Cytology of angiosarcoma. Findings in fourteen fine-needle aspiration biopsy specimens and one pleural fluid specimen

Cytomorphologic and immunocytochemical diagnosis of primary hepatic angiosarcoma in a young adult: Challenging diagnosis of a rare, aggressive malignancy

Primary hepatic angiosarcoma (PHA) is a rare, rapidly growing, highly aggressive hepatic malignancy, primarily seen in elderly males. Establishing an accurate clinical diagnosis is challenging owing to its rarity and nonspecific presentation. Rendering a cytologic diagnosis of PHA is extremely difficult, and immunocytochemistry(ICC) on cell block(CB) sections is essential to confirm the diagnosis. The characteristic cytomorphologic features of PHA have rarely been documented, further augmenting the diagnostic challenge. A 32-year-old male presented with abdominal pain, abdominal distension, and significant weight loss over the past 9 months. On examination, the abdomen was distended, with multiple spider angiomas and a large mass in the right hypochondrium. His renal function tests, liver function tests, and serum tumor markers were within normal limits. An abdominal triphasic computerized tomography revealed a large lobulated mass in the right lobe with central necrosis. An ultrasound-guided FNA was performed from the liver lesion. The cytologic smears showed singly scattered large, markedly pleomorphic, epithelioid-elongated tumor cells having oval-elongated nuclei, irregular nuclear contours, coarse chromatin, prominent macronucleoli, and abundant finely vacuolated cytoplasm in a background of blood. ICC on the CB demonstrated diffuse positivity for vimentin, CD31, and nuclear positivity for FLI-1, confirming a vascular origin. Hence, a final cytologic diagnosis of primary hepatic angiosarcoma was rendered. The index report describes the characteristic cytomorphologic and immunocytochemical features of a rare hepatic malignancy in a young male and reiterates the usefulness of FNAC coupled with CB-ICC in the quick and precise diagnosis of such challenging cases.

Metastatic sarcomas to pleural effusion: a 10-year large tertiary care center experience with emphasis on clinical features and cytomorphologic characteristics

INTRODUCTION

Metastatic sarcomas to pleural effusion are extremely rare, accounting for <1% of all malignant pleural effusions. We aim to present our experience with pleural effusion specimens containing metastatic sarcomas over a 10-year period.

METHODS

We performed a 10-year retrospective search of cytopathology archives to identify all pleural effusions that were involved by metastatic sarcoma. All available cytopathology and surgical pathology specimens were retrieved and reviewed.

RESULTS

Twenty-eight pleural fluids from 22 patients with metastatic sarcoma were identified in our search. The patients' ages ranged from 12 to 73 years. The pleural fluid volumes ranged from 10 to 1500 ml. Rhabdomyosarcoma was the most commonly encountered metastatic sarcoma to pleural effusion (n = 7). Other metastatic sarcomas were as follows: epithelioid angiosarcoma (n = 4), Ewing sarcoma (n = 3), clear cell sarcoma (n = 2), high grade conventional osteosarcoma (n = 2), undifferentiated pleomorphic sarcoma (n = 1), epithelioid sarcoma, proximal type (n = 1), dedifferentiated liposarcoma (n = 1), and conventional chondrosarcoma (n = 1). The time between initial diagnosis and effusion varied from 3 months to 25 years. Two patients are alive with disease at 6 and 21 months of follow-up. All other patients were dead of disease and the survival after a malignant pleural effusion ranged from <1 month to 18 months.

CONCLUSIONS

Metastatic bone and soft tissue sarcomas to pleural effusions are rare and their cytologic features can be mistaken for carcinoma, melanoma, or mesothelioma. Careful review of the patient's medical history, comparison of the previous pathology and the use of ancillary studies are crucial for the evaluation of pleural effusions involved by metastatic sarcomas.

Radiation-associated Angiosarcoma Presenting as Massive Pleural Effusion

A 67-year-old man was admitted to our hospital for massive pleural effusion. He had a history of mandibular gingival carcinoma treated with radiation therapy (RT). Based on the cytology findings of pleural effusion and a thoracoscopic pleural biopsy, we finally diagnosed him with radiation-associated angiosarcoma. Retrospective cell-block immunocytochemistry with pleural effusion also showed potential utility for the diagnosis. This case highlights the importance of considering the possibility of radiation-associated secondary cancer in patients with pleural effusion who have a history of RT.

Primary epithelioid angiosarcoma of the mediastinum, cytomorphologic features of a rare entity-A case report and literature review

Epithelioid angiosarcoma (EA) is a highly aggressive vascular neoplasm. Primary mediastinal EA is extremely rare with only few cases reported in the English literature. We herein present a case of a 78-year-old patient, who was found to have a right superior mediastinal mass associated with mediastinal and hilar lymphadenopathy. Endobronchial ultrasound guided fine needle aspiration cytology of a station 4R lymph node revealed a cellular, discohesive malignant neoplasm displaying primarily epithelioid morphology with occasional spindled, plasmacytoid, and tumor giant cells. The tumor cells had ample eosinophilic cytoplasm with pleomorphic nuclei and prominent nucleoli. Vasoformative features were noted, exemplified by widespread cytoplasmic vacuoles containing neutrophils and rare red blood cells (hemophagocytosis) and vascular channels identified solely in the cell block. By immunohistochemistry, the tumor cells stained strongly positive for vimentin, positive for ERG, CD-31, FLI-1, and focally positive for pan-cytokeratin. The cytomorphological features and immunostaining patterns were diagnostic of EA. No history of malignancy was reported, and no other lesions were identified on imaging. The diagnosis of primary mediastinal EA on cytology and small biopsy specimens may be challenging due to the rarity of this tumor, limited diagnostic material, and overlapping morphologic features with other entities in the differential diagnosis. A high index of suspicion, especially in cases with vasoformative features, and utilization of ancillary studies can help establish the diagnosis.

Ultrasound-guided fine needle aspiration cytology of angiosarcoma of head and neck: a review of cytomorphologic features and discussion of diagnostic pitfall of aspiration cytology of vascular lesions

Angiosarcoma is a rare malignant tumor of vascular origin (<2% of sarcomas). It represents <1% of all head-neck malignancies. A cytological diagnosis on fine needle aspiration (FNA) is extremely difficult. Most tumors yield a predominantly hemorrhagic aspirate with only rare neoplastic cells, a diagnostic pitfall of aspiration cytology of vascular lesions. An 81-year-old male, 2 years status post resection of a nasal tip angiosarcoma and adjuvant radiation therapy, presented to another institution with an enlarging left neck mass of 2 months duration. Outside FNA diagnosis of cyst was made. Patient was referred to our institution for a pathologist-performed ultrasound-guided FNA. Ultrasound examination revealed a hypoechoic cystic left neck mass. Direct smears showed blood with occassional single malignant spindled to epithelioid cells, with some cells showing "spider-leg" like cytoplasmic processes/projections and "tadpole/fiber" like morphology. Immunohistochemistry performed on cell block sections revealed the tumor cells to be positive for D2-40, CD31 and CD34, supported a diagnosis of regional recurrent angiosarcoma. Left neck dissection showed recurrent high-grade angiosarcoma infiltrating periparotid soft tissues and metastatic angiosarcoma involving multiple lymph nodes. A diagnosis of angiosarcoma on FNA samples can be challenging, as the aspirate may contain only rare tumor cells hidden in a background of abundant blood. Such cases require careful screening to avoid an incorrect diagnosis of inadequate or cyst contents. This short review highlights key cytomorphologic features of angiosarcoma, includes novel cytologic features of angiosarcoma which has not been described previously and also discusses challenges and diagnostic pitfalls of FNA of vascular lesions.

Cytologic and histological features of rare nonepithelial and nonlymphoid tumors of the thyroid

Thyroid tumors can be classified into epithelial, nonepithelial, and nonprimary lesions. Nonepithelial thyroid tumors are rare. They can be of primary origin within the thyroid gland, arise secondary to contiguous growth from adjacent tissues, or represent metastatic disease. The incidence of nonepithelial tumors of the thyroid is only 1% to 2%, most of which are lymphomas; the remainder includes mesenchymal and histiocytic tumors. This review examines the cytohistological features of various nonepithelial and nonlymphoid tumors of the thyroid, including vascular lesions, neural tumors (including granular cell tumor and paraganglioma), smooth muscle tumors, solitary fibrous tumor, histiocytic neoplasms (eg, Langerhans cell histiocytosis and Rosai-Dorfman disease), and follicular dendritic cell sarcoma. Their differential diagnosis is discussed, including recommendations to prevent the pitfall of mistaking these rare tumors for more common epithelial thyroid neoplasms.

Mediastinal sarcomas: experience using fine needle aspiration cytopathology

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

Soft tissue tumor diagnosis: A three prong approach utilizing pattern analysis, immunocytochemistry, and molecular diagnostics

Tissue diagnosis of a soft tissue neoplasm is of paramount importance for the development of an appropriate treatment plan. Biopsy technique including approach and biopsy method is important to the success of diagnosis and subsequent treatment. Histologic and cytologic diagnoses are difficult and complicated by the large number of soft tissue lesions described, distinctly different biopotential for morphologically similar lesions, often small biopsy specimen size, and the generally limited experience many pathologists have in the diagnosis of soft tissue neoplasms. While utilized less frequently than core-needle biopsies, fine-needle aspiration is a valuable initial approach for the classification of soft tissue neoplasms. The combination of pattern based morphologic analysis, immunohistochemistry, and molecular diagnostics represents a utilitarian and generally successful approach for the diagnosis of soft tissue lesions.

Updates in Effusion Cytology

Effusion cytology plays multiple roles in the management of benign and malignant disease, from primary diagnosis to tissue allocation for ancillary diagnostic studies and biomarker testing of therapeutic targets. This article summarizes recent advances in pleural effusion cytology, with a focus on the practical application of immunohistochemical markers, cytogenetic techniques, flow cytometry, and molecular techniques for the diagnosis and management of primary and secondary neoplasms of the pleura.

Primary Splenic Angiosarcoma with Liver Metastasis: A Rare Neoplasm Diagnosed on Fine-needle Aspiration Cytology and Cell Block Immunocytochemistry

Primary splenic angiosarcoma is a rare malignant vascular neoplasm of mesenchymal origin. The tumor is highly aggressive and has a high metastatic potential. It is usually diagnosed on histopathological examination of splenectomy specimen. Only few cases of angiosarcoma diagnosed by fine-needle aspiration (FNA) cytology alone have been reported in the literature. The cytologic features of angiosarcoma are heterogeneous, however, diagnosis can be suggested by FNA when vasoformative features are present. A 55-year-old female presented with abdominal pain and hepatosplenomegaly. Computed tomography scan revealed a heterogeneous splenic lesion with liver metastases. FNA from the splenic and liver lesions showed moderately pleomorphic tumor cells closely associated with anastomosing vascular channels. Cell block immunocytochemistry (ICC) showed tumor cells positive for CD31, CD34, CD68 as well as for CD99. FNA supplemented by cell block ICC can render a definite diagnosis of primary splenic angiosarcoma with liver metastasis.

Minimally invasive diagnosis of a pericardial mass by CT-guided fine-needle aspiration

The preferred management of a cardiac mass remains controversial, but it often includes open-chest surgical excision to obtain an adequate tissue sample for histological workup. We herein report a less invasive approach in which an accurate and timely cytological diagnosis of pericardial angiosarcoma was reached by studying a CT-guided fine-needle aspiration cell block. The cell block showed proliferation of atypical cells with occasional mitotic figures, vasoformative features, and immunoreactivity to WT1, vimentin, CD31, CD34, ERG, and Ki67. Recourse to fine-needle aspiration and cell block study is a valuable diagnostic approach to be considered when a cardiac mass is percutaneously accessible.

Radiation-Associated Angiosarcoma of the Breast: Clinical and Pathologic Features

Breast angiosarcoma is an unusual malignancy accounting for approximately 1% of soft tissue sarcomas. It can occur as a primary form without a known precursor or as a secondary form associated with radiotherapy. Adjuvant radiotherapy has a significant role in preventing local recurrence in women treated with conservation therapy for early stage breast carcinoma or multicentric tumors. Postradiation angiosarcoma usually affects the dermis of the breast within the radiation field and may occasionally develop in the breast parenchyma. Compared with the latency of other radiation-associated sarcomas, the latency for breast radiation-associated angiosarcoma is relatively short with a median of 6 years. The risk of developing secondary angiosarcoma does not outweigh the benefit of treatment; therefore, radiation therapy continues to be a mainstay modality in the treatment of breast cancer patients. Early detection is essential because angiosarcomas are associated with a poor prognosis. Wide surgical resection is the standard treatment for these tumors.

Angiosarcoma presenting with spontaneous hydropneumothorax: report of a case and review of the literature

Angiosarcoma is a rare malignant tumor of soft tissue. Because angiosarcoma originates from endothelial cells, it can occur in any organ and shows aggressive clinical features. Most commonly, angiosarcoma initially presents as a cutaneous lesion. Lung metastasis from scalp angiosarcoma can develop pneumothorax. We report a case of multiorgan involvement of an angiosarcoma, including the scalp, initially presenting with hydropneumothorax. Immunohistochemistry analysis of the cells obtained from the study confirmed the pleural invasion of the angiosarcoma.

The utility of ERG, CD31 and CD34 in the cytological diagnosis of angiosarcoma: an analysis of 25 cases

AIMS

Erythroblast transformation specific related gene (ERG), a proto-oncogene member of the erythroblast transformation specific transcription factor family, is a sensitive marker of endothelial differentiation and is expressed in vascular tumours, including angiosarcomas (AS). Immunohistochemistry is necessary for the diagnosis of AS in fine needle aspirates where low cellularity and lack of preserved tissue architecture impedes diagnosis. The aim of this study was to assess the utility of an ERG-enriched immunohistochemistry panel in the cytological diagnosis of AS.

METHODS

25 AS diagnosed on fine needle aspirates were stained for ERG, CD31, CD34, and AE1/AE3. Staining intensity and percentage tumour cell positivity were evaluated. Spearman's correlation was assessed for significant correlations between antibodies.

RESULTS

Sensitivities for ERG, CD31, CD34 and AE1/AE3 were 100%, 100%, 60% and 21%, respectively. Spearman's analysis revealed that ERG and CD31 staining correlated significantly; there was no significant correlation between CD31 and CD34 staining.

CONCLUSIONS

With equal sensitivity to, and strong correlation with CD31, ERG staining is highly suitable for the cytological diagnosis of AS. ERG and CD31 are more sensitive vascular markers than CD34. ERG, a nuclear stain, complements the cytoplasmic/membranous staining of CD31. Used in conjunction with CD31, ERG can corroborate the diagnosis of AS.

A case of metastatic angiosarcoma diagnosed by liquid-based preparation: peculiar cytoplasmic changes

Angiosarcoma with predominantly epithelioid features is a rare soft tissue neoplasm and the interpretation of its cytopathologic findings may be difficult. We report a case of metastatic angiosarcoma with predominantly epithelioid features diagnosed by liquid-based cytology. The cytopathologic findings in this case differed from those of the conventional preparation and we found a clean background, no hyperchromatic nuclei and several cytoplasmic changes, including intracytoplasmic vacuoles with peculiar shapes, juxtanuclear condensation and perinuclear clearing. Identification of these changes using liquid-based cytology supplemented with immunochemistry may be helpful in reaching a correct cytopathologic diagnosis.

Angiosarcoma of the prostate: a more frequent finding in the future owing to radiotherapy? A literature review with treatment implications based on a case report

OBJECTIVE

An increase in the incidence of prostate angiosarcoma may be expected owing to the exponential increase in the use of radiotherapy for prostate carcinoma in recent decades and the possible aetiology of radiation exposure on the development of angiosarcoma in general. The objective of this study was to give an overview of cases in the literature based on a case report of prostate angiosarcoma in a hospital in the Netherlands, and to discuss optimal treatment.

MATERIAL AND METHODS

All (related) articles In PubMed/Medline and Embase with possible cases of angiosarcoma were screened on title and abstract. A case of prostate angiosarcoma identified in the authors' institution was included.

RESULTS

The literature search yielded 13 cases of prostate angiosarcoma. The earliest six publications lack essential data. Four patients had a history of radiotherapy. The present patient developed angiosarcoma following brachytherapy for prostate cancer. Therapy consisted of radical surgery with or without chemotherapy in five cases. In eight cases curative therapy was not reported or not possible. Mean follow-up was only 1 year. Four patients died within 1 year of diagnosis, irrespective of treatment choice. One patient, treated with a combination of radical surgery and adjuvant chemotherapy, was still alive 36 months after therapy.

CONCLUSIONS

The findings confirm that prostate angiosarcoma is mostly radiation induced. This patient is the first case of prostate angiosarcoma after primary brachytherapy. Angiosarcoma may occur more often in the future owing to widespread use of brachytherapy and radiotherapy of the prostate. Current guidelines on management of angiosarcoma suggest radical surgery in local disease as the primary treatment of choice.

Cytopathologic characteristics of epithelioid vascular malignancies

OBJECTIVES

Epithelioid hemangioendothelioma (EHE) and epithelioid angiosarcoma (EAS) are rare vascular neoplasms that share many morphological characteristics on histology but demonstrate different clinical behavior. Given the many reported clinical and morphological features shared between EAS and EHE, we examined all cases of EAS and EHE diagnosed primarily on fine needle aspiration (FNA) at our three institutions that were confirmed by a tissue diagnosis.

STUDY DESIGN

A total of 29 cases from 25 patients were identified: 15 EHE from 11 patients and 14 EAS from 14 patients.

RESULTS

Many cytomorphological features existed on a spectrum that overlapped considerably between EAS and EHE cases. Common features between the two entities include epithelioid morphology and eccentrically placed nucleus. Intracytoplasmic lumens (ICL), a morphological feature that may suggest vascular origin, can be found in both entities but are not always present.

CONCLUSIONS

Given the general absence of vascular cytomorphological features, such as ICL, the proper classification of these tumors depends on the successful use of immunoperoxidase markers such as factor VIII-related antigen, ERG, or CD31 as well as a high index of suspicion. The distinction between EAS and EHE on FNA alone is treacherous at best.

Fine-needle aspiration cytology of primary renal angiosarcoma with histopathologic and immunocytochemical correlation: a case report

Primary renal angiosarcoma is an extremely rare neoplasm, with fewer than 28 cases reported thus far in the English literature. We report for the first time the cytomorphology and immunocytochemistry of this tumor in liquid-based (ThinPrep) fine-needle aspiration (FNA) samples in correlation with the conventional cytologic and histopathologic findings. Conventional smears showed pleomorphic tumor cells focally arranged in structures suggesting anastomosing vascular channels, while ThinPrep smears were less cellular with fewer and smaller tumor cells arranged in clusters or rosette-like formations. Immunocytochemical staining demonstrated positive results for vimentin, CD31, and CD34 and negative staining for epithelial markers, thus supporting the diagnosis of a mesenchymal tumor of vascular origin. The diagnosis of primary renal angiosarcoma was established after histopathologic evaluation of a metastatic liver nodule. The cytological differential diagnosis of this neoplasm and the utility of the ThinPrep method as a diagnostic adjunct to conventional FNA cytology are further discussed.

Pleural angiosarcoma mimicking pleural haematoma

Pleural angiosarcoma is an extremely rare disease. Although the clinical course could be indolent, the prognosis is very poor once the tumour spreads. Herein, a 69-year old male with a history of thyroid goitre was noted for 5 years before the symptoms of right chest pain and body weight loss developed. His serial chest roenterogram revealed loculated pleural effusion which rapidly progressed to be multiple pleural haematomas. After several sono-guided aspiration/biopsies with undiagnosed pleural haematomas, an exploratory thoracotomy confirmed the diagnosis of pleural angiosarcoma. Whole body image studies did not find other suspicious primary sites except for a thyroid tumour with eccentric calcification extending into the thoracic cage. Aspiration cytology of the thyroid tumour was shown to be morphologically consistent with angiosarcoma. This case reminds clinicians that pleural metastatic angiosarcomas presenting as haematomas have a high risk of massive and refractory haemothorax.

Hemangioendothelioma of soft tissue: Cytological dilemma in two cases at unusual sites

Hemangioendothelioma is a rare vascular tumor of intermediate malignancy. Cytologically, it can simulate a non-vascular malignant tumor. We report two cases of this tumor, which were misdiagnosed at cytology. In the first case, a 27-year-old man presented with an anterior abdominal wall tumor. Fine needle aspiration cytology (FNAC) of the tumor showed polygonal cells with vacuolated cytoplasm in clusters having moderate nuclear atypia in a background of necrosis. A diagnosis of metastatic carcinoma was made. The histological examination showed features of epithelioid hemangioendothelioma. In the second case, a 13-year-old female child presented with unilateral enlargement of the right tonsil. At ultrasound-guided FNAC, a diagnosis of, ‘small round cell tumor, could be consistent with alveolar rhabdomyosarcoma,’ was made. The histological examination showed features of papillary intralymphatic angioendothelioma (Dabska's tumor). We conclude that epithelioid hemangioendothelioma should be considered in the differential diagnosis of metastatic carcinoma and small round cell tumor even at unusual sites.

Squamous cell carcinoma arising from congenital lymphedema

Congenital lymphedema is a rare type of primary lymphedema occurring at birth or developing shortly later. Primary lymphedema can be classified according to whether it is familial or sporadic. The primary congenital familial lymphedema is also known as Milroy's disease. Majority of primary cases are sporadic type. Chronic lymphedema can be secondary to infections, surgery with lymph node excision, trauma, lymphadenectomy, radiotherapy, filarial infection, and so on. It is recognized that a variety of malignant tumors can arise in chronic congenital or acquired lymphedema; the most documented associations are lymphangiosarcoma, basal cell carcinoma, lymphoma, malignant melanoma, and Kaposi's sarcoma. A total of 13 cases of squamous cell carcinoma arising from chronic (primary or acquired) lymphedema have been reported, and only 3 cases of congenital lymphedema presented with squamous cell carcinoma as reported. A 32-year-old young male presented with chronic unilateral left lower limb lymphedema of 28 years duration. In addition, he had a 3-month history of a fungating cutaneous lesion on the lateral side measuring 2 cm × 1 cm in size. Fine-needle aspiration cytology was performed on the later mass, and a diagnosis of angiosarcoma was made. At histopathology, the appearances did not confirm angiosarcoma. However, an impression of carcinoma was made as squamous cells were observed in sheets. Immunohistochemistry was performed using markers for CD31, factor VIII (FVIII), and MiB. The epithelial marker cytokeratin was positive for squamoid cells and MiB index of 75%. The vascular markers FVIII and CD31 were negative, thus ruling out angiosarcoma. The final diagnosis was given as infiltrating squamous cell carcinoma in chronic lymphedema.

Cytologic features of epithelioid hemangioendothelioma

To determine cytologic features of epithelioid hemangioendothelioma (EHE) that would enable accurate diagnosis, we evaluated fine-needle aspiration biopsy (FNAB) smears from 11 histologically confirmed EHEs. The variably cellular smears comprised dispersed single cells and occasional cell aggregates. Dense stromal fragments were present in association with some tissue fragments. The cells were epithelioid, containing moderate or large amounts of dense cytoplasm. Nuclei exhibited mild pleomorphism, and nuclear grooves were identified in all cases. At least occasional intranuclear pseudoinclusions (INPIs) and intracytoplasmic lumina (ICLs) were present in all cases and in 9 cases (82%), respectively, and rare erythrocytes were seen within ICLs in 5 cases (45%). Mitotic figures were identified in 4 cases (36%). The background was bloody in 6 cases (55%) and contained hemosiderin and/or hemosiderin-laden macrophages in 5 cases (45%). The combination of the following features in FNAB samples should raise strong suspicion for EHE: predominantly dispersed single cells with occasional cohesive cell clusters; epithelioid cytomorphology; dense cytoplasm with well-defined cytoplasmic borders; ICLs (with or without erythrocytes), INPIs, and nuclear grooves. The presence of these features should prompt correlation with clinical, radiologic, and histologic features and immunohistochemical evaluation using vascular markers.

Rapidly progressive lung cysts and pleural effusion: a case report

Angiosarcoma is a rare but highly malignant tumor arising from vascular endothelial cells. Angiosarcoma commonly arises from the heart, liver, breast, and skin including the scalp. Angiosarcoma metastasizing to the lungs can present as either pneumothorax, hemothorax, or pleural effusions. They can rarely present as rapidly enlarging thin-walled pulmonary cysts. A review of the literature is included.

Epithelioid angiosarcoma of the kidney: a diagnostic dilemma in fine-needle aspiration cytology

Epithelioid angiosarcomas (EAS) of kidney are rare and aggressive tumors with noncharacteristic imaging features that overlap with those of inflammatory conditions and renal cell carcinoma (RCC). We report the fine-needle aspiration (FNA) cytology findings of a case of EAS that involved the left kidney of an 83-year-old male. The smears and cell block sections showed pleomorphic epithelioid cells with ample cytoplasm, eccentric nuclei, occasional cytoplasmic hyaline globules, and rare intracytoplasmic lumina. Immunohistochemical stains performed on cellblock sections showed that the tumor cells were positive for vimentin, CD31, CD34, Factor VIII, and CD10, but showed no staining for cytokeratins AE1/AE3 and 8/18, HMB45, CD45, smooth muscle actin, and S100. The morphological and immunohistochemical distinction between EAS, primary tumors of the kidney, and other epithelioid and rhabdoid neoplasms is discussed.

Fine-needle aspiration of metastatic radiation-induced cutaneous epithelioid angiosarcoma of the breast to the liver: A diagnostic dilemma

Radiation therapy is a significant risk factor for the development of angiosarcoma. With the increase in breast conservation treatment, the incidence of cutaneous radiation-induced angiosarcoma of the breast is rising. If the angiosarcoma demonstrates epithelioid features, the tumor cells may present a diagnostic dilemma on fine-needle aspiration cytology. We present a case of metastatic radiation-induced cutaneous epithelioid angiosarcoma of the breast to the liver and a review of the literature.

Bilateral angiosarcoma of the breast in a fourteen-year-old child

Malignant vascular tumors are rare and angiosarcomas of the breast in patients under 21 years of age are exceedingly uncommon. In this report an angiosarcoma in the breast of a 14-year-old girl is described. She died nine months after mastectomy with recurrent disease in the bones and the contralateral breast. The etiology of most primary angiosarcomas is unknown. Secondary angiosarcomas can develop after radiotherapy and chronic lymphedema. The histology of this angiosarcoma is illustrated.

Bilateral massive bloody pleurisy complicated by angiosarcoma

We report a case of angiosarcoma complicated by bilateral massive bloody pleurisy (hematocrit of 7.2%) in an 83-year-old woman. An autopsy revealed hemorrhagic tumors infiltrating both the diaphragm and serosal surface of the peritoneum. Histological examination confirmed an anastomosing vascular channel pattern of the tumor cells with characteristic immunohistochemical findings for angiosarcoma, such as positive staining for vimentin, CD31, CD34, D2-40, and factor VIII-related antigen. The tumor was thought to have originated from a small vessel on the serosal surface of the duodenum. We also reviewed cases of hemothorax associated with angiosarcoma, which suggested that primary or metastatic pleural angiosarcoma should be considered a cause of spontaneous hemothorax, especially in patients with bilateral and/or intractable hemothorax.

Fine-needle aspiration diagnosis of angiosarcoma of the spleen: a case report and review of the literature

Primary angiosarcoma of the spleen is a very rare neoplasm with a poor prognosis. The definitive diagnosis is usually based on the histologic evaluation of the splenectomy specimen. We describe a case of angiosarcoma diagnosed by fine-needle aspiration cytology prior to splenectomy. A 69-year-old white woman presented with heterogeneous lesions in the spleen during a follow-up computed tomographic scan for a history of liposarcoma of the right buttock. A malignant endothelial neoplasm was diagnosed by fine-needle aspiration cytology using immunocytochemistry, and a splenectomy confirmed the presence of angiosarcoma. To our knowledge, this is the first well-documented and confirmed case of primary angiosarcoma of the spleen diagnosed by fine-needle aspiration cytology. This report emphasizes the value of fine-needle aspiration cytology as an important diagnostic tool in splenic neoplasms.

A case of diffuse hepatic angiosarcoma diagnosed by FDG-PET

A 76-year-old woman was admitted to our hospital with a 2-month history of increasing abdominal distension, leg edema, and dyspnea. The serum transaminase level was about twice the upper limit of normal. The CT showed no tumor. Fluorine-18 2-deoxy-2-fluoro-D-glucose (FDG)-positron emission tomography (PET) showed diffuse abnormal accumulation throughout the entire liver. She was diagnosed by histopathological examination as having hepatic angiosarcoma causing veno-occlusive disease (VOD). This is the first report of hepatic angiosarcoma with FDG-PET.

Aspiration biopsy of nodular pseudoangiomatous stromal hyperplasia of the breast: clinicopathologic correlates in 10 cases

Nodular pseudoangiomatous stromal hyperplasia (PASH) of the breast is rare and often indistinguishable from fibroadenoma, clinically and on aspiration biopsy smears. We report our observations in 10 patients with PASH, evaluated by fine-needle aspiration (FNA) biopsy and core biopsy. We retrospectively reviewed the clinical, radiographic, cytologic, and histologic findings in 10 cases of pure nodular PASH. Ten patients with a presumed clinical and radiologic diagnosis of fibroadenoma underwent aspiration biopsy. The aspiration smears were diagnosed as fibroadenoma (4 cases), cellular fibroadenoma (1 case), schwannoma versus neurofibroma (1 case), fibrocystic change (3 cases; 2 with atypia), and "not specific for a lesion" (1 case). A diagnosis of PASH was not suspected in any case. A discrepant or imprecise cytologic diagnosis and/or the presence of dissociated spindle or epithelial cells, or cellular stromal fragments prompted a surgical excision in 7 of 10 patients (70%). The remaining 3 patients exhibited cytologic features of fibroadenoma and were diagnosed as such; however, surgical excision was recommended. Three patients underwent a subsequent core biopsy, with a diagnosis of PASH being made in 1 patient. FNA biopsy could not discriminate PASH from fibroadenoma in 4 of 10 patients (40%) or suggest a diagnosis of PASH in any case. On retrospective review, the finding of plump, spindle-shaped mesenchymal cells may be a cytologic clue to suggest a diagnosis of PASH.

Angiosarcoma after breast-conserving therapy: Fine-needle aspiration biopsy, immunocytochemistry, and clinicopathologic correlates

BACKGROUND

Angiosarcoma that arises after breast-conserving therapy can present clinically as a cutaneous and/or subcutaneous breast lump, which is misinterpreted easily as a recurrence of carcinoma. To the authors' knowledge, the role of fine-needle aspiration (FNA) cytology in the early diagnosis of this life-threatening complication of breast carcinoma therapy has not been established fully.

METHODS

The authors studied three new patients with this type of secondary angiosarcoma diagnosed by FNA biopsy and immunocytochemistry, reviewed the literature on the topic, and examined relevant differential diagnostic issues.

RESULTS

Patients presented with a discrete skin lump that had arisen several years after breast-conservative therapy for early-stage breast carcinoma near the scar from the previous surgery. The lesions were interpreted clinically as recurrent carcinoma. FNA yielded moderately cellular to highly cellular samples with variable patterns of cellular aggregation. Cells were epithelioid and spindle-shaped. Angioformative changes were subtle, and the overall picture suggested an epithelial malignancy, possibly a metaplastic carcinoma. Immunostaining of smears, however, provided conclusive evidence of the endothelial differentiation of tumor cells, and an FNA diagnosis of angiosarcoma was rendered in all patients. The histopathology of all surgically excised tumors confirmed the diagnosis of high-grade angiosarcoma.

CONCLUSIONS

Based on the authors' experience, the FNA cytologic appearance of angiosarcoma that presented as a breast skin nodule in a breast carcinoma survivor easily could have been misinterpreted as carcinoma. A correct diagnosis of this tumor relies on the proper evaluation of clinical findings and, as also shown by a review of the literature, requires immunocytochemical evidence of endothelial differentiation.

Fine-needle aspiration cytology of epithelioid angiosarcoma: A diagnostic dilemma

A 28-year-old woman with a 2-yr history of unilateral chronic leg swelling, initially thought to be secondary to deep vein thrombosis, later thought to be due to congenital venous malformation, eventually developed a pelvic mass, which was biopsied by fine-needle aspiration. On the basis of cytologic features on smears, high-grade sarcoma was reported. The patient underwent surgery to resect the pelvic mass, which showed anastomosing vascular channels arising from external iliac vein in histology. However, the tumor cells unexpectedly showed strong and diffuse immunohistochemical expression of cytokeratin and epithelial membrane antigen. The case was sent for expert consultation, and the expert's opinion was epithelioid angiosarcoma. The expert's diagnosis was confirmed 2 yr later by local recurrence. The clinical presentation, cytology, histology, and immunohistochemistry of the current case and 15 other cases of epithelioid angiosarcoma found in the cytology literature are summarized. This case illustrates that morphology with clinicopathologic correlation tends to be a better guide than available special techniques.

Cytological features of epithelioid mesenchymal neoplasms: A study of 21 cases

Epithelioid mesenchymal neoplasms (EMNs) are rare tumors that share cytological, histological, and immunohistochemical features with epithelial tumors. It is important to distinguish EMNs from epithelial tumors in cytology specimens due to their different clinical management and prognosis. The cytomorphological features of histologically confirmed EMN were reviewed. Twenty-one cytological specimens of EMN were evaluated and characterized by polygonal cells with moderate to abundant dense cytoplasm, prominent nucleoli, and pleomorphism. Additional findings included the presence of a distinct population of spindle cells, hemosiderin-containing cells, multinucleated cells, and granuloma-like structures in selected cases. Cytokeratin immunoreactivity was seen in two cases and was negative in one case. This study shows that the cytological features of EMNs and epithelial tumors overlap; nonetheless, some features are more helpful in suggesting EMN. A panel of immunocytochemical studies must include specific mesenchymal markers to avoid a misdiagnosis of carcinoma in cases of cytokeratin-positive EMN.

Cytohistologic correlations in angiosarcoma including classic and epithelioid variants: Institut Curie's experience

To characterize the cytological features of angiosarcomas, we reviewed the fine-needle aspiration material and corresponding histologic sections of 29 tumors in 23 patients. Histologically, 24 tumors were of the classic type, and 5 were epithelioid angiosarcomas. The original corresponding cytologic diagnoses were as follows: angiosarcoma, 17 cases; sarcoma not otherwise specified, 8 cases; and rhabdomyosarcoma, 1 case. Three samples were cell-poor and were considered suspicious of malignancy. The review of cytology samples showed that smears were cell-rich in 17 tumors and cell-poor in 12 tumors. A hemorrhagic background was present in 9 cases. Tumor cells were polymorphous, including spindle-shaped, round to oval, and polygonal epithelioid cells and giant cells in different proportions. Erythrophagocytosis was seen in 12 tumors. Smears of classic angiosarcomas were polymorphous and lacking specific characteristics, whereas smears of epithelioid tumors were morphologically similar and composed of round to oval and polygonal, epithelial cells frequently arranged in clusters, and showing erythrophagocytosis. The wide spectrum of cellular components of angiosarcomas accounts for the difficulty in establishing accurate tumor typing, particularly with cell-poor samples and low-grade classic angiosarcoma. Entities to consider in the differential diagnosis are carcinoma, epithelioid sarcoma, pleomorphic rhabdomyosarcoma, and malignant melanoma.

Cytologic findings of malignant vascular neoplasms: a study of twenty-four cases

Cytologic characterization of malignant vascular neoplasms (MVN) is difficult due to the wide range of differential diagnoses and sampling errors. The objective of this study was to identify criteria helpful in the cytologic diagnosis of MVN. The clinical presentation and cytomorphologic features of 22 angiosarcomas and two hemangioendotheliomas were analyzed. The criteria evaluated included cellularity, cellular arrangement, cell shape and size, pleomorphism, cytoplasmic borders, nuclear shape and number, chromatin pattern, nucleoli, background, and presence of angioformative structures. A previous history of MVN was noted in 18 of 24 patients. Specimens with epithelioid morphology were more cellular and pleomorphic and contained multinucleated cells. Specimens with spindle morphology were usually less cellular and less pleomorphic. Angioformative structures were identified in 11 of 24 cases. Awareness of features suggestive of MVN is necessary to raise the possibility of vascular origin, which can be confirmed with appropriate immunocytochemical studies.

Fine-needle aspiration of renal angiosarcoma

Angiosarcoma of the kidney is an unusual neoplasm, and primary renal angiosarcoma is exceedingly rare, with fewer than 11 well-documented cases reported to date. To our knowledge, no publication to date has correlated the fine-needle aspiration cytologic findings in renal angiosarcoma with the gross, histologic, and immunohistochemical findings. A 50-year-old man presented with a left kidney mass and multiple liver and pulmonary nodules. Computed tomography-guided fine-needle aspiration biopsies of the renal mass and a hepatic nodule were performed and demonstrated malignant spindle cells consistent with angiosarcoma. The diagnosis was confirmed at autopsy through histologic examination and associated ancillary studies. This case presents the fine-needle aspiration cytologic findings in renal angiosarcoma and correlates these findings with the gross pathologic, histologic, and immunohistochemical findings.

Sinonasal angiosarcoma with marrow involvement at presentation mimicking malignant lymphoma: cytogenetic analysis using multiple techniques

Angiosarcoma of the head and neck most commonly involves the skin of the scalp or face; primary involvement of the sinonasal region is exceedingly rate. We report a patient with sinonasal angiosarcoma who showed marrow involvement at presentation. Marrow aspiration smears showed many large, often segregated blast-like cells, mimicking malignant lymphoma. However, trephine biopsy revealed formation of anastomosing vascular spaces by the tumor cells and immunoreactivity for CD31, supporting a diagnosis of angiosarcoma. DNA ploidy analysis showed an apparent diploidy. Nevertheless, conventional cytogenetics demonstrated very complex chromosomal abnormalities with the presence of multiple hypodiploid clones, together with several near-triploid to near-tetraploid clones showing structural abnormalities involving chromosomes 1, 3, 4, 9, 14, 16, 17, 18, and 22. The identification of these karyotypic changes has been facilitated by the application of comparative genomic hybridization and spectral karyotyping.