Vascular Lesions

Vascular lesions in childhood are comprised of vascular tumors and vascular malformations. Vascular tumors encompass neoplasms of the vascular system, of which infantile hemangiomas (IHs) are the most common. Vascular malformations, on the other hand, consist of lesions due to anomalous development of the vascular system, including the capillary, venous, arterial, and lymphatic systems. Capillary malformations represent the most frequent type of vascular malformation. IHs and vascular malformations tend to follow relatively predictable growth patterns in that IHs grow then involute during early childhood, whereas vascular malformations tend to exhibit little change. Both vascular tumors and vascular malformations can demonstrate a wide range of severity and potential associated complications necessitating specialist intervention when appropriate. Evaluation and treatment of the most common types of vascular lesions are discussed in this article. [Pediatr Ann. 2016;45(8):e299-e305.].

Angiolymphoid Hyperplasia with Eosinophilia in Association with a Vascular Malformation

A unique case is presented in which a lesion of angiolymphoid hyperplasia occurs in association with a vascular malformation. The skin and the intravascular lesion showed, on microscopic examination, angiolymphoid hyperplasia, which to my understanding, is a reactive process. The nodule represents, in my view, satellite lesions of the A-V malformation--in other words a skin manifestation of the intravascular process. The same phenomenon has been reported in some pyogenic granulomas and hemangiomas.

Tumor-induced hypophosphatemic osteomalacia associated with tertiary hyperparathyroidism: a case report

BACKGROUND

Tumor-induced hypophosphatemic osteomalacia is a syndrome characterized by urinary phosphate wasting related to the presence of a slowly-growing tumor of mesenchymal origin. The characteristic laboratory findings are normal serum calcium, marked hypophosphatemia, increased serum alkaline phosphatase, markedly reduced renal tubular reabsorption of phosphorus and inappropriately low levels of 1,25-dihydroxyvitamin D [1,25-(OH)2D].

CASE PRESENTATION

A 65-year-old woman presented with a 17-year clinical history of musculoskeletal pain, muscular weakness in the pelvic girdle, spontaneous fractures and difficulty in walking. Over the ensuing years the patient suffered other multiple spontaneous fractures, surgically treated, and the muscular pains worsened until she became bedridden. During the years before hospital admission the patient received treatment with clodronate, oral calcium salts and vitamin D therapy. Standard laboratory, ultrasonography and scintigraphic findings provided a "convenient" diagnosis of primary hyperparathyroidism, but the low plasma level of phosphorus induced to perform an Indium111-octreotide scintigraphy. Scintigraphy visualized an area of pathologic increased signal uptake in the left groin, consistent with a mass containing a high density of somatostatin receptors. After surgery, histologic examination and immunostaining of the resected specimen indicated an hemangiopericytoma. Nevertheless, the persistently low blood phosphorus level, in association with the increased serum calcium and PTH levels, were attributed to the prolonged phosphate therapy the patient underwent over the years, and the persisting abnormal laboratory indexes indicated the development of a tertiary hyperparathyroidism. We performed a subtotal parathyroidectomy and intraoperative assay of serum PTH showed that levels had diminished by more than 80% from preoperative values. Over the ensuing months Ca+2, PTH and serum phosphorus values returned to normal, and the pain symptoms disappeared.

CONCLUSIONS

Tumour-induced osteomalacia is a very rare syndrome associated in 5% of cases with tertiary hyperparathyroidism due to long-term therapy with phosphorus and vitamin D. The initial diagnosis of primary hyperparathyroidism, confirmed by the parathyroid MIBI-scintigraphy, would lead us to an inappropriate surgical treatment. Therefore we want to stress the importance of In111-octreotide scintigraphy in detecting tumours, rich in somatostatin receptors, in presence of an hypophosphatemic syndrome.

[Vascular tumors as syndromic indicators]

Haemangiomas can be indicators or clue signs for serious syndromes. Although less well known than those related to vascular malformations, there are some syndromes of important diagnostic value that are associated with haemangomias. Early recognition of problematic haemangiomas, together with a prompt intervention, may help to minimise their future morbidity. Neonatal haemangiomas warrant a special follow-up, since their growth pattern might be unpredictable at such an early age. Several clinical presentations are relevant because of their risk of syndromic association: cervicofacial haemangiomas, especially the extensive ones, may be markers for severe dysmorphic conditions like the PHACE(S) syndrome. Those distributed in the beard area are occasionally associated with haemangiomas of the airway. Lumbosacral haemangiomas usually hide an underlying spinal dysraphism or anorectal and urogenital anomalies. Multiple cutaneous haemangiomas may be a sign of visceral haemangiomatosis, most often hepatic, which becomes complicated by cardiac insufficiency or thyroid disease. Finally, there are two vascular neoplasms of rapid and invasive growth - kaposiform haemangioendothelioma and angioblastoma or tufted angioma - which, unlike infantile haemangioma, are markers for the Kasabach-Merritt syndrome.

Coexistence of cystic intra-abdominal lymphangiomas and diffuse venous haemangiomas in adult life

Diffuse haemangioma and intra-abdominal lymphangioma are rare in adults. In this case report, we present a 33-year-old female with coexisting multiple cutaneous and visceral cavernous haemangiomas and two huge intra-abdominal lymphangiomas of 25 and 35 cm in diameter. The organs involved were the liver, pericardium, renal hilus and bladder. She died due to disseminated intravascular coagulation and multiorgan failure, which resembled Kasabach-Merritt syndrome. The coexistence of generalised haemangiomas and intra-abdominal lymphangiomas and the lack of complaints until the age of 33 years makes her an unusual case in the literature. We also emphasise the other clinical conditions that should be considered in the differential diagnosis.

Vascular lesions of the gastrointestinal tract

Vascular lesions of the gastrointestinal (GI) tract include arterio-venous malformations as angiodysplasia and Dieulafoy's lesion, venous ectasias (multiple phlebectasias and haemorroids), teleangiectasias which can be associated with hereditary hemorrhagic teleangiectasia (HHT), Turner's syndrome and systemic sclerosis, haemangioma's, angiosarcoma's and disorders of connective tissue affecting blood vessels as pseudoxanthoma elasticum and Ehlers-Danlos's disease. As a group, they are relatively rare lesions that however may be a major source of upper and lower gastrointestinal bleeding. Clinical presentation is variable, ranging from asymptomatic cases over iron deficiency anaemia to acute or recurrent bleeding that may be life-threatening. Furthermore, patients may present with other symptoms, e.g. pain, dysphagia, odynophagia, the presence of a palpable mass, intussusception, obstruction, haemodynamic problems resulting from high cardiac output, lymphatic abnormalities with protein loosing enteropathy and ascites, or dermatological and somatic features in syndromal cases. Diagnosis can usually be made using endoscopy, sometimes with additional biopsy. Barium radiography, angiography, intraoperative enteroscopy, tagged red blood cell scan, CT-scan and MRI-scan may offer additional information. Treatment can be symptomatic, including iron supplements and transfusion therapy or causal, including therapeutic endoscopy (laser, electrocautery, heater probe or injection sclerotherapy), therapeutic angiography and surgery. The mode of treatment is of course depending on the mode of presentation and other factors such as associated disorders. If endoscopic or angiographic therapy is impossible and surgical intervention not indicated, pharmacological therapy may be warranted. Good results have been reported with different drugs, albeit most of them have not been tested in large trials.

[Primary leiomyosarcoma of vascular origin in the groin causing lower extremity venous compression]

A soft tissue tumor causing left lower extremity swelling in a 43 years old female was detected in the left inguinal region and resection was performed at the Department of Cardiovascular Surgery of Semmelweis University of Medicine, Budapest. Histologic examination revealed primary leiomyosarcoma of vascular origin. On the base of this case attention is called to this rare disease, which has poor prognosis. Early diagnosis and complete resection plays key role in the treatment of leiomyosarcoma and may improve survival.

[The dural arteriovenous fistula treatment by embolization]

The transverse sinus is one of the most common locations for dural fistulas. A 43-year-old man with pulsatile tinnitus had arteriography that showed a left transverse dural arteriovenous fistula. We report on the treatment of the fistula with embolization of the supplying arteries. Primary transarterial embolization failed to completely obliterate the fistula and the recurrent symptoms were observed. Subsequent embolization was tried by using PVA (polyvinyl alcohol), spongostan and mechanical detachable coils and resulted in the improvement of the patient's tinnitus. The additional arteriographical finding was microangioma located on the branch supplying the fistula arising from the left vertebral artery.

Angiosarcoma arising in a solitary schwannoma (neurilemoma) of the sciatic nerve

Angiosarcomas rarely develop within a peripheral nerve or a peripheral nerve sheath tumor. We describe an epithelioid angiosarcoma that arose in a benign schwannoma (neurilemoma) of the right thigh in a 65-year-old man who did not have von Recklinghausen's disease. Histologically, the resected tumor was a high-grade undifferentiated sarcoma that was predominantly arranged in solid sheets or nests and composed of epithelioid cells. The endothelial origin of the tumor was suggested by Factor VIII R-ag, Ulex europaeus-I, CD34, CD31, BNH9, and vimentin immunoreactivity, along with the ultrastructural evidence of occasional Weibel-Palade bodies. In this location, epithelioid angiosarcoma should be distinguished from malignant transformation of a schwannoma with epithelioid changes. This observation stresses the importance of immunohistochemical and ultrastructural analysis in the differential diagnosis of vascular tumors with features of epithelioid sarcoma.

Malignant vascular tumors of the liver presenting as liver failure and portal hypertension

We describe three patients referred for orthotopic liver transplantation with liver failure and portal hypertension who were found to have malignant vascular tumors: two patients with angiosarcoma and one patient with epithelioid hemangioendothelioma. Their clinical presentation mimicked decompensated chronic liver disease. None had tumor masses on computed tomography and ultrasonography. Massive tumor involvement of the liver was identified in the two patients studied by magnetic resonance imaging. Pathological examination of the explanted liver at the time of transplantation in one patient and autopsy in a second patient showed angiosarcoma. Laparoscopic liver biopsies in the third patient showed epithelioid hemangioendothelioma. The vascular origin of the tumor was established by histopathologic examination and confirmed with immunohistochemistry. Malignant vascular tumors of the liver should be included in the differential diagnosis of liver failure of unclear etiology.

Intravascular bronchioloalveolar tumor of the lung presenting as pulmonary thromboembolic disease and pulmonary hypertension

Intravascular bronchioloalveolar tumor, the pulmonary counterpart of epithelioid hemangioendothelioma, typically presents as bilateral pulmonary nodules in young women. We report a case of intravascular bronchioloalveolar tumor that clinically mimicked acute pulmonary thromboembolic disease initially and was subsequently proven to have pulmonary hypertension with right ventricular dysfunction by angiography. The diagnosis of intravascular bronchioloalveolar tumor was confirmed by immunohistochemical and ultrastructural studies after it was suspected on routine histologic examination. In addition, the tumor cells expressed glycoprotein cell adhesion molecule CD44, which has been implicated in increased tumor invasiveness and metastasis in various carcinomas and several aggressive non-Hodgkin's lymphomas.

Malignant 'angioendotheliomatosis'--(intravascular lymphomatosis) an unusual cutaneous lymphoma in rheumatoid arthritis

A case of cutaneous malignant 'angioendotheliomatosis' (intravascular lymphoma) is described in a patient with RA and Sjögren's syndrome. The association of RA with this rare form of lymphoma has not been reported in the literature.

Vascular abnormalities of the extremities: clinical findings and management

A retrospective review identified 41 patients with angiodysplastic lesions of the extremities. Twenty-two patients had a mass, 11 had limb length discrepancy and/or hemihypertrophy, and two had recurrent joint effusions. Enhanced computed tomography (CT) and magnetic resonance imaging (MRI) were most valuable for both diagnosis and preoperative planning. Many patients were diagnosed clinically and treated symptomatically. Twenty-nine patients (71%) required operation. Descriptive pathology and histologic diagnosis were not determinants of clinical outcome, whereas anatomic location and overall size were predictive of symptomatology. Subcutaneous hemangiomas irritated sensory nerves, intramuscular lesions mimicked compartment syndromes, intraarticular lesions caused recurrent hemarthroses, and periarticular or large lesions resulted in hypertrophy or limb length discrepancy. Simple excision under tourniquet control with incomplete exsanguination is possible but often incomplete (48% recurrence) owing to the invasive nature of the lesion.

Neoplastic angioendotheliomatosis

A 60-year-old white man presented with aphasia, seizures, paraparesis, and incontinence. His serologic and hematologic profiles were unremarkable. His cerebrospinal fluid showed pleocytosis, increased daily central nervous system IgG synthesis, increased myelin basic protein, and negative cytology and cultures. Cerebral computed tomography exhibited multiple areas of hypodensity but spinal computed tomography and myelography showed no abnormalities. Cranial and spinal magnetic resonance imaging revealed areas of increased signal on T2-weighted images. The use of gadolinium-pentetic acid on T1-weighted images delineated smaller areas of cortical enhancement with surrounding rim of decreased signal. Brain biopsy showed intravascular malignant cells positive for leukocyte common antigen and B-cell markers. The diagnosis was neoplastic angioendotheliomatosis (intravascular lymphomatosis). To our knowledge, this is the first report on the use of both cranial and spinal magnetic resonance imaging in this condition.

A study of estrogen and progesterone receptors in spider telangiectasias of the lower extremities

There is an association of some vascular tumors with estrogen receptors and an association of vascular telangiectasias with high levels of circulating estrogen. Because of this, a study of patients with lower extremity starburst telangiectasias and predisposing factors associated with hyperestrogenemic and hyperprogesteronemic states was undertaken in order to look for estrogen and progesterone receptors in biopsy specimens of lower extremity telangiectasias noted to arise in this setting. Contrary to expected results, using immunocytochemical techniques, no patient in this study was found to have estrogen or progesterone receptors present in their lower extremity telangiectasias. Possible explanations for these results are discussed.

Intracranial tumor-forming papillary endothelial hyperplasia--a case report

This is a report of extensive intracranial papillary endothelial hyperplasia in a 12-day-old twin. The infant presented with progressive macrocephaly, anemia and hydrocephalus. An MR image showed a large (6 x 5 cm) mass in the right middle cranial fossa. Histologic examination of the resected mass revealed multifocal hemorrhage, organizing in a floridly papillary pattern, in proximity to numerous fibrous bands containing reactive fibroblasts, scattered chronic inflammatory cells and foci of extramedullary hematopoiesis. Although the pattern was complex, neither the papillary regions nor the other areas in the lesion displayed solid proliferations of endothelial cells to support a diagnosis of angiosarcoma. Subsequent to the resection, the infant continued to have hemostatic abnormalities and increasing hydrocephalus. Repeat scans showed a recurrent mass (4 x 4 cm). The child was placed on a protocol for chemotherapy treatment. We hypothesize that the hemorrhage and subsequent organization could have been superimposed upon a preexistent vascular malformation or hemangioma even though Masson's trichrome stain does not unequivocally demonstrate this feature. Most importantly, we would like to emphasize the dilemmas involved in diagnosis and management of this benign disorder.

Tumor-induced osteomalacia and rickets

Tumor-induced osteomalacia is a clinicopathological entity in which vitamin D-resistant osteomalacia or rickets occurs in association with a tumor. A total of 72 cases (three current, 69 from review of literature) has been reported to date. Men and women are equally affected. The majority are adults over 30 years old who exhibit progressive lower leg and back pain. Forty bone and 31 soft-tissue tumors were responsible for this syndrome; two-thirds occurred in the extremities. Chemical findings are typical: low serum phosphorus, normal serum calcium, and elevated alkaline phosphatase. Serum levels of 1,25-dihydroxyvitamin D were low or undetectable. Histologically, more than a third were classified as vascular tumors, and half of these cases were hemangiopericytomas that were distributed equally between bone and soft tissues. Other common diagnoses included nonossifying fibromas, "mesenchymal" and giant-cell tumor variants. Features common to all tumors were prominent vascularity, and giant and primitive stromal cells. Only 10 were histologically malignant. Ultrastructural studies have not shown any secretory granules suggestive of a hormone-secreting tumor. It is clear, however, that the tumor is responsible for the osteomalacia because the complete removal generally results in a dramatic reversal of all symptoms and signs.

Congenital soft tissue dysplasia: a new malformation entity and concept

We report 185 children with clinical manifestations of various conditions classically described as giant hamartoma, angiodysplasia, congenital hypertrophy, congenital trophoedema, localised gigantism (e.g. macrodactyly), etc. It is proposed to group all these conditions into a single entity: congenital soft-tissue dysplasia (CSTD). According to recent advances in fundamental embryology and cell biology, CSTD appears to be a consequence of embryonal or fetal cell biosynthetic dysregulation. The concept of the CSTD entity leads to a common protocol for clinical investigation and a common therapeutic plan, with special reference to the stability and the benign nature of the condition. Treatment should be confined to improving function rather than attempting to correct cosmetic deficits.

Cervical carotid artery dissection secondary to malignant fibrous histiocytoma

A rare case of malignant fibrous histiocytoma of the cervical carotid artery is presented. Erosion of the vessel wall by this neoplasm resulted in dissection and pseudoaneurysm formation. The etiology and diagnosis of and the therapeutic alternatives for this unique disorder are discussed briefly.

[Acute venous thrombosis as the first symptom of malignant diseases (author's transl)]

Up to this time, malignant diseases not clinically manifest have repeatedly been found as causes of acute venous thromboses. Among our own patients this occurred in 5 cases out of 35 acute venous thromboses in 3 years. Since the indication for venous thrombectomy is greatly restricted by the presence of a malignant disease as the cause of this thrombosis, exclusion of a tumor must be aimed at before indication for thrombectomy is made. Very rare intravascular tumors of the vessel require careful histological investigation of every thrombus removed.

Fatal hemorrhage as a complication of neurofibromatosis

Rupture of a major artery occurred in a patient with Von Recklinghausen's disease. The adventitia and media of the artery in the region of the rupture were invaded by neurofibroma.

Numerous cases of hemorrhage into neurofibromata have been reported1 2, 3, several of these with a fatal outcome. Cases have been reported describing neurofibromatous involvement of the adventitia of blood vessels with the devel opment of aneurysms 4, 5 and hypertension 5,6. In 1882, Frederick Von Reckling hausen reported a case of neurofibromatosis with rupture of a pulmonary artery aneurysm 7, 8. Unfortunately, microscopic examination of the vessel was not performed. We report a fatal case of rupture of a major artery secondary to neurofibromatous involvement of the adventitia and media of the vessel.