J Cutan Pathol 2014: 41: 823–830 doi: 10.1111/cup.12385 John Wiley & Sons. Printed in Singapore

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Journal of Cutaneous Pathology

Verrucous hemangioma: a clinicopathological and immunohistochemical analysis of 74 cases Background: Verrucous hemangioma is a rare form of vascular malformation. Previous studies have reported positive expression of Wilms tumor 1 (WT-1) and Glut-1 and negative expression of lymphatic markers such as D2-40 and Prox1 in verrucous hemangioma cases. However, the sample sizes of these studies were usually small. Methods: We analyzed 74 cases of verrucous hemangioma diagnosed in a single dermatology department and performed immunohistochemical analysis of vascular and lymphatic markers in all cases. Results: Verrucous hemangioma was usually located on the extremities. Most lesions presented as solitary or multiple hyperkeratotic plaques or nodules with various diameters. Histopathologically, the lesions showed proliferation of small- to medium-sized vessels from the papillary dermis to subcutaneous tissue. The density of the proliferated vessels varied between cases. The vessels were positive for CD31 in 74 cases, focally positive for Prox1 in 63 cases, focally positive for D2-40 in 10 cases, negative for lymphatic vessel endothelial hyaluronan receptor-1 in 74 cases, negative for WT-1 in 60 cases, and positive for Glut-1 in 49 cases. Conclusion: Verrucous hemangioma is a vascular malformation with an incomplete lymphatic immunophenotype, as indicated by positive staining for Prox1 and negative staining for WT-1 in the majority of instances. Keywords: D2-40, Prox1, verrucous hemangioma, Wilms tumor 1 Wang L, Gao T, Wang G. Verrucous hemangioma: a clinicopathological and immunohistochemical analysis of 74 cases. J Cutan Pathol 2014; 41: 823–830. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Verrucous hemangioma is a rare vascular proliferation that usually presents at birth or in early childhood. In 1967, Imperial and Helwig1 reported 21 cases of verrucous hemangioma and distinguished it from other variants of

Lei Wang, Tianwen Gao and Gang Wang Department of Dermatology, Xijing Hospital, Fourth Military Medical University, Xian, China

Prof. Gang Wang, and Prof. Tianwen Gao, Department of Dermatology, Xijing Hospital, Fourth Military Medical University, No. 15 of Changlexi Road, Xian 710032, China Tel: +86 2984775401 Fax: +86 2984775401 e-mail: [email protected]; [email protected] Accepted for publication September 1, 2014

angiokeratomas. Thereafter, several small case series were reported and showed results similar to those of the original report.2 – 4 Verrucous hemangioma is usually located on the extremities. It presents as solitary or multiple

823

Wang et al. hyperkeratotic nodules and sometimes shows linear distribution of the lesions.5 – 7 Histopathologically, it is characterized by the proliferation of small vessels in the dermis and subcutaneous tissue, and the superficial epidermis usually shows a papillary appearance with ectatic vessels mimicking angiokeratomas.1 – 4 It is widely accepted that verrucous hemangioma is a vascular malformation and thus is misnamed.1 – 3 However, this viewpoint was challenged by a recent study by Trindade et al.4 which showed that verrucous hemangioma is positive for Wilms tumor 1 (WT-1) and suggested that it is a vascular neoplasm. However, this result is not consistent with the clinical characteristics of verrucous hemangioma, which is recognized as a vascular malformation by most authors. Expression of lymphatic markers in verrucous hemangioma has not been widely investigated. A small number of cases tested negative for D2-40 and Prox1.4,8,9 In this study, we presented our clinicopathologic and immunohistochemical analyses of 74 cases of verrucous hemangioma. Materials and methods This study included 74 patients who presented with verrucous hemangioma at a dermatology department of a tertiary hospital between 2003 and 2013. In all cases, clinical photographs were obtained before excisional biopsy was performed. The diagnosis was confirmed by the three authors based on the clinical and histopathologic characteristics. Immunohistochemical analysis was performed in all cases. Sections were stained for CD31 (Clone JC70A, 1 : 100, Dako, Glostrup, Denmark), D2-40 (Clone D2-40, 1 : 100, Dako), Prox1 (polyclone, 1 : 200, AngioBio, Del Mar, CA, USA), lymphatic vessel endothelial hyaluronan receptor-1 (LYVE-1) (polyclone, 1 : 100, Abcam, Cambridge, MA, USA), smooth muscle actin (SMA) (1A4, 1 : 200, Dako), WT-1 (Clone 6F-H2, 1 : 200, Dako) and Glut-1 (polyclone, 1 : 500, Thermo Scientific, Waltham, MA, USA). The Dako EnVision detection system was used. Antigen retrieval was performed by heating slides with tris-ethylenediaminetetraacetic acid buffer (pH 9) in a pressure cooker (140 KPa for 2 min). Results Clinical findings The subjects included 40 male and 34 female patients aged between 2 months and 59 years.

824

Seventy-two lesions were congenital, and two lesions were developed during the first 2 years. Fifty-three lesions were located on the lower extremities and buttocks (Fig. 1A), 18 lesions were located on the upper extremities (Fig. 1B), 1 lesion was located on both the upper and the lower extremities, and 2 lesions were separately located on the abdomen (Fig. 1C) and axillary region. Forty-one patients had solitary lesions that showed varying degrees of hyperkeratosis, and the diameters of these lesions ranged from 5 mm to 25 cm. Thirty-three patients had multiple lesions, including 20 cases of lesions with a linear arrangement (Fig. 1A) and 13 cases without a linear arrangement. One patient showed two separate papules on neighboring digits (Fig. 1D). Forty-four patients were asymptomatic, 22 patients reported pain, tension or itching, and 16 patients reported erosion or ulceration. Ten cases had been previously treated with laser therapy, seven cases had been treated with radiotherapy, five cases had been treated with surgery, and five cases had been treated with cryotherapy, topical corticosteroids or other unknown methods. All of these treatments were ineffective or showed only partial success. Microscopic findings All lesions showed proliferation of small- to medium-sized vessels in the dermis and subcutaneous tissue (Fig. 2A). In most cases, hyperkeratosis, papillomatosis or irregular acanthosis of the epidermis was prominent (Fig. 2B). However, in three cases, hyperkeratosis and acanthosis of the epidermis were very subtle (Fig. 2C). The proliferated vessels in the superficial dermis usually consisted of bizarre-shaped small vessels composed of a single layer of endothelial cells (Fig. 2D). The proliferated vessels in the dermis and subcutaneous tissue were either dense (Fig. 2E) or sparse (Fig. 2F). In five cases, deep vascular proliferation was more extensive than the changes in the papillary dermis, and clinically, these lesions usually presented as small papules with a deeply located soft tissue mass (Fig. 3). In four cases, prominent proliferation of eccrine glands around the abnormal vessels was observed, which was very similar to the histopathology of eccrine angiomatous hamartoma (Fig. 4A). In one case, reactive sebaceous differentiation in the epidermis was noted (Fig. 4B). Proliferation of nerve fascicles was observed in one case, and focal calcinosis was noted in one case. Fibrosis or focal regression of

Verrucous hemangioma

Fig. 1. A) Linear arrangement of hyperkeratotic plaques on the thigh. B) Two separate red hyperkeratotic nodules on the wrist area. C) A large hyperkeratotic plaque with an irregular border on the abdomen. D) Two closely located nodules on opposite sides of neighboring digits.

hemangioma because of various therapies was noted in seven cases.

49 cases (Fig. 5G) and were negative for Glut-1 in the other 25 cases (Fig. 5H).

Immunohistochemistry In all cases, the endothelial cells of the abnormal vessels were positive for CD31, and pericytes around the endothelial cells were positive for SMA. The vessels were focally nuclear positive for Prox1 in 63 cases (Fig. 5A) and were completely negative for Prox1 in the other 11 cases (Fig. 5B). The vessels were focally positive for D2-40 in 10 cases (Fig. 5C) and were negative for D2-40 in the other 64 cases (Fig. 5D). All cases were negative for LYVE-1. The proliferated vessels were focally or weakly positive for WT-1 in 14 cases (Fig. 5E) and were negative for WT-1 in the other 60 cases (Fig. 5F). The vessels were positive for Glut-1 in

Discussion In this study, we present the clinical and pathologic characteristics of a large case series of patients with verrucous hemangioma. In contrast to the findings reported by previous studies,4,8,9 our results indicate that most cases of verrucous hemangioma were focally positive for Prox1 and negative for WT-1, which suggests that it is a vascular malformation with incomplete lymphatic phenotypes. The diagnosis of verrucous hemangioma is not difficult in typical cases. However, in a small number of cases, hyperkeratosis and proliferation of epidermal and superficial vessels were not

825

Wang et al.

Fig. 2. A) Scanning magnification of a typical lesion showing hyperkeratosis and proliferation of vessels in the dermis and subcutaneous tissue. B) A lesion with a prominent papillary appearance with ectatic vessels. C) A lesion with slight hyperkeratosis and ectatic vessels in the superficial dermis. D) A lesion with bizarre-shaped vessels in the superficial dermis. E) A lesion with prominent proliferation of vessels in the subcutaneous tissue. F) A lesion with scarce proliferation of vessels in the subcutaneous tissue.

prominent. Therefore, clinicopathologic correlation is needed, especially in superficially biopsied lesions. This is also essential in cases with fibrosis or focal regression after therapy. We found that some cases presented as very small red lesions, which showed more prominent vascular proliferation in the deep dermis than in the superficial dermis. Such cases may be misdiagnosed as cavernous hemangioma if the sections are not cut through the center and clinical photographs are lacking. This phenomenon has also been previously described by Yang and Ohara.2 We found prominent eccrine gland proliferation in four cases. In these lesions, the proliferated eccrine glands usually appeared similar to their normal counterparts and were

826

usually surrounded by abnormal vessels. The same condition has been reported as verrucous hemangioma with features of eccrine angiomatous hamartoma previously.10 – 14 The expanded eccrine glands in verrucous hemangioma and eccrine angiomatous hamartoma represent reactive hyperplasia induced by excessive blood supply from the abnormal vessels surrounding them, as has been proposed by Kazakov et al.15 In our study, sebaceous proliferation was also noted in one case, which also probably represents a reactive proliferation. We investigated the expression of lymphatic markers in verrucous hemangioma cases, and the results differed from those of the previous studies.4,8,9 The results showed that the majority

Verrucous hemangioma

Fig. 3. A) A very small red papule on the lower leg. B and C) Histopathologic analysis showed a slight proliferation of vessels in the focal area of the papillary dermis and prominent proliferation of vessels in the subcutaneous tissue.

Fig. 4. A) Prominent eccrine gland proliferation intermixed with abnormal vessels. B) Prominent sebaceous hyperplasia associated with vascular ectasia.

of cases stained focally positive for Prox1, and a small number of cases stained focally positive for D2-40. Prox1 is a transcription factor that is recognized as a key regulator of lymphatic endothelial differentiation.16 – 18 It is reported to be specifically expressed in normal lymphatic endothelial cells and lymphatic vascular proliferation.19 – 21 Recently, Miettinen and Wang21 reported that some capillary hemangiomas and cavernous hemangiomas stained positive for Prox1. However, detailed clinical and histopathological features of these cases are lacking. In recent years, Prox1 has been reported to be expressed in benign vascular lesions including tufted angioma,21 kaposiform hemangioendothelioma,22 and spindle cell hmangioma,23 and these reports suggest that such lesions have a lymphatic origin. In tufted angioma, kaposiform hemangioendothelioma and spindle cell hemangioma, Prox1 was reported to show a focally positive nuclear staining pattern, which is the same as that observed in verrucous hemangioma. Recently, we reported the expression of Prox1 and lymphatic markers in angiokeratomas,24 which are histopathologically similar to verrucous hemangioma. We found that 10 cases showed very focal positive staining for D2-40, which suggests lymphatic differentiation in these cases. Similarly, 1 of 13 cases in a study by Trindade et al.4 was focally positive for D2-40. In our study, all cases were negative for LYVE-1, another lymphatic marker. LYVE-1 is a specific

827

Wang et al.

Fig. 5. A) The vessels in the papillary dermis were positive for Prox1. B) A lesion showed negative staining for Prox1. C) The vessels were focally positive for D2-40. D) The vessels were negative for D2-40. E) The vessels were weakly positive for WT-1. F) The vessels were negative for WT-1. G) The vessels were weakly positive for Glut-1. H) The vessels were negative for Glut-1.

marker of lymphatic differentiation.25 However, it is not a sensitive marker of lymphatic differentiation, as only 6% of the lymphangiomas were positive for LYVE-1.26 Traditionally, vascular proliferations are classified into vascular and lymphatic types, according to the positive

828

or negative expression of lymphatic markers. On the basis of this results, we presume that verrucous hemangioma represents an intermediate state that is characterized by overlapping immunophenotypes of blood and lymphatic vessels.

Verrucous hemangioma WT-1 has been recognized as an ideal marker for differentiating between vascular neoplasms and vascular malformations.27,28 Recently, Trindade et al.4 and Laing et al.9 showed positive staining for WT-1 in verrucous hemangioma cases, and the results support the neoplastic nature of verrucous hemangioma. However, this result is not consistent with the clinical characteristics of verrucous hemangioma. In a study by Al Dhaybi et al.28 30 angiokeratoma and verrucous hemangioma lesions were stained for WT-1, of which 29 were negative and only one verrucous hemangioma lesion was positive for WT-1. However, it was not defined how many cases of verrucous hemangioma were included in their study. In our study, most of the cases showed negative staining for WT-1, and the results suggest that verrucous hemangioma is a vascular malformation. In cases with positive staining for WT-1, the staining was weak and focal, which was different from that in true hemangioma. Recently, Fernandez-Flores et al29 suggested that WT-1 positive cells in verrucous hemangiomas may represent pericytes. However, this theory cannot explain why only a small number of cases were positive for WT-1, as pericytes were present consistently in verrucous hemangioma. We suggest

that the WT-1 positive cells represent endothelial cells (Fig. 5E) because some of the positive cells had an epithelioid and hobnail appearance, which is a common morphology of endothelial cells of vascular and lymphatic origins. Glut-1 is expressed in infantile hemangiomas and is recognized as a marker for differentiating between vascular malformations and hemangiomas.30,31 Previous studies reported positive expression of Glut-1 in verrucous hemangioma cases.3,4 Similarly, in our study, approximately two-thirds of the verrucous hemangioma cases stained positive for Glut-1; however, the staining intensity of Glut-1 is usually weaker in verrucous hemangioma cases than in infantile hemangioma cases. It is not clear why Glut-1 is expressed in verrucous hemangioma. Glut-1 has been shown to be negative in vascular and lymphatic malformations.30,31 In conclusion, we present herein the clinical and microscopic characteristics of a large case series of patients with verrucous hemangioma. The majority of the cases showed positive staining for Prox1 and negative staining for WT-1, and these results suggest that verrucous hemangioma represents a vascular malformation with incomplete lymphatic phenotypes.

References 1. Imperial R, Helwig EB. Verrucous hemangioma. A clinicopathologic study of 21 cases. Arch Dermatol 1967; 96: 247. 2. Yang CH, Ohara K. Successful surgical treatment of verrucous hemangioma: a combined approach. Dermatol Surg 2002; 28: 913. 3. Tennant LB, Mulliken JB, Perez-Atayde AR, Kozakewich HP. Verrucous hemangioma revisited. Pediatr Dermatol 2006; 23: 208. 4. Trindade F, Torrelo A, Requena L, et al. An immunohistochemical study of verrucous hemangiomas. J Cutan Pathol 2013; 40: 472. 5. Wentscher U, Happle R. Linear verrucous hemangioma. J Am Acad Dermatol 2000; 42: 516. 6. Hayashi H, Shimizu T, Nakamura H, Shimizu H. Linear verrucous haemangioma on the abdomen. Acta Derm Venereol 2004; 84: 79. 7. Wang G, Li C, Gao T. Verrucous hemangioma. Int J Dermatol 2004; 43: 745. 8. Clairwood MQ, Bruckner AL, Dadras SS. Verrucous hemangioma: a report of two cases and review of the literature. J Cutan Pathol 2011; 38: 740. 9. Laing EL, Brasch HD, Steel R, et al. Verrucous hemangioma expresses primitive markers. J Cutan Pathol 2013; 40: 391.

10. Tsuji T, Sawada H. Eccrine angiomatous hamartoma with verrucous features. Br J Dermatol 1999; 141: 167. 11. Galan A, McNiff JM. Eccrine angiomatous hamartoma with features resembling verrucous hemangioma. J Cutan Pathol 2007; 34(S1): 68. 12. Cheong SH, Lim JY, Kim SY, Choi YW, Choi HY, Myung KB. A case of eccrine angiomatous hamartoma associated with verrucous hemangioma. Ann Dermatol 2009; 21: 304. 13. Holcomb M, Sun G, Eldin K, Brandon K. Verrucous hyperpigmented plaque in a 15-month-old boy. Eccrine angiomatous hamartoma (EAH) associated with verrucous hemangioma (verrucous hemangioma). Int J Dermatol 2013; 52: 25. 14. Fathaddin AA, Alhumidi AA. Eccrine angiomatous hamartoma, with verrocous hemangioma-like features: a case report. Int J Health Sci (Qassim) 2013; 7: 103. 15. Kazakov DV, Michal M, Kacerovska D, McKee P. Cutaneous adnexal tumors. Philadelphia: Lippincott Williams & Wilkins Health, 2012; 158. 16. Wigle JT, Harvey N, Detmar M, et al. An essential role for Prox1 in the induction of the lymphatic endothelial cell phenotype. EMBO J 2002; 7: 1505. 17. Hirakawa S, Hong YK, Harvey N, et al. Identification of vascular lineage-specific

18.

19.

20.

21.

22.

genes by transcriptional profiling of isolated blood vascular and lymphatic endothelial cells. Am J Pathol 2003; 162: 575. Hong YK, Detmar M. Prox1, master regulator of the lymphatic vasculature phenotype. Cell Tissue Res 2003; 314: 85. Wilting J, Papoutsi M, Christ B, et al. The transcription factor Prox1 is a marker for lymphatic endothelial cells in normal and diseased human tissues. FASEB J 2002; 16: 1271. Castro EC, Galambos C. Prox-1 and VEGFR3 antibodies are superior to D2-40 in identifying endothelial cells of lymphatic malformations – a proposal of a new immunohistochemical panel to differentiate lymphatic from other vascular malformations. Pediatr Dev Pathol 2009; 12: 187. Miettinen M, Wang ZF. Prox1 transcription factor as a marker for vascular tumors-evaluation of 314 vascular endothelial and 1086 nonvascular tumors. Am J Surg Pathol 2012; 36: 351. Le Huu AR, Jokinen CH, Rubin BP, et al. Expression of prox1, lymphatic endothelial nuclear transcription factor, in Kaposiform hemangioendothelioma and tufted angioma. Am J Surg Pathol 2010; 34: 1563.

829

Wang et al. 23. Wang L, Gao T, Wang G. Expression of Prox1, D2-40, and WT1 in spindle cell hemangioma. J Cutan Pathol 2014; 41: 447. 24. Wang L, Yuan W, Geng S, et al. Expression of lymphatic markers in angiokeratomas. J Cutan Pathol 2014. DOI: 10.1111/cup.12349. 25. Akishima Y, Ito K, Zhang L, et al. Immunohistochemical detection of human small lymphatic vessels under normal and pathological conditions using the LYVE-1 antibody. Virchows Arch 2004; 444: 153. 26. Bhawan J, Silva C, Taungjaruwinai WM. Inconsistent immunohistochemical

830

expression of lymphatic and blood endothelial cell markers in cutaneous lymphangiomas. J Cutan Pathol 2013; 40: 801. 27. Trindade F, Tellechea O, Torrelo A, Requena L, Colmenero I. Wilms tumor 1 expression in vascular neoplasms and vascular malformations. Am J Dermatopathol 2011; 33: 569. 28. Al Dhaybi R, Powell J, McCuaig C, Kokta V. Differentiation of vascular tumors from vascular malformations by expression of Wilms tumor 1 gene: evaluation of 126 cases. J Am Acad Dermatol 2010; 63: 1052.

29. Fernandez-Flores A, Saeb-Lima M. Correct evaluation and interpretation of WT-1 immunostaining in vascular lesions. J Cutan Pathol 2014; 41: 754. 30. North PE, Waner M, Mizeracki A, Mihm MC Jr. GLUT1: a newly discovered immunohistochemical marker for juvenile hemangiomas. Hum Pathol 2000; 31: 11. 31. Leon-Villapalos J, Wolfe K, Kangesu L. GLUT-1: an extra diagnostic tool to differentiate between haemangiomas and vascular malformations. Br J Plast Surg 2005; 58: 348.

This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.

Verrucous hemangioma: a clinicopathological and immunohistochemical analysis of 74 cases.

Verrucous hemangioma is a rare form of vascular malformation. Previous studies have reported positive expression of Wilms tumor 1 (WT-1) and Glut-1 an...
2MB Sizes 0 Downloads 5 Views