Primary ovarian angiosarcoma: a rare and recognizable ovarian tumor

Large atypical perilobular hemangioma in the breast: a potential misdiagnosis as angiosarcoma

BACKGROUND

Atypical perilobular hemangioma (APH) of the breast is a rare type of tumor. This tumor is often small, measuring no more than 2 mm in diameter, difficult to detect or palpate, and has a good prognosis.

CASE PRESENTATION

We report a unique case of APH in a 47-year-old female patient, which was 12 mm in diameter and characterized by tumor cell atypia. To date, six cases of APH have been reported in the literature, including the present case. The mean age of the APH patients was 49.5 years (range: 39-75 years). The majority of APHs (4/6) in the breast were initially diagnosed as angiosarcoma. The tumor in our study presented diagnostic challenges as an atypical APH due to its substantial size (12 mm), the presence of indistinct borders in certain regions, an extensive growth pattern, the hobnail appearance of endothelial cells, and the mitotic count.

CONCLUSION

In this study, we present this case to help with proper diagnosis and treatment of the tumor, to emphasize additional characteristics of APH, to summarize the clinicopathological features of this tumor as documented in the literature, and to enhance the understanding of this tumor type, particularly the differentiation between APH and low-grade angiosarcoma.

CLINICAL TRIAL NUMBER

Not applicable.

The Spectrum of Vascular Lesions of the Upper Female Genital Tract: A Report of 55 Cases

Upper female genital tract vascular proliferations are rare and generally not well characterized. We evaluated types, differences in distribution, and associations of such lesions. Fifty-five vascular lesions were identified: 42 benign (ovary 24; uterine corpus 11; para-adnexal 4; fallopian tube 1; ovaries, fallopian tubes, and corpus 1; ovary and fallopian tube 1) and 13 angiosarcomas. Patients with benign vascular lesions had a mean age of 55 (range: 13-82) yr. Twenty-six lesions were incidental findings, and 11 were associated with clinical manifestations. They had a mean size of 2.0 (range: <1-13) cm, and often were grossly cystic and hemorrhagic. Uterine benign vascular lesions included 6 arteriovenous malformations, 3 venous hemangiomas/malformations, 2 cavernous hemangiomas, and 1 mixed venous-cavernous hemangioma. In the ovary, there were 10 anastomosing hemangiomas, 8 arteriovenous malformations, 6 venous (2 in mature cystic teratomas, 1 bilateral in a patient with Klippel-Trenaunay syndrome), and 2 cavernous hemangiomas. Anastomosing hemangiomas were frequently associated with peripheral stromal luteinization/hilar cell hyperplasia; intravascular growth, extramedullary hematopoiesis, and one with adipocytic metaplasia. Venous hemangiomas/malformations were noted at a younger age in the ovary when compared to the uterine corpus. Patients with angiosarcomas had a mean age of 32 (range: 12-58) yr and a mean tumor size of 9.7 (range: 1.5-23) cm. Eight presented with a pelvic mass. Most angiosarcomas were grossly hemorrhagic and/or necrotic. Eleven arose in the ovary, 4 of them were associated with mature cystic teratoma, 1 with adenosarcoma with sarcomatous overgrowth, and 1 was part of a malignant mesenchymoma. Five were predominantly spindled, 3 epithelioid, 2 spindled and epithelioid, and one pleomorphic. Both uterine angiosarcomas were epithelioid. Follow-up was available for 8 patients: 7 died of disease between 6 and 43 mo, and 1 was alive and well at 106 mo. Vascular lesions in the upper female genital tract are uncommon, morphologically heterogeneous, and more frequent and clinically evident in the adnexa. Anastomosing hemangioma is the most common benign vascular lesion in the ovary and may be misdiagnosed as a steroid cell tumor due to associated stromal luteinization/hilar cell hyperplasia. Arteriovenous malformation is the most common benign vascular lesion in the uterine corpus. Angiosarcomas may be associated with another neoplasm, more commonly mature cystic teratoma, and have a poor prognosis.

Atypical Pelvic Tumors in Children

Due to the complex anatomy of the pelvis, various tumors may arise in this region. Some of these tumors are well known and have distinctive features that allow them to be identified by magnetic resonance imaging (MRI). These include sacrococcygeal teratoma (SCT), the most prevalent congenital tumor in children, often diagnosed prenatally and most frequently occurring in this anatomical location, and ovarian teratoma, which in its mature form is the most common ovarian neoplasm in children and adolescents. Additionally, rhabdomyosarcoma (RMS), commonly found in the bladder in both genders and in the prostate in males, and Ewing sarcoma (ES), affecting the flat bones of the pelvis, are relatively common tumors. In this study, selected atypical pelvic tumors in children are presented. Most of them are tumors of the reproductive system, such as cervical cancer, small cell neuroendocrine carcinoma of the ovary, ES/primitive neuroectodermal tumor (PNET) of the ovary, diffuse large B-cell lymphoma (DLBCL) of the ovaries and ovarian Sertoli-Leydig cell tumor (SLCT) with RMS due to DICER1 syndrome. Additionally, tumors originating from the nervous system, including neuroblastoma (NBL) and plexiform neurofibroma (pNF), associated and not associated with neurofibromatosis type 1 (NF1), are discussed. Furthermore, Rosai-Dorfman disease involving the pelvic and inguinal lymph nodes is presented. By reviewing the literature and presenting our cases, we tried to find radiological features of individual tumors that would bring the radiologist closer to the correct diagnosis, ensuring the implementation of appropriate treatment. However, the MR images cannot be considered in isolation. Additional patient data, such as the clinical picture, comorbidities/syndromes, and laboratory test results, are necessary.

Ovarian Angiosarcoma With Intractable Intraperitoneal Hemorrhage: A Case Report and Review of the Literature

Primary ovarian angiosarcoma is an extremely rare malignant soft tissue tumor that arises from the vascular endothelium, with a limited number of reports. It has no specific symptoms, and it is rarely diagnosed in the early stages because of rapid progression. Furthermore, no standard drug therapy is available, and the prognosis is poor.  The patient was a 68-year-old woman suspected of having a ruptured ovarian tumor on plain abdominal computed tomography and anemia was observed. An emergency laparotomy was performed to stop the bleeding. Thereafter, one transcatheter arterial embolization, three laparotomies, and local radiotherapy were performed in an attempt to achieve hemostasis. However, the intraperitoneal bleeding remained intractable, and the transfusion was terminated after thorough consultation with the patient. The patient died 44 days after admission. Autopsy findings confirmed the diagnosis of primary ovarian angiosarcoma and pulmonary metastasis. Intractable intraperitoneal hemorrhage similar to that observed in this case has been reported, and because the prognosis is extremely poor, establishing an appropriate treatment regimen is desirable. Previously, the most commonly used drug regimens included anthracyclines and ifosfamide. However, recently, the possibility of treatment with molecular targeted agents and immune checkpoint inhibitors has been reported. In the future, case accumulation and genetic analyses will be required to establish appropriate treatment methods.

Ovarian angiosarcoma: A systematic review of literature and survival analysis

Ovarian angiosarcoma (OA) is rare, with only sporadic cases reported in English literature. We performed a systematic review of cases published in the PubMed, Science Direct, and Google Scholar databases with the aim of describing the reported clinicopathological features of OA. Fifty-three articles that reported 60 patients were reviewed. Of the 60 patients, 7 (11.6 %) were diagnosed with secondary (metastatic) ovarian angiosarcoma and 53 (88.3 %) were diagnosed with primary ovarian angiosarcoma. The mean age at presentation for ovarian angiosarcoma was 38.3±17.8 years. The average tumor size for ovarian angiosarcoma was 11.9±6.1 cm. Abdominal distention was reported in 45/60 (75 %). Microscopic examination revealed necrosis in 28/60 (46.7 %), pleomorphism in 32/59 (54.2 %), mitotic figures in 44/60 (73.3 %), spindle-shaped cells in 27/36 (75 %), epithelioid-shaped cells in 20/36 (55.5 %), and mixed epithelioid and spindle-shaped cells in 12/36 (33.3 %) patients. On immunohistochemistry CD 31 was positive in 41/41 (100 %), CD 34 in 38/39 (97.4 %), and Factor VIII related antigen in 18/21 (85.7 %) patients. Metastasis was present in 43/60 (71.6 %) patients. Chemotherapy and surgery was performed in 36/52 (69.2 %). The median follow-up time for ovarian angiosarcoma was 7 months (IQR1-IQR3:2-13.5 months). 24 (48 %) of the 50 patients with available survival data were alive and 26/50 (52 %) were dead of disease. Survival analyses (KM curves) revealed that the presence of necrosis (log-rank test; p = 0.05) and absence of spindle-shaped cells (log rank test; p = 0.04) on histopathology were associated with worse outcomes, while treatment with combined chemotherapy and surgical excision was associated with better survival (P < 0.001) therefore, prompt diagnosis and early treatment with combined chemotherapy and surgical excision can prolong survival in OA.

Primary Ovarian Angiosarcoma: Diagnostic Challenges and Conundrums

Angiosarcoma is an extremely uncommon mesenchymal neoplasm overall and moreso in female genital organs such as the ovary. Diagnosing primary ovarian angiosarcoma remains challenging on clinical grounds due to the absence of specific clinical symptoms as well as on histopathological analysis especially in poorly differentiated subtypes due to non-specific and overlapping morphologic features. Misdiagnosis in such scenarios can be devastating as this tumor is clinically very aggressive. We describe a case of primary ovarian angiosarcoma in a 33-year-old multiparous female with bilateral ovarian masses and metastasis at diagnosis. Histopathologic appraisal revealed a poorly differentiated malignant tumor with varied differential diagnoses. The saviour in such a scenario was the immunohistochemistry findings, underlining the incredible utility of this technique in the precise diagnosis and evasion of misdiagnosis. This case accentuates the paramount importance of precise diagnostic modalities in shaping clinical practice and enriching the scientific understanding of rare and aggressive neoplasms. Against this backdrop, the potential pitfalls and pearls while dealing with this entity have been elucidated, along with a review of the recent literature.

Primary ovarian angiosarcoma: Two case reports and review of literature

BACKGROUND

Angiosarcoma (AS) is a rare and highly aggressive soft tissue disease that most commonly arises in deep soft tissues. There are only a few reported cases of AS involving the ovary and even fewer reports of the underlying molecular abnormalities. Here, we briefly review two cases of primary ovarian AS (oAS) with specific molecular events and immune checkpoints. The clinical features and prognosis of the disease, diagnosis, differential diagnosis, and new treatment approaches are discussed based on a literature review.

CASE SUMMARY

Case 1: A 51-year-old female patient was admitted with right lower limb pain for 5 mo, and lower abdominal pain with hematuria for 1 mo. Partial removal of rectus abdominis muscle and fascia, partial hysterectomy, bilateral salpingo-oophorectomy, and inguinal and pelvic lymphadenectomy were performed. Pathology revealed primary oAS. Fluorescence in situ hybridization revealed c-MYC gene amplification. MESNA + ADM + IFO + DTIC (MAID) regimen was administered, but stable disease was achieved. The patient died 1 mo later. Case 2: A 41-year-old female patient presented with fatigue, nausea, decreased appetite, and diffuse abdominal pain. On physical examination, the abdomen was distended and a complex cystic mass was palpable in the right pelvic cavity. Pathology revealed primary oAS. MAID chemotherapy was administered and programmed death ligand 1 (PD-L1) staining was performed on the tumor samples. The patient benefited from anti-PD-1 immunotherapy and is alive without any evidence of disease 27 mo off therapy in follow-up.

CONCLUSION

Long-term survival benefit for primary oAS can be achieved by alternative therapeutic strategies using pathological indicators to inform treatment.

LeMeDISCO is a computational method for large-scale prediction & molecular interpretation of disease comorbidity

To understand the origin of disease comorbidity and to identify the essential proteins and pathways underlying comorbid diseases, we developed LeMeDISCO (Large-Scale Molecular Interpretation of Disease Comorbidity), an algorithm that predicts disease comorbidities from shared mode of action proteins predicted by the artificial intelligence-based MEDICASCY algorithm. LeMeDISCO was applied to predict the occurrence of comorbid diseases for 3608 distinct diseases. Benchmarking shows that LeMeDISCO has much better comorbidity recall than the two molecular methods XD-score (44.5% vs. 6.4%) and the S_AB score (68.6% vs. 8.0%). Its performance is somewhat comparable to the phenotype method-based Symptom Similarity Score, 63.7% vs. 100%, but LeMeDISCO works for far more cases and its large comorbidity recall is attributed to shared proteins that can help provide an understanding of the molecular mechanism(s) underlying disease comorbidity. The LeMeDISCO web server is available for academic users at: http://sites.gatech.edu/cssb/LeMeDISCO .