Epithelioid angiosarcoma of bone

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 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.

Cytologic and histological features of rare nonepithelial and nonlymphoid tumors of the thyroid

Thyroid tumors can be classified into epithelial, nonepithelial, and nonprimary lesions. Nonepithelial thyroid tumors are rare. They can be of primary origin within the thyroid gland, arise secondary to contiguous growth from adjacent tissues, or represent metastatic disease. The incidence of nonepithelial tumors of the thyroid is only 1% to 2%, most of which are lymphomas; the remainder includes mesenchymal and histiocytic tumors. This review examines the cytohistological features of various nonepithelial and nonlymphoid tumors of the thyroid, including vascular lesions, neural tumors (including granular cell tumor and paraganglioma), smooth muscle tumors, solitary fibrous tumor, histiocytic neoplasms (eg, Langerhans cell histiocytosis and Rosai-Dorfman disease), and follicular dendritic cell sarcoma. Their differential diagnosis is discussed, including recommendations to prevent the pitfall of mistaking these rare tumors for more common epithelial thyroid neoplasms.

Primary multiple angiosarcoma of vertebra: A case report

RATIONALE

Angiosarcoma is a rare malignant tumors. The objective of this study is to report a patient who suffered from a progressive low back pain and left lower extremities radiation pain for about 8 months, After diagnoses, this was identified as an extremely rare case of primary multiple angiosarcoma of vertebra.

PATIENT CONCERNS

A 54-year-old man with a history of 2-year hypertension and 8-year diabetes, both of which were well controlled by drug management. Lately, he suffered from a progressive low back pain and left lower extremities radiation pain for about 8 months.

DIAGNOSES

Magnetic resonance imaging of lumbar showed a clear pathological fracture and primary multiple angiosarcoma of all vertebra. Postoperative pathology and High-throughput sequencing confirmed the diagnosis of primary multiple angiosarcoma of vertebra.

INTERVENTIONS

The patient underwent minimally invasive pedicle screw fixation combined with bone cement augmentation for the purpose of stabilizing the damaged vertebrae. Following operation, he received both radiotherapy and chemotherapy for a period of time.

OUTCOMES

The operation has achieved positive results in relieving pain and stabilizing the spine. No wound problem or operative complications occurred after operation. The patient reported an obvious remission of low back pain and was only capable to perform restricted physiological activities. A long-term palliative radiotherapy and chemotherapy were performed after operation. Unfortunately, the patient died 18 months later.

CONCLUSION

This article emphasizes primary multiple angiosarcoma of vertebra. Despite being rare, it should be part of the differential when the patient manifested back pain and radiculopathy. We recommended the minimally invasive pedicle screw fixation for angiosarcoma of vertebra. Osteoplasty by bone cement augmentation was also an ideal choice for surgical treatment. It also advocates the use of specific targeted radiotherapy drugs based on gene analysis of tumors.

A Case of Metastatic Epithelioid Angiosarcoma in the Lamina Propria of a Sigmoid Tubulovillous Adenoma

Epithelioid angiosarcoma is an extremely rare tumor. It is generally a secondary tumor and the preferred sites of such metastases are the heart, pericardium, lung, breast, liver, spleen, bone, and brain. In rare cases the lung has been described as the primary site. The prognosis of this neoplasm is extremely poor. We report a case of epithelioid angiosarcoma with multiple bilateral lung infiltration, bone metastasis, and metastasis of the lamina propria of a tubulovillous adenoma of the colon.

Primary epithelioid angiosarcoma of the temporal bone with initial presentation of otalgia

Primary angiosarcoma of the bone is exceedingly rare. Here, we report a case of epithelioid angiosarcoma arising from the right temporal bone in a 57-year-old woman who presented with otalgia that was refractory to conventional treatment.

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.

Right femoral pathological fracture caused by primary bone epithelioid angiosarcoma: Case report

RATIONALE

Epithelioid angiosarcoma (EAS) is an extremely rare malignant disease, which accounts no more than 1% of all soft tissue sarcomas. In this article, we would report a new case of EAS with multiple bone destruction and right femoral pathological fracture, which was an even rarer manifestation of EAS.

PATIENT CONCERNS

In this case, a 64-year-old man with right femoral fracture was reported. He had suffered from a progressive low back pain for about 8 months, and the imaging examinations prompted a multiple bone destruction in his vertebra and lower limbs. He then got a right femoral fracture without any obvious traumatic injury, and came to our hospital.

INTERVENTIONS

He underwent an operation of radical resection, bone cement filling and dynamic condylar screw internal fixation. During the operation, we found that the soft tissue around the fracture had a rotten fish change, which suggested a malignant disease.

DIAGNOSES

The postoperative pathological diagnosis reported an EAS, which is extremely rare and highly malignant.

OUTCOMES

The patient died in 83 days after the surgery, and the survival time from the symptoms started to the end was only 11 months, which showed a rapid progress and poor prognosis of EAS.

LESSONS

EAS is very hard to be diagnosed by clinical manifestation or radiological examinations. As in our case, pathological analysis is the final diagnosis. The images of the patient may offer some tips for the skeletal presentation of EAS, and do more help in future study of this disease.

Aggressive clinical course of epithelioid angiosarcoma in the femur: a case report

Background

Epithelioid angiosarcoma is a rare variant of angiosarcoma, and is characterized by an epithelioid morphologic appearance that mimics carcinoma. These tumors usually arise in extraskeletal sites; origination in bone is rare.

Case presentation

A 69-year-old woman presented with right knee pain. Plain radiographs and magnetic resonance imaging showed an osteolytic lesion with a large soft-tissue extension into the distal femur. Under a diagnosis of metastatic carcinoma of unknown origin based on the biopsy specimen, resection and replacement with an artificial joint were performed. Histologic analysis of the resected material confirmed epithelioid angiosarcoma, supported by immunoexpression of cytokeratins and vascular markers. Three months after surgery, metastasis to the bone and lymph nodes was observed, and the patient died of the disease shortly thereafter.

Discussion

Epithelioid angiosarcoma of bone is characterized by an aggressive clinical course. A possibility of epithelioid angiosarcoma of bone should be considered in cases with such epithelial features, particularly if only small specimens are available.

Epithelioid angiosarcoma of the spine: A case report of a rare bone tumor

Epithelioid angiosarcoma (EA) is an extremely rare subtype of angiosarcoma, which is characterized by large cells with an epithelioid morphology. EA typically arises in deep soft tissues, including the adrenal gland, skin and thyroid, however, EA rarely arises in the spine. The current study presents a case of osteolytic lesions involving the fourth lumbar (L4) level of the spine. Preoperatively, the patient was misdiagnosed with metastatic carcinoma, however, a radiological examination detected the presence of osteolytic or destructive lesions in the vertebrae, which extended into the pedicles. Histopathological and immunohistochemical evaluations were performed on the tumor tissue obtained from a decompression specimen of the L4 vertebra. A bone lesion composed of sheet-like malignant cells exhibiting atypical epithelioid morphology with vascular formation was observed. The presence of anastomosing vascular channels lined by epithelioid endothelial cells also indicated that focal endothelial differentiation had occurred. In addition, immunohistochemistry assays revealed that the lesion was positive for the endothelial cell markers, CD31, CD34 and vimentin. The tumor was treated with decompression of the L4 vertebra, followed by posterior stabilization. The patient subsequently refused chemotherapy and radiotherapy but completed six months of follow-up. At the time of writing, the tumor remains under control and the patient is asymptomatic. This case highlights the difficulty of diagnosing EA, which requires careful pathological examination and immunophenotype labeling. At present, CD31 is the most sensitive marker for detecting EA.

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.

Angiosarcoma of the proximal humerus: a case report and review of the literature

Introduction

Angiosarcoma of bone is an uncommon primary bone neoplasm that is composed of tumor cells that show endothelial differentiation. This is an aggressive malignancy characterized by frequent local recurrence and distant metastases. The majority of patients die within one year of diagnosis, and this shows that angiosarcoma of bone is an aggressive high-grade tumor.

Case presentation

We present the case of a 65-year-old Japanese woman who had primary angiosarcoma of the proximal humerus with a pathological fracture. An open biopsy confirmed a diagnosis of primary angiosarcoma of bone. Our patient was treated with neoadjuvant chemotherapy and wide resection. One month after surgery, she developed multifocal distant metastasis to her liver and spleen.

Conclusions

Angiosarcoma of the humerus is extremely rare. Radiographically, there is no specific finding associated with angiosarcoma of bone as opposed to other malignant bone tumors. The cornerstone of treatment is en bloc resection followed by as much adjuvant radiation therapy as possible. However, the role of chemotherapy remains undefined, and better systemic agents are clearly needed.

Multicentric epithelioid angiosarcoma of bone

Bone epithelioid angiosarcoma is rare and generally shows positive immunostaining for epithelial markers. Multicentric bone epithelioid angiosarcoma is easily misdiagnosed as carcinoma, including metastatic carcinoma, multiple myeloma, and multiple lymphoma of bone. This article describes a case of multicentric bone epithelioid angiosarcoma. The patient was first misdiagnosed as having metastatic carcinoma. Examination showed osteolytic lesions in the bilateral heels and the lower left humerus. The diagnosis was confirmed postoperatively and corrected after immunohistochemical analysis of the biopsy. The immunohistochemical analysis revealed that the tumor mass was strongly positive for CD31, factor VIII, vimentin, and neuron-specific enolase. The patient refused chemotherapy and died of lung metastasis 4 months postoperatively.Most bone epithelioid angiosarcomas are immunopositive for epithelial markers (ie, keratin, cytokeratin, high-molecular-weight keratin, and epithelial membrane antigen), vascular endothelial markers (ie, CD31, CD34, and von Willebrand factor), and factor VIII-associated antigen. Bone epithelioid angiosarcoma shows a relatively high degree of malignancy. Patients often die of distant metastasis, including those found in the lung and lymph node tissue. A wide excision of epithelioid angiosarcoma should be performed during the operation of the primary tumor. A better understanding of the clinicopathologic features of this disease may help to clarify the confusion, provide better treatment, and improve the clinical prognosis.

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.

A rare cardiac neoplasm: case report of cardiac epithelioid angiosarcoma

Primary cardiac angiosarcoma is a rare neoplasm and the epithelioid variant is exceedingly rare. We report a case of an epithelioid angiosarcoma that involved the right atrium and aorta of a 47-year-old male. The patient presented with atrial fibrillation and presyncopal spells. Following clinical evaluation, including computed tomography scan and trans-esophageal echocardiography, the neoplasm was surgically removed. It was a poorly differentiated malignant neoplasm composed of medium-sized epithelioid cells with a moderate amount of amphophilic cytoplasm. Immunohistochemical staining, including positive staining for CK22, AE1/AE3, melan-A, vimentin, and CD31, indicated the neoplasm was best categorized as an epithelioid angiosarcoma.

Primary angiosarcoma of the thyroid gland with recurrence diagnosed by fine needle aspiration: a case report

Angiosarcoma of the thyroid is a rare and aggressive primary malignant tumor of the thyroid originally reported in patients from the Swiss Alpine region. Diagnosis of this tumor rests mainly on characteristic histopathological features of a malignant vascular tumor supported by immunopositivity for vascular markers e.g., CD31, Factor VIII, and CD34. Its cytological features, however, are not well-defined. We describe a case of primary angiosarcoma of the thyroid in a 48-year-old female, who presented with a rapidly enlarging neck mass associated with compressive symptoms. She had a history of hypothyroidism. The initial fine needle aspiration cytology of the neck mass was negative. She then underwent left hemithyroidectomy. Histologically, the tumor showed poorly differentiated malignant cells with eccentrically-placed nuclei, prominent nucleoli, and intracytoplasmic vacuoles admixed with mixed inflammatory cells. These showed immunopositivity for CD31 but were negative for CD34, Factor VIII, CK5/6, EMA, TTF-1, Thyroglobulin, Calcitonin, Melan A, and Calretinin. A diagnosis of poorly differentiated malignant tumor consistent with angiosarcoma was made. The patient was treated with radiation therapy but developed recurrence of the tumor. Second aspiration cytology of the recurrent tumor yielded hypocellular smears containing singularly dispersed atypical cells having eccentrically-placed nuclei with prominent macronucleoli and intracytoplasmic vacuoles within a background of inflammatory cells, consistent with recurrent angiosarcoma. Chemotherapy was started but she succumbed to the disease 7 months after diagnosis. The cytological, histopathological, immunohistochemical findings, and the clinical course are discussed.

Multicentric epithelioid angiosarcoma of the spine: a case report of a rare bone tumor

BACKGROUND CONTEXT

Epithelioid angiosarcoma (EA) is a high-grade sarcoma of vascular origin. EA is a rare variant of angiosarcoma. It is characterized by large cells with an epethelioid morphology. EA has been reported in sites like skin thyroid, adrenal gland, soft tissue, and rarely in bone.

PURPOSE

The current article describes a case of multicentric EA of the spine that presented simultaneously at T4 spine and the posterior one third of the left fourth rib. STUDY DESIGN/SETTINGS: This study included a patient with a rare spinal tumor, which presented insidiously. Radiologically, the lesions were osteolytic with erosion of cortices. The tumor was composed of nests and cords of malignant cells with epithelioid morphology with areas of vascular differentiation, necrosis, and hemorrhage. Anastomosing vascular spaces lined by epithelioid endothelial cells suggested focal endotheliod differentiation.

METHODS

Histopathological evaluation of the tumor obtained from en bloc resection of the fourth rib and specimen from decompression of the fourth thoracic vertebra was done. Immunohistochemistry showed positivity for endothelioid cell markers like CD31 and factor VIII related antigen. The authors point out the need for immunohistochemical evaluation after careful histological analysis for vascular differentiation for an accurate diagnosis of vascular bone tumors with epithelioid features so that an erroneous diagnosis of metastatic carcinoma can be avoided. EA occurs rarely in bone. EA is marked by the presence of large polygonal epithelioid malignant cells with marked cellular atypia and pleomorphism. The arrangement of the cells may mimic epithelial neoplasm. These types of lesions are a definite diagnostic challenge in bone biopsy. The tumor was treated with en bloc resection of the rib and decompression of the body of T4 spine, followed by megavoltage radiotherapy. Follow-up X-rays showed regression of the tumor at 2 years. CD31 is the most sensitive marker for EA. Even in the absence of obvious vascular differentiation, abundant intratumoral hemorrhage and intratumoral neutrophils are definite morphologic changes that should suggest a vascular origin.

RESULTS

The patient was followed up for 2 years. A conservative surgical approach with a radical course of megavoltage radiotherapy could yield a good result in EA of bone. At the time of writing this report, there is no evidence of tumor recurrence.

CONCLUSION

It is important to differentiate EA from other tumors because the clinical course and treatment are specific for these conditions. Careful histologic and immunohistochemical analysis will clinch the diagnosis. Even though rare, we stress the importance to be aware of the existence of this tumor, which is essential for correct diagnosis.

Epithelioid and spindle cell haemangioma of bone

A case of epithelioid and spindle cell haemangioma of bone occurring in the proximal femur is presented. The tumour had typical microscopic features with a striking lobular pattern comprising spindled and epithelioid areas with admixed inflammatory cells. The case represents only the eighth reported example of this rare tumour, which appears to fit in the spectrum of epithelioid haemangioma. This is the first case to involve the proximal portion of a long bone. A review of the classification and features of similar vascular tumours of bone is presented.

Cytokeratin and epithelial membrane antigen expression in angiosarcomas: an immunohistochemical study of 33 cases

CONTEXT

Expression of epithelial cell markers can occur in mesenchymal tumors and has been reported in angiosarcomas with variable frequency. In these situations, establishing the diagnosis becomes problematic.

OBJECTIVE

To determine the expression of cytokeratin and epithelial membrane antigen in angiosarcoma.

DESIGN

To address this issue, 33 well-documented cases of angiosarcomas were retrieved from the archival material of Shands Hospital at the University of Florida, Gainesville, and Jackson Memorial Hospital at the University of Miami, Miami, Florida. These cases were all reviewed and studied using a cytokeratin cocktail (CAM 5.2 and AE1/AE3) and epithelial membrane antigen using standard immunohistochemical techniques. All 33 cases had available material for cytokeratin analysis; however, only 20 cases had enough material for epithelial membrane antigen staining.

RESULTS

In the 33 cases studied, the age range of the patients was 2 to 88 years (mean, 63 years). There were 23 (70%) men and 10 (30%) women. One (3%) of 33 was cytokeratin-immunoreactive and 2 (10%) of 20 were epithelial membrane antigen-immunoreactive.

CONCLUSION

Cytokeratin and epithelial membrane antigen immunoreactivity in angiosarcomas is infrequent but may be encountered. Interpretation of such expression should be done with caution and in conjunction with the characteristic clinical and morphologic features of the tumor as well as the expression of endothelial cell antigens.

Epithelioid and Epithelial Neoplasms of Bone

Context.—Epithelioid and epithelial neoplasms seen in bone are rare and include epithelioid variants of vascular lesions, osteoblastoma, osteosarcoma, chordoma, and chondroblastoma as well as adamantinoma and metastatic carcinoma.

Objective.—To provide an overview of tumors with epithelioid histology and address the clinical context and diagnostic issues.

Data Sources.—Pertinent literature is reviewed with emphasis on recent and controversial issues.

Conclusions.—The differential diagnosis in epithelioid/ epithelial lesions of bone is limited. The primary consideration in many cases is distinguishing primary from metastatic lesions.

Sacral epithelioid angiosarcoma associated with a bleeding diathesis and spinal epidural hematoma: case report

Epithelioid angiosarcoma of bone is a rare, high-grade lesion that is highly vascular and can be associated with a bleeding diathesis. An association has been reported in angiosarcomas in other locations with coagulopathy from tumor-related disseminated intravascular coagulopathy and fibrinolysis. The authors report the case of a rare occurrence of a primary sacral epithelioid angiosarcoma associated with a large epidural hematoma and a severe bleeding diathesis. A 25-year-old woman presented with weakness, fatigue, neck and low-back pain, and progressive left S-1 radiculopathy. Imaging studies revealed a large ventral epidural hematoma extending from the sacral region rostrally to C-2 and a vascular tumor located in the sacrum. The patient underwent a sacral laminectomy, complicated by postoperative bleeding from the wound, and required massive transfusions. Ultimately, multimodal therapy was required to obtain hemostasis, including the use of endovascular embolization, radiation therapy, and an infusion of epsilon-aminocaproic acid with heparin. This case represents the first report of a primary epithelioid angiosarcoma in the sacrum and emphasizes that the coagulopathy seen in angiosarcoma is also a feature of this epithelioid variant.

Multicentric contiguous variant of epithelioid angiosarcoma of the bone

Epithelioid angiosarcoma of the bone is a rare tumor and is a diagnostic challenge. Here we present an autopsy case of a 62-year-old man with multifocal osteolytic lesions in the extremities and the pelvis. The initial diagnosis of a tibial biopsy was poorly differentiated adenocarcinoma. On the occasion of autopsy, a fungating thrombotic nodule was found at the anterior wall of the right atrium, and small hemorrhagic infarcts with tumor thrombi were found in the lung. Histologically, the above lesions were identical to the former tibial biopsy and they showed large eosinophilic epithelioid cells with irregular ovoid nuclei and prominent eosinophilic nucleoli. Rare intracytoplasmic lumina were identified. Immunohistochemically, the tumor cells were positive for cytokeratins (CAM5.2 and AE1/AE3), CD31, factor VIII-related antigen, and vimentin. This case showed angiotropic spread of the tumor only to the right atrium and the lung, with no solid mass in other organs. Multicentric epithelioid angiosarcoma of the bone is a pitfall in pathological diagnoses, especially if a strong radiological impression of metastatic carcinoma is provided. Therefore, pathologists should be aware of this rare variant.

ORAL PRESENTATION OF EPITHELIOID ANGIOSARCOMA WITH FIRST SIGN IN THE SCAPULA: REPORT OF A CASE AND REVIEW OF THE LITERATURE

Occurrence of a primary or metastatic angiosarcoma in the oral cavity is extremely rare. The term "epithelioid angiosarcoma" (EA) has been used to designate a morphological variant of angiosarcoma characterized by poorly differentiated epithelial-like cells arranged in carcinoma-like fashion, but which still forms identifiable vascular channels. To our knowledge, EA in the oral region is extremely rare. Only two previous instances of EA in the maxilla have been reported. We present an additional oral case of EA in a 71-year-old man. Histology of the initial oral biopsy revealed suspicion of un-differentiated carcinoma. In order to confirm the diagnosis, immunohistochemical examinations were performed. The final diagnosis was EA. The patient died of multiple metastases shortly after the final diagnosis, implying an aggressive clinical course. This case showed that it was essential to use the vascular markers, such as FVIII-Rag and CD34, for a correct histological diagnosis of EA. The oral EA described here almost certainly represents a metastatic focus, rather than the primary site of tumor origin. This is because clinical history of EAs appears to arise in deep, rather than in more superficial tissues.

Epithelioid angiosarcoma of the bone: a series of 10 cases

The clinical and pathologic features of 10 epithelioid angiosarcomas of bone were analyzed. There were eight males and two females who ranged in age from 26 to 83 years (mean 62 years). Four tumors were solitary and six were multifocal. In two consultation cases, the submitted diagnosis was metastatic carcinoma. Microscopically, the tumor cells were arranged in solid and infiltrative sheets, and in most cases vascular channels or cystically dilated spaces were present. The neoplastic cells had abundant eosinophilic cytoplasm and large nuclei with open chromatin and prominent eosinophilic nucleoli. Intratumoral hemorrhage, neutrophilic infiltrates, and intracytoplasmic lumina were frequently present. All 10 tumors stained positive for one or more endothelial markers, with CD31 being the most sensitive marker. Seven cases stained positive for cytokeratin. Ultrastructural examination in three tumors confirmed their endothelial differentiation. In the absence of obvious vascular differentiation, abundant intratumoral hemorrhage and intratumoral neutrophils are useful ancillary morphologic features that may suggest a vascular origin. Six patients are dead of disease, one is alive with metastasis, and two patients are currently disease free. Epithelioid angiosarcoma of bone should be included in the differential diagnosis of epithelioid neoplasms of bone, and endothelial markers should be a part of their immunohistochemical analysis to avoid the misdiagnosis of a metastatic carcinoma because of the significant differences in the treatment and clinical outcomes of these entities.

Primary angiosarcoma of the femur: a diagnostic dilemma with a rare bone tumour

We describe a rare case of high-grade primary angiosarcoma of the proximal femur in a 66-year-old man that proved fatal secondary to pulmonary metastases. The difficulties experienced in histological and immunohistochemical diagnosis of these tumours, and the resultant need for a high index of suspicion by surgeons in general and orthopaedists dealing with bone tumours in particular, is emphasized, as is the need for multidisciplinary management.

Cardiac epithelioid angiosarcoma presenting as cutaneous metastases

BACKGROUND

Cardiac angiosarcoma is a rare tumor that has a predilection for middle-aged males and a marked predominance in the right atrium. The tumor may present abruptly with a fulminant clinical course. Initial presentation with metastatic disease is rare. Only one case has been reported of a patient who presented with cutaneous metastases.

METHODS AND RESULTS

We here report the case of a 51-year-old man who initially presented with cutaneous metastases in the absence of cardiac symptoms. The skin biopsy was diagnosed as metastatic undifferentiated sarcoma. The patient died 26 days later with widely disseminated disease. At autopsy a tumor arising in the wall of the left atrium and in the interatrial septum was found. After an immunohistochemical study including CD31 and CD34 stains the diagnosis of cardiac pure epithelioid angiosarcoma was made. To the best of our knowledge this tumor variant has not been documented in the heart until now.

CONCLUSION

Although cardiac angiosarcoma is a rare neoplasm, its presence should be suspected in patients with cutaneous metastatic angiosarcoma without an evident source of the tumor, even in absence of cardiac symptoms.

Epithelioid vascular tumors of bone: a review and proposal of a classification scheme

Skeletal vascular tumors composed of epithelioid endothelial cells commonly result in diagnostic difficulty. Although tumors with this morphology have been recognized for many years, there is a considerable degree of confusion regarding their nomenclature and classification. In this article what is believed to represent the morphologic features of this family of tumors is outlined, the historical context of epithelioid endothelial tumors is briefly discussed, and pertinent literature and texts pertaining to the subject is reviewed. It is proposed that the osseous epithelioid endothelial tumors should be classified in a similar manner to their soft tissue counterparts and it is suggested that this approach should help to clarify the confusion surrounding this subject of surgical pathology.

Cytology of angiosarcoma. Findings in fourteen fine-needle aspiration biopsy specimens and one pleural fluid specimen

We report the cytologic features of 15 cases of angiosarcoma from various sites and include 14 fine-needle aspiration (FNA) biopsy specimens and 1 pleural fluid specimen. Six were initial diagnoses with histologic confirmation; an additional case in the liver was an initial diagnosis without tissue confirmation. One case represented lymph node metastasis from a primary prostatic epithelioid angiosarcoma. In 10 cases, immunohistochemical staining for factor VIII-related antigen, CD34, CD31, or Ulex europaeus agglutinin I was performed on the cytology or histology specimen. The aspirates varied in cellularity, and the degree of nuclear atypia ranged from relatively bland in a case of low-grade angiosarcoma of the prostate to highly pleomorphic in a lymph node metastasis from a facial cutaneous angiosarcoma. Vasoformative features such as intracellular RBCs, well-formed vessels, attempts at microacinar/lumen formation, and intracytoplasmic lumens were variably present. The background was bloody in all specimens, with necrosis in rare cases. This cytologic series emphasizes that the cytologic features are heterogeneous but that the diagnosis can be suggested by fine-needle aspiration (FNA) when vasoformative features are present. The diagnosis can be made conclusively by FNA with immunocytochemical confirmation of endothelial differentiation.

Angiosarcoma arising in a bone infarct

A primary angiosarcoma of the femur arose in continuity with a bone infarct in a 74-year-old man. The tumor, resected by amputation, had pleomorphic polygonal and spindle cells in solid and cystic patterns with focal vasoformative features. The immunohistochemical stains CD31, CD34, factor VIII-related antigen, and Ulex europeus corroborated the endothelial differentiation of the tumor. The patient died after developing pulmonary metastases. This is the oldest reported patient with a well-documented angiosarcoma associated with a bone infarct.

Epithelioid angiosarcoma arising in a surgically constructed arteriovenous fistula: a rare complication of chronic immunosuppression in the setting of renal transplantation

Immunosuppression in the setting of solid organ transplantation is associated with the development of a variety of malignant tumors, most commonly squamous carcinomas and non-Hodgkin's lymphomas. Sarcomas, apart from Kaposi's sarcoma, are relatively infrequent. We recently encountered a 71-year-old man with chronic renal failure, treated by allograft kidney transplantation, who developed a high-grade epithelioid angiosarcoma at the site of a nonfunctioning arteriovenous fistula, previously constructed for hemodialysis. At diagnosis, the patient had numerous satellite nodules of angiosarcoma involving the distal skin, soft tissues, and bones. After a below-elbow amputation, there was a rapid local recurrence at the amputation stump. Currently, the patient is alive with numerous pulmonary metastases, 6 months after amputation. A literature review identified three recently reported identical cases of epithelioid angiosarcoma arising in nonfunctioning arteriovenous fistulae. All three patients had been treated by kidney transplantation for renal failure, suggesting a possible causal association between these events. We performed polymerase chain reaction for human herpes virus 8, the recently recognized herpes virus proposed as a major etiologic agent of Kaposi's sarcoma, and possibly some conventional angiosarcomas, but we failed to identify any viral DNA within the tumor.