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Splenic Angiosarcoma: a Clinicopathologic and Immunophenotypic Study of 28 Cases Thomas S

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Splenic Angiosarcoma: A Clinicopathologic and Immunophenotypic Study of 28 Cases Thomas S. Neuhauser, M.D., Gregory A. Derringer, M.D., Lester D. R. Thompson, M.D., Julie C. Fanburg-Smith, M.D., Markku Miettinen, M.D., Anne Saaristo, M.B., Susan L. Abbondanzo, M.D. Departments of Hematopathology (TSN, GAD, SLA), Endocrine and Otorhinolaryngic-Head & Neck Pathology (LDRT), Soft Tissue Pathology (JCF-S, MM), Armed Forces Institute of Pathology, Washington, DC; Molecular/Cancer Biology Laboratory, Haartman Institute, University of Helsinki, Finland (AS); Wilford Hall Medical Center, Lackland AFB, Texas (TSN) entiation (CD34, FVIIIRAg, VEGFR3, and CD31) Primary angiosarcoma of the spleen is a rare neo- and at least one marker of histiocytic differen- plasm that has not been well characterized. We de- tiation (CD68 and/or lysozyme). Metastases de- scribe the clinical, morphologic, and immunophe- veloped in 100% of patients during the course of notypic findings of 28 cases of primary splenic their disease. Twenty-six patients died of dis- angiosarcoma, including one case that shares fea- ease despite aggressive therapy, whereas only tures of lymphangioma/lymphangiosarcoma. The two patients are alive at last follow-up, one with patients included 16 men and 12 women, aged 29 to disease at 8 years and the other without disease 85 years, with a mean of 59 years and median of 63 at 10 years. In conclusion, primary splenic an- years. The majority of patients (75%) complained of giosarcoma is an extremely aggressive neo- abdominal pain, and 25% presented with splenic plasm that is almost universally fatal. The ma- rupture. The most common physical finding was jority of splenic angiosarcomas coexpress splenomegaly (71%). Seventeen of 21 patients were histiocytic and endothelial markers by immu- reported to have anemia. Macroscopic examination nohistochemical analysis, which suggest that showed splenomegaly in 85% cases. Sectioning re- some tumors may originate from splenic lining vealed discrete lesions in 88% of cases, ranging from cells. well-circumscribed firm nodules to poorly delin- eated foci of necrosis and hemorrhage associated KEY WORDS: Angiosarcoma, Hemangioma, Histo- with cystic spaces. Microscopically, the tumors were genesis, Immunohistochemistry, Littoral cell angi- heterogenous; however, all cases demonstrated at oma, Lymphangioma, Lymphangiosarcoma. least a focal vasoformative component lined by Mod Pathol 2000;13(9):978–987 atypical endothelial cells. Solid sarcomatous, papil- lary, and epithelioid growth patterns were observed. Primary malignant vascular neoplasms of the The solid sarcomatous component resembled fibro- spleen are rare and carry a dismal prognosis regard- sarcoma in two cases and malignant fibrous- less of the treatment regimen (1–5). Although all histiocytoma in one case. Hemorrhage, necrosis, cases demonstrate at least a focal vasoformative hemosiderin, extramedullary hematopoiesis, and component, malignant splenic vascular tumors intracytoplasmic hyaline globules were frequently may be mistaken for benign vascular or malignant identified. A panel of immunohistochemical studies non-vascular tumors because of their frequently revealed that the majority of tumors were immuno- highly variable histology. The pathologic features reactive for at least two markers of vascular differ- and a comprehensive immunohistochemical pro- file have not been well addressed in the literature to date. Copyright © 2000 by The United States and Canadian Academy of We describe the clinical, pathologic, and immu- Pathology, Inc. VOL. 13, NO. 9, P. 978, 2000 Printed in the U.S.A. nophenotypic features of 28 splenic angiosarcomas Date of acceptance: March 23, 2000. and analyze this data as it relates to disease course The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of and patient outcome. We also compare the immu- the Department of the Air Force, the Department of the Navy, or the Department of Defense. nohistochemical features of these tumors to three Address reprint requests to: Thomas S. Neuhauser, MD, Wilford Hall benign primary splenic tumor subtypes: lym- Medical Center, Department of Pathology, 2200 Bergquist Drive, Suite #1, Lackland AFB, TX 78236; e-mail: [email protected]; phangioma, hemangioma, and littoral cell angi- fax: 210-292-7484. oma. 978 MATERIALS AND METHODS Department of Defense Directive 3216.2 relating to human subjects in research. Fifty-three cases of angiosarcoma involving the Hematoxylin and eosin (H&E) and periodic acid- spleen were selected from a review of 376 splenec- Schiff stained slides for all cases were reviewed to tomy specimens retrieved from the archives of the confirm that established light microscopic his- Hematopathology Tumor Registry at the Armed topathologic criteria for angiosarcoma were ful- Forces Institute of Pathology (AFIP), Washington, filled (3). Criteria include the presence of a vasofor- DC, between 1970 and 1998. Twenty-five of the 53 mative component and cytologic features of cases of angiosarcoma were excluded from further malignancy, including cellular atypia and mitotic study because they did not fulfill our inclusion cri- activity. Five of our cases were previously reported teria: primary origin in the spleen, sufficient mate- (3). A number of histomorphologic characteristics rial for immunohistochemical analysis, and ade- quate clinical information. The remaining 28 cases were tabulated for each case, including histologic represented approximately 7.4% of all benign or growth pattern(s), presence or absence of necrosis, malignant primary splenic tumors (376) seen in hemorrhage, hemosiderin, hyaline globules, he- consultation during this time. Primary origin in the mophagocytosis, calcification, thrombosis, ex- spleen was defined as no metastasis at the time of tramedullary hematopoiesis, and fibrosis. Nuclear presentation as determined by sophisticated radio- atypia was separated into three grades (mild, mod- logic procedures and/or surgical staging (18/28 cas- erate, and severe) with benign endothelial cells as a es), or overwhelming tumor burden in the spleen in reference. Mild atypia referred to nuclei with min- cases with concomitant metastasis (10/28 cases). imal pleomorphism and hyperchromasia, severe The spleen was virtually replaced by the malig- atypia referred to nuclei showing frank anaplasia nancy in the majority of the latter cases. Twenty- with large irregular nuclei with hyperchromasia, three cases were obtained from civilian sources and and moderate atypia referred to those nuclei that five cases from military hospitals and Veterans Ad- fell between the two extremes. Mitotic figures were ϫ ministration Medical Centers. counted on an Olympus BH-2 microscope at 40 . Materials within the files of the AFIP were sup- The areas with the highest number of mitoses were plemented by a review of the patient demographics, chosen for counting. signs and symptoms at presentation, duration of Immunophenotypic studies were performed on a symptoms before presentation, medical history, ra- single block by the standardized avidin-biotin diographic studies performed, laboratory test re- method of Hsu et al. (6) using 4-␮m thick sections sults, surgical pathology and operative reports, can- on all formalin-fixed, paraffin-embedded cases of cer registry records, and by written questionnaires splenic angiosarcoma, 10 cases of littoral cell angi- or oral communication with the treating physi- oma, and nine cases each of splenic hemangioma cian(s). Follow-up data included information re- and splenic lymphangioma. Table 1 indexes the garding environmental exposures, occupational immunohistochemical antibody panel chosen. history, the specific type(s) and length of treatment When required, proteolytic antigen retrieval was methods used, and the current status of the disease performed with predigestion for 3 min with 0.05% and patient. This clinical investigation was con- Protease VIII (Sigma Chemical Co., St. Louis, MO) ducted in accordance and compliance with all stat- in a 0.1-M phosphate buffer at a pH of 7.8 at 37° C utes, directives, and guidelines of the Code of Fed- (7). Antigen enhancement (recovery) was per- eral Regulations, Title 45, Part 46, and the formed, as required, using formalin-fixed, paraffin- TABLE 1. Immunohistochemical Panel Primary Antigen Antibody (Clone) Company Dilution Antibody Recovery CD31 (JC/70) mm DAKO, Carpinteria, CA 1:100 Microwave CD34 (Q BEND) mm AMAC, Westbrook, ME 1:100 N/A Factor VIIIRAg rp DAKO 1:50 N/A VEGFR3 (9D9) mm Dr. Kari Alitalo, Helskinki, Finland {88} 1:1000 Microwave CD68 (KP1) mm DAKO 1:500 Enzyme Lysozyme rp DAKO 1:1000 Enzyme Ki-67 mm Coulter Immunotech, Westbrook, ME 1:40 Microwave EMA (E29) mm DAKO 1:100 N/A Cytokeratin (AE1/AE3, CK1) mm Boehringer, Indianapolis, IN 1:400 N/A S-100 R rp Sigma Diagnostics, St. Louis, MO 1:2000 N/A CD21 (1F8) mm DAKO 1:50 Enzyme CD8 (C8/144B) mm DAKO 1:100 Microwave N/A, not applicable; mm, mouse monoclonal; rp, rabbit polyclonal; VEGFR3, vascular endothelial growth factor receptor 3; EMA, epithelial membrane antigen; Enzyme, enzymatic protein digestion; Microwave, microwave epitope retrieval. Splenic Angiosarcoma (T.S. Neuhauser, et al.) 979 embedded tissue treated with a buffered citric acid (n ϭ 13). Four patients had leukocytosis and four solution and heated for 20 min in a calibrated mi- patients had thrombocytopenia. Additional labo- crowave oven (8). Following this,
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