Malignant vascular lesions of bone: radiologic and pathologic features

Neoplastic and Non-neoplastic Bone Lesions of the Knee

Numerous anatomical variants are described around the knee, many of which look like bony lesions, so it is important to know them to avoid unnecessary complementary tests and inadequate management. Likewise, several alterations in relation to normal development can also simulate bone lesions.However, numerous pathologic processes frequently affect the knee, including traumatic, inflammatory, infectious, and tumor pathology. Many of these entities show typical radiologic features that facilitate their diagnosis. In other cases, a correct differential diagnosis is necessary for proper clinical management.Despite the availability of increasingly advanced imaging techniques, plain radiography is still the technique of choice in the initial study of many of these pathologies. This article reviews the radiologic characteristics of tumor and nontumor lesions that may appear around the knee to make a correct diagnosis and avoid unnecessary complementary radiologic examinations and inadequate clinical management.

Aortic Angiosarcoma Manifesting as Multiple Musculoskeletal Metastases: A Case Report

Aortic angiosarcomas are rare. Due to its rarity and metastatic presentation, it is difficult to diagnose metastatic aortic angiosarcoma. We describe the clinicopathological and radiologic features of a metastatic aortic angiosarcoma presenting as musculoskeletal metastases. A 59-year-old male patient presented with left thigh pain. Plain radiographs revealed multifocal osteolytic lesions in the left femur shaft. Abdominopelvic computed tomography showed a lobulated osteolytic lesion in the left iliac bone. Magnetic resonance images revealed multifocal soft tissue lesions in the thigh musculature. A positron emission tomography/computed tomography (PET/CT) scan demonstrated multiple foci of increased uptake in the left femur bone, pelvis, left thigh, and calf musculature. Focal increased uptake in the lower abdominal aorta was newly detected. Pelvis biopsy showed tumor cell nests of epithelioid cells. The tumor cells showed vasoformative features. Immunohistochemically, the tumor cells showed positivity for vimentin, CD31, and ERG. The pathologic diagnosis of epithelioid angiosarcoma was established. The origin of the tumor was presumed to be the aorta. This case underscores the importance of PET scans in identifying primary lesions. In terms of the histopathologic diagnosis of biopsy samples with tumor cells exhibiting epithelioid neoplastic morphology, employing appropriate ancillary techniques such as immunocytochemistry with vascular markers may assist in accurately diagnosing metastatic angiosarcoma.

Metastatic Epithelioid Hemangioendothelioma of the Bone: A Case Report and Literature Review

Epithelioid hemangioendothelioma (EHE) is an extremely rare vascular tumor, which can pose a diagnostic dilemma. It affects women more than men and is mainly found in the liver, lung, and bone. To date, there are no known predisposing factors. Limited data are available on the management of EHE at metastatic stages. The only optimal treatments to prevent metastatic dissemination are surgical resection and amputation in addition to radiotherapy at early stages. The oncologist in this rare entity plays an important role in the guided and standardized management of this disease, especially for advanced stages. In this article, we report the case of a 74-year-old patient admitted with swelling on the outer aspect of the right calf associated with pain and total functional impairment of the limb. The diagnosis favored a high-risk vascular tumor resembling EHE, confirmed by bone (tibia) and soft tissue biopsy. The patient underwent staging investigations, revealing diffuse metastases to the liver, bones, and lungs. The objective of this article is to advocate for oncological intervention in this entity, particularly in the advanced stages of the disease. Despite its rarity, the advancement of clinical trials and therapeutic recommendations remains crucial for optimal treatment.

Primary vascular tumors of bone: A comprehensive literature review on classification, diagnosis and treatment

Primary vascular tumors of bone are a heterogeneous group of neoplasms, ranging from benign hemangiomas to frankly malignant epithelioid hemangioendotheliomas and angiosarcomas. Over the years, their classification has been a matter of discussion, due to morphologic similarities and uncertainty regarding biologic behavior. Over the past decade, with the development of next-generation sequencing, there has been a significant improvement in the molecular characterization of these lesions. The integration of their morphologic, immunohistochemical and molecular features has led to a better stratification, with important prognostic and therapeutic implications. Nevertheless, primary vascular bone tumors still represent a challenge for medical oncologists. Given their rarity and heterogeneity, in the last few years, there has been no significant progress in medical treatment options, so further research is needed. Here we present a review of the current knowledge regarding primary vascular tumors of the bone, correlating clinicopathologic features with tumor behavior and therapeutic approaches.

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.

Multicentric Epithelioid Angiosarcoma of Bones Showing Angiotropic Spread: A Case Report

Epithelioid angiosarcoma is a rare variant of angiosarcoma characterized by an epithelioid morphology that mimics carcinoma. Therefore, multicentric epithelioid angiosarcoma is easily misdiagnosed as bone metastasis from carcinoma and has an aggressive clinical course. Here, we present a rare case of a 61-year-old male with multicentric epithelioid angiosarcoma of the bone. Plain radiography, CT, and MRI revealed multiple osteolytic lesions in both femurs; some lesions showed soft tissue extension with cortical bone destruction. Interestingly, PET-CT revealed that the lesions were only distributed along the bones of the lower extremities, including the pelvic bones, femurs, and tibiae. Despite histological analysis initially suggesting metastatic carcinoma, after additional immunohistological staining, including that for vascular markers (CD31 and ERG), the final diagnosis was epithelioid angiosarcoma. A better understanding of the clinicoradiological features of this disease may help eliminate diagnostic confusion and provide better management.

Primary Angiosarcoma of Lumbar Pedicle and Transverse Process Revealed by FDG PET/CT

ABSTRACT

The primary angiosarcoma of bone is rare. It typically occurs in tubular bones, pelvis, and trunk. However, its occurrence in the lumbar pedicle, and transverse process is infrequent. Thus, we present the imaging findings of FDG PET/CT in a rare case of primary angiosarcoma of lumbar pedicle and transverse process. It presented as solitary osteolytic bone destruction in the right pedicle and transverse process of L4 with intense FDG uptake. This case added knowledge of another rare occurrence site of primary angiosarcoma of bone, which should be considered as a differential diagnosis when we meet similar image appearance on FDG PET/CT.

Massive Calcified Epithelioid Hemangioendothelioma With Multifocal Involvement: An Imaging Diagnosis Dilemma and a Rare Case Report

Epithelioid hemangioendothelioma (EHE) is a rare malignant vascular tumor that develops from vascular endothelial or pre-endothelial cells. More than 60% patients have single-organ involvement, and involvement of multiple organs including the liver, lungs, and bones is extremely rare. The typical radiographic features of EHE include multiple small nodules in both lungs, which are usually located near small- and medium-sized blood vessels and the bronchi, and solitary, multiple, or diffuse lesions located at the hepatic periphery, spreading within the branches of the portal and hepatic veins. Radiologic calcification has been rarely reported in the literature. Here, we firstly described a case of a 53-year-old woman with EHE who presented with lungs, liver, bone, and right hilar lymph node involvement, manifesting as massive calcification on computed tomography. This case reminds physicians that EHE may present with unusual imaging manifestations, like massive calcification, and should be considered during the diagnostic process.

Imaging features of primary sites and metastatic patterns of angiosarcoma

Angiosarcomas are rare, aggressive soft tissue sarcomas originating from endothelial cells of lymphatic or vascular origin and associated with a poor prognosis. The clinical and imaging features of angiosarcomas are heterogeneous with a wide spectrum of findings involving any site of the body, but these most commonly present as cutaneous disease in the head and neck of elderly men. MRI and CT are complementary imaging techniques in assessing the extent of disease, focality and involvement of adjacent anatomical structures at the primary site of disease. CT plays an important role in the evaluation of metastatic disease. Given the wide range of imaging findings, correlation with clinical findings, specific risk factors and patterns of metastatic disease can help narrow the differential diagnosis. The final diagnosis should be confirmed with histopathology and immunohistochemistry in combination with clinical and imaging findings in a multidisciplinary setting with specialist sarcoma expertise. The purpose of this review is to describe the clinical and imaging features of primary sites and metastatic patterns of angiosarcomas utilising CT and MRI.

Primary Angiosarcoma of Humerus - A Case Report and Literature Review

INTRODUCTION

Osseous angiosarcoma is a very rare tumor of bone with aggressive behavior, propensity for recurrences, and distant metastasis. The etiology of osseous angiosarcoma is uncertain; however, specific risk factors have been recognized. The diagnosis of angiosarcoma of bone demands multimodality imaging in conjunction with histopathological and vascular marker evaluation to aptly differentiate them from other vascular tumors. Treatment of osseous angiosarcoma remains controversial.

CASE REPORT

A 53-year-old male presented with pain and swelling of the right upper 1/3rd of the arm following heaviness while lifting weight for 3 months. He had a history of significant weight loss and appetite with no history of inciting trauma or irradiation in the past. On examination, a diffuse swelling was noted in the right shoulder and right scapular aspect with varied consistency and ill-defined borders and margins. The skin over the swelling was stretched and shiny with dilated engorged veins over it. The plain radiograph of the right shoulder with humerus revealed a large expansile lytic soft-tissue mass in the right proximal humerus with a wide zone of transition without sclerotic margins. Magnetic resonance imaging showed T1 hypointense, T2/PDFS hyperintense large well-defined expansile lytic lesion with multi-loculated cysts, and multiple blood-fluid levels involving right proximal humerus. The patient underwent an incisional biopsy which exhibited angiosarcoma of the humerus. The patient was treated with six cycles of chemotherapy with a mesna, doxorubicin, ifosfamide, and dacarbazine regimen. The patient was still under follow-up.

CONCLUSION

Being a rare clinical entity, controversy exists in angiosarcoma of humerus regarding its etiology and recommended management protocols. Histopathology and immunohistochemistry remain the gold standard in differentiating osseous angiosarcoma from other osseous vascular tumors. The treatment protocol has to be standardized to decrease morbidity and to improve the functional quality of life of the patient.

A Clinical Model of Bone Angiosarcoma Patients: A Population-based Analysis of Epidemiology, Prognosis, and Treatment

Objective

To investigate the epidemiological data, prognostic factors, and treatment outcomes of bone angiosarcoma (BA).

Methods

This retrospective study was based on the Surveillance, Epidemiology, and End Results (SEER) database. The medical records of BA patients were selected from the SEER database from 1975 to 2016. Variables including patients' baseline demographics (age, sex, marital status, and year of diagnosis), tumor characteristics (tumor size, grade, and SEER Historic Stage A), and treatment (surgery and radiotherapy) were selected for further analysis. The research endpoints were overall survival (OS) and cancer‐specific survival (CSS). The optimal cutoff values of continuous variables including age, year of diagnosis, and tumor size were identified using the X‐tail program. Univariate Cox regression was used to identify potential prognostic factors and multivariate Cox regression was used to identify independent prognostic factors. All prognostic factors were included to predict the survival time compared to the median OS and CSS times via the novel nomograms. To validate the internal validation of nomograms, we analyzed the concordance indices (C‐index).

Results

This study enrolled a total of 271 patients with malignant vascular bone tumors among residents of the United States between 1975 and 2016. After applying the exclusion criteria (one case without active follow‐up), this study included 152 patients with BA. The median survival time of BA was significantly shorter than that of malignant vascular bone tumors for OS (9 months vs 27 months, P < 0.001). Age, year of diagnosis, tumor size, grade, stage, and surgery were identified as potential prognostic factors for OS or CSS in univariate Cox regression. However, only age (P < 0.001, P < 0.001), stage (P = 0.002, P < 0.001), and surgery (P = 0.001, P = 0.002) were independent prognostic factors for CSS and OS, respectively, in the multivariate analysis. Younger patients less than 54 years have significantly better prognosis for CSS/OS than patients between 54 and 67 years (Hazard ratios [HRs]: 1.651 [1.763–3.575], 2.557 [1.395–4.687]) and more than 67 years (HRs: 4.404 [2.237–8.670], 5.113 [2.923–8.942]). For CSS/OS, the survival time of patients with localized stage was significantly longer than that of patients with regional stage (HRs: 1.530 [0.725–3.228], 1.548 [0.834–2.873]) and that of patients with distant stage (HRs: 1.706 [0.899–3.237], 2.101 [1.254–3.520]). Patients with surgery had more survival time than patients without surgery for CSS/OS (HRs: 2.861 [1.542–5.310], 2.103 [1.308–3.379]). All factors were further included to generate nomograms for CSS and OS. The C‐indexes for the internal validation of OS and CSS prediction were 0.787 (95% confidence interval [CI]: 0.738–0.836) and 0.768 (95% CI: 0.717–0.819), respectively.

Conclusions

Age, stage, and surgery were closely associated with prognosis in patients with BA, and this clinical model was a favorable tool to evaluate survival possibilities.

Prognostic Determinants Analysis and Nomogram for Bone Malignant Vascular Tumors: A Surveillance, Epidemiology and End Results (SEER) Analysis

Background

The aim and objective of our investigations were to explore the prognostic value of various clinical and pathological factors of bone malignant vascular tumors and establish a nomogram for their outcome predictions.

Material/Methods

All data of primary bone malignant vascular tumors (MVTs) patients were randomly selected from the Surveillance, Epidemiology and End Results (SEER) database. However, selected patients were clinically diagnosed with various cancers during 1988–2015. The potential prognostic factors were analyzed using SPSS (Windows, version 22.0). All prognostic factors were combined to formulate a nomogram to predict the overall survival (OS).

Results

A total of 266 selected patients were included in our study. In the univariate model, age (P<0.001), sex (p=0.0255), primary site (P<0.001), surgery (P<0.001), histologic type (P<0.001), metastasis (p=0.000), and pathological grade (P<0.001) were statistically significant for patient survival. The results of Cox analysis revealed that age (≥64) HR: 3.636, 95% CI [1.955–6.762], p=0.000, the primary site in skull HR: 2.6, 95% CI [1.584–4.268], p<0.001], without surgery HR: 1.473 95% CI [1.239–1.751], p<0.001, metastasis HR: 3.076 95% CI [1.983–4.771] p=0.000, man HR 1.802, 95% CI [1.032–3.004], p=0.045, and high malignant grade HR: 3.029, 95% CI [2.101–4.366], p=0.003 were independent unfavorable prognostic factors. Angiosarcoma had highest mortality rate among all vascular malignancies. The nomogram predicting overall survival achieved a C-index of 0.694 (95% CI 0.631, 0.745) in the SEER cohort.

Conclusions

Surgery can significantly increase OS survival time for bone MVTs, and low-grade malignancy is a significant factor for OS. However, advanced age, tumor metastasis, primary site in skull, AS, and male sex are predictors of poor prognosis.

Angiosarcoma of bone: a retrospective study of the European Musculoskeletal Oncology Society (EMSOS)

Angiosarcoma of bone (B-AS) is a rare malignant tumor of vascular origin. The aim of this retrospective study is to report on treatments and prognosis. Data were collected from the EMSOS website. 80 patients in 9 centers included: 51 male/29 female; median age 54 years (range 17 to 92); 56% with localized disease, 44% metastatic. Primary tumor surgery: 76% (30% amputation, 26% intralesional margins); radiotherapy (RT): 41%; chemotherapy (CT): 47% (56% in metastatic, 41% in localized cases). With a median follow-up of 31 months (range 40 to 309), 5-year overall survival (OS) was 27% (95%CI 16–30): 41% (95%CI 25–56) for localized patients, and 8% (95%CI 0–20) for metastatic (p = 0.002). In metastatic patients, 1 year OS was significantly influenced by chemotherapy response: 67% (95CI% 29–100) for those who responded or had stable disease (n = 7), and 18% (95CI% 0–41) for patients with progressive disease (n = 11), p 0.002. The surgical complete remission (SCR) status was pivotal in localized patients (5-year OS 45% for SCR, 17% no SCR, p = 0.03); also 5-year OS was significantly influenced by age and site of the tumor. After multivariate analysis, the addition of radiotherapy to surgery significantly influenced the disease-free survival (DFS) rate, whereas the use of chemotherapy lost the significance showed at the univariate analysis. Overall, patients with metastatic B-AS have a dismal prognosis, with a prolonged survival in case with a response to chemotherapy. Experimental trials with more active systemic treatment regimens are needed. In patients with localized disease, the patient’s age and site of the tumor are prognostic factors and any effort must be made to achieve an SCR status. No definitive conclusions can be drawn from our data on the use of adjuvant chemotherapy, while the use of adjuvant radiotherapy might improve DSF in patients surgically free of disease.

Pseudomyogenic hemangioendothelioma-A case report and review of the literature

Pseudomyogenic hemangioendothelioma (PMH) of bone is a very rare tumor and frequently presents at multiple locations. PMH is difficult to diagnose by imaging and histopathologic features. Various and partially discordant imaging findings have been reported in case reports and small case series. We report a case of a 63-year-old man with PMH isolated to the sacrum, presenting with chronic intermittent buttock pain that was incidentally identified on imaging for acute pancreatitis. We believe that learning about PMH of bone will help to include this disease in the differential diagnosis of lytic lesions of the sacrum. Becoming aware of the various and sometimes discordant imaging findings of this rare entity is important and helpful for radiologists, pathologists, and orthopedic surgeons.

Survival Analysis of Patients with Osseous Malignant Vascular Tumors: Results of the Surveillance, Epidemiology, and End Results (SEER) Database from 1973 to 2015

Background

Osseous malignant vascular tumors (OMVTs) are rare lesions. Moreover, the prognostic determinants of OMVTs have not been reported. This study aimed to present epidemiological data and analyze the prognostic factors of survival in OMVT patients.

Material/Methods

OMVT patients who were diagnosed between 1973 and 2015 were screened using the Surveillance, Epidemiology, and End Results (SEER) program database, with special attention paid to osseous hemangiosarcoma (OAS) and osseous hemangioendothelioma (OHE). We assessed the prognostic values of cancer-specific survival (CSS) and overall survival (OS) rates with a Cox proportional hazards regression model and univariate and multivariate analyses. OS and CSS curves were obtained using the Kaplan-Meier method.

Results

A total of 202 cases were selected from the SEER database. The specific histopathological diagnoses were osseous hemangiosarcoma (n=127) and osseous hemangioendothelioma (n=75). Among OMVT patients, histology was an important factor in determining survival. Using multivariate analysis, old age, distant tumor stage, surgery, and low tumor grade were predictors of OS for OAS patients. Old age, surgery, and low tumor grade were predictors of CSS. Using multivariate analysis, old age and surgery were predictors of OS and CSS for OHE patients.

Conclusions

This study is the largest population-based study to show the demographic characteristics and analyze the prognosis of OMVT patients. Independent predictors of OS for patients with AS included old age, distant tumor stage, low tumor grade, and surgery. Old age, surgery, and low tumor grade were also predictors of CSS for patients with OAS. Independent predictors of CSS and OS for patients with OHE included old age and surgery.

Imaging findings in epithelioid hemangioendothelioma

PURPOSE-OBJECTIVE

Epithelioid hemangioendothelioma (EHE) is a rare vascular malignancy with varying biologic behavior. The purpose of this study was to identify imaging findings most characteristic of EHE.

METHODS

Retrospective review of clinical and imaging records in patients referred to our Vascular Anomalies Center over a 17 year period with biopsy proven EHE.

RESULTS

We evaluated 29 patients (17 F) with median age of 16 years (range 2-76 y). The most common presenting symptoms were pain (n = 13) and palpable mass (n = 7). 22 (70%) had multifocal disease. Most common sites of involvement were lung (n = 25), liver (n = 16), bone (n = 12), soft tissue (n = 3) and lymph nodes (n = 1). Of patients with single site disease, 3 had lung, 3 liver, and 1 had bone lesions. In 18/25 with lung disease, there were multiple nodules of varying sizes and characteristics. In 14/16 with hepatic disease there were multiple nodules with predominantly peripheral distribution. Subcapsular retraction was seen in 10/16 and a "lollipop" sign (hepatic or portal vein tapering at the edge of a well-defined hypoenhancing lesion) identified in 5/16. Of 12 osseous lesions, 11 were lytic, 8 involved vertebrae and 9 involved the axial skeleton.

CONCLUSION

EHE has varied imaging findings. The most common sites are lungs, liver, and bone, with multi-organ involvement seen in most. Lung disease is most commonly characterized by multiple nodules. Hepatic lesions demonstrate the most distinctive findings, with peripheral distribution, lack of early enhancement, subcapsular retraction and "lollipop" sign. Osseous lesions are commonly lytic and more prevalent in the axial skeleton.

Epithelioid hemangioendothelioma of the bone: A case report with findings of bone scintigraphy

INTRODUCTION

Epithelioid hemangioendothelioma (EHE) of the bone is a very rare malignant vascular neoplasm, with biologic behavior between that of locally aggressive epithelioid hemangioma and malignant epithelioid angiosarcoma. We report a case of a patient with EHE who underwent bone scintigraphy, try to identify the characteristics of it, to highlight the clinical importance of whole-body bone scintigraphy and single-photon emission computed tomography/computed tomography (SPECT/ CT) in the diagnosis and treatment of EHE.

PATIENT CONCERNS

A 67-year-old man with no history of trauma who reported pain in both lower limbs for 6 months, which had been worsening over the last 20 days. Anteroposterior and lateral radiographs of both lower limbs revealed numerous osteolytic lesions in the tibia and fibula bilaterally. Tc-methylene diphosphonate (MDP) bone scintigraphy demonstrated increased tracer uptake in the pelvic and bilateral lower limb bones. SPECT/CT bone imaging showed numerous osteolytic lesions cluster in the same anatomic region, with high tracer uptake in lesion margins.

DIAGNOSIS

EHE of the bone.

INTERVENTIONS

Two months after the diagnosis was confirmed, the patient was rehospitalized. Nonopioid analgesic use had not provided pain relief. Magnetic resonance imaging (MRI) of both thighs showed the bone cortex was destroyed with numerous irregular lesions, and soft-tissue was involved. A second bone scintigraphy did not show any new lesions. He was administrated with recombination human endostatin injection 15 mg ivgtt qd for 14 days, combined with apatinib mesylate tablets 500 mg po qd for 18 days.

OUTCOMES

He was discharged voluntarily and died 2 months later.

CONCLUSION

EHE of the bone is a very rare malignant vascular neoplasm with no specific radiographic imaging features. Whole-body bone scintigraphy, especially SPECT/CT bone imaging, significantly reduces ambiguous diagnoses and is recommended before treatment.

Prognostic Factors of Patients With Malignant Epithelioid Vascular Tumors in the Spine: Retrospective Analysis of 46 Patients in a Single Center

STUDY DESIGN

A retrospective study of 46 patients with malignant epithelioid vascular tumors (MEVT) in the spine was performed.

OBJECTIVE

The purpose of this study was to illustrate the clinic characteristics of MEVT in the spine and to discuss prognostic factors by survival analysis.

SUMMARY OF BACKGROUND DATA

MEVT in the spine is relatively uncommon, and there is little published information regarding this subject. Therefore, prognostic factors of this disease are still controversial.

METHOD

The univariate and multivariate analysis of various clinic characteristics were performed to identify the independent factor that affects prognosis for patients with MEVT in the spine who underwent surgical treatment in Changzheng Hospital Orthopedics Oncological Center (CHOOC) between 2005 and 2015. Disease-free survival (DFS) and overall survival (OS) were estimated by Kaplan-Meier method to identify potential prognostic factors. Factors with P values of 0.1 or less were subjected to multivariate analysis by Cox regression analysis. P values of 0.05 or less was considered statistically significant.

RESULT

A total of 46 patients with MEVT in the spine were included in the study. The mean follow-up period was 42.6 months (range, 5-143 mo). Recurrence was detected in 22 patients after initial surgery in our center, whereas death in 18 patients. The univariate analysis suggested that age (<30 yr/≥30 yr), metastasis, preoperative Frankel score, postoperative Frankel score, malignant grade and resection mode were potential prognostic factors for DFS and OS. However, as they were submitted to multivariate analyses, only malignant grade and resection mode were independent prognostic factors.

CONCLUSION

Total en bloc spondylectomy can significantly improve DFS for MEVT in the spine and low-grade malignancy was favorable factor for DFS. Total spondylectomy and low-grade malignancy considerably improve OS for patients with MEVT in the spine.

LEVEL OF EVIDENCE

4.

Primary angiosarcoma of the femur in a patient with Takayasu arteritis

Primary osseous angiosarcoma is a rare entity with variable biological behavior and poor prognosis. Little is known about the oncologic treatment and its etiology is still unknown. This study presents a case of lytic lesion in the right femur with dissemination to other bones, such as the vertebral column and skull, and to the lungs and central nervous system. Orthopedic surgery was performed in order to improve quality of life. Surgical specimen confirmed the diagnosis of high-grade malignant osseous angiosarcoma. Despite oncologic and orthopedic treatment, the patient had rapid and aggressive progression with a poor outcome.

Vascular Tumors of Bone: The Evolvement of a Classification Based on Molecular Developments

The classification of vascular tumors of bone has been under debate over time. Vascular tumors in bone are rare, display highly overlapping morphology, and, therefore, are considered difficult by pathologists. Compared with their soft tissue counterparts, they are more often multifocal and sometimes behave more aggressively. Over the past decade, with the advent of next-generation sequencing, recurrent molecular alterations have been found in some of the entities. The integration of morphology and molecular changes has led to a better characterization of these separate entities.

Solitary Primary Intraosseous Angiosarcoma of the Mandible

Angiosarcoma is a malignant vascular tumor derived from the mesenchymal cells which have undergone an angioblastic differentiation. About half of the angiosarcomas are reported to localize in the skin and soft tissues of the head and neck, i.e., found predominantly to arise from the scalp and face. Angiosarcomas rarely involve the skeletal system, wherein they generally have a tendency for multicentricity. Primary bony angiosarcoma accounts for about 6% of all the angiosarcomas and about 1.4% of all the primary bony sarcomas. A majority of angiosarcomas are reported to occur in the elderly males; its occurrence in the pediatric population is extraordinarily rare. We report a rare case of a solitary primary intraosseous mandibular angiosarcoma in a 7-year-old male child. The unique clinical presentation, the histopathological features along with the management challenges of this fascinating yet aggressive tumor is discussed.

Epithelioid hemangioma of the scapula treated with chemoembolization and microwave ablation: Α case report

Bone epithelioid hemangiomas are classified within benign vascular tumours but are commonly misdiagnosed as low-grade angiosarcomas or epithelioid hemangioendotheliomas. Current therapeutic interventions include various treatment options but local recurrence or distal lymph node involvement has been reported. We report a rare case of scapular epithelioid hemangioma that was initially treated using a combination of chemoembolization and microwave ablation. This combination has not been previously reported in the literature regarding the management of this tumour. A year after the first course of treatment, the tumour size has been reduced more than 70% and the patient has remarkable clinical improvement. Results reported in this case study demonstrated that combination of chemoembolization and microwave ablation is a feasible, safe and effective technique in the treatment of bone epithelioid hemangiomas. Even if the tumour is still present afterwards, a substantially smaller surgical excision will be needed.

Epithelioid Angiosarcoma in Femur: A Case Presentation

Primary malignant vascular tumors which constitute less than 1% of the primary bone tumors are very rarely encountered. Epithelioid angiosarcoma is a very uncommon subtype of angiosarcomas presenting with an epithelioid phenotype and mimicking carcinomas clinically. These tumors select mostly extra-skeletal locations but rarely bones as their medium. A 31-year-old male patient applied to our clinic with a nonspecific left hip pain. X-ray evaluation revealed a cystic expansile mass in the trochanteric region of the femur extending to the femoral neck. Computed tomography examination proved that the mass was cystic and 7 cm in its greatest width and contained septum. Moreover, magnetic resonance imaging examination was reported as a mass resembling aneurysmal bone cyst. The final diagnosis of epithelioid angiosarcoma was made by histological examination and biopsy of the mass. The excised specimen was examined further to verify the preoperative diagnosis.

Differential CT and MR imaging diagnosis between low- and high-grade malignant vascular tumors of bone

Objective

To investigate the CT and MR imaging findings and differential diagnosis of malignant vascular tumors of bone.

Materials and methods

CT and MR imaging findings of 18 patients with histopathology-proven malignant vascular tumors of bone were examined. Assessed image features included age, sex, location, CT findings, and MR imaging appearances and dynamic contrast-enhanced MR imaging.

Results

The study group comprised 18 cases, of which 7 were categorized as low-grade malignant vascular tumors (LMT), and 11 were categorized as high-grade malignant vascular tumors (HMT). Malignant vascular tumors of bone showed osteolytic lesions with heterogeneous signs and enhancement, and frequently associated with soft tissue masses and peritumorous edema. The mean age of patient was respectively 34.7 years in LMT with 3 patients younger than 20 and 49.9 years in HMT with 3 patients older than 60 years. The mean lesion diameter was 3.6 cm (range 2–7.2) in LMT with two lesions <3 cm and 7.1 cm (range 3–13) in HMT with 3 lesions greater than 10 cm. LMT showed multifocal (57.1 %) and well-defined (71.5 %) lesions with residual bone (57.1 %), peripheral sclerosis (85.7 %), and slightly hetergeneous enhancement (71.4 %), compared to those of HMT with 9.1, 45.5, 27.3, and 72.7 %, and 9.1 % respectively. Also, HMT appeared as expansive (54.5 %), ill-defined (54.5 %), macroscopic necrosis/cystic (81.8 %) or hemorrhagic (27.3 %) lesion with pathological fracture (27.3 %), and often presented with obviously hetergeneous enhancement (81.8 %), compared to those of LMT with 42.9, 28.6, 42.9, 0, 14.3 and 14.3 % respectively.

Conclusions

There are some differences in the imaging features between LMT and HMT, while unifocal/multifocal, expansive, ill-defined, necrosis/cystic, hemorrhagic features with age, lesion diameter, peripheral sclerosis, residual bone tissue, pathological fracture and slightly/obviously hetergeneous enhancement highly suggest their differential diagnosis.

Epithelioid Hemangioma of Bone: A Potentially Metastasizing Tumor?

The case of a 15-year-old boy with a severe swelling of the 2nd toe in the left foot and a large swelling of the left inguinofemoral region is described. Histologic examination of the foot lesion showed a typical epithelioid hemangioma of bone that extended into the soft tissues, with a secondary location in the groin, suggestive of lymph node involvement. Subsequently, imaging also revealed swelling of iliac and para-aortic lymph nodes, which probably indicates further lymph node spread.. Besides the fact that epithelioid hemangioma of the toe has not been reported yet, our case showed a noncontinuous localization, most likely in draining lymph nodes. This finding suggests metastatic disease, an event that is extremely rare for epithelioid hemangioma. As such, epithelioid hemangioma might be comparable to another benign vascular tumor, the retiform hemangioendothelioma, which occasionally metastasizes to the lymph nodes without systemic spread.

Multiple epithelioid hemangioedothelioma of the skull in a child: A case report

INTRODUCTION

Epithelioid hemangioedothelioma (EHE) is a rare vascular tumor characterized by neoplastic proliferation of epithelioid or histiocytoid epithelial cells. EHE of bone constitutes <1% of primary malignant bone tumor. EHE in the skull is an extremely rare case. Here, we report a case of multiple neoplasm of the skull in a 15-month-old boy who presented with gradual facial swelling for 2 months. On computed tomography (CT) scan, multiple irregular osteolytic lesions were seen on the right maxillary, sphenoid, left zygoma, and roof of the left orbit. Excisional surgery of the lesion was planned. Histopathological and immunohistochemical examination of excised specimen suggest it to be epithelioid hemangioedothelioma. Follow-up for 6 months showed no recurrence.

CONCLUSION

Epithelioid hemangioedothelioma is a locally aggressive tumor with metastatic potential. CT imaging could help in assessment of lesion, but final diagnosis is possible only with histopathology. Complete surgical resection at the early stage of the disease is the most effective treatment with better prognosis.

Epithelioid Hemangioendothelioma of the Distal Radius: A Case Report

Epithelioid hemangioendothelioma is a rare vascular tumor with cytologic behavior between angiosarcoma and hemangioma. We present the case of a 58-year-old male with primary epithelioid hemangioendothelioma of the distal radius measuring 6.2 × 5 cm with extension into the pronator quadratus and brachioradialis muscles. We discuss our approach to performing a limb-sparing resection combined with reconstruction to preserve upper extremity function. A review of the clinical, radiographic, and pathologic features of epithelioid hemangioendothelioma is also presented.

Multicentric Primary Angiosarcoma of Bone Mimicking Metastasis on (18)F-FDG PET/CT in a Patient with a History of Sigmoid Colon Cancer: a Case Report

Primary angiosarcoma of the bone (PAB) is a rare and fatal high-grade malignant vascular bone tumor. We report a rare case of multicentric PAB mimicking bone metastasis in a 59-year-old female patient with a history of sigmoid colon cancer. This patient complained of lower back and pelvic pain and presented with multiple osteolytic bone lesions on plain radiography and pelvic computed tomography. First, bone metastasis of sigmoid colon cancer was suspected. However, on the (18)F-fluorodeoxyglucose ((18)F-FDG) positron emission tomography/computed tomography (PET/CT) scan, the patient presented unusual multiple hypermetabolic osteolytic bone lesions involving contiguous bones of the lower half of the body. After bone biopsy, these lesions were confirmed to be multicentric PAB. To the best of our knowledge, this is the first case report of an (18)F-FDG PET/CT scan in a patient with multicentric primary bone angiosarcoma.

Fusion events lead to truncation of FOS in epithelioid hemangioma of bone

Epithelioid hemangioma of bone is a locally aggressive vascular neoplasm. It can be challenging to diagnose because of the wide histological spectrum, which can make it difficult to differentiate from other vascular neoplasms such as epithelioid hemangioendothelioma or epithelioid angiosarcoma. COBRA-FISH karyotyping identified a balanced t(3;14) translocation. Transcriptome sequencing of the index case and two other epithelioid hemangiomas revealed a recurrent translocation breakpoint involving the FOS gene, which was fused to different partners in all three cases. The break was observed in exon 4 of the FOS gene and the fusion event led to the introduction of a stop codon. In all instances, the truncation of the FOS gene would result in the loss of the transactivation domain (TAD). Using FISH probes we found a break in the FOS gene in two additional cases, in none of these cases a recurrent fusion partner could be identified. In total, FOS was split in 5/7 evaluable samples. We did not observe point mutations leading to early stop codons in any of the 10 cases where RNA was available. Detection of FOS rearrangement may be a useful diagnostic tool to assist in the often difficult differential diagnosis of vascular tumors of bone. Our data suggest that the translocation causes truncation of the FOS protein, with loss of the TAD, which is thereby a novel mechanism involved in tumorigenesis.

The myriad of diseases that present with polyostotic bone lesions

Many diseases result in polyostotic bone lesions including benign entities, benign entities with malignant potential, intermediate entities, and malignant entities. Imaging plays a key role in identifying complications of these disorders, most importantly malignant transformation of a benign lesion. The most common polyostotic bone lesions are reviewed and examples of malignant transformation are highlighted.

Thoracic epithelioid malignant vascular tumors: a clinicopathologic study of 52 cases with emphasis on pathologic grading and molecular studies of WWTR1-CAMTA1 fusions

Malignant thoracic epithelioid vascular tumors are an uncommon and heterogenous group of tumors that include low-grade to intermediate-grade epithelioid hemangioendothelioma (EHE) and high-grade epithelioid angiosarcoma (EAS). We examine the morphologic and immunohistochemical features of 52 malignant epithelioid vascular tumors (10 low-grade EHE, 29 intermediate-grade EHE, and 13 EAS) involving the thorax (lung, pleura, mediastinum, heart, great vessels) including cases with exclusively thoracic disease (35) and with multiorgan disease including the thorax (17). Intermediate-grade EHE differs from low-grade EHE by the presence of necrosis, increased mitotic activity, and increased atypia. Morphologic features such as intranuclear inclusions, intracytoplasmic vacuoles, and stromal changes (chondroid, myxoid, or hyalinized stroma) are seen more frequently in EHE, whereas blood lakes, proliferation of slit-like vessels, and prominent nucleoli favor EAS. Fluorescence in situ hybridization analysis showed CAMTA1-WWTR1 fusions in 4/7 low-grade and 23/23 intermediate-grade EHE (P<0.001). In EAS, CAMTA1 rearrangement was negative in all cases, whereas a WWTR1 complex abnormality was found in 1/5 cases (P<0.001). This offers an objective means of differentiating intermediate-grade EHE from EAS, especially on limited biopsies. All cases show expression of at least 1 vascular marker, which allows differentiation from primary thoracic epithelial malignancies, although keratin expression is a potential pitfall with 29% of EHE and 25% of EAS showing keratin expression. Survival analysis shows that higher tumor grade for all tumors (P=0.026) as well as lung and pleural tumors only (P=0.010) and the presence of pleural involvement in lung and/or pleural tumors (P=0.042) correlate with poor prognosis.

Primary angiosarcoma of bone: a retrospective analysis of 60 patients from 2 institutions

BACKGROUND

Angiosarcoma of bone is a rare high-grade malignant vascular tumor. The literature regarding treatment and outcome of patients with this tumor is limited.We performed a 2 institutional retrospective study to analyze treatment and survival of patients with angiosarcoma of bone.

PATIENTS AND METHODS

We reviewed patients with the histologic diagnosis of primary angiosarcoma of bone treated from 1980 to 2009. Demographic details, histology, treatment, and survival were reviewed.

RESULTS

A total of 38 men and 22 women (median age, 54 y) were recruited. Most lesions occurred in the femur and the pelvis. Metastatic disease at presentation was diagnosed in 24 patients (40%). Forty-three patients underwent surgery, with 30 of them achieving surgical complete remission (SCR). Radiotherapy was applied to 17 patients, and chemotherapy to 13/35 and 15/22 patients with localized and metastatic disease, respectively.The 5-year overall survival (OS) was 20%: 33% for patients with localized disease and 0% for metastatic patients. Higher 5-year OS was reported for patients who achieved SCR (46%) than for those who did not (0%). In nonmetastatic patients, a trend toward improved survival was observed after SCR and adjuvant chemotherapy based on cisplatin, doxorubicin, and ifosfamide.Fifteen patients received chemotherapy for metastases. Two RECIST partial responses of 13 evaluable patients were documented (paclitaxel [n=1] and doxorubicin [n=1]). Stable disease was observed in 2 patients.

CONCLUSIONS

Complete surgical resection is essential for outcome. Survival of patients with metastatic or unresectable disease is very poor. Activity of taxanes and anthracycline was observed in the metastatic setting and merits further evaluation.

A systematic approach to vertebral hemangioma

Vertebral hemangiomas (VHs) are a frequent and often incidental finding on computed tomography (CT) and magnetic resonance (MR) imaging of the spine. When their imaging appearance is "typical" (coarsened vertical trabeculae on radiographic and CT images, hyperintensity on T1- and T2-weighted MR images), the radiological diagnosis is straightforward. Nonetheless, VHs might also display an "atypical" appearance on MR imaging because of their histological features (amount of fat, vessels, and interstitial edema). Although the majority of VHs are asymptomatic and quiescent lesions, they can exhibit active behaviors, including growing quickly, extending beyond the vertebral body, and invading the paravertebral and/or epidural space with possible compression of the spinal cord and/or nerve roots ("aggressive" VHs). These "atypical" and "aggressive" VHs are a radiological challenge since they can mimic primary bony malignancies or metastases. CT plays a central role in the workup of atypical VHs, being the most appropriate imaging modality to highlight the polka-dot appearance that is representative of them. When aggressive VHs are suspected, both CT and MR are needed. MR is the best imaging modality to characterize the epidural and/or soft-tissue component, helping in the differential diagnosis. Angiography is a useful imaging adjunct for evaluating and even treating aggressive VHs. The primary objectives of this review article are to summarize the clinical, pathological, and imaging features of VHs, as well as the treatment options, and to provide a practical guide for the differential diagnosis, focusing on the rationale assessment of the findings from radiography, CT, and MR imaging.

Epithelioid hemangioendothelioma of the spine: results at seven years of average follow-up in a series of 10 cases surgically treated and a review of literature

PURPOSE

To review a series of ten cases with epithelioid hemangioendothelioma of the spine, that have undergone surgery to describe clinical presentation, results and complications associated with surgical treatment; a review of literature reporting the main characteristics of the cases already published has been reported.

METHODS

A review of patients affected by epithelioid hemangioendothelioma surgically treated by the senior author from 1995 to 2012 was carried out. Ten cases were identified and clinical and radiological characteristics, therapy, complications and survival were valued.

RESULTS

Wide margin was achieved in two out of ten cases, marginal margin in seven and intralesional margin in one case. Average intraoperative blood loss was about 2,800 ml. Reported complications were one case of cord injury, one of dural tear, two cases of massive blood loss, a case of reconstruction failure, a wound dehiscence with deep infection, a pneumonia episode and a deep vein thrombosis with pulmonary embolism. Average follow-up was 84.4 months. Two local recurrences, after 32 and 37 months and two deaths for metastasis, after 14 and 36 months, were reported. Although several chemotherapy protocols are available for the treatment of EH of soft tissue, they are not relevant for the bone.

CONCLUSIONS

Wide surgery is probably associated with a better prognosis. Indeed most deaths and local recurrences reported in literature happened after intralesional surgery or chemotherapy/RT alone. The presenting study suggests that the best approach to achieve long-term local control and a major survival could be wide surgery, nevertheless more cases series are necessary to verify survival rate.

Epithelioid hemangioendothelioma of the bone: a review and update

Epithelioid hemangioendothelioma is a vascular tumor of low to intermediate malignancy that was initially described in the soft tissue. Since then, epithelioid hemangioendothelioma has been described in various anatomic sites including parenchymal tissues and the bone. In the bone, these tumors must not only be distinguished from other vascular tumors that can arise in this location, primarily epithelioid hemangioma and epithelioid angiosarcoma, but also from metastatic carcinoma. Discussion of the historical context and the pertinent literature on the subject forms the basis of this review.

Multifocal epithelioid hemangioendothelioma of the foot and ankle: a case report

We report on a 41-year-old man with multiple epithelioid hemangioendothelioma of the left foot and ankle. The patient was treated with curettage and fixation with 2 separate plates, but later developed local infection. Owing to the potential for malignancy, below-knee amputation was suggested, but the patient declined and was treated symptomatically with close monitoring. The patient underwent removal of the plates, excision of the distal fourth of the fibula, intralesional curettage of all lesions, and fusion of the ankle and subtalar joints with a retrograde intramedullary nail. After 5.5 years, the patient had recovered well and had no evidence of malignancy. The tumour was considered definitively benign.

Intraosseous angioleiomyoma the tibia: a case report

Angioleiomyoma (vascular leiomyoma/angiomyoma) is a morphologically distinctive tumor characterized by proliferating smooth muscle cells admixed with prominent vascular elements. The majority of angioleiomyomas involve the superficial soft tissues. Examples of this lesion originating in bone, particularly in the appendicular skeleton, are extremely rare. The present report details the clinicopathologic features of an unusual case of an intraosseous angioleiomyoma arising in the distal tibia. The skeletal tumor exhibited the typical histologic appearance and immunophenotypic features of this entity. Due to its rarity, angioleiomyoma of bone can pose problems in diagnosis. Awareness that angioleiomyoma can present as a primary intraosseous lesion is important so as not to confuse this neoplasm with more commonly encountered bone tumors.

The molecular basis for the pharmacokinetics and pharmacodynamics of curcumin and its metabolites in relation to cancer

This review addresses the oncopharmacological properties of curcumin at the molecular level. First, the interactions between curcumin and its molecular targets are addressed on the basis of curcumin's distinct chemical properties, which include H-bond donating and accepting capacity of the β-dicarbonyl moiety and the phenylic hydroxyl groups, H-bond accepting capacity of the methoxy ethers, multivalent metal and nonmetal cation binding properties, high partition coefficient, rotamerization around multiple C-C bonds, and the ability to act as a Michael acceptor. Next, the in vitro chemical stability of curcumin is elaborated in the context of its susceptibility to photochemical and chemical modification and degradation (e.g., alkaline hydrolysis). Specific modification and degradatory pathways are provided, which mainly entail radical-based intermediates, and the in vitro catabolites are identified. The implications of curcumin's (photo)chemical instability are addressed in light of pharmaceutical curcumin preparations, the use of curcumin analogues, and implementation of nanoparticulate drug delivery systems. Furthermore, the pharmacokinetics of curcumin and its most important degradation products are detailed in light of curcumin's poor bioavailability. Particular emphasis is placed on xenobiotic phase I and II metabolism as well as excretion of curcumin in the intestines (first pass), the liver (second pass), and other organs in addition to the pharmacokinetics of curcumin metabolites and their systemic clearance. Lastly, a summary is provided of the clinical pharmacodynamics of curcumin followed by a detailed account of curcumin's direct molecular targets, whereby the phenotypical/biological changes induced in cancer cells upon completion of the curcumin-triggered signaling cascade(s) are addressed in the framework of the hallmarks of cancer. The direct molecular targets include the ErbB family of receptors, protein kinase C, enzymes involved in prostaglandin synthesis, vitamin D receptor, and DNA.

Angiosarcoma of the humerus presenting with fluid-fluid levels on MRI: a unique imaging presentation

Fluid-fluid levels are a known feature of a number of osseous lesions, but have never before been described in primary osseous angiosarcoma, which is itself a rare malignancy. We report a case of humeral angiosarcoma presenting with fluid-fluid levels. Recognizing this entity as a possible etiology for fluid-fluid levels could help radiologists to avoid potential confusion in the differential diagnosis on imaging.

Active TGF-β signaling and decreased expression of PTEN separates angiosarcoma of bone from its soft tissue counterpart

Angiosarcomas constitute a heterogeneous group of highly malignant vascular tumors. Angiosarcoma of bone is rare and poorly characterized. For angiosarcoma of soft tissue, some pathways seem to be involved in tumor development. Our aim was to evaluate the role of these pathways in angiosarcoma of bone. We collected 37 primary angiosarcomas of bone and used 20 angiosarcomas of soft tissue for comparison. Immunohistochemistry was performed on constructed tissue microarrays to evaluate expression of CDKN2A, TP53, PTEN, BCL2, CDK4, MDM2, cyclin D1, β-catenin, transforming growth factor-β (TGF-β), CD105, phospho-Smad1, phospho-Smad2, hypoxia-inducible factor-1α, plasminogen activator inhibitor type 1 (PAI-1), VEGF, CD117 and glucose transporter--1. PIK3CA was screened for hotspot mutations in 19 angiosarcomas. In nearly 55% of the angiosarcoma of bone, the retinoblastoma (Rb) pathway was affected. Loss of CDKN2A expression was associated with a significantly worse prognosis. No overexpression of TP53 or MDM2 was found, suggesting that the TP53 pathway is not important in angiosarcoma of bone. Angiosarcoma of bone showed highly active TGF-β signaling with immunoreactivity for phospho-Smad2 and PAI-1. Although the phosphatidylinositol 3-kinase (PI3K)/Akt pathway seems to be active in both tumor groups, different mechanisms were involved: 41% of angiosarcoma of bone showed a decrease in expression of PTEN, whereas in angiosarcoma of soft tissue overexpression of KIT was found (90%). PIK3CA hotspot mutations were absent. In conclusion, the Rb pathway is involved in tumorigenesis of angiosarcoma of bone. The PI3K/Akt pathway is activated in both angiosarcoma of bone and soft tissue, however, with a different cause; PTEN expression is decreased in angiosarcoma of bone, whereas angiosarcomas of soft tissue show overexpression of KIT. Our findings support that angiosarcomas are a heterogeneous group of vascular malignancies. Both angiosarcoma of bone and soft tissue may benefit from therapeutic strategies targeting the PI3K/Akt pathway. However, interference with TGF-β signaling may be specifically relevant in angiosarcoma of bone.

Novel YAP1-TFE3 fusion defines a distinct subset of epithelioid hemangioendothelioma

Conventional epithelioid hemangioendotheliomas (EHE) have a distinctive morphologic appearance and are characterized by a recurrent t(1;3) translocation, resulting in a WWTR1-CAMTA1 fusion gene. We have recently encountered a fusion-negative subset characterized by a somewhat different morphology, including focally well-formed vasoformative features, which was further investigated for recurrent genetic abnormalities. Based on a case showing strong transcription factor E3 (TFE3) immunoreactivity, fluorescence in situ hybridization (FISH) analysis for TFE3 gene rearrangement was applied to the index case as well as to nine additional cases, selected through negative WWTR1-CAMTA1 screening. A control group, including 18 epithelioid hemangiomas, nine pseudomyogenic HE, and three epithelioid angiosarcomas, was also tested. TFE3 gene rearrangement was identified in 10 patients, with equal gender distribution and a mean age of 30 years old. The lesions were located in somatic soft tissue in six cases, lung in three and one in bone. One case with available frozen tissue was tested by RNA sequencing and FusionSeq data analysis to detect novel fusions. A YAP1-TFE3 fusion was thus detected, which was further validated by FISH and reverse transcription polymerase chain reaction (RT-PCR). YAP1 gene rearrangements were then confirmed in seven of the remaining nine TFE3-rearranged EHEs by FISH. No TFE3 structural abnormalities were detected in any of the controls. The TFE3-rearranged EHEs showed similar morphologic features with at least focally, well-formed vascular channels, in addition to a variably solid architecture. All tumors expressed endothelial markers, as well as strong nuclear TFE3. In summary, we are reporting a novel subset of EHE occurring in young adults, showing a distinct phenotype and YAP1-TFE3 fusions.

Vascular bone tumors: a proposal of a classification based on clinicopathological, radiographic and genetic features

The classification of vascular bone tumors remains challenging, with considerable morphological overlap spanning across benign to malignant categories. The vast majority of both benign and malignant vascular tumors are readily diagnosed based on their characteristic histological features, such as the formation of vascular spaces and the expression of endothelial markers. However, some vascular tumors have atypical histological features, such as a solid growth pattern, epithelioid change, or spindle cell morphology, which complicates their diagnosis. Pathologically, these tumors are remarkably similar, which makes differentiating them from each other very difficult. For this rare subset of vascular bone tumors, there remains considerable controversy with regard to the terminology and the classification that should be used. Moreover, one of the most confusing issues related to vascular bone tumors is the myriad of names that are used to describe them. Because the clinical behavior and, consequently, treatment and prognosis of vascular bone tumors can vary significantly, it is important to effectively and accurately distinguish them from each other. Upon review of the nomenclature and the characteristic clinicopathological, radiographic and genetic features of vascular bone tumors, we propose a classification scheme that includes hemangioma, hemangioendothelioma, angiosarcoma, and their epithelioid variants.

[Multifocal epithelioid angiosarcoma of bone with lung metastases]

Angiosarcoma is a rare mesenchymal neoplasm that may arise from vascular or lymphatic tissue. Bone primary angiosarcoma is extremely rare, representing less than 1% of all angiosarcomas. It́s a very aggressive neoplasm and patients have metastatic disease at initial diagnosis in a large percentage of cases. On radiographs, these lesions are usually aggressive osteolytic lesions, commonly with soft-tissue mass extension, and tumoral enhancement on CT or MR imaging. The appearance of the bone scan is variable, describing studies with tracer uptake or low uptake. These tumours are more often found in the long bones, but spinal involvement has been reported in 10% of patients. There are a few reports in the literature of bone angiosarcoma with lung metastases. We present a patient with multifocal epithelioid angiosarcoma (spine and ribs) and multiple lung metastasis, evidenced by CT and conventional bone scintigraphy, with a fast growth.

Epithelioid hemangioma of bone and soft tissue: a reappraisal of a controversial entity

BACKGROUND

The controversy surrounding diagnosis of an epithelioid hemangioma (EH), particularly when arising in skeletal locations, stems not only from its overlapping features with other malignant vascular neoplasms, but also from its somewhat aggressive clinical characteristics, including multifocal presentation and occasional lymph node involvement. Specifically, the distinction from epithelioid hemangioendothelioma (EHE) has been controversial. The recurrent t(1;3)(p36;q25) chromosomal translocation, resulting in WWTR1-CAMTA1 fusion, recently identified in EHE of various anatomic sites, but not in EH or other epithelioid vascular neoplasms, suggests distinct pathogeneses.

QUESTION/PURPOSES

We investigated the clinicopathologic and radiologic characteristics of bone and soft tissue EHs in patients treated at our institution with available tissue for molecular testing.

PATIENTS AND METHODS

Seventeen patients were selected after confirming the pathologic diagnosis and fluorescence in situ hybridization analysis for the WWTR1 and/or CAMTA1 rearrangements. Four patients had multifocal presentation. Most patients with EH of bone were treated by intralesional curettage. None of the patients died of disease and only four patients had a local recurrence.

RESULTS

Our results, using molecular testing to support the pathologic diagnosis of EH, reinforce prior data that EH is a benign lesion characterized by an indolent clinical course with an occasional multifocal presentation and rare metastatic potential to locoregional lymph nodes.

CONCLUSION

These findings highlight the importance of distinguishing EH from other malignant epithelioid vascular tumors as a result of differences in their management and clinical outcome.

LEVEL OF EVIDENCE

Level IV, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Skeletal Metastasis

The most commonly diagnosed tumor in the skeleton represents metastatic disease. Metastatic carcinoma should be the first consideration in older patients with atypical radiologic findings or clinical features suggestive of a bone lesion. The primary goal in the setting of skeletal metastasis is usually palliation.

Multicentric epithelioid hemangioendothelioma of bone. Report of a case with radiologic-pathologic correlation

Epithelioid hemangioendothelioma (EHE) is a rare vascular tumor of uncertain biologic behavior. Most cases come out as a single lesion of the soft tissue but also may appear in the lung, liver, and other locations. Epithelioid hemangioendothelioma of bone is an extremely rare tumor and more prevalent in the second and third decades of life; its behavior is uncertain, it most commonly is unifocal, and it affects preferentially lower extremities. In this work, we present the clinical, radiologic, and pathologic findings of a 19-year-old man with a multicentric EHE of bone that involved 3 vertebrae and developed lung metastasis.