Angiosarcoma of the maxillary sinus: literature review and case report

Adult sinonasal soft tissue sarcoma: analysis of 48 cases from the French Sarcoma Group database

OBJECTIVE

The aim of this study was to determine the frequency of primary sinonasal adult sarcoma, identify histological subtypes, and analyze prognostic factors.

STUDY DESIGN

Retrospective review.

METHOD

Forty-eight adult sinonasal sarcomas included in the French Sarcoma Group database (Conticabase) were reviewed.

RESULTS

The most frequent tumor types were alveolar rhabdomyosarcoma (33.3%), embryonal rhabdomyosarcoma (14,6%), unclassified sarcoma (14.6%), and leiomyosarcoma (12.5%). All round cell tumors were rhabdomyosarcomas. The 5-year overall survival (OS), metastasis-free survival (MFS), and local recurrence-free survival (LRFS) rates were 62.3%, 73%, and 88.8%, respectively. Histotype was a prognostic factor for OS, MFS, and LRFS, with the worst prognosis associated with rhabdomyosarcomas, regardless of the subtype. The tumor grade influenced the OS and MFS. Surgery was a predictive factor for a complete response.

CONCLUSIONS

These results suggest that sinonasal tract should be considered as an unfavorable site for rhabdomyosarcoma. Moreover, surgery should always be considered in treatment.

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.

Primary angiosarcoma of the larynx: a rare entity

Angiosarcomas are extremely rare malignant tumours of the larynx. We present a case of laryngeal angiosarcoma in a 58-year-old man who presented with hoarseness of voice, dysphagia and neck swelling. The patient underwent a total laryngectomy with a pre-operative and frozen section diagnosis of a poorly differentiated carcinoma of the larynx. Histopathological and immunohistochemical evaluation revealed features of a laryngeal angiosarcoma. The case is presented for its rarity and diagnostic difficulty.

Preoperative radiotherapy and bevacizumab for angiosarcoma of the head and neck: Two case studies

BACKGROUND

Angiosarcoma of the face is a vascular tumor with poor local control and short median survival despite standard treatment. Bevacizumab is a humanized monoclonal antibody to vascular endothelial growth factor (VEGF), which can inhibit tumor growth. It is synergistic with radiotherapy in gastrointestinal malignancies. Given the vascular nature of angiosarcoma and the need for better treatment of this disease, we investigated the concurrent use of bevacizumab with preoperative radiotherapy for head and neck angiosarcoma.

METHODS

Two patients diagnosed with angiosarcoma of the nose were treated preoperatively with bevacizumab (5-10 mg/kg) and concurrent radiotherapy (50 Gy), followed by resection of the tumor bed.

RESULTS

Both patients had a complete pathologic response with no residual disease. Neither has developed recurrence, with follow-up of 8.5 months and 2.1 years.

CONCLUSIONS

The neoadjuvant combination of bevacizumab and radiation therapy is promising and should be further studied in the setting of vascular malignancies.

Sinonasal tract angiosarcoma: a clinicopathologic and immunophenotypic study of 10 cases with a review of the literature

BACKGROUND

Primary sinonasal tract angiosarcoma are rare tumors that are frequently misclassified, resulting in inappropriate clinical management. There are only a few reported cases in the English literature.

MATERIALS AND METHODS

Ten patients with sinonasal tract angiosarcoma were retrospectively retrieved from the Otorhinolaryngic Registry of the Armed Forces Institute of Pathology.

RESULTS

Six males and four females, aged 13 to 81 years (mean, 46.7 years), presented with epistaxis and bloody discharge. Females were on average younger than their male counterparts (37.8 vs. 52.7 years, respectively). The tumors involved the nasal cavity alone (n = 8) or the maxillary sinus (n = 2), with a mean size of 4.3 cm; the average size was different between the genders: males: 2.8 cm; females: 6.4 cm. Histologically, all tumors had anastomosing vascular channels lined by remarkably atypical endothelial cells protruding into the lumen, neolumen formation, frequent atypical mitotic figures, necrosis, and hemorrhage. All cases tested (n = 6) demonstrated immunoreactivity with antibodies to Factor VIII-RA, CD34, CD31, and smooth muscle actin, while non-reactive with keratin and S-100 protein. The principle differential diagnosis includes granulation tissue, lobular capillary hemangioma (pyogenic granuloma), and Kaposi's sarcoma. All patients had surgery followed by post-operative radiation (n = 4 patients). Follow-up was available in all patients: Six patients died with disease (mean, 28.8 months); two patients had died without evidence of disease (mean, 267 months); and two are alive with no evidence of disease at last follow-up (mean, 254 months).

CONCLUSIONS

Sinonasal tract angiosarcoma is a rare tumor, frequently presenting in middle-aged patients as a large mass usually involving the nasal cavity with characteristic histomorphologic and immunophenotypic features. Sinonasal tract angiosarcoma will often have a poor prognosis making appropriate separation from other conditions important.

Prolonged survival of angiosarcoma on the nose: a report of 3 cases

The nose is a rare site for presentation of angiosarcoma. Although this presentation if difficult to study because of its rarity, previous authors have suggested improved survival in patients with angiosarcoma on the nose compared with other anatomic sites. If true, improved survival may be a result of early detection, small tumor size at time of presentation, and increased likelihood of combined surgery and radiation treatment. We report the cases of 3 patients who presented with nasal angiosarcoma and then survived 7, 7, and 4 years to date.

Epithelioid angiosarcoma of the maxillary sinus and the maxilla: a case report and review of the literature

Epithelioid angiosarcoma is a rare malignant tumor that arises from the endothelium of the blood vessels. In the head and neck area, most of these lesions affect the scalp and facial soft tissues, and the maxillary sinus and the maxilla are among the rarest locations involved. In this paper, we present a case of angiosarcoma of the left maxillary sinus, with extension into the left maxilla. We review the literature and discuss the differential diagnosis of endothelial neoplasms and the management and the prognosis of this tumor.

A case of angiosarcoma of the nose

A case of angiosarcoma arising from the nose of a 69-year-old man is presented in this report. The patient was treated with a combination of recombinant interleukin-2 (rIL-2, Celeuk), electron beam irradiation, and surgery. He died 27 months after diagnosis, but there was no apparent remote metastasis.

Laryngeal angiosarcoma: a clinicopathologic study of five cases with a review of the literature

OBJECTIVE

Primary laryngeal angiosarcoma (LA) is rare without a reported series evaluating these tumors.

STUDY DESIGN/METHODS

Five patients with LA were retrospectively retrieved from the Otorhinolaryngic Registry of the Armed Forces Institute of Pathology.

RESULTS

Three men and 2 women, aged 29 to 71 years, presented with hoarseness (n = 4) and hemoptysis (n = 1). Two patients had previous neck radiation. The tumors involved the supraglottis (n = 4) with a mean size of 3.1 cm. Histologically, all tumors had anastomosing vascular channels lined by remarkably atypical endothelial cells protruding into the lumen, frequent atypical mitotic figures, and hemorrhage. All cases tested (n = 4) demonstrated immunoreactivity with antibodies to Factor VIII-RA and CD34. All patients had surgery followed by postoperative radiation (n = 3 patients). Three patients died with disease (mean, 17 mo), whereas one patient is alive with no evidence of disease at 18 years.

CONCLUSIONS

LA is a rare tumor, frequently associated with previous radiation, usually involving the supraglottis with characteristic histomorphologic and immunophenotypic features. LA has a poor prognosis, making appropriate separation from other conditions important.

Factors in the pathogenesis of tumors of the sphenoid and maxillary sinuses: a comparative study

OBJECTIVES/HYPOTHESIS

To explain the processes that lead to the development of tumors in the maxillary and sphenoid sinuses.

STUDY DESIGN

A 32-year review of the world's literature on neoplasms of these two sinuses and a randomized case-controlled study comparing the normal mucosal architecture of the maxillary to the sphenoid sinus.

METHODS

Analysis of a 32-year world literature review reporting series of cases of maxillary and sphenoid sinus tumors. Tumors were classified by histological type and separated into subgroups if an individual incidence rate was reported. Histomorphometry of normal maxillary and sphenoid sinus mucosa was performed in 14 randomly selected patients (10 sphenoid and 4 maxillary specimens). Specimens were fixed in 10% formalin, embedded in paraffin, and stained with periodic acid-Schiff (PAS) and hematoxylin. Histomorphometric analysis was performed with a Zeiss Axioscope light microscope (Carl Zeiss Inc., Thornwood, NY) mounted with a Hamamatsu (Hamamatsu Photonics, Tokyo, Japan) color-chilled 3 charge coupled device digital camera. The images were captured on a 17-inch Sony (Sony Corp., Tokyo, Japan) multiscan monitor and analyzed with a Samba 4000 Image Analysis Program (Samba Corp., Los Angeles, CA). Five random areas were selected from strips of epithelium removed from each sinus, and goblet and basal cell measurements were made at magnifications x 100 and x 400.

RESULTS

The literature review revealed that the number and variety of tumors in the maxillary sinus are much greater than those in the sphenoid. The incidence of metastatic lesions to each sinus is approximately equal. No recognized pattern of spread from any particular organ system could be determined. On histomorphometric study there were no statistically significant differences between the sinuses in the concentration of goblet cells, basal cells, or seromucinous glands.

CONCLUSIONS

Factors involved in the pathogenesis of tumors of the maxillary and sphenoid sinuses include differences in nasal physiology, embryology, morphology, and topography. There are no significant histological differences in the epithelium and submucous glands between the two sinuses to explain the dissimilar formation of neoplasms.

Angiosarcomas of the head and neck: clinical and pathologic characteristics

Between 1974 and 1992, 32 patients with pathologically diagnosed angiosarcoma of the head and neck were evaluated at our institution. The primary treatment group consisted of 24 patients who had the initial diagnosis made or confirmed at our institution, and the other 8 patients formed the salvage group. There were 23 men and 9 women. The median age in the primary treatment group was 63 years (range 18 to 91 years). The overall median survival among the primary group patients was 4.8 years, and the 3-year survival was estimated to be 57% (95% confidence interval 39% to 84%). The median follow-up was 2.1 years (range 83 days to 9.7 years). Patients who had tumors less than 7.0 cm in diameter and tumors with invasion only to the subcutaneous tissues had better overall survival and longer time to first adverse event. Diploid DNA content was a significant favorable prognostic factor for time to first adverse event. Mitotic activity was of borderline significance with both end points. Patients who had tumors of less than 1.5 cm were treated successfully with surgery alone. Patients treated with combined surgery and radiotherapy also tended to do better. Because most patients in whom regional recurrences developed had tumors larger than 7.0 cm, we conclude that patients with tumors of this size may benefit from regional neck node dissection at the time of primary excision or from elective neck irradiation.

Epithelioid hemangioendothelioma of the orbital bones

PURPOSE

The authors report a case of an epithelioid hemangioendothelioma arising in the orbital bones. A review of the literature related to this rare orbital neoplasm identified eight well-documented cases, one of which occurred in a patient younger than that reported here, but none of which originated in bone.

METHODS

A 3 1/2-month-old boy had a left inferior orbital mass that had grown rapidly over a 3-day period. An emergency computed tomography scan showed a large neoplasm with significant bone destruction of the zygoma and maxilla. Initial examination suggested a rhabdomyosarcoma, and a transconjunctival biopsy was performed, which was complicated by significant blood loss. The final pathologic diagnosis was an epithelioid hemangioendothelioma, or grade 2 hemangioendothelioma, of bone origin. No other sites of disease were found on metastatic survey. Subsequent treatment consisted of an en bloc tumor resection sparing the orbital soft tissues and globe.

RESULTS

The patient is free of disease and has normal visual fixation and ocular motility 20 months after surgery.

CONCLUSION

Epithelioid hemangioendothelioma, a vascular malignancy of endothelial cell origin, very rarely involves the orbit. This case is notable for its early development, rapid growth, bony origin, and epithelioid histology.

Angiosarcoma of the nasal cavity

Angiosarcoma of the nasal cavity is extremely rare. We present a case of angiosarcoma of the nasal cavity in an eight-year-old boy. He was treated with medial maxillectomy via lateral rhinotomy. The histological diagnosis was confirmed by immunohistological stain with Factor VIII-like antigen. Magnetic resonance imaging (MRI) was useful in determining the extent of the tumour.

Haemangiosarcoma of the maxillary antrum

Angiosarcomas are extremely rare in the head and neck and the histological diagnosis is often difficult. We present a case of a haemangiosarcoma of the maxillary antrum in a 33 year old male. The histological diagnosis and subsequent management are discussed.

Mandibular metastasis of angiosarcoma. A case report

A case of mandibular metastasis of angiosarcoma is described, along with its clinical manifestations and histopathological features. This is the 5th case ever reported of metastasis of angiosarcoma to the mandible.

Orbital angiosarcoma with subconjunctival presentation. Report of a case and literature review

An otherwise healthy 37-year-old woman had, over the course of 2 years, a recurring subconjunctival lesion associated with blepharoptosis. Computed tomography (CT) demonstrated a large anterior and superior orbital mass. A diagnosis of angiosarcoma (AS) was made from biopsy material. The patient is alive and well 18 months after exenteration and radiation therapy. The clinical and histopathologic features of this tumor are discussed with emphasis on the differential diagnosis of malignant vascular tumors of the orbit.

Angiosarcoma of the maxilla--a case report and review of the literature including angiosarcoma of maxillary sinus

A rare case of angiosarcoma of the maxilla is presented. It was treated with embolisation, radiotherapy, chemotherapy and surgery but resulted in death 14 months after initial presentation. Review of the literature shows three other cases of primary angiosarcoma of the maxilla and six of the maxillary sinus treated with poor results.

Malignant tumors of the paranasal sinuses: radiologic, clinical, and histopathologic evaluation of 200 cases

Malignant tumors of the paranasal sinuses are often found to be greatly advanced by the time a clinical or radiologic diagnosis is established. Therefore, the overall cure rate is low, even when surgery and radiation therapy are combined. The clinical manifestations and pathologic findings are analyzed in 200 cases to illustrate the wide spectrum of these tumors as to their type, specific location, and the extent to which they can spread within the sinuses and to adjacent anatomic areas. The various radiologic modalities, including conventional x-ray films, angiography, and conventional and computed tomography are presented. Their relative merit in the diagnosis and staging of these tumors is evaluated.

Epithelioid angiosarcoma of the orbit presenting as Tolosa-Hunt syndrome. A clinicopathologic case report with review of the literature

The clinical diagnosis of Tolosa-Hunt syndrome was first considered in a 66-year-old man with facial pain and diplopia. A complete neuroradiologic evaluation as well as an oncologic work-up yielded normal results. Several courses of oral prednisone provided no significant benefit. Within a year the patient became clinically worse and a CT scan disclosed an abnormal area of enhancement at the left orbital apex. An orbital exploration was performed elsewhere and a histologic diagnosis of myositis was obtained. Because of further worsening the patient was re-evaluated 3 months later and a CT scan showed a mass in the left orbital apex and superior orbital fissure. A second orbital exploration was performed and a sausage-shaped mass encompassing the optic nerve was excised. By light microscopy a poorly differentiated malignant tumor was infiltrating the orbital tissues with areas of intra- and perineural invasion. The tumor cells were arranged in strands and tubules with a definite tendency to form lumens that often contained red blood cells. Electron microscopic studies disclosed features consistent with a neoplasm of endothelial cell origin displaying a polarized basal lamina and rare micropinocytotic vesicles on the luminal side. The presence of multiple, slender microvilli and sometimes tonofilaments as well as desmosomes were interpreted as epithelioid metaplasia of an angiosarcoma.

The pathology of head and neck tumors: vasoformative tumors, part 9B

There are three principal malignant vasoformative tumors that can be found in the head and neck--hemangiopericytoma, angiosarcoma, and Kaposi's sarcoma. All are uncommon and provide challenges for the pathologist and the therapist both. The histogenesis of each tumor is different. Kaposi's sarcoma has many features which suggest that it is an altered immune-response disease. Angiosarcoma is a malignancy of endothelium. Hemangiopericytoma is a tumor whose cell of origin is considered to be the perithelial pericyte. The general prognosis for patients with Kaposi's sarcoma is good. The biologic course of a hemangiopericytoma is variable and unpredictable, but there appears to be a site dependency. Angiosarcomas, particularly high grade lesions, are resistant to therapy.

Angiolymphoid hyperplasia with eosinophilia: a disease that may be confused with malignancy

Twelve new cases of an unusual, benign vasoproliferative and inflammatory disorder of unknown etiology, angiolymphoid hyperplasia with eosinophilia (ALHE), are described and contrasted clinically and pathologically with those appearing in the literature. Only recently recognized in the United States, the disease is of singular importance because the vascular component may be confused histologically with angiosarcoma, thereby resulting in unwarranted aggressive therapeutic measures. ALHE characteristically affects adults and presents in the head and neck region as either solitary or multiple cutaneous tumors. The lesions are pruritic, frequently bleed after minor trauma, and may be associated with peripheral eosinophilia and regional lymphadenopathy. On rare occasions, the disease may masquerade as a salivary-gland tumor, cause stenosis of the external auditory canal, or present as an osseous lesion of the skull. Extrafacial tumors are uncommon. Excision is the most frequent form of therapy; however, local irradiation, corticosteroids, electrodessication with curettage, and chemotherapy have also had varying degrees of success.

Clinical course of unusual malignant sarcomas of head and neck

The clinical manifestations of 29 recently encountered sarcomas of the head and neck were analyzed in an attempt to define more accurately the diagnostic characteristics and therapeutic responses of these unusual tumors. The host factors of age, sex distribution, race, habits and associated features differ sufficiently to distinguish the sarcoma from the carcinoma population. In addition, the clinical course of sarcoma patients as monitored by mode of presentation, site of involvement, tumor histology, diagnostic features and certain elements of management and outcome, further indicates that these tumors can be defined and managed as a distinct group of lesions. A review of the recent literature supports the major conclusions of this study.