma managed with minimally invasive surgery: A case report

BACKGROUND

Hepatic epithelioid hemangioendothelioma (HEHE) is a rare malignant vascular liver tumor diagnosed by histopathological evaluation. Standardized treatment is challenging because of its rarity; hepatectomy is preferred for solitary lesions and multiple transplantations. There is no consensus on the optimal treatment for HEHE; however, surgical excision is often considered effective. This report presents a case of initially suspected cholangiocarcinoma or renal cell carcinoma (RCC) metastasis, which was later confirmed as HEHE, with no recurrence during follow-up.

CASE SUMMARY

A 52-year-old man with a history of left nephrectomy for RCC presented with an incidentally detected liver mass and nonspecific abdominal discomfort. Imaging revealed a 3-cm centripetal enhancing lesion in the right hepatic dome with indeterminate malignant potential. The patient underwent a laparoscopic right anterior sectionectomy and remained recurrence-free without complications during the 3-year follow-up period.

CONCLUSION

Managing HEHE is challenging. Accurate diagnosis and surgical options, such as resection or transplantation, are essential with tailored multidisciplinary follow-up. The authors have read the CARE Checklist (2016) and the manuscript was prepared and revised according to the CARE Checklist (2016).

Liver transplantation as a treatment for cancer: comprehensive review

BACKGROUND

Liver transplantation for cancer indications has gained momentum in recent years. This review is intended to optimize the care setting of liver transplant candidates by highlighting current indications, technical aspects and barriers with available solutions to facilitate the guidance of available strategies for healthcare professionals in specialized centres.

METHODS

A review of the most recent relevant literature was conducted for all the cancer indications of liver transplantation including colorectal cancer liver metastases, hilar cholangiocarcinoma, intrahepatic cholangiocarcinoma, neuroendocrine tumours, hepatocellular carcinoma and hepatic epitheloid haemangioendothelioma.

RESULTS

Transplant benefit from the best available evidence, including SECA I, SECA II, TRANSMET studies for colorectal liver metastases, various preoperative protocols for cholangiocarcinoma patients, standard, extended selection criteria for hepatocellular carcinoma and neuroendocrine tumours, are discussed. Innovative approaches to deal with organ shortages, including machine-perfused deceased grafts, living donor liver transplantation and RAPID procedures, are also explored.

CONCLUSION

Cancer indications for liver transplantation are here to stay, and the selection criteria among all cancer groups are likely to evolve further with improved prognostication of tumour biology using adjuncts such as radiomics, cancer genomics, and circulating DNA and RNA status. International prospective registry-based studies could overcome the limitations of smaller patient cohorts and lack of level 1 evidence.

Role of Liver Transplant in Primary and Secondary Liver Malignancies

Hepatocellular carcinoma (HCC) and cholangiocarcinoma are the primary hepatic malignancies with established pathways to transplantation and model for end-stage liver disease (MELD) exception points. Other tumors managed with liver transplantation (LT) include hepatic epithelioid hemangioendothelioma and fibrolamellar HCC. LT for metastatic neuroendocrine tumor has been established with patient selection criteria and a path to MELD exception points. Additionally, recent data on LT for patients with unresectable hepatic colorectal metastases demonstrate increasingly encouraging initial results.

A Rare Case of Solitary Primary and Recurrent Hepatic Epithelioid Hemangioendothelioma Undergoing Repeat Liver Resections

INTRODUCTION

Hepatic epithelioid hemangioendothelioma (HEHE) is a rare vascular tumor. Treatment strategy remains controversial because of its rarity. Liver resection is considered as the optimal treatment for solitary HEHE, while a small subset of patients have a solitary tumor. We present the rare case of a patient with solitary primary HEHE who experienced solitary recurrence following liver resection and underwent subsequent liver resection.

CASE PRESENTATION

A 55-year-old man was referred to our department with a suspected intrahepatic cholangiocarcinoma, based on imaging findings. Anatomic liver resection of segment 8 was performed, and the tumor was confirmed to be HEHE from the pathological findings. Fifteen months later, a solitary recurrence developed in segment 7. After a 5-month observation period, partial liver resection was performed, and the tumor was consistent with recurrent HEHE. The postoperative course was uneventful, and the patient remained recurrence-free for 9 months following the procedure.

CONCLUSIONS

Repeat liver resection may be a feasible treatment option for patients with solitary recurrent HEHE.

Expanding Indications in Transplant Oncology

Liver transplantation is aptly described as the only curative treatment for cirrhosis and cirrhosis with co-morbid hepatocellular carcinoma (HCC). Its utility in the management of various other primary and secondary liver cancers is gaining traction rapidly, with more thorough assessments on broader populations continuing to emerge. Most prominently, this includes colorectal cancer liver metastasis (CRLM), cholangiocarcinoma (CCA), neuroendocrine tumors (NETs), and more. Furthermore, despite being a well described treatment for HCC for many years, growing evidence supports a change in oncological strategy for HCC, with broadened selection criteria and more advanced systemic and locoregional therapies available. Our review aims to describe the evidence supporting the expansion of indications and selection criteria for liver transplantation in various oncologic indications of primary and secondary liver tumors.

CAMTA1-immunonegative epithelioid hemangioendotheliomas of the liver: a clinicopathological and molecular analysis of seven cases

Background

Epithelioid hemangioendothelioma (EHE) is a rare malignant vascular tumor. Most EHEs (>90%) cases harbor WWTR1::CAMTA1 fusion gene, and CAMTA1 immunohistochemistry (IHC) is a highly sensitive and specific tool for EHE diagnosis. However, there exist CAMTA1-immunonegative cases, the majority of which harbor YAP1::TFE3 fusion, with a few cases having more rare fusions. Liver is one of the most common sites of EHE, where the CAMTA1 subtype dominates, and the other variants are extremely rare. Hence, we focused on the hepatic CAMTA1-immunonegative EHEs to analyze the clinicopathological and molecular features of these peculiar cases.

Methods

The SNOMED search of the hospital pathology files between January 2016 to November 2023 identified 57 hepatic EHEs and 7 cases were CAMTA1-immunonegative. Fluorescence in situ hybridization (FISH), next generation sequencing (NGS) and Sanger sequencing were performed to identify the genetic change of the 7 cases.

Results

This series included 3 females and 4 males, aged from 33 to 64 years. All the 7 cases were negative for CAMTA1 IHC. Four cases were positive for TFE3 IHC and exhibited YAP1::TFE3 fusion. Another 3 cases were also negative for TFE3, while WWTR1::CAMTA1 fusion were detected by NGS in 1 case and demonstrated by FISH in all the 3 cases. Morphologically, among the 4 TFE3 rearrangement cases, 3 cases showed the TFE3-sutype morphologic appearance, while the histology of 1 case was similar to that of CAMTA1- subtype. In the 3 CAMTA1-rearranged lesions, 2 cases had classic EHE morphology, and 1 case exhibited atypical histology, with higher atypia and well-formed vessels. Surgical resection was performed on five cases and two cases were biopsied and received chemotherapy. Follow-up information was available in 6 patients (median 46 months), including 4 patients were alive without disease and 2 patients were alive with disease.

Conclusion

Our study reported 7 CAMTA1-immunonegative hepatic EHEs and most of them were TFE3-rearranged EHEs with morphology variation. Moreover, there does exist the CAMTA1-immunonegative but CAMTA1-rearranged EHE cases. Therefore, the diagnosis of EHE should be based on morphology, combined with CAMTA1 and TFE3 IHC, and if necessary, supplemented by genetic analysis including FISH and NGS, to establish correct diagnosis.

Mesenchymal Tumors of the Liver: An Update Review

Hepatic mesenchymal tumors (HMTs) are non-epithelial benign and malignant tumors with or without specific mesenchymal cell differentiation. They are relatively uncommon. Except for mesenchymal hamartoma, calcified nested stromal-epithelial tumor, and embryonal sarcoma, most mesenchymal lesions are not specific to the liver. Pathologists face challenges in diagnosing HMTs due to their diverse morphologies and phenotypic variations. Accurate diagnosis is critical for directing appropriate patient care and predicting outcomes. This review focuses on mesenchymal tumors with a relative predilection for the liver, including vascular and non-vascular mesenchymal neoplasms. It provides a thorough and up-to-date overview, concentrating on clinical and pathological features, differential diagnosis, and diagnostic approaches.

Outcomes of Liver Transplant for Hepatic Epithelioid Hemangioendothelioma

INTRODUCTION

Hepatic epithelioid hemangioendothelioma (HEH) is a rare indication of liver transplant with limited evidence.

METHODS

Adult recipients undergoing first-time liver-only transplant from 2002 to 2021 in the United States were identified using the UNOS/OPTN database. We compared post-transplant outcomes of recipients receiving liver transplant for HEH versus other diagnoses. Survival was visualized using Kaplan-Meier curves and compared using log-rank test and multivariable Cox regression. Propensity score matching for recipient age, sex, and MELD was performed, with baseline characteristics and survival compared between groups.

RESULTS

Of 111 558 liver transplant recipients identified, 121 (0.1%) underwent transplant for HEH. Donors to HEH recipients were more often living donors. Recipients with HEH were younger, more likely to be female, and had lower BMI. Recipients with HEH had higher albumin, lower bilirubin, lower INR, and lower serum creatinine, as well as lower MELD scores and rates of ascites and encephalopathy. Similar post-transplant survival was observed for recipients with HEH (16.6 [lower 95% CI 14.9] years) and non-HEH diagnoses (13.8 [95% CI 13.6-13.9] years, log-rank p = 0.28), even after adjusting for baseline donor and recipient characteristics (aHR 1.28 [95% CI 0.94-1.74], p = 0.12). The propensity score matched cohort also had similar post-LT survival.

CONCLUSIONS

This national study represents the largest known report on liver transplant for HEH. The survival of recipients with HEH was similar to other etiologies, supporting the use of liver transplantation (LT) in advanced HEH.

Discontinuous peripheral enhancement of focal liver lesions on CT and MRI: outside the box of typical cavernous hemangioma

The discontinuous peripheral enhancement is a pattern of enhancement usually attributed to typical cavernous hemangioma, that is the most common benign solid lesion of the liver. The discontinuous peripheral enhancement, however, may be encountered in many other benign and malignant focal liver lesions as an atypical presentation or evolution, and hemangiomas with discontinuous peripheral hyperenhancement on hepatic arterial phase may not always have the typical post-contrast pattern on portal venous and delayed phases. Therefore, abdominal radiologists may be challenged in their practice by lesions with discontinuous peripheral enhancement. This pictorial essay aims to review the spectrum of benign and malignant focal liver lesions that may show discontinuous peripheral enhancement. A particular point of interest is the diagnostic tree pathway that may guide the radiologists in the differential diagnosis.

Hepatic epithelioid hemangioendothelioma with TFE3 rearrangement: a case report and literature review

Epithelioid hemangioendothelioma (EHE) is a rare low-grade malignant tumor of vascular origin. It may be confusing as its manifestations of multifocal lesions on imaging and epithelial histomorphology in pathology. EHE is easy to be mistaken for a metastatic tumor by radiologists and clinicians. Correct diagnosis and therapy are important owing to the variable clinical course and special treatment. EHEs harbor major CAMTA1 rearrangement and <5% TFE3 rearrangement. Meanwhile, EHE with TFE3 rearrangement has distinctive morphology features. Currently, there are only two cases of hepatic EHE with TFE3 rearrangement reported, we present another case here that occurred in a 34-year-old female. Both the clinician and radiologist provisionally considered it as a metastatic tumor. The tumor cells have mild atypia but infiltrative growth patterns like benign vascular tumors. Our case is unique mainly in that the absence of its characteristic well-defined vessels, and the presence of unreported morphology of intraluminal papillary proliferation of tombstone or hobnail endothelial cells. The final diagnosis of EHE with TFE3 rearrangement was made by combining morphological, immunohistochemical, and molecular test results. The patient did not receive any treatment according to her condition and no change was detected in the mass's size and number on CT images during 3.5 years of follow-up.

Clinical, Histopathological, and Immunophenotypic Spectrum of Hepatic Epithelioid Hemangioendothelioma: Eight Years' Data of a Tertiary Care Center from North India

BACKGROUND/AIMS

Epithelioid hemangioendothelioma (EHE) is an uncommon vascular tumor that commonly affects the liver. Hepatic EHE (HEHE) presents with variable clinical and histopathological features. We describe detailed clinico-histopathological features, differential diagnosis, and treatment outcomes of the cases of HEHE diagnosed in our center.

METHODS

All cases of HEHE diagnosed in our institute in the last eight years (2016-2023) were reviewed (n = 8; 11 samples) (total 36 cases of EHE; 22.2%). The clinical features, radiology, histopathology, immunophenotype, molecular features, and treatment outcomes of all cases were evaluated.

RESULTS

The median age of presentation was 49.5 years with a female: male ratio of 7:1. Abdominal pain was the commonest presentation. Approximately two-thirds of the patients had multifocal lesions. Histopathology showed purely epithelioid, predominantly epithelioid, and predominantly spindle-cell morphology in 50%, 25%, and 25%, respectively. All cases showed typical myxohyaline/fibrous stroma and organized thrombi of the portal/central veins. CD31 was the most commonly used immunostain with positivity in all cases. CAMTA1 break-apart fluorescence in situ hybridization was positive in 75% of cases, while none showed TFE3 immunopositivity. Chemotherapy was the most commonly employed therapy (n = 5) followed by surgery (n = 2). The median duration of follow-up was 26 months. Five patients were alive with disease (two patients ≥3 years), one patient died of sudden cardiac death, and two patients were lost to follow-up. Two patients developed metastatic disease at follow-up.

CONCLUSIONS

We describe the clinico-histopathological features and differential diagnosis of HEHE. This appears to be the largest case series of HEHE from India.

Diagnostic approach to hepatic vascular lesions: a paediatric perspective

The pathological evaluation of hepatic vascular lesions in children requires special consideration. Inconsistent terminology, rarity of pathology specimens and overlapping pathological features between various lesions may pose a serious diagnostic challenge. In this review, we highlight the importance of using the International Society for the Study of Vascular Anomalies (ISSVA) classification scheme to characterise these lesions. Selected entities are discussed, including hepatic vascular tumours exclusively seen in the paediatric age group, hepatic infantile haemangioma and hepatic congenital haemangioma. Vascular malformations, with emphasis on their syndromic associations (venous malformation in blue rubber bleb naevus syndrome) and complications (hepatocellular nodules in Abernethy malformation) are also covered.

Primary hepatic epithelioid hemangioendothelioma: a case report

Epithelioid hemangioendothelioma is a low-grade malignant tumor of vascular origin. The rarity of hepatic epithelioid hemangioendothelioma (HEHE) makes the diagnosis and treatment of this entity challenging. We report a case of a 69-year-old female patient who suffered from HEHE and complained of abdominal distension pain with dizziness and appetite loss for more than half a month. Enhanced computed tomography of the upper abdomen indicated multiple space-occupying lesions in the liver. The pathological results of color ultrasound puncture suggested HEHE. We performed transcatheter arterial chemoembolization and relevant examinations according to the patient's condition and their choice. We followed the patient for 5 years and found that she developed recurrent intrahepatic metastasis of the tumor. Computed tomography was performed again after 3 months of treatment with anlotinib and the tumor did not show any progression. HEHE is a relatively rare hepatic malignant tumor derived from vascular endothelial cells, with a low incidence, atypical clinical manifestations, and a difficult diagnosis that can only be confirmed with pathological results. Currently, appropriate treatment methods should be selected according to the specific conditions of the patient.

The challenges of hepatic epithelioid hemangioendothelioma: the diagnosis and current treatments of a problematic tumor

BACKGROUND

Hepatic epithelioid hemangioendothelioma (HEHE) is a malignant vascular tumor known for its rarity. The different types of this hepatic tumor (single, multiple-nodular or diffused) indicate different prognosis and treatment plans. However, the heterogenic clinical manifestation creates a dilemma and a wide range of challenges when attending to HEHE patients. This review addresses the unique profile and clinical challenges that complicate the diagnosis and treatment of HEHE while focusing on current therapeutic strategies and their limitations.

MAIN TEXT

The unclear etiology is a challenging feature of HEHE. The exact involvement of potential risk factors and mechanism of development are still undefined. Relevant genetic alterations like WWTR1-CAMTA1 fusion have been investigated; however, they are only applicable as diagnostic markers and their influence on therapeutic efficacy is largely unknown. Other characteristics include asymptomatic manifestation, lack of unique hepatic functional alterations, high rates of misdiagnosis and late-stage identification when metastases already exist. Currently, tissue biopsy is the main tool to establish a definite diagnosis but is challenged with the limited awareness to suspect HEHE at early stages and the lack of relevant guidelines due to the rarity and the insufficiency of relevant research. The absence of treatment guidelines is the greatest challenge of HEHE. Generally, Surgical approaches are recommended due to the benefits of prolonged survival and enhanced prognosis. Nonetheless, only a minority of patients are eligible for resections while liver transplants are faced with severe insufficiency of donor organs and long wait-lists. On the other hand, a variety of non-surgical treatments (like anti-angiogenic agents, interferon alpha-2B and sirolimus) are presented with a promising potential. However, relevant studies are challenged with limited sample-sizes and lack of prospective designs.

CONCLUSION

Regardless to decades passing since its discovery, HEHE still creates a dilemma due to its challenging clinical profile and lack of treatment guidelines. Raising awareness of HEHE in clinical practices improves the ability to diagnose this rare tumor at early stages and develop stronger research strategies and treatment guidelines to regulate the medical care provided to HEHE patients.

Hepatic epithelioid Hemangioendothelioma presenting synchronously with hepatocellular carcinoma-a case report

BACKGROUNDS

Primary hepatic epithelioid hemangioendothelioma (HEHE) is a rare neoplasm of vascular origin with varying biologic behavior, making it challenging to diagnose.

CASE PRESENTATION

We present a case of synchronous hepatocellular carcinoma (HCC) and HEHE in a 43-year-old Chinese male patient. Multiple hypoechoic liver lesions were depicted, but no specific imaging findings were detected on enhanced computed tomography (CT) or contrast-enhanced magnetic resonance imaging (MRI). The patient then underwent [18F]-FDG PET/CT, [11C]-acetate PET/CT, and [68Ga]Ga-FAPI-04 PET/CT. The HEHE lesions demonstrated no uptake on both 18F-FDG and 11C-acetate PET/CT imaging, but presented a clear visualization in [68Ga]Ga-FAPI-04 PET/CT. The largest lesion located in segment VII was finally diagnosed as HCC, while the other smaller ones were diagnosed as HEHE, which was confirmed by immunohistochemical staining for CD31. To the best of our knowledge, only 2 cases have been reported in the worldwide literature, and the first case undertook both 11C-acetate and [68Ga]Ga-FAPI-04 PET/CT instead of 18F-FDG PET/CT.

CONCLUSION

In this report, we show that HCC and HEHE may occur synchronously, and HEHE should be considered when liver lesions are detected. [68Ga]Ga-FAPI-04 PET/CT has great potential in the detection, staging and therapy selection of HEHE.

Comprehensive evaluation of clinical outcomes in hepatic epithelioid hemangioendothelioma subsets: insights from SEER Database and departmental cohort analysis

Background

Epithelioid hemangioendothelioma (EHE), is an uncommon, intermediate-grade malignant vascular tumor that can manifest in diverse organs, including the liver, lungs, and bones. Given its unique malignancy profile and rarity, there lacks a consensus on a standardized treatment protocol for EHE, particularly for hepatic epithelioid hemangioendothelioma (HEHE). This study aims to elucidate factors influencing the clinical prognosis of EHE by analyzing data from the SEER database, complemented with insights from a departmental cohort of 9 HEHE cases. Through this, we hope to shed light on potential clinical outcomes and therapeutic strategies for HEHE.

Methods

Using SEER data from 22 registries, we analyzed 313 liver cancer patients with ICD-O-3 9130 and 9133 histology. Twelve variables were examined using Cox regression and mlr3 machine learning. Significant variables were identified and compared. Clinical data, imaging characteristics, and treatment methods of nine patients from our cohort were also presented.

Result

In univariate and multivariate Cox regression analyses, Age, Sex, Year of diagnosis, Surgery of primary site, Chemotherapy, and Median household income were closely related to survival outcomes. Among the ten survival-related machine learning models, CoxPH, Flexible, Mboost, and Gamboost stood out based on Area Under the Curve(AUC), Decision Curve Analysis(DCA), and Calibration Curve Metrics. In the feature importance analysis of these four selected models, Age and Surgery of primary site were consistently identified as the most critical factors influencing prognosis. Additionally, the clinical data of nine patients from our cohort not only demonstrated unique imaging characteristics of HEHE but also underscored the importance of surgical intervention.

Conclusion

For patients with resectable HEHE, surgical treatment is currently a highly important therapeutic approach.

Long-term prognosis and treatment modalities of hepatic epithelioid hemangioendothelioma: a retrospective study of 228 patients

BACKGROUND

Hepatic epithelioid hemangioendothelioma (EHE) is an extremely rare tumour. The aim of this study was to investigate the long-term prognosis and its relationship with treatment modalities.

METHODS

From March 2014 to June 2024, a total of 234 patients with histologically confirmed hepatic EHE were treated or followed up regularly by our team. The patients' clinical data at the time of diagnosis and initial treatment modalities were retrospectively collected. Kaplan-Meier curves were constructed to determine overall survival (OS). To explore prognostic factors and treatment outcomes, univariable and multivariable Cox proportional hazard models were developed.

RESULTS

A total of 228 patients were ultimately included. The median age of the cohort was 41 years. For all patients, the OS of 1-, 3- and 5-year were 96.2%, 87.9% and 84.9%, respectively. For patients who underwent liver transplantation (LT), the OS of 1- and 3-year were 62.5% and 25%, respectively. No difference was found in the OS between patients who received surgical therapy and those who did not (1-year: 100% vs. 96.9%; 3-year: 90.1% vs. 91.5%; 5-year: 87.2% vs. 88.2%; P = 0.891). In the multivariable analysis, age ≥ 60 years [HR (95% CI): 4.207 (1.266-13.973), P = 0.019], the size of the largest lesion > 10 cm [HR (95% CI): 12.140 (1.419-103.872), P = 0.023] and LT [HR (95% CI): 5.502 (1.343-22.536), P = 0.018] were poor prognostic factors.

CONCLUSIONS

Compared with nonsurgical therapy, surgical therapy has no advantage in terms of long-term survival. The role of LT in the management of hepatic EHE should be reevaluated. Age ≥ 60 years and the size of the largest lesion > 10 cm are poor prognostic factors.

Management and Long-Term Outcomes of Patients With Hepatic Epithelioid Hemangioendothelioma

BACKGROUND AND OBJECTIVES

Hepatic epithelioid hemangioendothelioma (HEHE) is an uncommon vascular neoplasm characterized by variable clinical behavior. Our aim was to describe the therapeutic approach for HEHE at diagnosis and define clinicopathological characteristics associated with tumor progression and long-term survival.

METHODS

This is a retrospective study that includes patients with HEHE who received treatment at Mayo Clinic Rochester between 1984 and 2023.

RESULTS

Eighty patients were included in the study (median age: 44 years; 62.5% female), 24 underwent liver transplantation, 26 underwent liver resection, and 30 were managed medically. The 3-year overall survival rates were 86.7%, 80.9%, and 51.1%, respectively. Notably, 26 patients had extrahepatic metastases at the time of diagnosis, four (16.7%) in the transplantation group, four (15.4%) in the resection group, and 18 (69.2%) in the nonsurgical group. On multivariable modeling, bone metastasis was independently associated with long-term mortality (HR 6.3, p < 0.001) while lung metastasis and surgical intervention were not associated with long-term mortality (HR 0.8, p = 0.8; HR 1.1, p = 0.9, respectively).

CONCLUSION

Bone metastasis emerged as a strong predictor of poor survival. Hence, aggressive surgical intervention may not be advantageous in patients with skeletal metastases but can still be offered for those with other extrahepatic metastases.

Primary Intranodal Epithelioid Haemangioendothelioma in the Submandibular Region: A Case Report

Epithelioid haemangioendothelioma (EHE) is a rare vascular tumour that primarily affects the liver, lungs and bone. It is very rarely described in the head and neck region, and is exceptionally uncommon within the submandibular region. We report a very rare case of EHE originating in a lymph node within the submandibular salivary gland of a 54-year-old female patient. The tumour was resected and the patient was regularly followed up, with no recurrence of disease at 24 months postoperatively. A review of existing literature, clinical and immunohistopathological features are discussed, which highlight the diagnostic dilemma, absence of consensus for management and appropriate surveillance method associated with EHE.

Imaging features of hepatic angiosarcoma: retrospective analysis of two centers

PURPOSE

Identifying primary hepatic angiosarcoma (PHA) preoperatively is challenging, often relying on postoperative pathology. Invasive biopsy increases bleeding risk, emphasizing the importance of early PHA diagnosis through imaging. However, comprehensive summaries of ultrasound, abdominal computed tomography (CT), magnetic resonance imaging (MRI), and whole- body positron emission tomography-CT (PET-CT) in this context are lacking. This study aimed to investigate the comprehensive imaging characteristics of PHA.

PATIENTS AND METHODS

Imaging data were collected from 7 patients diagnosed with PHA via pathology between January 2000 and December 2019 in two provincial grade III hospitals. All patients underwent routine color ultrasound examinations before surgery, with 3 patients receiving contrast-enhanced ultrasound (CEUS).CT scans, both plain and enhanced, were performed on 5 patients, and whole-body PET-CT examinations were conducted on 2 patients.

RESULTS

Among the 7 patients with PHA, 4 presented with a single solid intrahepatic mass (2 of which were large), 1 with a single exophytic macroblock type, 1 with a mixed type featuring multiple masses and nodules, and 1 with a multiple nodule type. Conventional ultrasound of PHA showed uneven echoes within the tumor, potentially accompanied by septal zone echoes, and a blood flow grade of 0-I. CEUS displayed early-stage circular high enhancement, a central non-enhancement area, and a "vascular sign" around the tumor. CT scans revealed low-density shadows in the plain scan stage, high peripheral ring enhancement, and punctate nodular enhancement in the arterial phase, with varying intensities and the presence of a "vascular sign." During the portal vein stage, the interior of the tumor was consistently unfilled and exhibited structural disorder. PET-CT showed low-density lesions in the liver and low fluorodeoxyglucose metabolism.

CONCLUSIONS

Imaging diagnosis plays a crucial role in PHA diagnosis. When liver tumor imaging matches the above characteristics, consider PHA.

68 Ga-PSMA Versus 18 F-FDG PET/CT in the Evaluation of Epithelioid Hemangioendothelioma

ABSTRACT

A 32-year-old man with epithelioid hemangioendothelioma was imaged with 68 Ga-PSMA PET/CT to evaluate the potential of 177 Lu-PSMA radionuclide therapy after progression findings were observed on follow-up 18 F-FDG PET/CT imaging. Liver lesions showed low FDG SUV max . The lesion-to-background ratio (TBR) was calculated as 5.1/2.9 on 18 F-FDG PET/CT imaging. However, 68 Ga-PSMA PET/CT showed moderate PSMA SUV max . TBR was calculated as 4.5/1.1. In conclusion, in this case report, we demonstrated that 68 Ga-PSMA with moderate TBR in epithelioid hemangioendothelioma may be promising for 177 Lu-PSMA radionuclide therapy.

Epithelioid hemangioendothelioma-its history, clinical features, molecular biology and current therapy

Epithelioid hemangioendothelioma (EHE) is a remarkably rare tumor arising from endothelial cells that is classified as a vascular tumor in the WHO classification. The tumor is predominantly characterized by the presence of fusion genes, such as WWTR1-CAMTA1 or YAP1-TFE3, with a minority of cases exhibiting other rare fusion genes. EHE exhibits a broad age of onset, typically presenting at ~50 years, but it is not uncommon in pediatric populations. It manifests in a variety of organs, including the liver, lung, soft tissue and bone. Initial multiple-organ involvement is also observed. The tumor's biological behavior and prognosis vary substantially based on the primary site of manifestation. From a therapeutic perspective, initial active surveillance might be considered in selected cases, although surgical intervention remains the mainstay of treatment, especially for localized single-organ involvement. Chemotherapy is administered to patients with progressive unresectable tumors. Recent advances in the biological analysis of EHE fusion genes have elucidated their diverse functions. Additionally, next-generation sequencing has facilitated the identification of other mutations beyond the fusion genes. These continuous efforts to understand the biology of the fusion genes themselves and/or the dysregulated signaling by fusion genes are expected to lead to the development of novel therapeutic strategies for EHE. This article aims to provide a comprehensive review of EHE, encompassing its historical context, clinical manifestations, molecular biology and the current state of treatment.

Image-Guided Thermal Ablation for Hepatic Epithelioid Hemangioendothelioma: A Multicenter Experience

PURPOSE

To investigate the feasibility, safety, and clinical outcomes of image-guided thermal ablation in patients with hepatic epithelioid hemangioendothelioma (HEHE).

MATERIALS AND METHODS

This was a multicenter retrospective investigation of 18 patients (43.9 years [SD ± 14.8]; 6 men) who underwent image-guided thermal ablation for HEHE between January 2013 and February 2023. A total of 31 ablation sessions (24 involving microwave ablation and 7 involving radiofrequency ablation) were evaluated. The rates of technical success, adverse events, and outcomes were assessed. The Kaplan‒Meier method was used to estimate progression-free survival (PFS) and overall survival (OS) rates. The risk factors affecting PFS were investigated using Cox proportional hazard regression analysis.

RESULTS

The technical success rate was 93.5% (29/31). No major adverse events occurred. Local tumor progression occurred after 2 sessions (6.5%, 2/31), and intrahepatic distant metastasis occurred after 16 sessions (51.6%, 16/31). During the medium follow-up time of 37.2 months (range, 3-117 months), the OS and PFS rates were 87.6% and 62.2%, respectively, at 1 year; 75.5% and 37.4%, respectively, at 3 years; and 75.5% and 37.4%, respectively, at 5 years. The median OS and PFS were 90.5 months (95% CI: 68.1-112.8) and 23.8 months (95% CI: 15.4-32.2), respectively. According to the multivariate analysis, a larger tumor size (P = .026) was associated with shorter PFS.

CONCLUSIONS

Image-guided thermal ablation is a feasible and safe treatment option for patients with HEHE that resulted in local tumor control and a favorable long-term prognosis.

Irreversible Electroporation as a Valid Treatment Option for Hepatic Epithelioid Hemangioendothelioma: An International Multicenter Experience

PURPOSE

Hepatic epithelioid hemangioendothelioma (HEHE) is a rare tumor with currently no established standard of care. This international multicenter retrospective study assesses the use of percutaneous irreversible electroporation (IRE) as an ablative tool to treat HEHE and provides a clinical overview of the current management and role of IRE in HEHE treatment.

MATERIAL AND METHODS

Between 2017 and 2023, 14 patients with 47 HEHE tumors were treated with percutaneous IRE using CT-scan guidance in 23 procedures. Baseline patient and tumor characteristics were evaluated. Primary outcome measures included safety and effectiveness, analyzed using Common Terminology Criteria for Adverse Events (CTCAE) and treatment response by mRECIST criteria. Secondary outcome measures included technical success, post-treatment tumor sizes and length of hospital stay. Technical success was defined as complete ablation with an adequate ablative margin (intentional tumor free ablation margin > 5 mm).

RESULTS

IRE treatment resulted in technical success in all tumors. Following a median follow-up of 15 months, 30 tumors demonstrated a complete response according to mRECIST criteria. The average tumor size pre-treatment was 25.8 mm, accompanied by an average reduction in tumor size by 7.5 mm. In 38 out of 47 tumors, there was no evidence of local recurrence. In nine tumors, residual tumor was present. There were no cases of progressive disease. Median length of hospital stay was one day. Only one grade 3 CTCAE event occurred, a pneumothorax requiring chest tube placement.

CONCLUSION

The current study provides evidence that IRE is a safe and efficacious minimally invasive treatment option for HEHE.

Proposed diagnostic and prognostic markers of primary malignant hepatic vascular neoplasms

INTRODUCTION

Primary malignant hepatic vascular tumors with various malignant potentials include epithelioid hemangioendothelioma (EHE) and angiosarcoma (AS), which may overlap pathologically. This study aimed to compare the pathological findings of hepatic EHE with those of AS, in association with patient outcomes.

METHODS

Fifty-nine histologically confirmed patients with 34 EHE and 25 AS were admitted to a tertiary hospital from 2003 to 2020. Their EHE and AS pathological features were compared. Immunohistochemistry for CD31, ERG, CAMTA-1, TFE3, P53, and Ki-67 labeling was performed on paraffin-embedded blocks. Markers, along with histological findings, were analyzed for the purposes of diagnostic and prognostic significance by multivariate analysis.

RESULTS

CAMTA-1 was 91.2% positive in EHE, but negative in AS (p = < 0.001). AS was significantly correlated to an aberrant p53 expression, high Ki-67 labeling, and high mitotic activity, compared to EHE (all, p = < 0.001). EHE can be classified as low grade (LG) and high grade (HG) using the prognostic values of mitotic activity and ki-67 labeling (sensitivity = 1, specificity = 1). Low grade-EHE showed significantly better overall survival than high grade-EHE (p = 0.020).

CONCLUSIONS

Immunohistochemistry for CAMTA-1, P53, and Ki-67 labeling may help distinguish EHE and AS in histologically ambiguous cases, especially small biopsied tissue. Moreover, the combination of mitotic activity and Ki-67 labeling can be a prognostic factor for EHE with various clinical features.

Hepatic Epithelioid Hemangioendothelioma in a Dog

A 5-year-old spayed female Breton dog was referred for a thyroid nodule. A total body CT scan evidenced multifocal hepatic nodules. Cytological liver samples were hemodiluted and non-diagnostic. Following a thyroidectomy, the histology was consistent with a follicular-compact thyroid carcinoma. On laparoscopy, most hepatic lobes had multifocal dark-red nodules that were biopsied for histology. Microscopically, the hepatic parenchyma in the nodules was substituted by blood channels lined by bland spindle cells but adjacent to epithelioid neoplastic cells, single or in clusters, embedded in a moderate amount of edematous collagen matrix. These cells had optically empty cytoplasmic space, occasionally containing erythrocytes (microlumina). Spindle and epithelioid cells expressed membranous-to-cytoplasmic CD31 and FVIII-RA consistent with endothelial origin. Based on morphology and immunolabelling, a hemangioendothelioma with epithelioid differentiation was diagnosed. Lesions in the liver were initially stable, showing progression with time. The dog was alive with no systemic clinical signs 36 months after laparoscopy.

Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation

Liver transplantation is a highly complex and challenging field of clinical practice. Although it was originally developed in western countries, it has been further advanced in Asian countries through the use of living donor liver transplantation. This method of transplantation is the only available option in many countries in the Asia-Pacific region due to the lack of deceased organ donation. As a result of this clinical situation, there is a growing need for guidelines that are specific to the Asia-Pacific region. These guidelines provide comprehensive recommendations for evidence-based management throughout the entire process of liver transplantation, covering both deceased and living donor liver transplantation. In addition, the development of these guidelines has been a collaborative effort between medical professionals from various countries in the region. This has allowed for the inclusion of diverse perspectives and experiences, leading to a more comprehensive and effective set of guidelines.

Image-guided percutaneous ablation of hepatic epithelioid hemangioendothelioma

PURPOSE

Disease control and survival following percutaneous ablation of hepatic epithelioid hemangioendothelioma (EHE) was studied retrospectively.

METHODS

Six patients underwent 16 image-guided ablation procedures to treat 35 liver tumors from 2015 to 2022 (17 microwave ablation, 9 irreversible electroporation, 8 cryoablation, and 1 radiofrequency ablation). Technical success, local progression, intrahepatic progression, distant progression, overall survival, and adverse events were assessed.

RESULTS

Four of six (67%) patients were treatment naïve prior to ablation. The mean length of imaging follow-up from first ablation procedure was 43.0 ± 31.2 months. Thirty-three of 35 (94.3%) ablated tumors did not progress locally. Three of 6 patients (50%) had new intrahepatic progression and underwent repeat ablation or systemic treatment. No extrahepatic progression was observed. One patient died from EHE 2.7 years after initial diagnosis. No severe adverse events occurred.

CONCLUSION

Percutaneous ablation is feasible, often in a staged fashion, and may provide favorable intermediate to long-term disease control for patients with hepatic EHE.

Ultrasound findings of hepatic epithelioid hemangioendothelioma: comparison with other malignant hepatic tumors

PURPOSE

To investigate and compare the ultrasonic features of hepatic epithelioid hemangioendothelioma (HEHE) and other common hepatic malignancies, such as hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (ICC) and hepatic metastatic tumor (HMT).

METHODS

A total of 37 patients with pathologically proven HEHE, 37 HCC cases, 37 ICC cases, and 37 HMT cases were enrolled from single hospital. The clinical characteristics and ultrasonic features of all cases were summarized and statistically analyzed.

RESULTS

There were significant differences in sex and age between the HEHE group and other three groups (P < 0.001). The probability of HEHE infection with hepatitis B virus was lower than that of HCC and ICC groups (P < 0.05). The probability of elevated serum tumor markers in HEHE was significantly lower than that in the other three groups (P < 0.05). On conventional ultrasound (CUS), the probability of multiple lesions in HEHE was significantly higher than that in the other three groups (P < 0.05). On contrast-enhanced ultrasound (CEUS), the time to wash out in HEHE was significantly shorter than that of the other three groups (P < 0.001). The proportion of synchronous or slow enhancement in HEHE was significantly higher than that of the other three groups (P < 0.001). The proportion of HEHE with iso- or hypo-enhancement was significantly higher than in HCC and HMT groups (P < 0.05).

CONCLUSION

HEHE mainly performed multiple hypoechoic lesions on CUS and displayed greater odds of synchronous enhancement in arterial phase, iso- or hypo-enhancement in peak time and wash out more quickly on CEUS, which allowed for differentiation from other common malignant tumors.

Treating rare tumors with liver transplantation

PURPOSE OF REVIEW

The success of liver transplantation (LT) in treating unresectable hepatocellular carcinoma (HCC) has resulted in interest in LT for other oncologic conditions. Here, we discuss the role of LT for rare oncologic indications including metastatic gastroenteropancreatic neuroendocrine tumors (GEP-NETs), hepatic epitheliod hemangioendothelioma (HEHE), fibrolamellar hepatocellular carcinoma (FLC), and hepatic angiosarcoma (HAS).

RECENT FINDINGS

Conditions reviewed have been documented indications for LT in the available literature. We summarize the experience of LT for these indications and proposed management guidelines.

SUMMARY

GEP-NETs with isolated metastases to the liver can be treated with LT with excellent long-term outcomes (10-year survival 88%) if strict selection criteria are used (low-intermediate grade, Ki-67% < 20%, complete resection of primary tumor, stable disease for 6 months, <50% hepatic involvement). HEHE is a rare hepatic tumor for which LT can be performed with reported 10-year survival around 70%. FLC is a distinct clinical entity to HCC and is optimally treated with surgical resection though experience with LT is described in observational series (5-year survival 50%, recurrence in 10%). HAS is a rapidly progressive tumor with a dismal prognosis with or without treatment, including LT.

Liver transplantation meets gastrointestinal cancer

Liver transplantation (LT) has emerged as a standard of care for patients with end-stage liver disease, providing a life-saving intervention for patients with severely compromised liver function in both the acute and chronic setting. While LT has also become a routine procedure for early-stage hepatocellular carcinoma (HCC), offering a potential cure by treating both the tumor and the underlying liver disease, its relevance in the context of other malignancies such as cholangiocellular carcinoma (CCA), combined hepatocellular-cholangiocarcinoma (cHCC-CCA) or liver metastases is still the subject of intense debate and no definite recommendations have yet been established. This review summarizes the current therapeutic standards in the context of LT for gastrointestinal malignancies and provides a reflection and outlook on current scientific and clinical developments.

Pediatric hepatic vascular tumors: clinicopathologic characteristics of 33 cases and proposed updates to current classification schemes

Pediatric hepatic vascular tumors (HVTs) are rare neoplasms with features distinct from their cutaneous counterparts. Their behavior ranges from benign to malignant, with each subtype having therapeutic differences. Histopathologic descriptions of large cohorts are scarce in the literature. Thirty-three putative HVTs diagnosed from 1970 to 2021 were retrieved. All available clinical and pathologic materials were reviewed. Lesions were reclassified according to the World Health Organization (WHO) classification of pediatric tumors [1] as hepatic congenital hemangioma (HCH; n = 13), hepatic infantile hemangioma (HIH; n = 10), hepatic angiosarcoma (HA; n = 3), and hepatic epithelioid hemangioendothelioma (HEH; n = 1). Vascular malformations (n = 5) or vascular-dominant mesenchymal hamartoma (n = 1) were excluded. HCH frequently showed involutional changes, whereas HIH often had anastomosing channels and pseudopapillae formation. HA had solid areas with epithelioid and/or spindled endothelial morphology, significant atypia, increased mitoses, high proliferation index, and occasionally necrosis. On morphology analysis, a subset of HIH showed features worrisome for progression to HA including solid glomeruloid proliferation, increased mitoses, and epithelioid morphology. The widely metastatic and fatal HEH was observed in a 5-year-old male with multiple liver lesions. Immunohistochemically, HIHs and HA were Glucose transporter isoform 1 (GLUT-1) positive. One HIH patient died from postoperative complications, whereas 3 are alive without disease. Five HCH patients are alive and well. Two of three HA patients died of disease, and 1 is alive without recurrence. To our knowledge, this is the largest series of pediatric HVTs reviewing clinicopathologic features based on current Pediatric WHO nomenclature [1]. We highlight diagnostic challenges and propose inclusion of an intermediate category between HIH and HA which warrants closer follow-up.

Primary hepatic epithelioid hemangioendothelioma masquerading as metastases: A rare case report

Epithelioid hemangioendothelioma (EHE) of the liver is an extremely rare malignant tumor of vascular origin, representing less than 1 % of all vascular tumors. Nearly 260 cases have been reported in English literature. Radiologically it is seen as multifocal lesions. It can be seen at different sites like lungs, bones, lymph nodes, breasts, and soft tissue. Often it is misdiagnosed with metastases, cholangiocarcinoma, or angiosarcoma. No definite treatment protocol is available due to its rarity, however, these malignancies are treated by radical resection of the tumor or liver transplant and/or chemotherapy. Here we present a primary hepatic epithelioid hemangioendothelioma (HEHE) which was mimicking metastases in a 42-year-old male who was treated with chemotherapy and radiotherapy. Sadly the patient expired after 1 year of complete course of treatment. Imaging features can help to improve the diagnostic accuracy of this tumor.

A Matched Molecular and Clinical Analysis of the Epithelioid Haemangioendothelioma Cohort in the Stafford Fox Rare Cancer Program and Contextual Literature Review

BACKGROUND

Epithelioid haemangioendothelioma (EHE) is an ultra-rare malignant vascular tumour with a prevalence of 1 per 1,000,000. It is typically molecularly characterised by a WWTR1::CAMTA1 gene fusion in approximately 90% of cases, or a YAP1::TFE3 gene fusion in approximately 10% of cases. EHE cases are typically refractory to therapies, and no anticancer agents are reimbursed for EHE in Australia.

METHODS

We report a cohort of nine EHE cases with comprehensive histologic and molecular profiling from the Walter and Eliza Hall Institute of Medical Research Stafford Fox Rare Cancer Program (WEHI-SFRCP) collated via nation-wide referral to the Australian Rare Cancer (ARC) Portal. The diagnoses of EHE were confirmed by histopathological and immunohistochemical (IHC) examination. Molecular profiling was performed using the TruSight Oncology 500 assay, the TruSight RNA fusion panel, whole genome sequencing (WGS), or whole exome sequencing (WES).

RESULTS

Molecular analysis of RNA, DNA or both was possible in seven of nine cases. The WWTR1::CAMTA1 fusion was identified in five cases. The YAP1::TFE3 fusion was identified in one case, demonstrating unique morphology compared to cases with the more common WWTR1::CAMTA1 fusion. All tumours expressed typical endothelial markers CD31, ERG, and CD34 and were negative for pan-cytokeratin. Cases with a WWTR1::CAMTA1 fusion displayed high expression of CAMTA1 and the single case with a YAP1::TFE3 fusion displayed high expression of TFE3. Survival was highly variable and unrelated to molecular profile.

CONCLUSIONS

This cohort of EHE cases provides molecular and histopathological characterisation and matching clinical information that emphasises the molecular patterns and variable clinical outcomes and adds to our knowledge of this ultra-rare cancer. Such information from multiple studies will advance our understanding, potentially improving treatment options.

Mesenchymal Neoplasms of the Liver

Mesenchymal neoplasms of the liver can be diagnostically challenging, particularly on core needle biopsies. Here, I discuss recent updates in neoplasms that are specific to the liver (mesenchymal hamartoma, undifferentiated embryonal sarcoma, calcifying nested stromal-epithelial tumor), vascular tumors of the liver (anastomosing hemangioma, hepatic small vessel neoplasm, epithelioid hemangioendothelioma, angiosarcoma), and other tumor types that can occur primarily in the liver (PEComa/angiomyolipoma, inflammatory pseudotumor-like follicular dendritic cell sarcoma, EBV-associated smooth muscle tumor, inflammatory myofibroblastic tumor, malignant rhabdoid tumor). Lastly, I discuss metastatic sarcomas to the liver, as well as pitfalls presented by metastatic melanoma and sarcomatoid carcinoma.

Hepatic epithelioid hemangioendothelioma-a single-institution experience with 51 cases

Objectives

The aim of the present study was to describe the experience at a single institution in the management of hepatic epithelioid hemangioendothelioma (HEHE).

Methods

We included 51 patients with histologically confirmed HEHE. We performed log-rank (Cox-Mantel) survival analyses using Kaplan-Meier methods to test differences in survival between patients in different groups. Univariate Cox regression analyses and multivariate proportional hazards regression model were carried out to identify independent prognostic factors.

Results

Different imaging modalities were used to diagnose HEHE with various presentations. Liver resection (LR), liver transplantation (LT), systemic treatment (ST), and surveillance had been used in our study. A significant difference was noted between the LR group and the surveillance group with respect to mean survival (p = 0.006), as was in the LR group and the ST group (p = 0.036), and in surgical approach (LR and LT) and nonsurgical approach (ST and surveillance) (p = 0.008). The mean survival between the ST group and the surveillance group was not significantly different (p = 0.851). LR (p = 0.010) and surgical approach (p = 0.014) were favorable predictors of outcome, while macrovascular invasion (MaVI) (p = 0.037), lung metastasis (p = 0.040), and surveillance (p = 0.033) were poor prognostic factors in univariate analysis. Multivariate analysis showed that LR (p = 0.010) and surgical approach (p = 0.014) were independently associated with good OS, while surveillance (p = 0.033) was independently associated with poor OS. After adjusting for confounding factors, patients in the LR group have much better OS than those in the surveillance group (p = 0.013). However, there was no significant difference in OS between the LR group and ST group (p = 0.254), as was in the ST group and the surveillance group (p = 0.857).

Conclusions

The definitive diagnosis of HEHE was dependent on histopathology, and it was not possible to make a specific diagnosis without biopsy because the radiological findings were similar to those in some hepatic malignancies. ST was not recommended for patients who were not candidates for surgical approaches, and surgical approaches should be warranted regardless of disease stage. The retrospective nature and the small size of the data limited the generalizability of the study, designing a worldwide database that contains all data about patients with HEHE independent of their therapy, which was highly recommended.

A Liver-Derived Vascular Lesion: Hepatic Hemangioma or Hepatic Epithelioid Hemangioendothelioma?

Hepatic epithelioid hemangioendothelioma (EHE) is an uncommon vascular endothelial cell tumor of the liver with numerous symptoms and features. The median affected age is 41, and females are more frequently affected than men. In the following article, a 37-year-old nurse is presented who was referred to the hospital with severe right upper quadrant pain. She had been misdiagnosed with hepatic hemangioma for years, which finally turned out to be hepatic EHE. Liver transplantation has been recognized as the therapeutic method of choice due to the considerable extent of liver involvement and nonresponse to medications.

18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in a Rare Case of Epithelioid Hemangioendothelioma - A Diagnostic Challenge

Our case highlights the 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) scan findings in a rare case of biopsy-proven epithelioid hemangioendothelioma (EHE) in a 66-year-old woman with multi-organ involvement (lung, liver, and bone) who was subsequently treated with palliative radiation therapy and oral pazopanib. Furthermore, follow-up 18F-FDG PET/CT findings are detailed. EHE is a rare malignant vascular neoplasm (<1% of all vascular tumors) with an epithelioid and histiocytoid appearance arising from the vascular endothelial and preendothelial cells.

A rare case of hepatic epitheliod hemangioendothelioma

Hepatic epithelioid hemangioendothelioma (HEHE) is an extremely uncommon tumor of the liver. It typically lacks recognizable clinical signs and is diagnosed with the aid of imaging and histopathology combined with immunohistochemical analysis. We discuss the case of a 40-year-old woman with HEHE. The aim of this case report and literature review is to increase doctors' knowledge of HEHE and reduce the incidence of missed clinical diagnoses.

Hepatic epithelioid hemangioendothelioma a case report and literature review

INTRODUCTION

Hepatic epithelioid hemangioendothelioma (HEHE) is a rare disease with a high probability of being misdiagnosed.

CASE PRESENTATION

We present a case of a 38-year-old female patient found with HEHE by physical examination. The tumor was removed by surgery successfully, but then had recurrence after the operation.

CLINICAL DISCUSSION

We review the current literature on HEHE; its prevalence, diagnosis and treatment. And our opinion is that using fluorescent laparoscopy for HEHE may has an advantage in visualizing tumors, but there is still high possibility of false positives. It is recommended to use it correctly during operation.

CONCLUSION

The clinical presentation, laboratory and imaging index for HEHE were lacking in specificity. Therefore, diagnosis still depends mainly on pathology results, in which the most effective treatment is surgery. Besides, the fluorescent nodule which is not shown on images need to be analyzed carefully in order to avoid damage to normal tissue.

CT and MRI features of hepatic epithelioid haemangioendothelioma: a multi-institutional retrospective analysis of 15 cases and a literature review

OBJECTIVE

To improve the current imaging understanding of MRI or CT for hepatic epithelioid haemangioendothelioma (HEHE) to aid in its successful preoperative diagnosis.

METHODS

The imaging features of 15 patients (median age 38.6, range 20-71; 7 M/8 F) from eight institutions with pathologically confirmed HEHE were retrospectively analysed. Additionally, the CT/MR imaging features of 180 patients in 15 literature publications were collected, analysed and compared with our case series.

RESULTS

Fifteen patients underwent CT and MRI (n = 2), CT (n = 9) or MR (n = 8) scans. A total of 92.9% (13/14) of the patients were initially diagnosed with other lesions on imaging. A total of 86.7% (13/15) were multifocal. Nodules (11/15, 73.3%) were predominantly peripheral in distribution (12/15, 80.0%). Some cases were associated with hepatic capsular retraction (13/15, 86.7%), "target signs" (8/15, 53.3%) and "lollipop signs" (5/15, 33.3%). Peripheral enhancement of various shapes in the early phase with a progressive centripetal filling was the most common pattern of enhancement (12/15, 80.0%). Abnormal vascularity was seen in 50.7% (6/15) of the patients. Suspicious tumour thromboses in the inferior vena cava were seen in 3 (20.0%) of the patients. Two of the 15 patients (13.3%) had a history of smoking.

CONCLUSIONS

HEHEs have common distinctive features, including multifocal lesions that are predominantly peripheral, "target signs", "lollipop signs", hepatic capsular retraction and peripheral enhancement of various shapes in the early phase with progressive centripetal filling. Additional aggressive imaging features that may be valuable clues to the diagnosis can be identified by CT or MRI.

Management and outcomes of advanced hemangioendothelioma at a medical oncology clinic in an Indian tertiary care center

AIM

Hemangioendotheliomas (HEs) are malignant vascular tumors with sparse descriptions in literature owing to their rarity.

STUDY DESIGN

Ours is a retrospective study among patients of advanced HEs registered between September 2015 and April 2021.

RESULTS

There were 13 patients with median age 34.6 (range: 4-69 years), male preponderance (69%) and predominant subtype of epithelioid HE (76.9%). Common primary sites were viscera (46.2%) and bone (30.8%). Tyrosine kinase inhibitors (TKIs) yielded objective responses in 30% patients whereas chemotherapy only produced disease stabilization in 7.7%.

CONCLUSION

We recognize an aggressive subset of HEs with manifestations such as acute liver failure and splenic rupture. Currently no biomarkers predict the efficacy of TKIs over chemotherapy; however, TKIs showed promising outcomes in this series.

A review of hepatic epithelioid hemangioendothelioma-Analyzing patient characteristics and treatment strategies

BACKGROUND

Hepatic epithelioid hemangioendothelioma (HEH) is a rare vascular tumor of unknown etiology and unpredictable natural history. To date, no large-scale studies have been published evaluating this disease due to its rare occurrence.

METHODS

The National Cancer Database was reviewed between 2004 and 2016 to identify patients with HEH. Univariate analysis with overall survival (OS) was performed by Cox proportional hazards model. Kaplan-Meier method was used to create OS curves and compared using the log-rank test.

RESULTS

We identified 229 patients with HEH. The majority of patients were female (61.1%), white (84.3%), and had a Charlson-Deyo score of 0 (75%). Chemotherapeutic intervention was seen in 26% of the patients while 33% received surgical intervention in the form of wedge/segmental liver resection (n = 27), hepatectomy lobectomy/extended lobectomy (n = 18), and liver transplant (n = 22). Five-year survival in surgical patients was 90.5%, 66.5% and 81%, respectively (p = 0.485). Age greater than 55 years (hazard ratio [HR], 2.78; p < 0.001), Asian ethnicity compared to white (HR, 2.84; p = 0.012), and a higher Charlson-Deyo score (score 1: HR, 2.28; p < 0.001 and score ≥2: HR, 2.76; p = 0.011) were associated with worse OS.

CONCLUSION

Treatment for HEH remains variable with only a third of the patients undergoing surgery. International collaboration is necessary to determine the optimal treatment for this rare disease.

The role of liver transplantation in the care of primary hepatic vascular tumours in children

Liver transplantation (LT) is the standard of care for many liver conditions, such as end-stage liver diseases, inherited metabolic disorders, and primary liver malignancies. In the latter group, indications of LT for hepatoblastoma and hepatocellular carcinoma evolved and are currently available for many non-resectable cases. However, selection criteria apply, as the absence of active metastases. Evidence of good long-term outcomes has validated the LT approach for managing these malignancies in the context of specialist and multidisciplinary approach. Nevertheless, LT's role in treating primary vascular tumours of the liver in children, both benign and malignant, remains somewhat controversial. The rarity of the different diseases and the heterogeneity of pathological definitions contribute to the controversy and make evaluating the benefit/risk ratio and outcomes quite difficult. In this narrative review, we give an overview of primary vascular tumours of the liver in children, the possible indications and the outcomes of LT.

Updated information regarding management of hepatic epithelioid hemangioendothelioma

Hepatic epithelioid hemangioendothelioma (HEHE) is a rare hepatic vascular tumor with a borderline biological behavior between hemangioma and hemangiosarcoma. It tends to be multiple or diffuse subcapsular lesions across the liver but has no characteristic clinical manifestations or imaging findings. On computed tomography and magnetic resonance imaging, these lesions usually have a hypodense appearance with heterogeneous enhancement and a "halo sign" or "lollipop sign" may be evident in some cases. HEHE is diagnosed mainly based on a pathological examination along with differential immunohistochemical markers such as CAMTA1, CD31, CD34, CD10, vimentin, and factor VIII antigen. Currently, there are no standardized treatment guidelines for HEHE, and surgery (curative resection and liver transplantation) remains the mainstay of treatment. Studies have indicated that extra-hepatic metastasis might not be a contraindication for resection or transplantation. Systemic chemotherapeutic agents including doxorubicin, vincristine, interferon-a, 5-fluorouracil, and thalidomide, as well as VEGF-related agents are being investigated, but no agents have been approved for the treatment of HEHE.