MRI and FDG PET/CT findings of hepatic epithelioid hemangioendothelioma. Clin Nucl Med. 2013;38:e66-e73. [PMID: 22996250 DOI: 10.1097/rlu.0b013e318266ceca]

A Rare Case of Solitary Primary and Recurrent Hepatic Epithelioid Hemangioendothelioma Undergoing Repeat Liver Resections

INTRODUCTION

Hepatic epithelioid hemangioendothelioma (HEHE) is a rare vascular tumor. Treatment strategy remains controversial because of its rarity. Liver resection is considered as the optimal treatment for solitary HEHE, while a small subset of patients have a solitary tumor. We present the rare case of a patient with solitary primary HEHE who experienced solitary recurrence following liver resection and underwent subsequent liver resection.

CASE PRESENTATION

A 55-year-old man was referred to our department with a suspected intrahepatic cholangiocarcinoma, based on imaging findings. Anatomic liver resection of segment 8 was performed, and the tumor was confirmed to be HEHE from the pathological findings. Fifteen months later, a solitary recurrence developed in segment 7. After a 5-month observation period, partial liver resection was performed, and the tumor was consistent with recurrent HEHE. The postoperative course was uneventful, and the patient remained recurrence-free for 9 months following the procedure.

CONCLUSIONS

Repeat liver resection may be a feasible treatment option for patients with solitary recurrent HEHE.

MRI and PET/CT of multiple primary hepatic angiosarcomas in 25-year-old man: A case report

This study aims to provide a comprehensive understanding of primary hepatic angiosarcoma, a rare and aggressive malignancy, focusing on its diagnostic challenges and unique imaging characteristics. The objective is to delineate the distinctive features of angiosarcoma through computed tomography and magnetic resonance imaging modalities, contributing to improved diagnostic precision and adding valuable insights to the scientific literature. We present the case of a 25-year-old male with primary hepatic angiosarcoma, emphasizing the challenges in distinguishing it from other vascular tumors.

Hepatic epithelioid hemangioendothelioma-a single-institution experience with 51 cases

Objectives

The aim of the present study was to describe the experience at a single institution in the management of hepatic epithelioid hemangioendothelioma (HEHE).

Methods

We included 51 patients with histologically confirmed HEHE. We performed log-rank (Cox-Mantel) survival analyses using Kaplan-Meier methods to test differences in survival between patients in different groups. Univariate Cox regression analyses and multivariate proportional hazards regression model were carried out to identify independent prognostic factors.

Results

Different imaging modalities were used to diagnose HEHE with various presentations. Liver resection (LR), liver transplantation (LT), systemic treatment (ST), and surveillance had been used in our study. A significant difference was noted between the LR group and the surveillance group with respect to mean survival (p = 0.006), as was in the LR group and the ST group (p = 0.036), and in surgical approach (LR and LT) and nonsurgical approach (ST and surveillance) (p = 0.008). The mean survival between the ST group and the surveillance group was not significantly different (p = 0.851). LR (p = 0.010) and surgical approach (p = 0.014) were favorable predictors of outcome, while macrovascular invasion (MaVI) (p = 0.037), lung metastasis (p = 0.040), and surveillance (p = 0.033) were poor prognostic factors in univariate analysis. Multivariate analysis showed that LR (p = 0.010) and surgical approach (p = 0.014) were independently associated with good OS, while surveillance (p = 0.033) was independently associated with poor OS. After adjusting for confounding factors, patients in the LR group have much better OS than those in the surveillance group (p = 0.013). However, there was no significant difference in OS between the LR group and ST group (p = 0.254), as was in the ST group and the surveillance group (p = 0.857).

Conclusions

The definitive diagnosis of HEHE was dependent on histopathology, and it was not possible to make a specific diagnosis without biopsy because the radiological findings were similar to those in some hepatic malignancies. ST was not recommended for patients who were not candidates for surgical approaches, and surgical approaches should be warranted regardless of disease stage. The retrospective nature and the small size of the data limited the generalizability of the study, designing a worldwide database that contains all data about patients with HEHE independent of their therapy, which was highly recommended.

Characteristic contrast‑enhanced ultrasound findings of hepatic epithelioid haemangioendothelioma: A case report and literature review

Hepatic epithelioid hemangioendothelioma (HEHE) is a rare liver tumor, which is usually diagnosed by pathological examination, since the diagnostic imaging criteria remain to be defined. However, contrast-enhanced ultrasound (CEUS) may reveal the characteristic features of HEHE to aid diagnosis. In the present study, two-dimensional ultrasound examination of a 38-year-old male patient showed a mass in the right liver. CEUS showed an S5 segment hypoechoic nodule, and imaging features resulted in the diagnosis of HEHE. Surgery was shown to be an appropriate and successful treatment for HEHE. In conclusion, CEUS may be valuable for the diagnosis of HEHE, thereby avoiding the serious consequences of misdiagnosis.

Retiform hemangioendothelioma of the breast in a man with 18F-flurodeoxyglucose accumulation on positron emission tomography: a case report

BACKGROUND

Retiform hemangioendothelioma (RH) is a rare, intermediate-grade vascular tumor that often arises in the trunk and extremities. The clinical and radiological features of RH remain largely unknown.

CASE PRESENTATION

A male patient in his 70s presented with shortness of breath on exertion, and computed tomography incidentally revealed a tumor in his right breast. Positron emission tomography (PET) revealed moderate ¹⁸F-fluorodeoxyglucose (FDG) uptake in the tumor. RH was observed in the resected specimens. Three months after surgery, the patient was free of local recurrence and distant metastasis.

CONCLUSIONS

RH was found in the male breast and was accompanied by FDG uptake on PET. PET may be useful in diagnosing RH. Although metastasis is rare in RH, local recurrence may occur, and careful follow-up is required.

Total-body PET/CT - First Clinical Experiences and Future Perspectives

Total-body PET has come a long way from its first conception to today, with both total-body and long axial field of view (> 1m) scanners now being commercially available world-wide. The conspicuous signal collection efficiency gain, coupled with high spatial resolution, allows for higher sensitivity and improved lesion detection, enhancing several clinical applications not readily available on current conventional PET/CT scanners. This technology can provide (a) reduction in acquisition times with preservation of diagnostic quality images, benefitting specific clinical situations (i.e. pediatric patients) and the use of several existing radiotracers that present transient uptake over time and where small differences in acquisition time can greatly impact interpretation of images; (b) reduction in administered activity with minimal impact on image noise, thus reducing effective dose to the patient, improving staff safety, and helping with logistical concerns for short-lived radionuclides or long-lived radionuclides with poor dosimetry profiles that have had limited use on conventional PET scanners until now; (c) delayed scanning, that has shown to increase the detection of even small and previously occult malignant lesions by improved clearance in regions of significant background activity and by reduced visibility of coexisting inflammatory processes; (d) improvement in image quality, as a consequence of higher spatial resolution and sensitivity of total-body scanners, implying better appreciation of small structures and clinical implications with downstream prognostic consequences for patients; (e) simultaneous total-body dynamic imaging, that allows the measurement of full spatiotemporal distribution of radiotracers, kinetic modeling, and creation of multiparametric images, providing physiologic and biologically relevant data of the entire body at the same time. On the other hand, the higher physical and clinical sensitivity of total-body scanners bring along some limitations and challenges. The strong impact on clinical sensitivity potentially increases the number of false positive findings if the radiologist does not recalibrate interpretation considering the new technique. Delayed scanning causes logistical issues and introduces new interpretation questions for radiologists. Data storage capacity, longer processing and reconstruction time issues are other limitations, but they may be overcome in the near future by advancements in reconstruction algorithms and computing hardware.

MRI appearances of hepatic epithelioid hemangioendothelioma: a retrospective study of 57 patients

Background

Hepatic epithelioid hemangioendothelioma (HEH) is extremely rare and the MRI features have never been investigated in a large group of patients.

Methods

A retrospective study was designed to review the MRI images of HEH patients. Two radiologists separately evaluated signal intensity (SI) on unenhanced imaging, morphological features, contrast-enhancement pattern at dynamic study. The MRI features were compared between patients with HEH and hepatic metastatic tumor (HMT).

Results

Fifty-seven HEH patients were included in this study and a total of 412 lesions were evaluated. On per-lesion analysis, the rate of coalescent lesion and subcapsular lesion were 18.2% and 39.8%, respectively. Capsular retraction and lollipop sign were observed in 47 lesions (11.4%) and 60 lesions (14.6%), respectively. Large lesions (> 5 cm) had the highest rate of coalescent lesion, subcapsular lesion, capsular retraction and lollipop sign. Target sign appeared in 196 lesions (47.6%) on T2 weighted (T2W) and 146 lesions (35.4%) on portal phase. Medium lesions (2–5 cm) had the highest rate of target sign on both T2W (72.9%) and portal phase (55.2%). On per-patient analysis, compare with HEH patients, HMT patients seldom had the appearance of lollipop sign (66.7% versus 6.4%, p < 0.01), capsular retraction (59.6% versus 3.2%, p < 0.01) and target appearance on both T2Wand portal phase (64.9% versus 12.7%, p < 0.01).

Conclusion

MRI features of HEH correlated with the lesion size. Capsular retraction, lollipop sign and coexistence of target sign on both T2W and portal phase were relatively specific MRI features of HEH, which could be helpful in suggesting the diagnosis.

Malignant Vascular Tumors of the Head and Neck-Which Type of Therapy Works Best?

Simple Summary

Malignant vascular tumors are extremely rare tumors with variable clinical courses, and few data on their clinical management are available. Diagnosis is difficult due to their wide morphologic appearance. The intent of the present review is to demonstrate the current knowledge and management on malignant vascular tumors of the head and neck area. The mainstay of treatment for malignant vascular tumors is surgery, but radiotherapy and chemotherapy are also parts of the treatment concept especially in angiosarcomas. Targeted therapy, antiangiogenetic drugs and immunotherapy have been studied as new treatment options.

Abstract

Malignant vascular tumors of the head and neck are rare neoplasms with variable clinical presentation, wide age distribution, and variable clinical courses. The heterogeneous presentation of angiosarcomas and epithelioid hemangioendothelioma often leads to misdiagnosis and unsuitable treatment. While risk factors for angiosarcomas are previous radiation, chronic lymphedema, and exposure to arsenic, thorium oxide, or vinyl chloride, there are only limited and retrospective data available on prognostic factors in EHE. In both angiosarcomas and EHE, surgery is the mainstay of treatment. There is limited evidence regarding the role of radiotherapy in EHE, although EHE is considered relatively radiosensitive. In angiosarcomas, adjuvant radiotherapy is recommended according to retrospective case series. A standard medical therapy for metastasized malignant vascular tumors is lacking. Chemotherapy, which is effective in angiosarcoma, is mostly ineffective in EHE. Targeted therapy, antiangiogenetic drugs and immunotherapy have been studied as new treatment options. The goal of this review is to summarize the current data regarding malignant vascular tumors along with their diagnosis and management.

Epithelioid hemangioendothelioma, an ultra-rare cancer: a consensus paper from the community of experts

Epithelioid hemangioendothelioma (EHE) is an ultra-rare, translocated, vascular sarcoma. EHE clinical behavior is variable, ranging from that of a low-grade malignancy to that of a high-grade sarcoma and it is marked by a high propensity for systemic involvement. No active systemic agents are currently approved specifically for EHE, which is typically refractory to the antitumor drugs used in sarcomas. The degree of uncertainty in selecting the most appropriate therapy for EHE patients and the lack of guidelines on the clinical management of the disease make the adoption of new treatments inconsistent across the world, resulting in suboptimal outcomes for many EHE patients. To address the shortcoming, a global consensus meeting was organized in December 2020 under the umbrella of the European Society for Medical Oncology (ESMO) involving >80 experts from several disciplines from Europe, North America and Asia, together with a patient representative from the EHE Group, a global, disease-specific patient advocacy group, and Sarcoma Patient EuroNet (SPAEN). The meeting was aimed at defining, by consensus, evidence-based best practices for the optimal approach to primary and metastatic EHE. The consensus achieved during that meeting is the subject of the present publication.

•

This consensus paper provides key recommendations on the management of epithelioid hemangioendothelioma (EHE).

•

Recommendations followed a consensus meeting between experts and a representative of the EHE advocacy group and SPAEN.

•

Authorship includes a multidisciplinary group of experts from different institutions from Europe, North America and Asia.

Primary splenic epithelioid hemangioendothelioma with diffuse metastases revealed by FDG PET/CT imaging: A case report

RATIONALE

Epithelioid hemangioendothelioma (EHE) is a rare low-to-intermediate grade malignant vascular neoplasm. We report a primary splenic EHE with diffused metastasis who underwent 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT). Our case emphasizes that EHE should be considered a differential diagnose of 18F-FDG-avid splenic malignancies.

PATIENT CONCERNS

A 39-year-old man presented with abdominal distension and chest distress for 20 days and lumbago for 2 days. Transthoracic echocardiography suggested a large amount of pericardial effusion. Contrast-enhanced CT imaging showed splenomegaly with multiple low-density nodules with ring enhancement. A large irregular mass was also found in the right superior mediastinum with heterogeneous density and enhancement. 18F-FDG PET/CT imaging revealed splenomegaly, filled with intense hypermetabolic nodules and masses. And multiple regions of increased 18F-FDG uptake were observed in the mediastinum, left pleura, and bones.

DIAGNOSIS

EHE of the spleen.

INTERVENTIONS

Half a month after the diagnosis was confirmed, the patient then underwent chemotherapy, Docetaxel combined with carboplatin, and Endu were administrated every 3 weeks.

OUTCOMES

During the 6-month follow-up period, the patient has finished 4 cycles of chemotherapy combined with 2 months of targeted drug. Efficacy assessment is partial remission through CT imaging, and clinical symptoms of patient improved significantly.

LESSONS

Primary splenic EHE is extremely rare, especially with diffuse systemic metastasis. Our report suggested that EHE should be considered a differential diagnosis of 18F-FDG-avid splenic malignancies. Furthermore, 18F-FDG PET/CT plays critical role in staging and accessing disease extent of EHE.

Imaging characteristics and prognostic values of hepatic epithelioid hemangioendothelioma on 18F-FDG PET/CT

Hepatic epithelioid hemangioendothelioma (HEHE) is a low-to-intermediate-grade malignant mesenchymal tumor. The diagnostic and prognostic values of 2-[18F] fluoro-2-deoxy-D-glucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) to patients with HEHE have not been fully validated. Patient survival outcomes (including overall survival [OS] and progression-free survival [PFS]), lesions characteristics and semi-quantitative parameters, in terms of maximum standardized uptake value (SUVmax), peak SUV (SUVpeak), total lesion glycolysis (TLG) and metabolic tumor volume (MTV) on 18F-FDG PET/CT of 20 cases with HEHE were measured and analyzed. A total of 310 liver lesions were detected (excluding the diffuse-type lesions in 3 cases). Most lesions had higher SUVmax in delayed imaging than in early imaging (P = 0.013). Patients with multiple organs involved had higher death rate (P = 0.022), higher progression rate (P = 0.020), shorter OS (P = 0.011), larger lesion SUVmax (P = 0.048) and TLG (P = 0.033) than those with only liver involved. The area under curves (AUCs) from the receiver operating characteristic (ROC) curve analysis were 0.960, 0.949, 0.980 and 0.960 for SUVmax, SUVpeak, TLG and MTV, respectively, in predicting OS (P = 0.005, 0.008, 0.001 and 0.024, respectively). For predicting PFS, the AUCs were 0.791, 0.824, 0.857 and 0.813 (P = 0.036, 0.019, 0.010 and 0.024), respectively. Dual-time-point imaging may improve lesions detectability. Patients with multiple organ involved had worse prognosis. The higher SUVmax, SUVpeak, TLG and MTV of lesions, the worse prognosis of patients were found.

Laparoscopic repeat liver resection for hepatic epithelioid hemangioendothelioma

BACKGROUND

Optimal treatment for patients with hepatic epithelioid hemangioendothelioma (HEHE) remains unclear. Laparoscopic repeat liver resection (LR) is a minimally invasive and potentially effective surgical option for multiple HEHEs.

CASE PRESENTATION

A 42-year-old woman with no relevant history was admitted for multiple liver tumors. Six tumors were observed on T2-weighted magnetic resonance imaging (MRI) including one in S2, two in S3, two in S7, and one in S8. Pathological evaluation of percutaneous tumor biopsy tissue suggested a diagnosis of HEHE and laparoscopic LR was planned. The procedure began with partial resection of S7 and partial resection of S8 and left lateral sectionectomy were performed. Another tumor was found intraoperatively on the surface of S6, necessitating removal by partial resection. Pathological evaluation of the resected tumor tissue from all seven tumors concurred with that of the preoperative biopsy. The patient was discharged on postoperative day 6 without any complications. A follow-up MRI 15 months after the primary surgery revealed one tumor each in S4, S6, and S8. Laparoscopic repeat LR was performed. The patient was discharged on postoperative day 5 without any complications. All three recurrent tumors were pathologically confirmed as HEHEs.

CONCLUSIONS

We successfully treated primary and recurrent HEHEs with laparoscopic LR, which is a reasonable minimally invasive procedure considering the possibility of multiple courses of liver surgery in patients with HEHE.

Hepatic epithelioid hemangioendothelioma: Update on diagnosis and therapy

With an estimated incidence of only 1-2 cases in every 1 million people, hepatic epithelioid hemangioendothelioma (HEHE) is a rare vascular endothelial cell tumor occurring in the liver and consisting of epithelioid and histiocyte-like vascular endothelial cells in mucus or a fibrotic matrix. HEHE is characterized as a low-to-moderate grade malignant tumor and is classified into three types: solitary, multiple, and diffuse. Both the etiology and characteristic clinical manifestations of HEHE are unclear. However, HEHE has a characteristic appearance on imaging including ultrasound, magnetic resonance imaging, and positron emission tomography/computerized tomography. Still, its diagnosis depends mainly on pathological findings, with immunohistochemical detection of endothelial markers cluster of differentiation 31 (CD31), CD34, CD10, vimentin, and factor VIII antigen as the basis of diagnosis. Hepatectomy and/or liver transplantation are the first choice for treatment, but various chemotherapeutic drugs are reportedly effective, providing a promising treatment option. In this review, we summarize the literature related to the diagnosis and treatment of HEHE, which provides future perspectives for the clinical management of HEHE.

Fast-growing epithelioid hemangioendothelioma of the liver: A case report

RATIONALE

Hepatic epithelioid hemangioendothelioma (HEH) is a rare vascular tumor of the liver with malignant potential. It can be of solitary type, multifocal type, or diffuse type. Although there are some characteristic features on radiologic imaging, the definitive diagnosis of HEH is based on histopathology. The surgical treatment of HEH includes liver resection and transplant.

PATIENT CONCERNS

A middle-aged woman presented with easy fatiguability and anorexia for 1 month was found to have multifocal lesions on radiological imaging.

DIAGNOSIS

HEH was diagnosed by needle biopsy. It can be seen from imaging that this case is a multifocal form. The largest lesion increased from 3 to 3.3 cm within 2 months, with an increase of 9.45%; no other relevant literatures have been reported.

INTERVENTIONS

The possibility of liver transplantation was suggested to the patient. However, the patient refused transplantation and was successfully treated by radical right hepatectomy and resection of the left lobe lesion.

OUTCOMES

She remained disease-free throughout a year follow-up period.

CONCLUSION

HEH is a rare disease with characteristic radiological and pathological features. Although liver transplantation is the preferred treatment for multifocal HEH, surgical excision represents one alternative when the lesions can be guaranteed to be completely excised.

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.

Comparison of the clinical and MRI features of patients with hepatic hemangioma, epithelioid hemangioendothelioma, or angiosarcoma

Background

Comparisons of hepatic epithelioid hemangioendothelioma (HEHE), hepatic hemangioma, and hepatic angiosarcoma (HAS) have rarely been reported. The purpose of our study was to analyze the clinical and magnetic resonance imaging (MRI) findings of these conditions.

Methods

A total of 57 patients (25 with hemangioma, 13 with HEHE, and 19 with HAS) provided hepatic vascular endothelial cell data between June 2006 and May 2017.

Results

The proportions of cases with circumscribed margins were 88% (22/25), 84.6% (11/13), and 31.6% (6/19) for hemangioma, HEHE, and HAS, respectively (P < 0.001). HAS lesions were less likely to have circumscribed margins. The proportions of lesions with hemorrhaging were 4% (1/25), 30.8% (4/13), and 36.8% (7/19) for hemangioma, HEHE, and HAS, respectively (P = 0.014). HEHE and HAS cases were more likely to show heterogeneous signals on T1-weighted (T1WI) MRI. HEHE and HAS cases were more likely to show heterogeneous signals on T2-weighted (T2WI) MRI. Centripetal enhancement was the most common pattern in vascular tumors, with proportions of 100, 46.2% (6/13), and 68.4% (13/19) for hemangioma, HEHE, and HAS, respectively. The difference in enhancement pattern between HEHE and HAS was not significant, but rim enhancement was more common for HEHE (46.2%, 6/13).

Conclusions

Our study revealed clinical and imaging differences between HEHE and HAS. The platelet count (PLT) and coagulation function of the HAS group decreased, whereas the alpha-fetoprotein (AFP) level increased. The 5-year survival rate for HAS was significantly lower than that of HEHE. A higher malignancy degree indicated a more blurred lesion margin, easier occurrence of hemorrhaging, and more heterogeneous T1WI and T2WI signals.

Hepatic hemangioendothelioma: CT, MR, and FDG-PET-CT in 67 patients-a bi-institutional comprehensive cancer center review

OBJECTIVE

To evaluate the imaging features of hepatic epithelioid hemangioendothelioma (HEH) on multiphasic CT, MR, and FDG-PET-CT.

METHODS

Bi-institutional review identified 67 adults (mean age, 47 years; 23 M/44 F) with pathologically proven HEH and pretreatment multiphasic CT (n = 67) and/or MR (n = 30) and/or FDG-PET-CT (n = 13).

RESULTS

HEHs were multifocal in 88% (59/67). Mean size of the dominant mass was 4.1 cm (range, 1.4-19 cm). The tumors were located in the peripheral, subcapsular regions of the liver in 96% (64/67). Capsular retraction was present in 81% (54/67 cases) and tumors were coalescent in 61% (41/67). HEH demonstrated peripheral ring enhancement on arterial phase imaging in 33% (21/64) and target appearance on the portal venous phase in 69% (46/67). Persistent peripheral enhancement on the delayed phase was seen in 49% (31/63). On MR, multilayered target appearance was seen on the T2-weighted sequences in 67% (20/30) and on the diffusion-weighted sequences in 61% (11/18). Target appearance on hepatobiliary phase of MRI was seen in 57% (4/7). On pre-therapy FDG-PET-CT, increased FDG uptake above the background liver parenchyma was seen in 62% (8/13).

CONCLUSION

HEHs typically manifest as multifocal, coalescent hepatic nodules in peripheral subcapsular location, with associated capsular retraction. Peripheral arterial ring enhancement and target appearance on portal venous phase are commonly seen on CT. Similarly, multilayered target appearance correlating with its histopathological composition is typically seen on multiple sequences of MR including T2-weighted, diffusion-weighted, and dynamic contrast-enhanced multiphasic MR.

KEY POINTS

• Hepatic epithelioid hemangioendotheliomas manifest on CT and MR as multifocal, coalescent hepatic nodules in peripheral subcapsular location, with associated capsular retraction. • Enhancement pattern on contrast-enhanced CT and MR can vary but peripheral ring enhancement on arterial phase and target appearance on portal venous phase are commonly seen. • Retrospective two-center study showed that cross-sectional imaging may help in the diagnosis.

Hepatic Hemangioendothelioma: An update

Primary epithelioid hemangioendotheliomas of the liver (EHL) are rare tumors with a low incidence. The molecular background of EHL is still under investigation, with WWTR1-CAMPTA1 mutation may function as a tumor marker. Commonly, this tumor is misdiagnosed with angiosarcoma, cholangiocarcinomas, metastatic carcinoma, and hepatocellular carcinoma (sclerosing variant). Characteristic features on imaging modalities such as ultrasound, computed tomography, magnetic resonance imaging and positron emission tomography/computed tomography guide in diagnosis and staging. The "halo sign" and the "lollipop sign" on computed tomography and magnetic resonance imaging are described in the literature. Currently, there are no standardized guidelines for treating EHL with treatment options are broad including: chemotherapy, ablation, surgery and liver transplantation with inconsistent results.

18F-fluorodeoxyglucose positron emission tomography/computed tomography in childhood metastatic epithelioid hemangioendothelioma of the liver: Altering the management plan

Hepatic epithelioid hemangioendothelioma (EHE) is an uncommon vascular tumor, primarily seen in 20-40 years of age. We report the case of a 14-year-old boy with EHE and distant metastases identified on 18F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT), leading to a change in the management plan. ¹⁸F-FDG PET/CT proved to be useful in identifying the rare sites of metastasis and planning further treatment.

68Ga-DOTA-E-[c(RGDfK)]2 positron emission tomography-computed tomography in the evaluation of hepatic hemangioendothelioma epithelioid

Hemangioendothelioma epithelioid is a rare tumor that originates in soft tissues. Imaging evaluation with conventional modalities (tomography and magnetic resonance) is difficult. Novel radiotracers which capably evaluate angiogenesis may have a higher impact on the therapeutic decisions. A 45-year-old man underwent workup for thrombosis and was diagnosed with hemangioendothelioma epithelioid based on the results of liver pathology and immunohistochemistry. The decision of the multidisciplinary board was to begin with thalidomide. After 4 months, progression of disease was documented and right hepatectomy was performed. A ⁶⁸Ga-DOTA-E-[c(RGDfK)]2 positron emission tomography–computed tomography scan showed residual lesions. After documented angiogenesis by ⁶⁸Ga-DOTA-E-[c(RGDfK)]2 positron emission tomography–computed tomography, nintedanib was administrated. And 1 year later, progression of the disease was documented by positron emission tomography–computed tomography. Ipilimumab plus nivolumab was started and partial response and excellent clinical response were documented. Molecular imaging with ⁶⁸Ga-DOTA-E-[c(RGDfK)]2 positron emission tomography–computed tomography is a good biomarker of the response of hemangioendothelioma epithelioid, and ipilimumab plus nivolumab therapy demonstrated a good response.

[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.

Complete metabolic response to therapy of hepatic epithelioid hemangioendothelioma evaluated with 18F-fluorodeoxyglucose positron emission tomography/contrast-enhanced computed tomography: A CARE case report

RATIONALE

Hepatic epithelioid hemangioendothelioma (EHE) is a rare malignant vascular tumor of endothelial origin with a highly variable clinical presentation and natural history. Given its vascular origin, new therapies with inhibitors of vascular endothelial growth factor (VEGF) have been introduced in the treatment of these patients and have shown promising results. Few reports have described the role of F-Fluorodeoxyglucose positron emission tomography/contrast-enhanced computed tomography (F-FDG PET/CT) in the evaluation of this tumor after treatment with anti-angiogenic agents. Our case reports how F-FDG PET-CT scan was critical in the assessment of this tumor after treatment with an anti-angiogenic agent, Pazopanib, demonstrating complete metabolic response.

PATIENT CONCERNS

A 30-year-old man with no previous significant medical history presented with pain in the right upper quadrant for over a year.

DIAGNOSES

Multiple hepatic masses were found on abdominal ultrasound. Liver biopsy confirmed the diagnosis of epithelioid hemangioendothelioma. F-FDG PET/CT was performed for staging. Multiple FDG-avid hepatic, splenic, and lymph nodes lesions were detected on F-FDG PET/CT. A subsequent spleen biopsy confirmed splenic involvement. Immunohistochemistry was positive for CD31, CD34, and ERG, supporting the diagnosis of epithelioid hemangioendothelioma.

INTERVENTIONS

A 1-year cyclophosphamide treatment was provided followed by Pazopanib for 17 months.

OUTCOMES

Six years after the first F-FDG PET/CT, F-FDG PET/CT performed for restaging demonstrated complete metabolic response to therapy. Follow-up CT demonstrated no interval changes in size of some of the treated lesions.

LESSON

F-FDG PET/CT is useful for baseline assessment and posttreatment follow-up of this rare cancer.

The Feature of Solitary Small Nodular Type of Hepatic Epithelioid Hemangioendothelioma

Hepatic epithelioid hemangioendothelioma (HEHE) is a rare tumor. Preoperative diagnosis of HEHE is difficult because it does not manifest specific symptoms or tumor markers. We report a resected case of small and solitary HEHE. The patient, a 74-year-old man, had undergone surgical resection for left renal cell carcinoma 20 years ago. During follow-up, a tumor approximately 1.3 cm in diameter was detected by computed tomography (CT) at liver segment VIII. It showed isodensity in the arterial phase, low density in the portal venous phase, and homogeneous enhancement in the late phase on CT and magnetic resonance imaging (MRI). We performed hepatic resection of the right hepatic vein drainage area. A pathological diagnosis of HEHE was made. Although small and solitary HEHE is rare, an enhancement pattern in each phase on CT and MRI, using contrast media, can yield clues for the diagnosis of HEHE.

Diffuse hepatic epithelioid hemangioendothelioma with multiple splenic metastasis and delayed multifocal bone metastasis after liver transplantation on FDG PET/CT images: A case report

RATIONALE

Malignant hepatic epithelioid hemangioendotheliom (HEH) is a rare vascular tumor of endothelial origin, with multiple metastases to the spleen. This report describes a diffuse HEH with splenic metastasis on 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) images and delayed mutifocal bone metastasis after liver transplantation (LTx).

PATIENT CONCERNS

A 30-year-old male was admitted to our hospital with a complaint of abdominal distension, fatigue, and anorexia for 2 months.

DIAGNOSES

Mild to moderate FDG uptake in the whole liver, and multifocal FDG uptake in the spleen were observed on 18F-FDG PET/CT scan. Ultrasound guided liver biopsy was performed, and a diagnosis of HEH was confirmed.

INTERVENTIONS

The patient underwent LTx and splenectomy.

OUTCOMES

The patient developed low back pain due to unknown etiology, 3 months after surgery. A follow-up 18F-FDG PET/CT scan demonstrated multifocal bone destruction. Unfortunately, the patient died 12 months after surgery.

LESSONS

It is noteworthy that despite liver transplantation for the treatment of HEH, there may be a risk of recurrence. For these patients with extrahepatic lesions, adjuvant chemotherapy may be a useful alternative treatment method for the prevention of recurrence.

Magnetic resonance findings of hepatic epithelioid hemangioendothelioma: emphasis on hepatobiliary phase using Gd-EOB-DTPA

PURPOSE

To examine the characteristic features of hepatic epithelioid hemangioendothelioma (HEH) on magnetic resonance imaging (MRI) using Gd-EOB-DTPA.

MATERIAL AND METHODS

Twelve patients (mean age, 50 years; male:female = 6:6) who were pathologically confirmed to have HEH in two tertiary institutions were retrospectively investigated. For qualitative analysis, the MRI features of HEH including core pattern were characterized, and lesions were divided into core and non-core groups. For quantitative analysis, standardized mean signal intensities (SI_st) measured at the tumor center, periphery, and liver parenchyma were plotted against the dynamic phases. Differences in SI_st between the core and non-core group were calculated for the tumor center and periphery. We also examined the radiologic and pathologic correlation for cases in which surgical resection was performed.

RESULTS

Forty-seven nodules in 12 patients were analyzed. The mean size of the lesions was 2.9 ± 1.0 cm. In the per-lesion analysis, ring-like arterial enhancement (74%) on arterial phase was the most frequent feature, followed by core pattern (51%), and hyperintense rim on T1-weighted imaging (43%). In the per-patient analysis, capsular retraction (75%) was the most common sign. The percentage of patients with core pattern was 58%. In the core group, the SI_st of the center showed slow enhancement starting from the transitional phase, resulting in divergence between the two graphs throughout the entire dynamic study (p < 0.05). Pathologically, the lesion center consisted of reduced cellularity with myxohyaline stroma and necrosis.

CONCLUSION

Core pattern can be considered a new diagnostic sign of HEH.

Magnetic Resonance Imaging of Primary Hepatic Malignancies in Patients With and Without Chronic Liver Disease: A Pictorial Review

Primary hepatic malignancies are less common than metastatic diseases, but a recognition of these lesions is important for diagnosis and treatment planning. Magnetic resonance imaging (MRI) provides the most imaging information to diagnose lesions noninvasively and to narrow differential diagnoses. This paper reviews the imaging findings of chronic liver disease and primary hepatic malignancies, including hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (CCA), epithelioid hemangioendothelioma, hepatic angiosarcoma, and primary hepatic lymphoma. Clinical and MRI features are reviewed to improve the readers’ recognition of these tumors, allowing for a narrower differential diagnosis when liver masses are encountered on abdominal imaging.

18-F-FDG PET-CT in Monitoring of Chemotherapeutic Effect in a Case of Metastatic Hepatic Epithelioid Hemangioendothelioma

Hepatic epithelioid hemangioendothelioma is a rare variant of mesenchymal tumor. Surgical resection or partial hepatectomy is the treatment of choice in the case of localized disease. However, in metastatic cases, chemotherapeutic drugs targeting the tyrosine kinase are being used. We hereby present 18-F-fludeoxyglucose positron emission tomography-computed tomography findings in a case of a 35-year old woman with metastatic HEHE showing significant response to Sorafenib therapy after 6 months.

2014 Revised Classification of Vascular Lesions from the International Society for the Study of Vascular Anomalies: Radiologic-Pathologic Update

Since the publication of the seminal work on the histology-based classification of vascular anomalies by Mulliken and Glowacki in 1982 and the subsequent adoption of an expanded and modified version in 1996 by the International Society for the Study of Vascular Anomalies, an increasing number of vascular lesions have been recognized as histologically distinct entities. Furthermore, there have been significant advances in detailing the behavior and underlying genetics of previously identified lesions. These developments have required restructuring and expansion of the classification scheme so that appropriate therapies may be studied and implemented in affected patients. The new classification retains the broad categories of neoplasms and malformations but now divides the tumor group into benign, locally aggressive or borderline, and malignant, with the malformation group being divided into simple, combined, those of major named vessels, and those associated with other anomalies. Additionally, a category has been created for lesions in which the histology and behavior do not yet allow clear separation into neoplasm or malformation (thus named "provisionally unclassified vascular anomalies"). The known clinical courses and imaging, histologic, and genetic findings of the most common and/or clinically relevant lesions in the newly adopted revised system are reviewed in this article. (©)RSNA, 2016.

Recurrence of Epithelioid Hemangioendothelioma during Pregnancy: Case Report and Systematic Review

INTRODUCTION

Epithelioid hemangioendothelioma (EHE) is a family of blood vessel tumors originating in blood vessels, bone, brain, kidney, liver, and lung. EHE is more common in women, and chemotherapy, radiation, and surgery have brought few successes.

CASE PRESENTATION

We present a case of a 28-year-old woman whose EHE recurred during pregnancy, suggesting hormonal involvement. We conducted a systematic review to provide analysis and interpretation of the potential significance of her disease recurring, with fatal outcome, during pregnancy.

DISCUSSION

Very little research has explored the use of individual hormonal markers. Strongly positive expression of placenta growth factor (PlGF) and 17-beta estradiol receptors have been reported. Expression of PlGF is noteworthy in our case, in that our patient's disease quickly and dramatically flared in the 25th week of pregnancy, near the peak in maternal PlGF production. PlGF binds to vascular endothelial growth factor-1 (VEGF-1), and PlGF may accelerate VEGF-induced angiogenesis. Taken together, these factors may explain our patient's EHE recurrence and rapid flare-up during pregnancy. Treatment of EHE with VEGF inhibition, potentially in combination with other antiangiogenic and tumor-inhibiting therapies such as lenalidomide, thalidomide, sorafenib, and sunitinib, may also hold promise.

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.

CT and MR imaging findings of hepatic epithelioid hemangioendotheliomas: emphasis on single nodular type

PURPOSE

To evaluate imaging findings of hepatic epithelioid hemangioendothelioma (HEH), with emphasis on solitary form at the initial presentation.

MATERIALS AND METHODS

Ten cases of pathologically confirmed HEH were retrospectively reviewed; seven patients had CT and MR images and three had only CT images. Two radiologists assessed the followings in consensus: lesion number, size, location, presence of capsular retraction and calcification, attenuation, signal intensity, and enhancement pattern.

RESULTS

Initially, HEHs manifested as a single mass (n = 5) or multiple masses (n = 5). One case demonstrated a solitary nodule at first, which subsequently transformed to multifocal nodules on serial follow-up. The maximal diameter of the lesions ranged from 1.8 to 10 cm (mean 4.2 cm). All cases showed predominant subcapsular location. Capsular retraction was seen in multinodular types, but not in solitary types. Two patients had intra-lesional calcifications. HEHs showed minimal enhancement (7/7 patients) on the hepatic arterial phase CT and rim-like enhancement (5/10 patients), minimal enhancement (2/10 patients), multilayered target enhancement (2/10 patients), and peripheral nodular enhancement (1/10 patients) on the portal venous phase CT. On MR images (n = 7), HEHs showed hypointensity on T1-weighted images and hyperintensity on T2-weighted images. Dynamic contrast-enhanced MR images revealed progressive centripetal fill-in enhancement (7/7 patients). On Gd-EOB-DTPA-enhanced hepatobiliary phase images, HEH manifested as homogeneous hypointensity (3/5 patients) and target-shaped hypointensity (2/5 patients).

CONCLUSION

HEH can manifest as single nodular, multinodular, or diffuse type. Common imaging features of HEH are multiple subcapsular nodules with coalescence, capsular retraction, peripheral, and delayed enhancement. However, HEH can manifest as a solitary subcapsular mass with minimal or rim-like enhancement at early phase and progressive centripetal fill-in enhancement during dynamic phase imaging, representing early stage of HEH. A single nodular type can progress to multifocal nodular type during follow-up.

Pediatric multifocal liver lesions evaluated by MRI

Objective:

The purpose of this study is to present our experience with MRI evaluation of multifocal liver lesions in children and describe the MRI characteristics of these lesions.

Patients and Methods:

A retrospective review of consecutive MRI exams performed for the evaluation of multiple liver lesions between 1 January 2007 and 31 December 2012 was done to note the number of lesions, the size of the largest lesion, MR signal characteristics, and background liver. Final diagnosis was assigned to each case based on pathology in the available cases and a combination of clinical features, imaging features, and follow-up in the remaining cases.

Results:

A total of 48 children (22 boys, 26 girls; age between 3 months and 18 years with average age 10.58 years and median age 11 years) were included in the study. Totally 51 lesion diagnoses were seen in 48 children that included 17 focal nodular hyperplasia (FNH), 8 hemangiomas, 7 metastases, 6 regenerative nodules, 3 adenomas, 3 abscesses, and one each of angiomyolipoma, epithelioid hemangioendothelioma, focal fatty infiltration, hepatocellular carcinoma, hepatic infarction, nodular regenerative hyperplasia, and hepatic cyst. Background liver was normal in 33, cirrhotic in 10, fatty in 3, and siderotic in 2 children. Most FNH, hemangiomas, and regenerative nodules showed characteristic MRI features, while metastases were variable in signal pattern.

Conclusion:

Many commonly seen multifocal liver lesions in children have characteristic MRI features. MRI can help to arrive at reasonable differential diagnoses for multifocal liver lesions in children and guide further investigation and management.

18F-fluorodeoxyglucose positron emission tomography/computed tomography findings of gastric lymphoma: Comparisons with gastric cancer

The role of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) in numerous malignant tumors, including gastric lymphoma, is well-established. However, there have been few studies with regard to the ¹⁸F-FDG PET/CT features of gastric lymphoma. The aim of the present study was to characterize the ¹⁸F-FDG PET/CT features of gastric lymphoma, which were compared with those of gastric cancer. Prior to treatment, ¹⁸F-FDG PET/CT was performed on 24 patients with gastric lymphoma and 43 patients with gastric cancer. The ¹⁸F-FDG PET/CT pattern of gastric wall lesions was classified as one of three types: Type I, diffuse thickening of the gastric wall with increased FDG uptake infiltrating more than one-third of the total stomach; type II, segmental thickening of the gastric wall with elevated FDG uptake involving less than one-third of the total stomach; and type III, local thickening of the gastric wall with focal FDG uptake. The incidence of the involvement of more than one region of the stomach was higher in the patients with gastric lymphoma than in those with gastric cancer. Gastric FDG uptake was demonstrated in 23 of the 24 patients (95.8%) with gastric lymphoma and in 40 of the 43 patients (93.0%) with gastric cancer. Gastric lymphoma predominantly presented with type I and II lesions, whereas gastric cancer mainly presented with type II and III lesions. The maximal thickness was larger and the maximal standard uptake value (SUV_max) was higher in the patients with gastric lymphoma compared with those with gastric cancer. A positive correlation between the maximal thickness and SUV_max was confirmed for the gastric cancer lesions, but not for the gastric lymphoma lesions. There was no difference in the maximal thickness and SUV_max of the gastric wall lesions between the patients without and with extragastric involvement, for gastric lymphoma and gastric cancer. Overall, certain differences exist in the findings between gastric lymphoma and gastric cancer patients on ¹⁸F-FDG PET/CT images, which may contribute to the identification of gastric lymphoma.

A Rare Cause of Right Upper Quadrant Pain in a 17-Year-Old Female

A 17-year-old Hispanic female presented to our hospital with complaints of right upper quadrant abdominal pain, vomiting, and fever. Physical exam was positive for hepatomegaly. Abdominal computed tomography showed multiple hypoechoic liver masses. Liver biopsy was done, which was diagnostic for hepatic epithelioid hemangioendothelioma.