Hemangiopericytoma. Literature review and clinical presentations

Large Haemangiopericytoma of the Posterior Cervical Space

We report a case of a 39-year old woman who upon developing a rapidly enlarging posterior cervical space tumour, underwent incisional biopsy prior to diagnostic imaging that resulted in nearly catastrophic haemorrhage.

Subsequently, MR imaging showed evidence of marked hypervascularity, prompting diagnostic angiography and endovascular microembolization prior to surgical resection.

The tumour turned out to be a large haemangiopericytoma arising from the paravertebral musculature.

The case is instructive by highlighting the need for considering rare locations of hypervascular tumours in the head and neck region before attempting biopsy, which can be predicted by cross-sectional imaging studies, and the benefits of pre-operative devascularization with modern superselective microembolisation techniques.

Solitary fibrous tumor of all sites: outcome of late recurrences in 14 patients

BACKGROUND

We explore the pattern of late recurrence (LR) in solitary fibrous tumor (SFT), focusing on histopathologic characteristics, clinical presentation and patients (pts) outcome.

METHODS

Clinical records of all pts with confirmed pathologic diagnosis of SFT treated at our Institution from 2005 to 2011 were reviewed. We analysed the data of pts who relapsed ≥10 years after initial diagnosis.

RESULTS

A total of 14 pts were identified. The primary site of origin was pleura (5 pts), pelvis (4 pts), head and neck (3 pts) and retroperitoneum (2 pts). Primary tumor was a typical SFT in 5 and a malignant SFT in 7 out of 12 pts whose tumor tissue was available for revision. The median time to first recurrence was 12 years (range 10-23). The first relapse was local in 11 cases, distant in 3. Five pts later developed distant metastases. Four out of 5 cases of typical SFT developed distant metastases in spite of their initial benign aspect. No patient was disease-free at the time of the analyses.

CONCLUSION

Our series suggests that LR can occur in SFT and some cases can behave aggressively even in the absence of any primary morphologic evidence of malignancy. A prolonged follow-up may be advisable.

Oncogenic osteomalacia diagnosed by blood pool scintigraphy

Oncogenic osteomalacia is a rare metabolic bone disease characterized by phosphaturia and hypophosphatemia. Certain tumors secrete a phosphaturic factor, which results in this metabolic abnormality; this factor called as phosphatonin, is in fact a fibroblast growth factor 23 (FGF-23) involved closely in phosphate homeostasis and skeletogenesis. Complete excision of these tumors facilitates reversal of the problem. We have reported here the case of a patient who was crippled with this disease and on thorough investigation revealed an oncogenic osteomalacia with tumor focus in the right tibia. The tumor was identified as a mesenchymal tumor, i.e., hemangiopericytoma. Tumor excision alleviated patient symptoms with rapid symptomatic and biochemical improvement.

Extremity haemangiopericytoma, a case report from Nigeria

Haemangiopericytoma is an uncommon soft tissue sarcoma of vascular origin. It occurs more frequently in the extremities than elsewhere in the body although it can arise in any organ. Wide surgical excision is the mainstay of treatment. However, adjuvant radiotherapy and chemotherapy are desirable because the malignant nature of this tumour is frequently unpredictable. Adjuvant therapy is recommended for metastases, recurrence and incomplete resection. Long term follow up is essential in all cases as recurrence can occur several years after treatment. Where little or no experience with managing this tumor exists, it is important to be aware of its clinical behaviour and the treatment options, hence this case reports.

From the Archives of the AFIP

Primary vascular neoplasms of the spleen constitute the majority of nonhematolymphoid splenic tumors. The benign primary vascular tumors include hemangioma, hamartoma, and lymphangioma, whereas those of variable or uncertain biologic behavior include littoral cell angioma, hemangioendothelioma, and hemangiopericytoma. The primary malignant vascular neoplasm of the spleen is angiosarcoma. Peliosis is a rare lesion of unknown cause that is usually found incidentally in asymptomatic patients but may be associated with hematologic or metastatic disease. Although these vascular neoplasms of the spleen are uncommon, their importance lies in that they must be differentiated from the more common neoplastic disorders of the spleen, such as lymphoma and metastasis. The most common echogenic solid or complex cystic mass in an asymptomatic patient is splenic hemangioma. However, the imaging appearance of splenic hemangiomas may be complex, and differentiation of these lesions from malignant disease may not be possible. The diagnosis of splenic hamartoma may be suggested when findings of increased blood flow on color Doppler images are seen in association with a homogeneous solid echogenic mass. A large subcapsular solitary cystic abnormality discovered incidentally in a child in association with internal septations and tiny mural nodules favors the diagnosis of lymphangioma. Any invasion of the surrounding splenic parenchyma by a splenic lesion should indicate a more aggressive or malignant process. Evaluation of a focal splenic abnormality identified on sonograms should be followed up with computed tomography or magnetic resonance imaging with and without contrast material enhancement. Splenectomy may be required for definitive evaluation of a splenic mass with atypical features.

Sarcomas of the head and neck region

PURPOSE OF REVIEW

This review discusses the classification, etiology, diagnosis, evaluation, treatment, and prognosis of sarcoma of the head and neck region.

RECENT FINDINGS

Sarcomas account for less than 1% of all malignancies in the United States with only 5 to 15% of these sarcomas occurring in the head and neck region. However, about 1 in 3 pediatric sarcomas will occur in the head and neck region. Occasionally, these tumors are associated with genetic syndromes or previous radiation exposures, but, most commonly, no clear etiology exists. Pathologic classification is critical to the ultimate treatment and prognosis of sarcoma of the head and neck. Osteosarcoma, rhabdomyosarcoma, malignant fibrous histiocytoma, and angiosarcoma are the most common types of sarcoma to occur in the head and neck region; however, up to 20% of head and neck sarcomas will remain unclassified. Surgery has been central to the management of these malignancies with some exceptions in the pediatric population. Adjuvant chemotherapy is being utilized and/or studied for most high-grade sarcomas and adjuvant radiotherapy is important for disease control in high-grade soft-tissue sarcomas. Prognosis is clearly related to tumor grade and margin status.

SUMMARY

Sarcomas of the head and neck region are rare malignancies often without a clear etiology. Expert pathologic review and classification is critical, as are quality imaging and multidisciplinary management.

Sarcomas of the head and neck

With the exception of pediatric RMS, soft tissue sarcomas only rarely arise in the head and neck region. Soft tissue sarcomas include a diverse array of histologic types because of the variety of mesenchymal tissues from which they originate. The combination of infrequent occurrence, varied pathologic features, and the many potential sites of presentation makes these tumors a challenge for the head and neck oncologist and underscore the need for review by a pathologist experienced with soft tissue tumors. Classification schemes that group sarcomas according to grade have been helpful in providing prognostic information. Although local control of the primary tumor is critical to successful treatment of both high- and low-grade lesions, the high rate of distant metastases in high-grade tumors supports the role of combined modality therapy. Compared with other types of head and neck neoplasms, such as squamous cell carcinoma, soft tissue sarcomas have low rates of regional metastases. Surgery generally has been recommended as the primary method of treatment for achieving local control, except in those high-grade tumors arising in sites not amenable to resection. Exceptions to this principle include RMSs of the orbit, paranasal sinuses, and masticator space in children; these are usually treated with radiotherapy and combined multiagent chemotherapy, thereby avoiding the functional and cosmetic impact of surgery. Also, extensive angiosarcomas of the scalp should be treated with multimodality therapy combining surgery and wide-field radiation therapy in an attempt to achieve local control. Adjuvant radiotherapy is generally recommended for high-grade sarcomas, large tumors, close or positive surgical margins, and certain histologic variants. Systemic chemotherapy is recommended for those tumors with a significant risk of distant metastases. Increasingly, neoadjuvant chemotherapy is being used to determine responsiveness to chemotherapy, which can help physicians select patients who may benefit from systemic postoperative therapy. Traditional predictors of treatment failure for soft tissue sarcomas include larger tumor size, high-grade histology, and positive surgical margins. The advent of more advanced reconstructive techniques, including free tissue transfer, has made more aggressive surgical resection of these tumors possible. Nevertheless, a considerable number of ancillary support staff are critical to the patient's postoperative rehabilitation and eventual return to a satisfactory level of function and quality of life. In the future, the discovery of the molecular pathogenesis of specific tumor types, such as the cytogenetic findings in synovial sarcoma, will improve physicians' prognostic abilities and selection of patients who are most likely to benefit from emerging adjuvant therapies.

Unusual primary lung tumors: a radiologic-pathologic overview

Although the great majority of lung carcinomas are histologically characterized as adenocarcinoma, squamous cell carcinoma, large cell undifferentiated carcinoma, or small cell carcinoma, a variety of rare benign and malignant lung tumors may sporadically affect the lung. Several nonneoplastic tumorlike lesions are seen infrequently but are also part of the differential diagnosis for lung masses. Conventional radiographic findings, although of limited value in the diagnosis of these entities, should be examined carefully when lung tumors are suspected. Computed tomography (CT) is well suited for making a definitive diagnosis of some disease processes. CT helps determine the location and features of the lesions and depicts associated findings to help document the extent of disease. The differential diagnosis can be narrowed when there are typical CT features (eg, the presence of fat in lipoid pneumonia). Although unusual primary lung tumors are difficult to diagnose on the basis of imaging findings alone because such findings are nonspecific in the majority of cases, cross-sectional imaging can play an important role in the diagnostic work-up of these unusual tumors by delineating their extent and directing the radiologist or bronchoscopist to the appropriate biopsy site.

Proliferation index as a prognostic marker in hemangiopericytoma of the head and neck

BACKGROUND

Hemangiopericytoma (HPC) of the head and neck is a rare neoplasm whose biologic behavior is difficult to predict by means of conventional histologic parameters.

METHODS

H & E-stained sections from 12 cases of HPC were reviewed. Proliferation index was assessed using an immunoperoxidase stain for MIB-1 (Ki-67).

RESULTS

The study group consisted of 4 adult men, 5 adult women, and 1 infant male. Necrosis, hypercellularity, and pleomorphism were found in 1, 5, and 6 case(s), respectively. The mitotic index per 10 high power fields varied from 0-1 to 15. Proliferation indices using MIB-1 ranged from 2.6% to 52.5%. Clinical follow-up revealed 3 cases with recurrence all possessing proliferation indices of approximately 10%.

CONCLUSIONS

Standard histomorphologic features may be inadequate predictors of clinical outcome. A proliferation index of 10% or greater may indicate a more aggressive subset of HPC of the head and neck.

Hemangiopericytoma: a 20-year single-institution experience

BACKGROUND

Hemangiopericytoma is an uncommon soft tissue sarcoma. We sought to evaluate the long-term outcome of a consecutively treated patient cohort with hemangiopericytoma.

METHODS

The study involved 36 adult patients (older than 16 years) with hemangiopericytoma treated at The University of Texas M. D. Anderson Cancer Center between July 1975 and July 1995. Data on clinicopathologic parameters, surgical treatment, adjuvant therapy, disease recurrence, and survival were obtained from a review of medical records.

RESULTS

The median follow-up was 57 months. Twenty-eight patients (78%) underwent complete and potentially curative resection of their primary disease. Of the nine patients (32%) who had local recurrences, four (57%) had epidural tumors and three (43%) had retroperitoneal tumors, but none had extremity tumors. Extremity tumors were associated with a significantly prolonged local recurrence-free survival compared to tumors at nonextremity anatomic sites (P <.05). Ten patients had recurrences at distant sites. Of the 13 patients who experienced any form of disease recurrence, four had recurrences after a disease-free interval of more than 5 years. The 5-year actuarial survival rate for the entire group of 36 patients was 71%. Noncurative surgical treatment (P=.007) and development of distant metastatic disease (P=.013) were associated with shortened survival.

CONCLUSION

Extended survival is common in hemangiopericytoma patients treated with curative intent. However, local and distant recurrences may occur after a prolonged disease-free interval, emphasizing the need for long-term follow-up. Retroperitoneal and meningeal tumors were associated with higher local recurrence rates; therefore, adjuvant therapies should be considered and evaluated for tumors at these sites.

Infantile hemangiopericytoma: a rare cause of a soft tissue mass

A case of infantile hemangiopericytoma in a neonate is presented. The clinicopathologic characteristics of this tumor are described. This tumor is often confused for other more aggressive malignant tumors and, thus, is likely under-reported and overtreated. These tumors exhibit features suggestive of malignancy such as increased mitotic activity, nuclear pleomorphism, and increased cellularity, yet are clinically unpredictable. A conservative surgical approach is advocated.

Hemangiopericytoma of the hand: a literature review and case study

We present a case of hemangiopericytoma of the hand. We also attempt to differentiate hemangiopericytoma from glomus tumor with a summary of the history and a comprehensive review of the literature demonstrating the malignant character of the neoplasm, and we offer some guidelines for treatment.

Intraoral infantile hemangiopericytoma: literature review and addition of a case

A rapidly growing neoplasm in the buccal mucosa of a 4-month-old baby was excised. By light and electron microscopy the neoplasm had features that were similar to those described in infantile hemangiopericytoma, a rare neoplasm of vascular origin. By light microscopy the neoplasm was multilobular with highly proliferating round to spindle-shaped cells interspersed with numerous vascular spaces. Ultrastructurally, round to elongated cells with short processes, pinocytotic vesicles, reduplicated basal lamina, and basal lamina-like material were identified. Immunohistochemically the cells were weakly positive with antibodies to vimentin, focally positive with HHF-35, a smooth-muscle cell antibody, negative with antibodies to S-100 protein, T-200, neuron-specific enolase, neurofilaments, desmin, and cytokeratins 35BH11 and 34BE12. Blood vessels were positive with Ulexeuropaeuslectin, but tumor cells were negative. Reticulin stain decorated a delicate network of fibrils surrounding tumor cells and vascular spaces. Clinically the neoplasm did not recur and the baby has been disease free for more than 26 months. The difficulty of the histologic diagnosis of this neoplasm is discussed and the literature is reviewed, with special emphasis on lesions occurring in the oral cavity.

Hepatic metastasis from a meningeal haemangiopericytoma

Intracranial tumours rarely metastasize outside the central nervous system (CNS). Meningeal haemangiopericytoma is an exception. We report the case of a 41-year-old female who initially presented in 1984 with what was thought to be a posterior fossa meningioma which was excised, as were two subsequent recurrences in 1987 and 1988. In October 1990 she represented, having discovered a mass in her abdomen. This proved to be a metastatic haemangiopericytoma in the liver which had similar histology to the original intracranial tumour. This metastasis, and another found at operation, have been excised, and at the time of this report, she is alive and well seven months after surgery without any evidence of other metastasis or recurrence. Hemangiopericytomas are unusual in their propensity to metastasize outside the CNS and successful resection of hepatic metastases from this tumour has not been reported before.

Capillary pericytes: perspectives and future trends

A complete understanding of the microcirculation requires full knowledge of the structure and function of each of the constituent cells, including pericytes. Vascular endothelium and smooth muscle cells have been investigated intensively during the last two decades, but much less is known about the metabolism and function of capillary pericytes. However, the development of new electron microscopy techniques and the application of new cell culture and molecular biology techniques should allow for the rapid elucidation of the cellular biochemistry and the microvascular function and pathology of this ubiquitous capillary cell.

Bilateral renal hemangiopericytoma

The first reported case of bilateral renal hemangiopericytoma is presented. The 19 previous renal hemangiopericytomas that have been reported in the world literature are reviewed. This lesion has afflicted patients ranging in age from sixteen to sixty-eight years (mean 41 years) with an equal sex distribution. Mortality from hemangiopericytoma of the kidney has been 50 percent, and the primary mode of therapy remains surgical.

Haemangiopericytoma--Queensland Radium Institute experience and a review of the literature

We report the presenting clinical characteristics, management, relapse patterns and survival of 17 patients with haemangiopericytoma treated at the Queensland Radium Institute, Australia from 1962 to 1989. Twelve patients were referred at the time of first diagnosis and were treated with curative intent. Three patients were treated with palliative intent when referred following initial diagnosis, and the remaining two patients were referred at the time of relapse. Disease was metastatic at presentation in 4 patients. Radiotherapy was used as a component of primary treatment of disease in 11 patients, in both patients referred for management of local relapse of haemangiopericytoma, and for palliation of metastatic disease developing in 3 patients. One patient received chemotherapy as part of initial treatment. Nine patients have died with survival from first treatment ranging from 3 to 139 months. All 8 surviving patients remain free of disease at 6 to 94 months from first treatment.

Aggressive malignant hemangiopericytoma in the neck

Hemangiopericytomas are rare vascular tumors, one fourth of which occur in the head and neck. These lesions are characteristically slow growing and slow to metastasize. We describe an otherwise healthy patient with a hemangiopericytoma on the left side of his neck that metastasized to his chest wall within 3 months after the tumor was first observed. The metastasis occurred while the patient was receiving radiation therapy. The patient died soon afterward. This case illustrates the aggressive malignant potential of hemangiopericytomas.

Hemangiopericytoma--the role of radiotherapy

Between 1955 and 1987, 15 patients with hemangiopericytomas were seen at the University of Iowa Hospitals and Clinics. Twelve of these were thought to have localized tumors and three had metastatic disease at diagnosis. Seven of the 12 patients with localized disease were treated with surgery alone, four were treated with surgery and postoperative radiation therapy, and one was treated with surgery and chemotherapy. Only one of the seven patients initially treated with surgery alone has remained continuously free of disease, although two others were salvaged with radiation therapy. In contrast, all four patients initially treated with surgery and postoperative radiation therapy have remained alive with no evidence of disease in spite of the fact that three of these patients had gross residual tumor at the time of irradiation. Ten patients received radiation therapy at some stage of their management. Local tumor control was achieved at all sites receiving greater than 5500 cGy. Six patients received chemotherapy sometime during the course of their management, although no complete or partial responses were observed. In this small series, mitotic activity was not an accurate predictor of biologic behavior.

Malignant hemangiopericytoma in three kindred members of one family

Three cases of malignant hemangiopericytoma in one family are reported. To our knowledge familial occurrence of malignant hemangiopericytoma has not been described before. Two of these lesions occurred in the head and neck region and one case presented as an intraabdominal tumor. Consanguinity of the parents seems to be likely, suggesting an autosomal recessive mode of inheritance in our family, whereas the similarity in age of onset in these three patients was apparent.

Does radiotherapy have a role in hemangiopericytoma management? Report of 14 new cases and a review of the literature

From 1948 to 1984, 14 adult patients received radiation therapy as a part of their treatment for hemangiopericytoma at the University of Texas M.D. Anderson Hospital and Tumor Institute at Houston. In addition to radiation therapy 11 patients were treated with surgery, with or without chemotherapy--5 as primary management and 6 after recurrence following surgical excision. Although 9 of these 11 patients had macroscopic and 1 had definite microscopic disease at the time of irradiation, none suffered local recurrence and 9 have survived from 3.5 years to 20 years free of disease. Two of the 11 patients died of distant metastases. Two patients completed treatment for palliation and 1 of them survived for 2 years after treatment. The results suggest that postoperative radiation therapy should be considered as an integral part of the primary treatment of hemangiopericytoma.

Malignant hemangiopericytoma of the parapharyngeal space

Hemangiopericytoma is a rare vascular neoplasm, occasionally occurring in the head and neck region. Diagnosis is made histologically, but even then, it is difficult to predict the behavior of the tumor in an individual patient. The patient described in this report presented with symptoms of parapharyngeal compression due to such a tumor. It is believed that malignant hemangiopericytoma has not been previously reported in this site.