Epithelioid hemangioendothelioma of bone

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

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

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

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

Mesenchymal Neoplasms of the Liver

Mesenchymal neoplasms of the liver can be diagnostically challenging, particularly on core needle biopsies. Here, I discuss recent updates in neoplasms that are specific to the liver (mesenchymal hamartoma, undifferentiated embryonal sarcoma, calcifying nested stromal-epithelial tumor), vascular tumors of the liver (anastomosing hemangioma, hepatic small vessel neoplasm, epithelioid hemangioendothelioma, angiosarcoma), and other tumor types that can occur primarily in the liver (PEComa/angiomyolipoma, inflammatory pseudotumor-like follicular dendritic cell sarcoma, EBV-associated smooth muscle tumor, inflammatory myofibroblastic tumor, malignant rhabdoid tumor). Lastly, I discuss metastatic sarcomas to the liver, as well as pitfalls presented by metastatic melanoma and sarcomatoid carcinoma.

Epithelioid hemangioendothelioma of the distal lower extremity and the role of radiotherapy: A report of two cases

We report two cases of epithelioid hemangioendothelioma (EHE) in the distal lower extremity. Our first patient had unicentric EHE of the left os calcis initially treated with an intralesional procedure; however, later developed two recurrences which were managed with radiation therapy. Our second patient had multicentric EHE of the distal tibia and fibula managed with primary radiation therapy. Although EHE is typically treated with wide resection or an intralesional procedure, we present two cases of EHE in the distal lower extremity to discuss the therapeutic role of radiation therapy in the management of distal EHE.

Multifocal Epithelioid Hemangioendothelioma Complicated with Disseminated Intravascular Coagulation

Epithelioid hemangioendothelioma (EHE) is a rare malignant vascular neoplasm that requires long-term management. Several reports describe disseminated intravascular coagulation (DIC) associated with angiosarcoma, but no association with EHE has been reported. We encountered a patient with DIC complicated by multifocal EHE. The patient was an 83-year-old woman with spinal lesions, small lung nodules, and a soft tissue mass in the right buttock. The tumor was biopsied and diagnosed as EHE. The patient received pain control therapy without antitumor therapy. One month later, DIC developed with tumor progression. DIC subsided with nafamostat mesylate infusion, and oral apixaban was administered. DIC was managed for 5 months until the patient died of brain metastases. This is the first report of a patient with DIC complicated by EHE. It should be noted that progression of EHE can cause DIC. We were able to manage DIC using anticoagulant agents.

Vascular Tumors of Bone: Updates and Diagnostic Pitfall

Vascular tumors of bone can be diagnostically challenging because of their rarity and histologic overlap with diverse mimics. Vascular tumors of bone can be categorized as benign (hemangioma), intermediate-locally aggressive (epithelioid hemangioma), intermediate-rarely metastasizing (pseudomyogenic hemangioendothelioma), and malignant (epithelioid hemangioendothelioma and angiosarcoma). Recurrent genetic alterations have been described, such as FOSB rearrangements in pseudomyogenic hemangioendothelioma and a subset of epithelioid hemangiomas; CAMTA1 or TFE3 rearrangements in epithelioid hemangioendothelioma. This review discusses the clinical, histologic, and molecular features of vascular tumors of bone, along with diagnostic pitfalls and strategies for avoidance.

A primary solitary vascular tumor of calcaneum: case report and review of literature

Epithelioid hemangioendothelioma (EHE) is a rare vascular tumor with metastatic potential and estimated prevalence of less than one case per million. Among the musculoskeletal system, the long bones are commonly involved with approximately half patients experiencing multicentric involvement. Clinical course of EHE is often variable and nonspecific. Poorly demarcated osteolytic lesions are most commonly seen radiologically. Diagnostic confirmation is usually obtained by biopsy and histopathological exam, including immunostaining for endothelial markers. We present a rare case of unicentric EHE involving the calcaneum. Our patient had an indolent course of disease after surgical resection and no recurrence in seven years on clinical and radiological surveillance.

Recurrent Epithelioid Hemangioendothelioma of Calcaneum: A Case Report of a Rare Tumor

Epithelioid hemangioendothelioma (EHE) is an uncommon malignant vascular tumor characterized by epithelioid or histiocytoid endothelial appearance. Here we present the case of a 65-year-old female with recurrent EHE of the left calcaneum. The patient had developed soft-tissue swelling over the lateral aspect of the left hindfoot three years ago, which was previously managed by excisional biopsy as per medical records and the histopathological examination (HPE) had revealed an EHE. A year later, she again developed a painful swelling with superficial ulceration over the same region and presented to us. A plain radiograph of the foot showed a soft-tissue swelling with cortical breach over the lateral aspect of calcaneum. MRI revealed a mass encasing peroneus tendons, with extension into the lateral surface of calcaneum. CT angiography revealed a mass eroding the lateral cortex of calcaneum and receiving blood supply from calcaneal branches of peroneal artery. PET-CT scan did not reveal any other primary or metastatic site. Core needle biopsy of calcaneum was suggestive of EHE. Limb salvage was difficult as the tumor was recurrent and involved the skin and the weight-bearing part of the calcaneum. The patient was managed with trans-tibial amputation. Immunohistochemical (IHC) staining of the excised tissue was positive for CD34, Vimentin, SMA, and Fli-1. The margins were negative for any tumor cells and she did not require any adjuvant therapy. At two years follow-up, she was free of any further recurrence or metastasis. Recurrent tumors of this variety are fast-growing with metastatic potential and may cause mortality. Hence, they need to be managed aggressively.

Epithelioid Haemangioma of Bone: A Case Series and Comprehensive Literature Review Reappraising the Diagnostic Classification of All Epithelioid Vascular Neoplasms of Bone

Epithelioid vascular neoplasms of the bone are classified by the World Health Organization (WHO) into only two tiers: low-grade epithelioid hemangioma (EH) and a more malignant category including both epithelioid hemangioendothelioma and epithelioid angiosarcoma. The World Health Organization defines bone EH as a locally aggressive neoplasm with no connotation of benign or intermediate malignancy. We reviewed three cases of EH in our lab archives with the perspective of appraising their histomorphological approach toward diagnosis. Patients were in the age range of 15-25 years. The site of the neoplasms ranged from the carpal bones to the metatarsal bones. Histomorphological examination of the lesions showed a nodular growth pattern of a vascular neoplasm without demonstrable vessel origin. The vasoformative area increased from the center to the periphery, with prominent epithelioid morphology of the endothelial cells at the periphery and an associated inflammatory infiltrate comprising eosinophils, lymphocytes, and plasma cells. The growth pattern was diffuse, with extension into the deeper dermis of overlying skin.

The 2020 WHO Classification of Tumors of Bone: An Updated Review

Bone tumors are a rare and heterogeneous group of neoplasms that occur in the bone. The diversity and considerable morphologic overlap of bone tumors with other mesenchymal and nonmesenchymal bone lesions can complicate diagnosis. Accurate histologic diagnosis is crucial for appropriate management and prognostication. Since the publication of the fourth edition of the World Health Organization (WHO) classification of tumors of soft tissue and bone in 2013, significant advances have been made in our understanding of bone tumor molecular biology, classification, prognostication, and treatment. Detection of tumor-specific molecular alterations can facilitate the accurate diagnosis of histologically challenging cases. The fifth edition of the 2020 WHO classification of tumors of soft tissue and bone tumors provides an updated classification scheme and essential diagnostic criteria for bone tumors. Herein, we summarize these updates, focusing on major changes in each category of bone tumor, the newly described tumor entities and subtypes of existing tumor types, and newly described molecular and genetic data.

Epithelioid hemangioendothelioma of bone: A survival analysis of 50 cases from the SEER database (1992-2016)

Epithelioid hemangioendothelioma (EHE) is a rare vascular tumor that may arise in bone. The purpose of this investigation was to determine the clinicopathological features and outcomes of osseous EHE in a large patient series, and to assess whether survival is impacted by demographics, tumor characteristics, or treatment factors. This was a retrospective review of the Surveillance, Epidemiology and End Results (SEER) database from 1992 to 2016. Kaplan-Meier was used to estimate overall survival (OS) and disease-specific survival (DSS). A Cox regression model was used to identify prognostic factors. Fifty patients from 1992 to 2016 with a median age of 54.5 years (IQR, 37–67) were reviewed. For location, 46% (n = 23) of tumors arose from the appendicular skeleton while 38% (n = 19) occurred within the axial skeleton (overlapping EHE: 16%, n = 8). Of the cases with recorded treatment factors, 54.8% (n = 23) had surgery, 26% (n = 13) received radiation, 22% (n = 11) were treated with chemotherapy, and 26% (n = 13) had surgery plus radiation. The 5-year OS probability was 49.2% (95% CI, 23.6–70.6), and the 5-year DSS probability was 63.9% (95% CI, 33.0–83.5). No surgery (surgery: HR, 0.262; 95% CI, 0.07–0.9); p = 0.041) and age older than 50 years (HR, 4.117; 95% CI, 1.1–15.4; p = 0.035) were negative prognostic factors of disease-specific mortality after controlling for confounding variables. There was no association between disease-specific mortality and adjuvant or multimodal therapy. The prognosis of EHE of bone is less than favorable, and the 5-year DSS probability of 64% emphasizes the intermediate grade nature of this tumor subtype. Surgical treatment, when feasible, is associated with a better prognosis.

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.

Primary Vascular Tumors of Bone: A Monoinstitutional Morphologic and Molecular Analysis of 427 Cases With Emphasis on Epithelioid Variants

Recent molecular discoveries have refined vascular bone tumor classification. To investigate the clinical relevance of these refinements, we reviewed all cases of primary vascular bone tumors treated at our Institute. On the basis of morphology, cases were assessed immunohistochemically and molecularly. A total of 427 cases of primary vascular tumor of bone with available follow-up and histologic material were retrieved and reclassified according to the most recent diagnostic criteria as follows: 289 hemangiomas, 38 epithelioid hemangiomas, 21 epithelioid hemangioendotheliomas, 2 retiform hemangioendotheliomas, 1 intraosseous papillary intralymphatic angioendothelioma, 24 pseudomyogenic hemangioendotheliomas, and 52 angiosarcomas (of these, 45 were epithelioid angiosarcomas and 7 spindle cell secondary angiosarcoma). Both epithelioid and classic hemangiomas behave as benign tumors with excellent prognosis. The distinction between cellular and conventional type of epithelioid hemangioma was not associated with a different clinical course. Conversely, epithelioid hemangioendothelioma exhibited a more aggressive clinical behavior than hemangioma, with higher rates of multifocality and distant spread. Immunohistochemical positivity for CAMTA1 or TFE3 did not have a prognostic implication. In epithelioid hemangioendothelioma, the presence of morphologic malignant features was associated with reduced disease-free (P=0.064) and overall survival (P=0.055). Pseudomyogenic hemangioendothelioma featured local aggressiveness in 5/24 patients exhibiting a clinical behavior closer to epithelioid hemangioma than epithelioid hemangioendothelioma. Last, 32/45 patients with epithelioid angiosarcoma died of disease with a median survival time of 10 months from diagnosis. In conclusion, the integration of morphologic, immunohistochemical, and molecular features allows a better stratification of primary vascular tumors of bone with significant prognostic and therapeutic implications.

A Review of the Spectrum of Imaging Manifestations of Epithelioid Hemangioendothelioma

OBJECTIVE. The purpose of this article is to review the spectrum of imaging manifestations of epithelioid hemangioendothelioma across different organ systems and briefly describe its current treatment strategies. CONCLUSION. Epithelioid hemangioendothelioma is a rare, locally invasive neoplasm with metastatic potential. Although most commonly occurring in liver, lungs, and bones, it can also present at multiple other sites. Because of its nonspecific clinical and imaging manifestations, it is often misdiagnosed. The possibility of epithelioid hemangioendothelioma must be considered in the presence of a slowly growing mass that invades adjacent structures. Imaging can help plan percutaneous biopsy, detect sites of disease, and identify poor prognostic factors.

Multifocal epithelioid hemangioma of the metacarpal bones: A case report

Epithelioid hemangioma of bone is a rare, locally aggressive but benign vascular tumor that is now recognized as a distinct entity from other vascular neoplasms. It is often difficult to distinguish on imaging studies from other vascular tumors, including epithelioid hemangioendothelioma, which can lead to misdiagnosis and inappropriate treatment. We present the characteristic features and multimodality imaging findings in the case of a 24-year-old female with multifocal epithelioid hemangioma of the first and second metacarpal bones with extension into the surrounding soft tissue.

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

Background

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

Material/Methods

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

Results

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

Conclusions

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

Imaging findings in epithelioid hemangioendothelioma

PURPOSE-OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

INTRODUCTION

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

PATIENT CONCERNS

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

DIAGNOSIS

EHE of the bone.

INTERVENTIONS

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

OUTCOMES

He was discharged voluntarily and died 2 months later.

CONCLUSION

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

[Epithelioid hemangioendothelioma]

We describe herein the inaugural manifestations, the radiological and histological diagnosis criteria for and the outcome of epithelioid hemangioendothelioma (EHE). Most of EHE (90%) display a specific reciprocal chromosomic translocation t(1;3)(p36;q23-25), which is associated with the synthesis of fusion protein WWTR1/CAMTA1. EHE are low-grade vascular sarcomas. EHE could be initially localized or multifocal. At localized stage, EHE are best treated with focal treatments. At multifocal stage, the upfront strategy is watchful follow-up. Some multifocal EHE display very indolent course with spontaneous stable disease for years or decades. In case of progressive multifocal EHE, there is no consensual treatment. Diagnostic and clinical management of EHE requires interdisciplinary expertise from labeled centers.

Unicentric epithelioid hemangioendothelioma of the calcaneus: a case report and review of literature

Background

This review of the literature combined with a clinical case will allow the illustration of a favorable outcome of this variable low grade malignancy, display a role for limb salvage surgery with intralesional treatment, and offer a clinical example of epithelioid hemangioendothelioma, a rare malignancy.

Case presentation

The case report presents a case of solitary epithelioid hemangioendothelioma (EHE) of the calcaneus in a 60-year-old male. Primary vascular tumors of the bone are rare; however, EHE is one of the most common primary malignant vascular tumors to occur in bone. A review of the literature found few cases that involved the calcaneus; those cases found that involved the calcaneus were either part of a multifocal or metastatic disease process. Our case presents a 45-month clinical follow-up of solitary EHE in the calcaneus treated with surgical excision by curettage and cementing.

Conclusion

This case has clinical follow-up greater than 2 years post-operatively and could be a guide for treatment of a rare disorder with a substantial paucity of literature.

Primary leiomyosarcoma of the distal fibula: A case report and review of the literature

We describe a primary leiomyosarcoma of bone located in the distal fibula in a 67- year-old man. Plain radiographs and computer tomography scan revealed a lytic destructive lesion in the distal metaepiphyseal region of the left fibula with little involvement of the surrounding soft tissues. The lesion was composed of proliferating spindle-shaped cells with very slim cytoplasm and narrow oval cigar shaped nuclei. Immunohistochemistry studies demonstrated a strong positivity for actin and desmin, and weak positivity for caldesmon.

Advances in the Genetic Characterization of Cutaneous Mesenchymal Neoplasms: Implications for Tumor Classification and Novel Diagnostic Markers

Cutaneous mesenchymal neoplasms often pose significant diagnostic challenges; many such entities are rare or show clinical and histologic overlap with both other mesenchymal and non-mesenchymal lesions. Recent advances in the genetic classification of many cutaneous mesenchymal neoplasms have not only helped define unique pathologic entities and increase our understanding of their biology, but have also provided new diagnostic markers. This review details these recent discoveries, with a focus on their implications for tumor classification and diagnosis.

Epithelioid hemangioendothelioma of the spine: case report and review of the literature

Epithelioid hemangioendothelioma (EHE) has been described as a rare vascular bone lesion with histological features between hemangioma and high-grade angiosarcoma. Spinal EHE is a quite rare disease with few case reports and series reported in the literature. The tumor cells are positive for vimentin, CD31and CD34, factor VIII related antigen, ERG, and FLI1. Radiological features are not specific; it may appear as an osteolytic lesion. It can present as a multifocal disease in 40% of cases. No clear correlation with age and sex; however, it is slightly more common in males. Focal neck or back pain is the most common presenting symptom. The natural history of spinal EHE is unpredictable, and currently, there is no standard of care for treatment. Treatment options include preoperative embolization, and surgical resection followed by radiotherapy and/or chemotherapy. A 34-year-old previously healthy male presented with mid-thoracic back pain. Magnetic resonance imaging (MRI) of the spine revealed a decrease in vertebral body height at T5 with an enhancing mass. He underwent T5 balloon kyphoplasty and needle vertebral body biopsy. Results of the biopsy samples were non-diagnostic. Approximately 3 months after surgery, the patient presented with unsteady gait. A subsequent MRI revealed progression of the T5 compression fracture with cord compression. The patient subsequently underwent T4-T6 bilateral posterior decompression for epidural tumor and T3-T7 posterior instrumentation with pedicle screws. Pathology of the lesion revealed EHE. The patient was started on local radiation therapy (RT). On follow-up, 3 months after the second surgery, the thoracic spinal pain had improved dramatically. Our review highlights the diagnosis, clinical presentation, and treatment of spinal EHE. Complete resection is associated with good outcome. Radiotherapy has been used in partially resected lesions. However, the role of radiotherapy as primary treatment is not yet defined. Further studies should develop a treatment algorithm for this rare tumour.

Epithelioid hemangioendothelioma of the thyroid: a case report

Background

Epithelioid hemangioendothelioma (EHE) of the thyroid is an extremely rare disease; only three cases have been reported in the English literature to date. Here, we describe a case involving a patient with thyroid EHE successfully treated with curative surgery.

Case presentation

A 74-year-old woman presented with a right thyroid mass. The nodule was approximately 2 cm in size and was diagnosed as an indeterminate lesion by fine needle aspiration cytology. She was treated with thyroid lobectomy. The histopathological and immunohistochemical findings indicated an EHE of the thyroid. At the latest follow-up, 3 years postoperatively, the patient showed no signs of recurrence.

Conclusion

There is currently no standard therapy for EHE; however, our case suggests that curative resection represents an effective treatment.

FDG PET/CT Findings of Multifocal Epithelioid Hemangioendotheliomas of the Bones

Epithelioid hemangioendothelioma of the bones is very rare. We report a 78-year-old patient suffering from epithelioid hemangioendothelioma of multiple pelvic bones and the right femur. FDG PET/CT scan showed intense activity in mainly lytic lesions of these bones.

Epithelioid Hemangioendothelioma of the Distal Radius: A Case Report

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

Epithelioid Hemangioendothelioma of Tibia and Talus: A Case Report

Epithelioid hemangioendothelioma (EHE) of the bone is extremely uncommon and consists of less than 1% of primary bone tumors. It is characterized by epithelioid endothelial cells and has variable biological behavior. EHE is more likely to occur between 20 and 30 years of age. Approximately half of EHE present with multifocal disease. Since the behavior of these tumors is intermediate, it is important to not misdiagnose EHE as an angiosarcoma. Here we describe the case of a 43-year-old male who presented with pain and swelling of the leg and ankle to Dr. Ram Manohar Lohia Hospital, India. Radiography and computed tomography of the ankle and leg were performed and suggested an expansile lytic lesion involving the distal tibia and talus bone. The lesion was excised and ankle arthrodesis performed. Histological evaluation of the lesion demonstrated the presence of EHE of the tibia and talus.

A trimodality approach in the management of metastatic low-grade epithelioid hemangioendothelioma of the bone

A 29-year-old man presented with a 2-week history of severe pain in the left foot with no preceding history of trauma. A left foot radiograph demonstrated a cortical lucency in the mid-distal shaft of the third metatarsal bone. MRI of the left foot showed an expansile lesion in the same location. A staging bone scan showed a focal uptake in the known lucency in the left third metatarsal and in the proximal left femur. A subsequent left hip radiograph demonstrated a lucency in the intertrochanteric region. CT scan of the chest, abdomen and pelvis was unremarkable. A biopsy of the left third metatarsal expansile lesion performed during an incision and curettage procedure revealed an epithelioid haemangioma (EHE) of the bone. MRI of the left hip performed in response to the findings on the bone scan showed metastatic disease in the left intertrochanteric region. A prophylactic left hip fixation surgery with an interlocking intramedullary femoral nail was therefore undertaken to avoid a pathological fracture of the left hip from the metastatic disease. Simultaneously, a left hip biopsy was performed, which also revealed an EHE. The patient underwent external beam radiation to the left femoral head and neck. This was followed by fractionated radiosurgery to the left third metatarsal. Once the left foot wound had healed, the patient subsequently received four cycles of doxorubicin and ifosfamide. A restaging positron emission tomography CT carried out after completion of therapy showed no metabolic evidence of residual primary tumour or metastasis. More than 2 years after completing his trimodality therapy, the patient remains fully functional and symptom free.

Primary pseudomyogenic haemangioendothelioma of bone: report of two cases

Pseudomyogenic haemangioendothelioma (epithelioid sarcoma-like haemangioendothelioma) is a recently described, rarely metastasising neoplasm of the soft tissues that often presents as multiple discontinuous nodules in different tissue planes of a limb. This tumour type is extremely difficult to diagnose because no morphological evidence suggestive of endothelial differentiation is present to confirm a radiological suspicion of vascular neoplasm. All but one case published in the literature underline that bone involvement is secondary to deep and superficial soft tissue nodules. Here, we report two cases of primary bone pseudomyogenic haemangioendothelioma occurring in the radius and cuboid bone with a multifocal presentation.

A rare case of intravascular epithelioid hemangioendothelioma of the cephalic vein treated with surgery and postoperative radiation therapy: a case report and review of the literature

INTRODUCTION

Epithelioid hemangioendothelioma (EHE) is a rare endothelial tumor with an intermediate grade of malignancy. Few cases of primary vascular hemangioendothelioma have been described in the literature. Surgery is the treatment of choice, but radiation therapy and chemotherapy should also be considered in particular cases.

CASE PRESENTATION

We present the case of a 44-year-old Caucasian woman affected by EHE of the cephalic vein, treated by complete surgical removal of the mass and postoperative local radiation therapy. At 5-year follow-up, our patient is alive, with no signs of local or distant relapse and with no late radiation-related effects.

CONCLUSIONS

Postoperative radiotherapy may play a role in cases in which tumor margins are close or cannot be assessed or when high-risk features are present.

Minimally invasive treatment of a painful osteolytic lumbar lesion secondary to epithelioid hemangioendothelioma

Study Design Case report. Objective Multifocal epithelioid hemangioendothelioma (EHE) of the spine is a rare disorder. We describe a novel, multimodal treatment of a painful osteolytic lumbar lesion secondary to EHE. The minimally invasive treatment results in an excellent patient outcome with decreased morbidity compared to traditional techniques. Methods A previously healthy young adult presented with a painful osteolytic lesion at the L2 vertebrae. Imaging revealed multifocal spinal lesions consistent with a history of EHE. Core needle biopsy confirmed the diagnosis. Preoperative cryoablation of L2 was followed by a staged surgery, which included a partial L2 corpectomy, tumor resection, bone grafting, and vertebral reconstruction using a minimally invasive technique. This treatment was followed by prolonged therapy with interferon and bisphosphonate. Results At 3.5 years' follow-up, the patient has maintained his vertebral body height, has not required a fusion, and has had no recurrence of disease. Conclusion Multimodal treatment consisting of tumor cryoablation, partial corpectomy, allograft reconstruction of the vertebrae, and adjuvant interferon and bisphosphonate can result in good outcomes for well-contained EHE tumors of the spine.

The myriad of diseases that present with polyostotic bone lesions

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

Bone multicentric epithelioid hemangioendothelioma of the lower and upper extremities with pulmonary metastases: A case report

The present study reports a rare case of bone multicentric epithelioid hemangioendothelioma (EH) involving the upper and lower extremities simultaneously, with visceral involvement of the lung. Osteolytic lesions were first identified in the right distal femur and proximal tibia. Slight increased radionuclide uptake was observed in the right shoulder joint on bone scintigraphy, however, this was ignored, as no clinical symptoms were present. The patient was initially misdiagnosed with multifocal chondroblastoma, and an extra-articular curettage of lesions was performed in the proximal tibia and medial femoral condyle, which was filled with bone cement. The histopathological diagnosis was corrected post-operatively following immunohistochemical analysis, which indicated EH, and subsequently, an amputation of the right leg at thigh level was performed. In addition, multiple lytic lesions in the right shoulder joint and pulmonary metastases were identified on whole-body radiological examination. Radiotherapy was administered to the right shoulder joint, however, the patient refused chemotherapy or further surgery. At 15 months after the initial surgery, the patient currently remains alive. This case indicates that an improved understanding with regard to the clinical features of this disease may prevent misdiagnosis and improve EH treatment.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Self Regressing Epitheloid Haemangioendothelioma of Tibia in an Infant-A rare case report and review of literature

INTRODUCTION

Epitheloid hemangioendothelioma is a rare vascular soft tissue tumour of intermediate malignant potential. The tumor affects any age group, and liver is the commonest internal organ affected. Bones as calvarium, spine, tibia and femur may also be affected. The lesion can be multifocal in the liver or the same bone itself and can metastasise to lungs. Here we report a rare case of epithelioid hemangioendothelioma involving tibia in a male infant, which regressed by itself without any treatment, after incisional biopsy over a period of one and half years.

CASE REPORT

A 7 month old male baby was presented with incessant cry, fever and swelling in left upper leg of 2 weeks duration. X-ray of leg showed a well demarcated lytic lesion in the meta diaphysial region of left tibia. Magnetic resonance imaging showed an irregular lytic lesion with intramedullary extension. Incisional biopsy showed a vascular tumor, epithelioid hemangioendothelioma grade 1. Meanwhile the patient became asymptomatic and subsequent follow ups showed regression in the size of the tumor and complete disappearance after one and half years. This points towards the need of a wait and watch policy in such intermediate grade vascular tumours even though the lesion is so extensive. This is the first case report of an extensive self regressing epithelioid hemangioendothelioma of tibia in an infant to our knowledge.

CONCLUSION

Intermediate grade vascular tumors can undergo spontaneous regression which points towards the need of a wait and watch policy in such tumors thus avoiding extensive surgeries, especially in young patients.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Epithelioid hemangioendothelioma of the bone: a review and update

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

Primary angiosarcoma of the skull: A rare case report

Background:

Angiosarcomas are rare high grade endothelial tumors characterized by rapidly proliferating anaplastic cells derived from blood vessels and lining irregular blood filled spaces. Primary neoplasms of the skull are rare, representing 2.6% of primary neoplasms of bone. Primary malignant neoplasms of the skull are even rarer, accounting for only 0.8% of primary malignant neoplasms of bone.

Case Description:

We report a 32-year-old female who presented with right parieto-occipital swelling, which gradually increased in size. Radiology was suggestive of a calvarial soft tissue lesion in the right parieto-occipital region with destruction of the adjacent parieto-occipital bone with intracranial extra-axial extension. Complete surgical excision of the calvarial lesion was done under general anesthesia. Postoperative computed tomography (CT) scan of brain (plain and with contrast) showed complete excision of the tumor mass. Histopathological diagnosis was consistent with ‘an angiosarcoma of the skull’. On immunohistochemistry, the atypical endothelial cells were highlighted by CD34, CD31, and factor VIII-related antigen. The patient received adjuvant radiotherapy to the tumor bed.

Conclusion:

Primary angiosarcoma of the skull is a rare tumor with less than 20 cases reported worldwide till date. The treatment should include complete surgical excision with a wide bony margin followed by adjuvant radiotherapy, which in our case has given a good locoregional control even at the end of 2 years. However, these patients should be followed up with repeated scans yearly to rule out locoregional as well as distant recurrence.

Vascular tumors of bone

Vascular tumors of the bone represent a variety of neoplasms, ranging from benign hemangiomas and epithelioid hemangiomas to intermediate grade hemangioendotheliomas to frankly malignant angiosarcomas. Over the years, there has been considerable debate concerning the aggressivity, nomenclature, and mere existence of various nosologic entities, due to morphologic similarities and uncertainty regarding biologic behavior. Such debate has led to confusion among pathologists and clinicians, thus diminishing the prognostic implications in the diagnosis of these lesions. Here we review the current knowledge concerning the primary vascular neoplasms of the bone and correlate clinicopathologic features with tumor behavior.

Vascular sarcomas

Vascular sarcomas are soft-tissue tumors that arise from the endothelium with a malignant potential. This review discusses the management of epithelioid hemangioendothelioma (EHE) and angiosarcoma. EHE is a vascular tumor of intermediate malignant potential with an indolent course. EHE arising from the liver, lung, or bone tends to be multifocal and the rate of progression is slow and often unpredictable. Treatment should be considered in patients with significant symptomatic deterioration and/or progressive disease on imaging studies. Various cytotoxic and targeted therapies are available for management, with disease stabilization as the most common outcome. Angiosarcoma is an aggressive vascular tumor with a high malignant potential. Multidisciplinary care is critical for the management of localized disease, and the best outcomes are often observed in patients when a combination of systemic and local therapy options is used. Metastatic angiosarcoma is treated primarily with systemic therapy, and several cytotoxic and targeted therapies are available, alone or in combination. The choice of therapy depends on several factors, such as cutaneous location of the tumor, performance status of the patient, toxicity of the treatment, and patient goals.

Metastatic epithelioid angiosarcoma to the mandible: report of a case and review of the literature

Angiosarcoma and its epithelioid variant are vascular malignancies that rarely affect the facial skeleton. Epithelioid angiosarcoma resembles carcinoma and can be difficult to diagnose. A case is presented of metastatic epithelioid angiosarcoma to the mandible from an angiosarcomatoid portion of renal carcinoma. The diagnostic challenge is outlined and the literature is reviewed.

Epithelioid hemangioendothelioma of the mastoid: resection for recurrence and adjuvant radiation with 8-year followup

Epithelioid hemangioendothelioma (EH) is a rare, vascular neoplasm that can affect any age group and has been reported previously in sites including bone, liver, lung, breast, and brain. We describe a case of EH located in the mastoid, which appears to be the first report of EH in this site. The patient was 62 years old when they presented with dizziness and nausea. A suboccipital surgical approach was utilized to resect the tumor. After 18-month followup, the patient was symptom-free; however, imaging demonstrated a recurrence and the patient was taken back to the operating room for a resection. There is no evidence of recurrence after 8 years of followup. This paper aims to reinforce the need for a timely radical excision and aggressive clinical followup as the best hope for cure. Here, we describe an illustrative case and review the pertinent literature.

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

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