Intravascular Cutaneous Disorders. A Clinicopathologic Review

Fatally Metastatic Diagnostic Pitfall: Pseudolymphomatous Epithelioid Cutaneous Angiosarcoma Arising From an Ulcerative Scalp Injury

Rare morphological variants of cutaneous angiosarcoma (AS) can be diagnostically challenging. Angiosarcoma located on the head and scalp of the elderly has been associated with especially poor prognosis. We report a difficult diagnostic pitfall of pseudolymphomatous AS variant with overlapping features of epithelioid variant and aberrant immunohistochemistry staining, arising on an ulcerative scalp lesion in a 79-year old woman. Initial histopathological exam showed extensive cutaneous necrosis with prominent dermal inflammation within which, scattered large cells were CD31 positive and CD34 negative. After cutaneous lymphoma was ruled out, these large cells within the inflammatory infiltrate were determined to be dermal histiocytes and initial biopsy was diagnosed as benign. Subsequent re-biopsy showed similar features and was also called benign. Post-mortem re-review found the large cells were positive for ERG and formed solid clusters and papillae in some areas. A diagnosis of pseudolymphomatous epithelioid AS was rendered. Autopsy demonstrated lung nodules to be metastatic AS, consistent with findings from scalp primary. Our case draws attention to multiple features that can confound angiosarcoma diagnosis, and we discuss the appropriate endothelial IHC panel to rule out angiosarcoma in this clinical context.

Intravascular Large B-Cell Lymphoma With Exclusively Cutaneous Involvement, Colonizing Pre-Existing Hemangiomas: A Rare Case With Aberrant HMB45 Expression

ABSTRACT

Intravascular large B-cell lymphoma (IVLBCL) is a rare and aggressive subtype of non-Hodgkin lymphoma. It is characterized by the presence of neoplastic lymphoid cells within blood vessels. We report a rare case of IVLBCL with exclusively cutaneous involvement colonization of hemangiomas. A 55-year-old man with a history of cutaneous angioma consulted dermatology because of the growth of some of the hemangiomas in recent months. Histologic examination revealed a dermal proliferation of small- and medium-sized vessels with lumina occupied by large pleomorphic cells with B immunophenotype and aberrant expression of HMB-45. Biopsy of a pre-existing hemangioma may be useful in the diagnosis of suspected cutaneous IVLBCL. The cutaneous variant has a better prognosis. It is also important to note that unexpected protein expression or loss of expression in malignant tumors may be a risk factor for misdiagnosis.

The art of dermatopathology

Dermatopathology, like dermatology, has evolved in many directions; however, both fields remain true to visual morphology-based diagnosis. Dr Irwin M. Braverman is a role model for the intersection of these two visual fields. One of his passions is correlating the clinical presentations of disease with histopathologic findings and teaching these skills to others at the bedside and the microscope. Dr Braverman's innovative approach to education is exemplified by his use of paintings to hone the observational skills of trainees. His creative and inquisitive lectures, such as a recent discussion of color blindness in art and medicine, stress that none of us interpret the world in the same way. Interobserver variability has implications for how we approach dermatologic diseases, highlighted herein with the example of reactive versus malignant angioendotheliomatosis. As a master dermatologist and dermatopathologist, Dr Braverman exemplifies how deep and broad knowledge positively influences dermatology and dermatopathology.

Cutaneous Intravascular Hematolymphoid Entities: A Review

Intravascular lymphomas are rare disease conditions that exhibit neoplastic lymphoid cells that are confined mainly to the lumens of small capillaries and medium-sized vessels. The majority of the intravascular lymphomas are of B-cell origin, but they can include NK/T-cell and CD30+ immunophenotypes. In the histologic differential diagnosis are benign proliferations such as intralymphatic histiocytosis and intravascular atypical CD30+ T-cell proliferation. In this review, we discuss the clinical, histopathologic, and molecular findings of intravascular B-cell lymphoma, intravascular NK/T-cell lymphoma, intralymphatic histiocytosis, and benign atypical intravascular CD30+ T-cell proliferation.

Giant papillary hemangioma-A rare tumor with an exceptional size

Papillary hemangioma (PH) is a recently described vascular tumor with a predilection for the skin of the head and neck. Histopathologically, it is characterized by a bland endothelial proliferation arranged in a papillary configuration, bearing resemblance to glomeruloid hemangioma seen in the context of polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, skin changes syndrome. The largest cutaneous PH reported to date measured 1.5 cm in greatest dimension. Here, we report a case of PH with an alarming size of 10 cm. We present this case to add to the limited literature on this rare tumor, highlight the histopathologic differences between PH and its mimics, and emphasize the variable nature of PH tumor size.

Lower Eyelid Complication After Blepharoplasty and COVID-19 Vaccination

BACKGROUND

Following COVID-19 mass vaccination campaign, new- and unknown-related reactions have emerged.

CASE REPORT

Four months after transcutaneous lower blepharoplasty and few days after the second dose of SARS-CoV-2 Pfizer mRNA vaccination, a 57-year-old man developed a bilateral palpebral ecchymosis. While the lesion healed spontaneously on the left side, the ecchymosis on the right lower lid did not regress. It presented swelling and hard consistency, clinically involving only skin layer. No alterations were revealed upon blood tests and instrumental evaluations. Histological examination showed lymphovascular hyperplasia on a probable reactive basis. The lesion was resistant to medical and surgical therapies. After 15 months, it regressed spontaneously.

CONCLUSIONS

In the reported case, an evident chronological relationship exists between surgical site and vaccine reaction, while other etiopathogenetic factors were excluded. This case represents a previously undescribed condition linking postvaccination reaction and long-term surgical outcome.

LEVEL OF EVIDENCE V

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Characterization of intravascular papillary endothelial hyperplasia: a multicenter cohort

Intravascular papillary endothelial hyperplasia (IPEH) is an uncommon benign malformation of the skin and subcutaneous tissue. In this retrospective multi-center study, we aimed to investigate the clinical and pathological features of 261 IPEH cases. We classified IPEH into three categories from most common to least common: pure (50%), mixed (46%), and extravascular types (4%). IPEH frequently stained positive for immunohistochemical markers such as CD31, SMA, ERG, CD34. Clinicians' initial impression of the lesion often included ambiguous terms such as "soft tissue mass." There is an opportunity for increased awareness of this lesion and its consideration within a differential diagnosis.

Intravascular histiocytosis: mimicker of cellulitis, angiosarcoma, inflammatory breast cancer, and others

BACKGROUND

Intravascular histiocytosis is an underrecognized reactive skin condition characterized by the clinical finding of poorly demarcated erythematous to violaceous patches and plaques. The diagnosis is confirmed by the histologic findings of intraluminal histiocytes on skin biopsy and exclusion of an alternative diagnosis.

METHODS

A review of patients with a histologic diagnosis of intravascular or intralymphatic histiocytosis and seen at Mayo Clinic, Rochester, Minnesota, from January 1, 2010, to October 10, 2020, was performed. Histologic and clinical information was collected from the medical records.

RESULTS

Nine patients were identified. Clinical impressions prior to biopsy varied widely, and no clinician included intravascular histiocytosis in the initial clinical differential diagnosis. Eight patients had preceding trauma to the affected area.

CONCLUSION

Intravascular histiocytosis remains a rare skin condition. Clinical identification remains low. Our cases add support to the hypothesis that intravascular histiocytosis is a reactive condition often preceded by trauma and/or surgery.