Hepatic angiosarcoma: aspiration biopsy cytology and immunocytochemical contribution

Vascular tumours of the liver: a particular story

Vascular tumours of the liver represent an underrated chapter of medical and surgical hepatology. These tumours cover a wide spectrum ranging from the frequent and most benign hepatic haemangioma (HH), via the rare and intermediately aggressive hepatic epithelioid haemangioendothelioma (HEHE) to the rare and most malignant hepatic haemangiosarcoma (HHS). In contrast to the treatment algorithms for hepatocellular and cholangiocellular cancer, the diagnostic and therapeutic approaches to HEHE and HHS are not well developed. The related uncertainty is explained by their rare occurrence and their protean clinical, morphological (imaging) and histopathological presentation and behaviour. This article gives an update about these particular tumours based on the analysis of the recent literature and of the studies on vascular tumours published by the European Liver Intestine Transplantation Association (ELITA)-European Liver Transplant Registry (ELTR). It focuses also on the place of liver transplantation (LT) in the respective therapeutic algorithms. The differential diagnosis between these vascular and other tumour types may be very difficult. Correct diagnosis is of utmost importance and is based on a high index of clinical suspicion and on the integration of clinical, radiological, histological [including immunohistochemistry (IHC) and molecular biology findings]. Surgery, be it partial or total hepatectomy (LT), should be proposed whenever possible, because it is the therapeutic mainstay. In HEHE, LT provides excellent results, with long-term disease-free survivals (DFS) reaching 75%. Good results can be obtained even in case of (frequent) extrahepatic spread. Based on the extensive ELITA-ELTR study a HEHE-LT prognostic score has been proposed in order to estimate the risk of recurrence after LT. In contrast, results of surgery and LT are extremely poor for HHS, for the almost invariably rapid recurrence (within 6 months) and related death within 2 years. LT remains a contraindication for HHS. Due to the still important recurrence rate after surgical resection (25% in HEHE and almost 100% in HHS), there is an urgent need to develop pharmacological treatments targeting angiogenic and non-VEGF angiogenic pathways. To date, some prospective pilot studies and case reports have shown some short-term stabilisation of the disease in small groups of patients. In order to make progress, combination of surgery, anti-angiogenic and immunotherapy seems worthwhile. To complete the panel of vascular liver tumours, infantile haemangioendothelioma, haemangiopericytoma, nodular regenerative hyperplasia (NRH) and hepatic small vessel neoplasms (HSVN) are also discussed.

Liver transplantation and vascular tumours

Based on analysis of the literature and of the audited ELITA (European Liver Intestinal Transplant Association)-ELTR (European Liver Transplant Registry) data, the place of liver transplantation (LT) in the treatment of vascular tumours is discussed. Hepatic epithelioid haemangioendothelioma has currently become a good indication for LT with 5- and 10-year post-LT patient survival rates of 83% and 74% respectively and 5- and 10-year recurrence-free survival rates of 82% and 64% respectively. In contrast, the results of LT for haemangiosarcoma (HAS) are disastrous with an universal tumour recurrence within 6 months and no single patient survival after 2 years. Therefore, HAS remains an absolute contraindication to LT. The value of LT in the treatment of infantile haemangioendothelioma is more difficult to evaluate because of the very reduced number of reported cases and because of the often difficult differential diagnosis with angiosarcoma. LT should be reserved to those children not responding to medical treatment on the condition that sarcomatous modifications are excluded by expert pathologists to avoid a futile transplant procedure.

Hepatic angiosarcoma manifested as recurrent hemoperitoneum

Angiosarcoma is a rare tumor that account for less than 1% of all sarcomas. Although hepatic angiosarcoma usually presents with unspecific symptoms, it rapidly progresses and has a high mortality. We report a rare case of primary hepatic angiosarcoma manifested as recurrent hemoperitoneum.

Primary vascular neoplasms unique to the spleen: littoral cell angioma and splenic hamartoma diagnosis by fine-needle aspiration biopsy

We report the fine-needle aspiration (FNA) biopsy diagnosis of two rare cases of primary vascular neoplasms unique to the spleen: a littoral cell angioma from a 31-yr-old Caucasian woman and a splenic hamartoma from a 46-yr-old black man. The cytologic features of splenic hamartoma and of littoral cell angioma of the spleen were described three times in cytologic literature: two were bench-top aspirates and one was FNA biopsy thought to be metastatic carcinoma. To the best of our knowledge, the current two cases were the first diagnosed by FNA biopsy. Our approach to the FNA biopsy diagnosis of these rare vascular neoplasms via compact cell block and immunohistochemistry is described. The differential diagnosis with other primary vascular splenic neoplasms is also discussed.

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.

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.

Spindle-cell lesions of the liver: diagnosis by fine-needle aspiration biopsy

Rarely, spindle-cell lesions in liver fine-needle aspiration biopsies (FNABs) are encountered. A retrospective review of our experience with lesions that are mesenchymal in origin or appearance was undertaken to elucidate the frequency and spectrum of these lesions. Image-guided liver FNABs performed over a 3-year period (n = 585) at our institution (1996-1998) were retrospectively evaluated. Cytologic smears, cell block preparations, and clinical follow-up of lesions with spindle-cell morphology were reviewed. Twenty-nine of 585 cases were of spindle-cell morphology (5%). Hemangiomas (n = 12, 41%) and metastatic sarcomas (n = 6, 21%) comprised the largest categories, followed by granulomatous inflammation (n = 3, 10%). Other cases included primary angiosarcoma and fibrolamellar hepatocellular carcinoma. The most frequent spindle-cell liver lesion encountered is hemangioma, followed by metastatic leiomyosarcoma and granulomatous hepatitis. Awareness of diagnostic possibilities, special attention to specimen adequacy, and use of ancillary procedures can maximize diagnostic yield.

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

We report the cytologic features of 15 cases of angiosarcoma from various sites and include 14 fine-needle aspiration (FNA) biopsy specimens and 1 pleural fluid specimen. Six were initial diagnoses with histologic confirmation; an additional case in the liver was an initial diagnosis without tissue confirmation. One case represented lymph node metastasis from a primary prostatic epithelioid angiosarcoma. In 10 cases, immunohistochemical staining for factor VIII-related antigen, CD34, CD31, or Ulex europaeus agglutinin I was performed on the cytology or histology specimen. The aspirates varied in cellularity, and the degree of nuclear atypia ranged from relatively bland in a case of low-grade angiosarcoma of the prostate to highly pleomorphic in a lymph node metastasis from a facial cutaneous angiosarcoma. Vasoformative features such as intracellular RBCs, well-formed vessels, attempts at microacinar/lumen formation, and intracytoplasmic lumens were variably present. The background was bloody in all specimens, with necrosis in rare cases. This cytologic series emphasizes that the cytologic features are heterogeneous but that the diagnosis can be suggested by fine-needle aspiration (FNA) when vasoformative features are present. The diagnosis can be made conclusively by FNA with immunocytochemical confirmation of endothelial differentiation.