Epithelioid hemangioendothelioma of the anterior mediastinum. Clinicopathologic, immunohistochemical, and ultrastructural analysis of 12 cases

Primary epithelioid hemangioendotheliomas and angiosarcomas of the pleura: a clinicopathological and immunohistochemical analysis of 13 cases

Thirteen cases of primary epithelioid hemangioendotheliomas (EHE) and epithelioid angiosarcomas (EA) of the pleura are presented. The patients were 7 men and 6 women between the ages of 34 and 65 years (mean: 47 years). The patients presented with non-specific symptoms of cough, dyspnea, and chest pain. Diagnostic imaging revealed the presence of either diffuse pleural thickening or pleural nodules involving the serosal surfaces. Open surgical biopsies were obtained in all cases. Histologically, eight tumors were characterized by the presence of a cellular proliferation composed of medium-sized epithelioid cells embedded in a myxohyaline stroma and a variable spindle cell component. Cellular atypia was mild to moderate and mitotic activity ranged from 1 to 2 per 2 mm2. Immunohistochemical stains for vascular markers, including CAMTA1 were positive, confirming a diagnosis of EHE. Five cases of epithelioid angiosarcomas were characterized by a neoplastic cellular proliferation admixed with areas of necrosis and hemorrhage and characterized by medium-sized epithelioid to spindle-shaped cells with eosinophilic cytoplasm, round to oval nuclei and prominent nucleoli. In addition, marked cytologic atypia and a mitotic activity ranging from 3 to 5 per 2 mm2 were identified. Immunohistochemical studies demonstrated positive staining for vascular markers; however, CAMTA1 was negative. Clinical follow-up obtained in eleven cases showed that all patients had died within 30 months post diagnosis. The current study highlights that even though it may be important to histologically separate EHE from EA for academic purposes, primary pleural origin of these tumors appears to portent an aggressive clinical behavior.

Anastomosing Hemangioma of the Ovary With Leydig Cell Hyperplasia: A Clinicopathologic Study of 12 Cases

Anastomosing hemangioma is a recently described vascular neoplasm, initially identified in the male genitourinary tract. Since its first description, it has been reported at multiple anatomic sites, including rare cases in the female genital tract, most in the ovary. Herein we report the largest series to date of 12 ovarian anastomosing hemangiomas identified at our institution over a 15-yr period. The patients' age at the time of resection ranged from 50 to 76 yr (median: 62 yr), 3 patients presented with symptomatic pelvic masses, 3 tumors were identified by imaging studies, and the remaining 6 were incidentally discovered in ovaries removed for other indications. All tumors were unilateral, occurred at the ovarian hilum, and contained a vaguely lobulated architecture with sinusoidal-like vessels lined by hobnail endothelial cells with minimal to no cytologic atypia. A rim of luteinized/Leydig cells with abundant, eosinophilic cytoplasm and round, centrally placed nuclei surrounding the hemangioma was present in 9/12 tumors. Reinke crystals were observed in 3 of these 9 tumors. The volume of luteinized cells relative to the vascular proliferation ranged from 2% to 30%. All tumors with luteinized/Leydig cells also displayed numerous small eosinophilic, globular intracytoplasmic inclusions within the endothelial cells. The 3 tumors without luteinized/Leydig cells were exclusively intravascular lesions. Despite the frequent presence of luteinization/Leydig cells none of the patients experienced hormonal manifestations. Awareness of this rare benign ovarian entity is important, as its association with luteinized cells/Leydig cell hyperplasia (often exuberant) may be misinterpreted as a steroid cell tumor, Leydig-cell tumor, or as a mixed stromal-vascular tumor.

[Epithelioid Hemangioendothelioma Presenting as a Right Paratracheal Mass: A Case Report]

Epithelioid hemangioendothelioma (EHE) is a low-grade malignant vascular neoplasm that can occur anywhere in the body. EHE has a low annual incidence (0.38/106) and prevalence (< 1/106), and primary mediastinal EHE is exceedingly rare. We report a case of EHE in a 53-year-old female which manifested as an incidentally discovered mass in the right paratracheal region. In this report, authors describe the pathological and radiological findings of primary mediastinal EHE invading the superior vena cava in the right paratracheal area.

Imaging Findings and Clinical Features of Primary Spinal Epithelioid Hemangioendothelioma

Rationale and Objectives

Primary spinal epithelioid hemangioendothelioma (SEHE) is an extremely rare angiocentric vascular neoplasm with inherent metastatic potential, which pursues a clinical course intermediate between hemangioma and angiosarcoma. The present study sought to present computed tomography (CT) and magnetic resonance imaging (MRI) findings and clinical features of primary SEHE and review the literature.

Materials and Methods

Clinical data of four patients with primary SEHE confirmed by pathology from January 2011 to May 2020 were analyzed retrospectively. Two cases underwent CT scan, while 3 cases underwent MRI scan. Image observation included the tumor location, bone changes, morphology, density/signal characteristics, and enhanced features.

Results

The four patients were all women who ranged in age from 25 to 74 years. Four cases of the lesions were in the vertebral body; among them, two cases involved the accessory of the vertebra. Soap bubble appearance was detected in 2 cases, honeycomb osteolytic appearance in 2 cases, a sclerotic margin in 3 cases, and accompanying vertebral compression fracture in 1 case. CT showed a slightly inhomogeneous low density with punctate high-density foci. MRI showed an inhomogeneous low signal on T₁-weighted image (T₁WI) and a high signal on T₂WI. Contrast-enhanced CT/MRI demonstrated moderate to intensive inhomogeneous enhancement of the lesions. The discs were normal. In one case, lesions presented a dural tail sign.

Conclusions

Primary SEHE is so rare in the clinic as an aggressive vascular tumor. The relatively typical clinical features and radiographic findings can help in preoperative diagnosis.

[Hemangioendothelioma of the right innominate vein]

The authors report a rare case of hemangioendothelioma of the right innominate vein complicated by superior vena cava syndrome. Considering development of enlarged venous collaterals, we performed circular resection of superior vena cava together with the right and left innominate veins without replacement. There were no postoperative complications. The use of vascular prosthesis in patients with long-standing superior vena cava compression and enlarged collaterals is associated with high risk of thrombosis and subsequent pulmonary embolism. Safe circular resection of superior vena cava without replacement is possible after intraoperative test clamping.

Mesenchymal Tumors of the Mediastinum: An Update on Diagnostic Approach

Mesenchymal tumors of the mediastinum are a heterogenous group of rare tumors with divergent lineages. Mediastinal mesenchymal tumors are diagnostically challenging due to their diversity and morphologic overlap with nonmesenchymal lesions arising in the mediastinum. Accurate histologic diagnosis is critical for appropriate patient management and prognostication. Many mediastinal mesenchymal tumors affect distinct age groups or occur at specific mediastinal compartments. Neurogenic tumors, liposarcoma, solitary fibrous tumor, and synovial sarcoma are common mesenchymal tumors in the mediastinum. Herein, we provide an update on the diagnostic approach to mediastinal mesenchymal tumors and a review of the histologic features and differential diagnosis of common benign and malignant mesenchymal tumors of the mediastinum.

Sarcomas of the mediastinum with epithelioid morphology

While soft tissue sarcomas typically have a spindled or pleomorphic appearance, a subset of malignant soft tissue neoplasms can have a prominent epithelioid morphology. In complex anatomic sites such as the mediastinum, such tumors can often be mistaken for a carcinoma or mesothelioma. Frequent expression of cytokeratin staining can further confound the diagnostic process and familiarity with these entities can help prevent an erroneous diagnosis. Particular entities that have been reported to occur in the mediastinum with such features include dedifferentiated liposarcoma, pleomorphic liposarcoma, malignant peripheral nerve sheath tumor, synovial sarcoma, SMARCA4-deficient thoracic sarcoma, alveolar soft part sarcoma and clear cell sarcoma. Many of these tumors exhibit unique clinical, genetic, molecular or immunohistochemical features which allow for accurate characterization. For example, pleomorphic liposarcoma contains bizarre appearing lipoblasts and dedifferentiated liposarcoma exhibits MDM2 gene amplification that is typically confirmed by fluorescence in-situ hybridization. Malignant peripheral nerve sheath tumor will often arise in association with a nerve or neurofibroma. Synovial sarcoma consistently exhibits rearrangements involving the SS18 gene and SMARCA4-deficient thoracic sarcoma shows loss of SMARCA4 staining in the tumor cells. Alveolar soft part sarcoma demonstrates an ASPL-TFE3 fusion transcript. Clear cell sarcoma often shows an EWSR1-ATF1 fusion transcript. When encountering a sarcoma of the mediastinum with epithelioid features, familiarity with these and other characteristics can help insure a correct diagnosis.

Vascular tumors of the mediastinum

Vascular tumors represent only a sliver of all tumors affecting the mediastinum, but they pose diagnostic challenges due to significant overlap among entities, ever-evolving classification schemes, and the exquisite rarity of some of the entities not only in the mediastinum but in pathology practice as a whole. Most of the vascular tumors are better known to the practice of soft tissue pathology, from which some of the knowledge of clinical behavior can be extrapolated. For example, the stratification of epithelioid hemangioendothelioma (EHE) into two biologically separate categories has effectively translated from the somatic soft tissues to the thorax. For other entities, the effective validation of soft tissue parameters is hindered by the small numbers of reported mediastinal cases. Many of the treatment modalities have also transferred over, with the key differences resting on the difficulty in achieving complete surgical resection for mediastinal tumors as opposed to those in the somatic soft tissues. Accordingly, systemic drug therapies have emerged as attractive options for some of the mediastinal vascular tumors, such as kaposiform hemangioendothelioma (KHE) and Kaposi sarcoma (KS). The categories presented herein mirror the classification scheme set forth by the 5th Edition WHO Classification of Soft Tissue and Bone Tumors. This review focuses on the biologically aggressive vascular neoplasms while limiting discussion of the benign entities to relevant comparisons in the differential diagnoses. While distinguishing among the benign entities has academic importance, in practice, the stakes are far higher for diagnosing the biologically aggressive tumors given their marked heterogeneity in clinical outcomes. Practical advice for problem areas in pathology will be reviewed alongside tumor pathobiology, including the latest in molecular diagnostics.

Mediastinal Epithelioid Hemangioendothelioma Invading Superior Vena Cava: A Case Report and Review of Literature

INTRODUCTION

Epithelioid Hemangioendothelioma (EHE) is a rare vascular neoplasm. Common locations of EHE are the bone, soft tissue, liver, and lung, but the mediastinal location is extremely rare. Few cases of mediastinal EHE, invading the Superior Vena Cava (SVC) have been reported.

CASE PRESENTATION

We report a case of a 21-year-old man with EHE invading the SVC, which was incidentally detected on performing chest radiography. A contrast-enhanced chest Computed Tomography (CT) scan demonstrated a well-defined, oval mass located on the right side of the anterior mediastinum. The mass showed homogeneous enhancement with punctate calcifications, and it invaded the SVC at the confluence area of the right and left brachiocephalic veins.

CONCLUSION

Mediastinal EHE invading the SVC may present as a homogeneously enhancing mass with punctate calcifications. It should be added to the differential diagnosis of tumors of the mediastinum. Accurate preoperative diagnosis of EHE is critical for surgical planning; therefore, knowledge of the radiologic features of EHE is important.

Mediastinal sarcomas: experience using fine needle aspiration cytopathology

Fine needle aspiration (FNA) cytology is a sparsely used diagnostic method in the evaluation of mediastinal sarcomas in most medical centers worldwide with most literature citations regarding this category of malignancies consisting of small series and individual case reports. Most of these published studies highlight vascular sarcomas such as epithelioid hemangioendothelioma, and angiosarcoma, various subtypes of liposarcoma including well-differentiated liposarcoma, myxoid liposarcoma, and pleomorphic liposarcoma, malignant peripheral nerve sheath tumor, and sarcomas of uncertain differentiation, primary synovial sarcoma and the Ewing sarcoma family of tumors. This paucity of cytopathology reports regarding mediastinal sarcomas is in marked contrast to the almost daily application of endobronchial ultrasound (EBUS)-guided FNA biopsy for sampling mediastinal lymph nodes and mediastinal masses for primary and metastatic carcinomas which, of course, are considerably more common that any type of sarcoma in this location. EBUS, endoscopic ultrasound-guided (EUS) needle biopsy, and percutaneous image-guided biopsy using either core needle, fine-needle, or both can serve a potentially useful role for diagnostic sampling of mediastinal sarcomas, be they primary or metastatic. This review catalogues much of the published data regarding FNA cytopathology and its application to mediastinal sarcomas. An attempt is made to primarily highlight case series rather than individual case reports; however, due to the paucity of these, case reports are cited and discussed where appropriate.

An Aggressive Large Epithelioid Hemangioendothelioma of the Anterior Mediastinum in a Young Woman

Hemangioendothelioma is a rare vascular tumor with involvement of the liver, brain, long bones, and lung. Among the 6 histological subtypes, epithelioid hemangioendothelioma (EHE) is the most aggressive. Its occurrence in the mediastinum is quite rare, and very few cases have been documented. The reported cases in the literature have described difficulties in the preoperative diagnosis due to the unusual histological appearance of the tumor. Immunohistochemistry remains the mainstay for a definitive diagnosis. Due to its low incidence, there is no standard treatment for mediastinal EHE, but curative resection is the preferred treatment option where possible, with chemotherapy used as an adjuvant treatment or in cases of widespread inoperable disease. The present case study describes an aggressive EHE occurring in an 18-year-old woman in the anterior mediastinum.

Mediastinal Composite Hemangioendothelioma. A Rare Tumor at an Unusual Location

Composite hemangioendothelioma is a rare vascular tumor; only 12 cases have been previously described in the extremities, tongue and axilla. We report the first case of composite hemangioendothelioma of the mediastinum in a 50-year-old woman. She was admitted to our hospital with dyspnea and cough lasting for two months. Her chest roentgenogram and computed tomography showed a 6 × 4 × 3 cm mass in the middle mediastinum compressing the trachea. She underwent total sternotomy and resection of the mass. Microscopically the most important feature at low power was the variability in the histological pattern. This case is presented not only for the rarity of the tumor type but also for its unusual location.

New Insights about Pulmonary Epithelioid Hemangioendothelioma: Review of the Literature and Two Case Reports

Pulmonary epithelioid hemangioendothelioma (PEH) is a rare neoplasm of vascular origin. There are three different major imaging patterns identified in thoracic manifestation of epithelioid hemangioendothelioma: (1) multiple pulmonary nodules; (2) multiple pulmonary reticulonodular opacities; and (3) diffuse infiltrative pleural thickening. Radiographically, presence of bilateral multiple nodules is the most common pattern of presentation. The diagnosis is made on the basis of histopathological findings and confirmed by positive immunohistochemistry staining. Although the prognostic factors for PEH have not yet been well established, a better prognosis is usually associated with the multinodular pattern. We report two different imagological presentations of this rare disease, based on two institutional experiences, along with a review of the relevant literature.

Clinico-radiological features and next generation sequencing of pulmonary epithelioid hemangioendothelioma: A case report and review of literature

Epithelioid hemangioendothelioma is a very rare, vascular, low‐grade malignant tumor found in the lungs, liver, bone, and other soft tissues. Most patients with pulmonary epithelioid hemangioendothelioma (PEH) are asymptomatic but usually present with multiple bilateral nodular lesions in the lungs. Currently, surgical lung biopsy, histology, and immunohistochemical methods are essential for diagnosis. However, there is no standard therapy for the treatment for PEH.

Our paper describes the clinico‐radiologic features and genomics of PEH based on next‐generation sequencing (NGS) in a 43‐year‐old male we encountered. The patient came to the hospital with right chest pain. After investigation, a lesion in the middle lobe of the right lung was found, together with smaller multiple lesions in both lungs. After resection of the lesion, histopathological analysis showed positive findings for PEH. The patient's blood and tumor tissue were sent for NGS analysis for further investigation. Results from the analysis revealed mutations of multiple genes. The information obtained from the genomic analysis of PEH using NGS may be significant for the planning and monitoring of treatment for this disease.

Epithelioid hemangioendothelioma of right innominate vein mimics a teratoma: A case report

RATIONAL

Epithelioid hemangioendothelioma (EHE) is a rare neoplasm commonly known to arise from the soft tissue, lung, and liver. EHE arising from right innominate vein (RIV) has scarcely been reported in English literature.

PATIENT CONCERNS

Herein, we present a rare case of EHE of RIV in a 51-year-old woman with right-lower chest pain for 4 days. Computed tomography of the chest revealed a spherical mass with calcification and fatty foci located in the anterior mediastinum, thus a presumptive diagnosis of teratoma was made.

DIAGNOSES, INTERVENTIONS, AND OUTCOMES

Video-assisted thoracoscopic explorations and resection of mediastinal tumor were then performed. The pathological examination showed that the tumor was EHE. Postoperative radiotherapy was delivered to the patient. Pulmonary metastases were found by chest CT a year after surgery.

LESSONS

A diagnosis of EHE might be considered, when a mediastinal tumor closely related to veins showing intratumoral calcification and obvious enhancement, despite the presence of a clear boundary and visible fat content.

A Case of an Epithelioid Hemangioendothelioma Arising from the Innominate Vein Mimicking Cervical Metastatic Lymphadenopathy

Background. Epithelioid hemangioendothelioma (EHE) is a rare tumor usually presenting in soft tissue. EHE is a vascular malignancy of intermediate clinical behavior, with a histologic appearance of endothelial cells growing in nests or cords. Although EHE often originates from a vessel, it is relatively rare for a primary vascular EHE to originate from a large vein or artery. Occurrence in the mediastinum is exceptionally rare. There are no known associations with other malignancies. Case Presentation. We present a case of mediastinal invasive EHE in a 39-year-old female with concurrent papillary thyroid cancer. She initially presented with a thyroid mass found by her primary care provider, with preoperative imaging concerning for extension into the superior mediastinum. Operative exploration revealed a mediastinal mass distinct from her thyroid carcinoma with invasion into the great vessels, requiring off-pump interposition graft bypass for en bloc resection. Final pathology confirmed pT3N1b multifocal papillary thyroid carcinoma with a separate grade 1 pT1b EHE. Review of the literature describes the demographics, updated pathologic outcomes, histologic findings, and reported incidence of EHE. Conclusions. This is the first reported case of thyroid malignancy with separate and concurrent EHE. Surgeons should remain aware of this entity given its variable behavior. Although initially described as an indolent neoplasm, tumors with poor prognostic factors have been shown to be locally aggressive.

Intrathoracic glomus tumors and glomangiosarcomas: a clinicopathological and immunohistochemical study of 14 cases with emphasis on anatomic distribution

Fourteen cases of primary intrathoracic glomus tumor and glomangiosarcoma are presented. The patients were 9 men and 5 women aged 36 to 63 years (mean, 49.5 years). Clinically, 11 patients presented with nonspecific symptoms including cough, hemoptysis, chest pain, and back pain while 3 patients were asymptomatic. Anatomically, 9 tumors were in an intrapulmonary location, 3 in the mediastinum, and 2 in the trachea. Surgical resection was performed in all cases, and grossly the tumors varied in size from 1.5 to 4.5 cm in greatest diameter. Histologically, 12 cases corresponded to glomus tumor characterized by a homogenous proliferation of medium-sized cells with round nuclei and inconspicuous nucleoli and no evidence of mitotic activity or necrosis. In 2 cases, the presence of marked cellular pleomorphism, nuclear atypia, and mitotic activity was more in keeping with a diagnosis of glomangiosarcoma. The 2 glomangiosarcomas were located in the lung, one of which was associated with lymph node metastasis. Immunohistochemical stains for smooth muscle actin were positive in all cases while negative for epithelial, vascular, neuroendocrine, and neural markers. Clinical follow-up showed that all patients with a glomus tumor are alive and well after a period of 12 to 36 months after surgical resection. In contrast, the 2 patients with glomangiosarcoma died of tumor 24 and 36 months, respectively, after initial diagnosis. The current cases highlight the ubiquitous distribution of these tumors within the thoracic cavity and stress the importance of including these tumors in the differential diagnosis of thoracic neoplasms.

Mesenchymal tumours of the mediastinum--part II

This is the second part of a two-part review on soft tissue tumours which may be encountered in the mediastinum. This review is based on the 2013 WHO classification of soft tissue tumours and the 2015 WHO classification of tumours of the lung, pleura, thymus and heart and provides an updated overview of mesenchymal tumours that have been reported in the mediastinum.

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.

Lipomatous tumors of the anterior mediastinum with muscle differentiation: a clinicopathological and immunohistochemical study of three cases

Three cases of primary lipomatous tumors of the anterior mediastinum with prominent muscle differentiation are presented. The patients were two women and one man between the age of 52 and 68 years. All patients presented with progressive shortness of breath. Radiographically, all patients demonstrated anterior mediastinal tumors which were surgically resected. In two cases, the gross findings were those of circumscribed tumors, while one lesion was described as an ill-defined and unencapsulated neoplasm. Histologically, two cases corresponded to a well-differentiated liposarcoma, while the third was a thymolipoma. Extensive areas of smooth muscle were identified in one of the liposarcomas, while the other contained areas of mature skeletal muscle. The thymolipoma displayed a prominent myoid component. Immunohistochemical studies for muscle markers including smooth muscle actin, desmin, and myoglobin showed positive staining in the corresponding components. Follow-up information showed that one patient with liposarcoma died 60 months after initial diagnosis, while the other two patients remain alive and well 16 and 36 months after diagnosis, respectively. The current cases highlight the spectrum of muscle differentiation that can be seen in adipose tumors of the anterior mediastinum and also emphasize the difficulty that such a diagnosis can pose when confronted with limited mediastinoscopic biopsies.

Mediastinal epithelioid hemangioendothelioma with abundant spindle cells and osteoclast-like giant cells mimicking malignant fibrous histiocytoma

Abstract

Epithelioid hemangioendothelioma is a relatively uncommon lesion usually presenting in soft tissues. The occurrence in the mediastinum is exceptional rare. Histologically, this tumor is characterized by epithelioid cells with intracytoplasmic vacuoles in a hyalinized or mucinous stroma. Occasionally, spindle cells or osteoclast-like giant cells can be observed. Herein, we present a case of epithelioid hemangioendothelioma in a 38 year-old Chinese male. The tumor was predominantly composed of abundant spindle cells with marked atypia and scattered osteoclast-like giant cells reminiscent of malignant fibrous histiocytoma. The unusual histological appearance can pose a great diagnostic challenge. It may be easily misdiagnosed, especially if the specimen is limited or from fine-needle aspiration.

Virtual slides

http://www.diagnosticpathology.diagnomx.eu/vs/5804918529726307

Surgical treatment of a rare case of epithelioid hemangioendothelioma of the azygos vein

Epithelioid hemangioendothelioma (EHE) of soft tissues is a rare low-grade vascular tumour, with variable malignancy. Mediastinal localization is exceptional. We report the first case of a radically resected EHE of the azygos vein (AV). A 47-year old man presented to our institution with an asymptomatic incidental neck-chest computerized tomography (CT) evidence of a 3 cm mediastinal mass, resembling a station 4R lymphadenopathy, with rather distinct margins, strictly adjacent to the AV. (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET)/CT revealed a SUV max of 2.3. Fiberbronchoscopy with EBUS-trans-tracheal needle aspiration of station 4R yielded nondiagnostic cytology result. A right lateral thoracotomy revealed an ovoidal mediastinal mass originating from the AV, unresectable from it but showing cleavage from the superior vena cava. The mass with the involved AV was resected en bloc by vascular stapler. Histopathology revealed a venous EHE arising from the AV. For the low mitotic rate and small tumour size, no adjuvant therapy was administered. Total body CT scan at one year from surgery shows neither local recurrence, nor distant metastases. EHE should be considered in the differential diagnosis of mediastinal masses in adult patients. After radical removal prognosis is generally favourable, but strict follow-up must be performed because aggressive forms have been described.

Clinical patterns and outcome in epithelioid hemangioendothelioma with or without pulmonary involvement: insights from an internet registry in the study of a rare cancer

BACKGROUND

Epithelioid hemangioendothelioma (EHE) is a rare vascular neoplasm of endothelial origin with clinical behavior intermediate between hemangioma and angiosarcoma. The natural history of EHE is highly variable. This study uses an Internet registry to identify clinical patterns with prognostic significance in EHE.

METHODS

Cases from the International Hemangioendothioma, Epithelioid Hemangioendothelioma, and Related Vascular Disorders (HEARD) Support Group were evaluated based on demographics, organ involvement, disease progression, presence or absence of pleural effusion, and treatment. Survival among various cohorts was compared using log-rank analysis of Kaplan-Meier plots.

RESULTS

Two hundred sixty-four patients were identified from April 2004 to November 2009. Fifty-eight cases were excluded because of inadequate information or wrong diagnosis. EHE was more common in female patients (61%). Male gender and age ≥ 55 years were associated with decreased survival. The most commonly affected organs were liver, lung, and bone. No specific organ or combination of organ involvement differentially affected survival, and survival was no different between patients with multiple vs single organ involvement. However, pattern B, defined as lesions without distinct borders (eg, pulmonary infiltrates, pleural effusion, ascites), hemoptysis, or involvement of more than two bones adversely affected survival in all cohorts.

CONCLUSION

A novel staging system with prognostic value for EHE is proposed. Pleural effusion or other signs of uncontained tumor growth, hemoptysis, and osseous involvement of more than two bones implied worse survival than did localized and discrete tumors, regardless of number of organs involved. A lay registry can provide useful insights into the clinical behavior of a rare cancer.

Mediastinal epithelioid haemangioendothelioma: a rare mediastinal tumour

We report the case of a 35-year-old patient with an incidental finding of an asymptomatic large (9.5 cm in diameter) anterior mediastinal tumour. Radiological findings favoured the diagnosis of a benign mediastinal teratoma. During surgical resection, we found a tumour adhering to the surrounding tissues, and encompassing the innominate vein which was totally occluded. Total tumoural exeresis was performed as well as the double cross-section of the innominate vein. Postoperatively, there was no left upper limb swelling, probably because of a chronic occlusion of the innominate vein. The hospital stay was uneventful. Immunohistochemistry diagnosed a mediastinal 'epithelioid haemangioendothelioma', which is a tumour of vascular origin. We believe that the tumour took origin from the innominate vein and invaded the anterior mediastinum. After a simple radiological follow-up, the patient is in complete remission 30 months after the operation. We present the case of this patient with the iconography, along with a review of the available literature concerning mediastinal epithelioid haemangioendotheliomas.

Epithelioid hemangioendothelioma of the head and neck: role of podoplanin in the differential diagnosis

Epithelioid hemangioendothelioma is an uncommon vascular tumor of soft tissue and bone that may rarely occur in the liver, lung and the head and neck. We present five new cases of epithelioid hemangioendothelioma of the head and neck region diagnosed and managed in one institution in order to define the phenotypic characteristics, podoplanin immunohistochemical staining and the biological outcome. Podoplanin is a transmembrane mucoprotein selectively expressed in lymphatic endothelium and recently in some vascular neoplasms. The patients were comprised of two male and three female patients ranging in age from 4 to 71 years. The lesions were found in the gingiva, submandibular region soft tissue, nasal cavity and tongue, and ranged in size from 0.7 to 2.5 cm. All tumors manifested infiltrative cords and nests of epithelioid cells with occasional spindle morphology in a myxoid stroma. Immunohistochemical analysis of vascular and epithelial markers showed strong and uniform cytoplasmic reactivity for podoplanin and variable intensity and staining of CD31 and lack of cytokeratin staining in tumor cells. Surgical treatment included simple and wide local excisions. Of the three patients with follow-up, one developed lymph node metastasis and one had no evidence of disease 10 months after surgery. The patient with multiple recurrences and LN metastases was additionally treated with chemotherapy and is under consideration for radiation therapy. Hemangioendothelioma of the head and neck is: (1) a low-grade malignancy with a tendency for local recurrence and regional lymph node metastasis, (2) complete excision with negative margins is the treatment of choice for localized disease and (3) podoplanin may be useful in differentiating epithelioid hemangioendothelioma from non-vascular tumors.

Epithelioid hemangioendothelioma presenting with severe myelofibrosis and a high serum hyaluronan level

Epithelioid hemangioendothelioma (EHE) is a rare tumor originating from the vascular endothelium; it has an intermediate malignant potential. EHEs affect all age groups and mostly originate from the soft tissues of the extremities, lungs, and liver. Spinal EHEs, especially those occurring in the bone marrow region, are extremely rare. We report a case of EHE with massive involvement of the liver, vertebrae, and cranial bones that caused severe myelofibrosis (MF) in a 67-yr-old-male patient. Hyaluronan deposits were diffusely observed in the tumor tissue biopsies obtained from both the liver and bone marrow. Furthermore, the serum hyaluronan level increased markedly along with rapid progression of the disease. To the best of our knowledge, this is the first report of MF occurring in an EHE; hyaluronan may have played an important role in the pathogenesis of fibrosis in this case.

Epithelioid hemangioendothelioma in the posterior mediastinum

Epithelioid hemangioendothelioma is a rare neoplasm usually presenting in soft tissues. A case of epithelioid hemangioendothelioma arising in the posterior mediastinum and presenting as a large pleural effusion in a young woman is presented.

Gingival swelling in a 13-year-old girl with multiple recurrences

We present a challenging case of gingival swelling that recurred several times in 3.5 years in a 13-year-old girl. Histologic evaluation of the initial biopsy revealed groups of epithelioid cells surrounded by lymphocytes in the submucosal fibrous connective tissue, and it was diagnosed as noncaseating granulomatous inflammation. With the tissue specimens from subsequent multiple excisions and several immunohistochemical studies, the diagnoses evolved to benign cellular infiltrate of undetermined origin, epithelioid hemangioma, proliferating endothelial cell neoplasm of uncertain biologic potential, atypical vascular tumor, epithelioid hemangioendothelioma, and kaposiform hemangioendothelioma. We discuss the list of differential diagnoses from various pathologists and propose our diagnosis of epithelioid hemangioendothelioma based on its clinical behavior, histologic features, and immunohistochemical findings.

Epithelioid hemangioendothelioma of the oral cavity: Report of two cases and review of the literature

The epithelioid hemangioendothelioma is an uncommon vascular neoplasm of borderline or intermediate malignant potential. Although numerous sites of involvement are possible, these tumors most commonly arise in soft tissue, liver, and lung. Involvement of the oral cavity is rare. Only 12 cases of intraoral epithelioid hemangioendothelioma have been reported in the English language literature. We review the salient features of these previously reported cases and present 2 additional intraoral cases--one presenting as an asymptomatic radiolucency in the posterior mandible of a 23-year-old female, and the other presenting as an asymptomatic, erythematous to purplish gingival nodule in a 28-year-old female. Intraoral tumors most commonly involve the gingival soft tissues and often are associated with adjacent alveolar bone resorption. Although it is not possible to estimate with accuracy the potential for recurrence and metastasis among intraoral tumors given the small number of previously reported cases, wide local excision with close clinical follow-up appears to be the treatment of choice for these tumors because of their unpredictable clinical behavior.

An authentic malignant epithelioid hemangioendothelioma of the thyroid: a case report and review of the literature

Hemangioendotheliomas of the thyroid are neoplasms that are rarely encountered in the Alpine region in Europe. The endemic goiter in this iodine-deficient region can be considered as a predisposing factor. We report the second case of an epithelioid hemangioendothelioma (EHE) of the thyroid gland and the first clinical case with malignant behavior. A 73-year-old woman with a long history of multinodular goiter presented with a rapidly growing thyroid mass, free of distant metastases. A total thyroidectomy was performed. Histologically the lesion had characteristic epithelioid and spindle cell proliferation in a background of chondromyxoid stroma. Cytoplasmic vacuolization in the epithelioid and spindle cells were present. Tumor cells were positive for factor VIII-related antigen, MNF116, PAN-ceratin, CD 34, and CD 31 and negative for cytokeratin allowing the diagnosis of EHE. Nine months after the primary resection the tumor locally recurred. A palliative resection was performed in a second operation followed by interferon-alpha therapy. The patient rapidly developed a second local relapse and died 13 months after the diagnosis of an EHE had been made. An improvement of the very poor prognosis of this rare tumor may depend on early tumor diagnosis and surgery combined with a multimodal treatment.

Spinal epithelioid hemangioendothelioma with epithelioid angiosarcomatous areas

Epithelioid hemangioendothelioma is a distinctive vascular tumor rarely involving bones. We report a case of epithelioid hemangioendothelioma in the cervical spine with angiosarcomatous areas. A 50-year-old female presented with dizziness while walking. A mixed sclerotic and osteolytic or destructive lesion was radiographically disclosed in her upper cervical vertebrae. Histologically, a laminectomy specimen exhibited areas of ordinary epithelioid hemangioendothelioma together with foci of more atypical epithelioid cell proliferation, closely resembling epithelioid angiosarcoma. This phenomenon has been exceptionally described in cases with skeletal lesions, which are typically of low-grade malignancy.

Hemangioendotelioma: tumor raro de mediastino

Apresentou-se para atendimento um homem de 30 anos, branco, natural e procedente de São Paulo, com quadro de dor em hemitórax esquerdo, na região anterior e lateral, constante e de leve intensidade havia três meses, associado a dispnéia aos grandes esforços havia um mês. Durante a investigação foi visualizada em radiograma, tomografia e ressonância magnética de tórax grande tumoração em mediastino anterior e médio, com possível invasão dos vasos da base. Ele foi submetido à mediastinotomia paraesternal esquerda com biópsia da massa mediastinal, a qual complicou por sangramento intenso. Optou-se pela esternotomia mediana total e toracotomia ântero-lateral esquerda de urgência, com controle do sangramento e ressecção completa do tumor. Houve boa evolução, com alta hospitalar no nono dia pós-operatório. O exame anatomopatológico mostrou tratar-se de hemangioendotelioma de mediastino.

Uncommon primary mediastinal tumours

The mediastinum is a unique anatomic area containing several structures and pluripotent cells that allow for the development of a range of tumours. Uncommon neoplasms of the mediastinum account for less than 10% of all mediastinal masses and include primary thymic carcinomas, neuroendocrine carcinomas, germ-cell tumours (GCTs), lymphomas, and neurogenic, endocrine, and mesenchymal tumours. Primary thymic carcinomas and neuroendocrine carcinomas, although rare, are highly malignant lesions. GCTs are thought to derive from primitive germ cells and can be classified in seminomatous and non-seminomatous GCTs. They are located predominantly in the anterior mediastinum, as are the primary mediastinal lymphomas that include Hodgkin lymphoma, large B cell lymphoma, and lymphoblastic lymphoma. Neurogenic tumours may arise from peripheral nerves, sympathetic ganglia, or rarely parasympathetic ganglia and are located predominantly in the posterior mediastinum. Endocrine tumours are the ectopic thyroid and parathyroid tumours. Mesenchymal tumours are rare tumours and no less problematic than they are in peripheral sites. The clinical, radiological, and therapeutic aspects of these tumours are reviewed.

Cystic Adenomatoid Tumor of the Mediastinum

A case of adenomatoid tumor presenting as a mass in the anterior mediastinum is described. The patient was a 56-year-old woman with left side chest wall pain who showed a mediastinal mass on chest x-ray and CT scans. Thorough clinical and radiographic examination did not reveal any evidence of tumor elsewhere. At surgery, the tumor was found adjacent to the anterior pericardial reflection. Grossly, the tumor measured 5.5 x 5.5 x 3 cm and showed a homogeneous cut surface with numerous cystic structures that varied from 0.5 to 1.5 cm in greatest diameter. Histologic examination showed numerous cystic spaces lined by flattened or cuboidal epithelial cells. The walls of the cysts showed a proliferation of small canalicular structures lined by round to polygonal epithelioid cells with vacuolated eosinophilic cytoplasm. Immunohistochemical studies showed strong positivity of the epithelioid cells for AE1/AE3 cytokeratin, CK5/CK6, and calretinin. Stains for CK7, CK20, alpha-fetoprotein, CD31, carcinoembryonic antigen, MOC 31, and chromogranin were negative. Electron microscopic examination showed numerous long microvilli on the cell surface and abundant tonofilaments/desmosomal plaques in the tumor cells, characteristic of mesothelial cells. The patient is alive and well and free of recurrence 1 year following surgery. Adenomatoid tumor is a rare neoplasm that should be added in the differential diagnosis of anterior mediastinal masses. Immunohistochemical and ultrastructural studies may be of aid in identifying the characteristic features of mesothelial cells and to avoid mistaking this lesion for more ominous conditions.

Epithelioid hemangioendothelioma with osteoclast-like giant cells

Epithelioid hemangioendothelioma is an unusual entity of intermediate malignant vascular tumors and rarely admixes with multinucleated osteoclast-like giant cells. We describe such a case in a 50-year-old woman with an 1-year follow-up period. When the patient was 39 years old, a 0.7 x 1-cm firm mass was found in the left neck. She developed ascites three years later. At that time, the specimen from the neck mass was excised and found to be composed of cords of epithelioid cells in a myxoid hyaline stroma. Scattered intracytoplasmic vacuoles were seen. Immunohistochemical studies confirmed the diagnosis of epithelioid hemangioendothelioma. Abdominal ultrasonography and computed tomographic scan revealed multiple low density areas in the liver. Eleven years later, a metastatic lesion was found in the thoracic spine at the level of Th7-8. The histologic findings were basically similar to those of the left neck mass. However, because of the presence of Kp-1-positive multinucleated osteoclast-like giant cells throughout the tumor, the thoracic lesion was diagnosed as an epithelioid hemangiothelioma with osteoclast-like giant cells. This unique form of epithelioid hemangioendothelioma is extremely rare and should be distinguished from other benign and malignant tumors with osteoclast-like giant cells.

Epithelioid hemangioendothelioma of the common femoral vein: Case report and review of the literature

A young competitive skier had venous claudication. A stenosis of the left common femoral vein was revealed by means of an examination. Exploration and vein patch angioplasty were performed, and because of both the unusual appearance (focal thickening of vein wall) and the unclear etiology of the lesion, frozen and permanent sections of the wall were obtained. Epithelioid hemangioendothelioma, a rare intravascular sarcoma, was revealed by means of an examination of the permanent sections. Two additional procedures were required to completely excise the epithelioid hemangioendothelioma. We discuss these rare vascular malignancies and include a review of the available literature. Also, oncologic principles important in both the diagnosis and therapy of intravascular sarcomas are discussed.

Mesenchymal tumors of the liver

Primary angiosarcoma of the liver accounts for up to 2% of all primary liver tumors and is the second most common primary malignant neoplasm of the liver. Approximately 10 to 20 new cases are diagnosed every year in the United States and the prevalence varies from 0.14 to 0.25 per million. In an autopsy series from Chicago, one hepatic angiosarcoma was noted for every 30 cases of hepatocellular carcinoma.

A case of childhood epithelioid hemangioendothelioma

Epithelioid hemangioendothelioma (EHE) is a unique tumor, mainly of adults, which is characterized by epithelioid or histiocytoid endothelial cells. It is a low-grade malignant vascular tumor first described as a distinctive entity in 1982 by Weiss and Enzinger. An 8-year-old girl presented with an approximately 3-year history of an erythematous plaque on the left frontal area of the scalp. The diagnosis of EHE confined to the skin was made by clinicopathologic and radiologic evaluation. To our knowledge, there are only 5 reported cases of EHE with skin involvement, 2 of which showed concomitant systemic involvement, and all occurred in adults. Our case is the fourth reported case of EHE confined to the skin and the first to describe childhood onset of isolated cutaneous EHE.