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Primary Polymorphous Hemangioendothelioma of the Maxillary Soft Tissue: Clinical and Immunopathological Aspects of a Rare Vascular Neoplasm
ROSARIO RULLO, FRANCESCO ADDABBO, FRANCESCO RULLO and VINCENZO MARIA FESTA
Department of Stomatology, Second University of Naples, Naples, Italy
Abstract. Polymorphous hemangioendothelioma (PH) is an been reported, lesions involving maxillary soft tissue have uncommon vascular neoplasm of borderline malignant not been described in the literature, to date. PH is potential characterized by a considerable variability in characterized by a considerable variability in patterns of patterns of cellular growth. Morphologically, PH may be cellular growth with the presence of vascular channels and confused with other lesions, from benign vasoformative endothelial cells, which make this neoplasm difficult to neoplasms and reactive inflammatory conditions to define histologically (5-7). A correct differential diagnosis malignancies such as angiosarcoma or squamous cell should include the broad spectrum of vascular carcinoma. Most occur in the lymph nodes, and to the best of malformations, Kaposi’s sarcoma, angiosarcoma, our knowledge, lesions involving the maxillary soft tissue hemangiopericytoma, and melanoma (6, 8). The frequent have not been described in the literature to date. A potential presence of a solid cellular architecture may cause diagnostic for local recurrence, as well as the ability to metastasize, has confusion with squamous cell carcinoma and the use of been for this type of neoplasm. Here we reported on a rare immunohistochemical analysis is often necessary to separate case of polymorphous hemangioendothelioma which PH from these lesions (6, 7). Although the potential for local presented as an asymptomatic subcutaneous mass in the recurrence, as well as the ability to metastasize, have been right zygomatic region of a 22-year-old white female. We reported (1, 2, 4), predictions regarding the biological discuss the histopathological aspects of this tumor, with behavior of PH in the oral region are not entirely possible emphasis on the role of immunohistochemical analysis in due to lack of described cases. differential diagnosis. The management of hemangioendotheliomas usually includes wide local surgical excision, investigation of Polymorphous hemangioendothelioma (PH) is a rare metastatic lesions, and close clinical follow-up due to risk of neoplasm, first described in 1992 as a borderline malignant recurrence (9). We report on a case of PH in the zygomatic- vascular tumor of endothelial cell origin. The term maxillary region of a 22-year-old woman, focusing our hemangioendothelioma was introduced to describe an attention on clinico/pathological and immunohistochemical uncommon vascular neoplasm of intermediate malignant features of the most common lesions encountered during potential, between hemangioma and angiosarcoma (1). PH differential diagnosis. represents a variety of the heterogeneous group of hemangioendotheliomas, which predominantly involve Case Report lymph nodes or extranodal locations such as the paravertebral region (2), mediastinum (3), and A 22-year-old woman with no previous medical problems retroperitoneum (4). Although unusual clinical presentation was referred to our Department for evaluation of an in the sub-mandibular (5) and neck regions (6) have also asymptomatic subcutaneous mass in the right zygomatic region, soft-elastic in consistency, and covered by normal- appearing skin. The lesion had progressively enlarged over the previous 10 months, developing a swelling in the buccal Correspondence to: Francesco Addabbo, Via Luigi De Crecchio n.6, vestibule, without anatomic connections with the oral cavity 80138 Napoli, Italy. Tel: +39 0815665508, Fax: +39 0815665508, e-mail: [email protected] and the cutaneous plane. There were no palpable locoregional lymph nodes. The provisional differential Key Words: Polymorphous hemangioendothelioma, vascular tumor, diagnosis focused on a probable mesenchymal tumor. maxillary, differential diagnosis. Computed tomographic scans showed a thickening of the
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Figure 1. Magnetic resonance imaging studies confirmed the presence of an ovular mass, hyperintense on T2-weighted sequences, situated laterally to the anterior margin of the masseter muscle, without any evidence of an infiltrative character.
right zygomatic-maxillary region in relation to the presence nature of the neoplasm, and the diagnosis of PH (Figure 4). of an isodense subcutaneous mass of about 2.5×1.5 cm, Nuclei of tumour cells did not stain significantly for Ki-67 adjacent to the zygomatic process of the maxilla and well- under immunohistochemistry; moreover, atypical mitotic dissociable from it. The radiographic appearance of the area figures, tumor necrosis, and significant nuclear pleomorphism did not demonstrate signs of bone resorption. Furthermore, were absent. At 1-year follow-up, no evidence of recurrence a preoperative magnetic resonance imaging confirmed the was noted, only a cutaneous scar persisted in the zygomatic presence of an ovular mass, hyperintense on T2-weighted region. sequences, situated laterally to the anterior margin of the masseter muscle (Figure 1). The margins were well- Discussion demarcated without any evidence of infiltrative character. Under local anesthesia, an excisional biopsy was performed Among the wide spectrum of vascular neoplasms, ranging with surgical access through the skin, and the specimen was from benign hemangioma to metastasizing angiosarcoma, PH submitted to microscopic examinations. represents a rare tumor of borderline malignant potential, Grossly, the mass measured 3.5×2.0 cm (Figure 2). characterized by a complex variety of growth patterns (1). PH Microscopic examination showed a polymorphous population is currently categorized as borderline neoplasm of vascular of polygonal to spindle-shaped cells with low mitotic activity origin exhibiting histological features and clinical behavior (Figure 3). This pattern was characterized by the presence of intermediate between hemangioma and angiosarcoma (1, 8). angiomatous areas with variably sized vascular channels lined The adjective “polymorphous” has been used to denote the by endothelial cells. Immunohistochemical staining revealed typical architectural variability of solid, primitive vascular, and CD34 positivity of the lesional cells, confirming the vascular angiomatous endothelial areas, which make this neoplasm
250 Rullo et al: Primary Polymorphous Hemangioendothelioma of the Head and Neck
Figure 2. Gross appearance of the lesion: a well-circumscribed hemorrhagic nodule of about 3.5×2.0 cm.
difficult to recognize histologically (5, 6). Usually, PH patterns of growth of a polymorphous population of predominantly involves lymph nodes, and only few cases of polygonal to spindle-shaped cells. This complex cellular primary occurrence in extranodal soft tissues have been mixture is completed by the presence of vascular channels described in literature (2, 5). Polymorphous hemangio- lined by endothelial cells as well as ectatic vessels (5-7). endothelioma showed tendency to recur locally, as well as to Because of the presence of a conspicuous polymorphous metastasize; however, it seems reasonable that the neoplasm solid component, the vascular nature of PH can be difficult should be able to present distant metastasis only after to recognize microscopically without immunohistochemical malignant transformation (2, 3, 4, 7). Nowadays, because of analysis, and a complete differential diagnosis should include the small number of cases reported the etiology is still lesions such as squamous cell carcinoma, angiosarcoma, unknown, and no consistent clinical or histological criteria for melanoma, Kaposi’s sarcoma, and hemangiopericytoma (6- predicting the biological behavior of this vascular tumor in the 8). In the maxillofacial region, hemangioendotheliomas can maxillofacial region have yet been identified. Nevertheless, clinically mimic benign vasoformative neoplasms, and some features considered suggestive of a more aggressive reactive inflammatory conditions, including pyogenic phenotype with recurrence and regional or distant metastasis, granuloma, peripheral giant cell granuloma, fibroma, include the presence of an increased number of mitotic figures, peripheral ossifying fibroma, and inflammatory fibrous cellular atypia, and areas of focal necrosis (10). hyperplasia (11, 12). Misdiagnosis of PH as a pure benign The case reported here illustrates a low-grade vascular lesion acquires relevance when the neoplasm shows neoplasm with no relevant cellular atypia or mitotic activity, intermediate or malignant biological behavior (2, 8). In such which suggest a generally good prognosis. Microscopically, cases, histomorphological analysis and immunohistochemical PH is typically characterized by a remarkable variety in stains are very useful to resolve any doubt and to guide the
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Figure 3. High-power field showing angiomatous areas composed of ovoid, polygonal, and spindle cells, with low mitotic activity (hematoxylin and eosin, ×400).
Figure 4. Immunohistochemical staining showing the neoplastic endothelial cells reactive for CD34, confirming the vascular nature of the tumor (original magnification, ×200).
252 Rullo et al: Primary Polymorphous Hemangioendothelioma of the Head and Neck clinician in the differential diagnosis. Moreover, the presence 2 Nascimento AG, Keeney GL, Sciot R and Fletcher CD: of polygonal cells arranged in a cord-like pattern may lead Polymorphous hemangioendothelioma: a report of two cases, to misinterpretation of a metastatic carcinoma; therefore, to one affecting extranodal soft tissues, and review of the literature. Am J Surg Pathol 21: 1083-1089, 1997. rule-out this malignancy, immunohistochemical assessment 3 Rehring TF, Deutchman A and Cross JS: Polymorphous for cytokeratins and epithelial markers such as epithelial hemangioendothelioma. Ann Thorac Surg 68: 1396-1397, 1999. membrane antigen, usually lacking in PH, would be 4 Moreno-Ramírez D, González-Cámpora R, Escudero AG, Martín beneficial (1, 10). Furthermore, stains for endothelial JJ and Obrador DM: Recurrent polymorphous haemangioendo- markers, such as lectin from Ulex europaeus, factor VIII- thelioma. Histopathology 45: 196-197, 2004. related antigen, CD34, and CD31 are negative in squamous 5 Falleti J, Siano M, De Cecio R, Somma A, Pettinato G and cell carcinoma. The presence of fibrosarcoma-like spindle Insabato L: Nodal and extranodal soft tissue polymorphous hemangioendothelioma: a case report and review of the cells along with positivity for Human Herpesvirus 8, may literature. Tumori 95: 94-97, 2009. help differentiate Kaposi’s sarcoma from PH. 6 Tadros M, Rizk SS, Opher E and Thompson LD: Polymorphous Hemangiopericytoma can imitate hemangioendothelioma in hemangioendothelioma of the neck. Ann Diagn Pathol 7: 165- routine hematoxylin and eosin staining with its tightly 168, 2003. packed round-to-fusiform cells arranged around an elaborate 7 Roncaroli F, Scheithauer BW and Papazoglou S: Primary vasculature, but silver reticulin stain can differentiate these polymorphous hemangioendothelioma of the spinal cord. Case two lesions, showing characteristic tumor cells of pericyte report. J Neurosurg 95: 93-95, 2001. 8 Weiss SW and Goldblum JR: Hemangioendothelioma: Vascular origin outside the reticulin network that encloses the vessels tumors of intermediate malignancy. In: Enzinger and Weiss’s (10, 13, 14). The distinction from angiosarcoma or other Soft Tissue Tumors, Forth Edition: Weiss SW and Goldblum JR neoplasms such as melanoma, metastatic carcinoma and (eds.). St Louis, MO, Harcourt, pp. 891-915, 2001. adenocarcinoma remains a crucial issue. In this perspect, the 9 Anderson PJ, Ross G, Felix D and Camilleri IG: The use of microscopic lack of cytological atypia, necrosis, and mitotic sentinel node biopsy in the management of epitheloid activity, are useful to separate PH from other malignancies haemangioendothelioma of the lip. Oral Oncol 39: 531-533, (10). Finally, CD34 immunoreactivity can easily be used to 2003. 10 Gnepp DR: Diagnostic Surgical Pathology of the Head and identify the primitive vascular nature of PH, and the Neck. WB Saunders, Philadelphia: pp. 821-826, 2001. histological demonstration of a non-infiltrative growth of a 11 Enzinger FM and Weiss SW: Soft Tissue Tumors. Mosby, St polymorphous population of polygonal to spindle-shaped Louis: pp. 533, 1988. cells confirms its diagnosis. 12 Marrogi AJ, Boyd D, el-Mofty S and Waldron C: Epithelioid The particular histopathological and immunohistochemical hemangioendothelioma of the oral cavity: Report of two cases features of PH require for careful evaluation to recognize and and review of literature. J Oral Maxillofac Surg 49: 633-638, treat this entity properly. Our rare case of PH with good 1991. 13 Wesley RK, Mintz SM and Wertheimer FW: Primary malignant prognosis was treated only by local excision. Nevertheless, hemangioendothelioma of the gingival. Report of a case and considering the spectrum of lesions included in the review of the literature. Oral Surg Oral Med Oral Pathol 39: 103- differential diagnosis, the clinician must take into account 112, 1975. that mis-diagnosis as a malignancy can cause significant 14 Uehara M, Shibahara K, Fujita S, Tobita T, Ohba S, Fujisawa A, treatment errors. Because the number of reported cases of Nonaka M and Inokuchi T: Epithelioid hemangioendothelioma PH is very small in literature, the ideal treatment for these of tongue: A case report with immunohistochemical studies. Oral tumors, and a definitive prognosis, are still not established. Oncology Extra 42: 101-104, 2006. Further studies are necessary to clarify the possible malignant biological behavior of the neoplasm and to define the most appropriate clinical management.
References
1 Chan JK, Frizzera G, Fletcher CD and Rosai J: Primary vascular tumors of lymph nodes other than Kaposi’s sarcoma. Analysis Received November 16, 2013 of 39 cases and delineation of two new entities. Am J Surg Revised February 13, 2014 Pathol 16: 335-350, 1992. Accepted February 14, 2014
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