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Vascular Tumors in Children and Adults Thuy Phung, MD, PhD Houston Methodist Hospital Texas Children’s Hospital Baylor College of Medicine

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Page 1: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Vascular Tumors in

Children and Adults

Thuy Phung, MD, PhD

Houston Methodist Hospital

Texas Children’s Hospital

Baylor College of Medicine

Page 2: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

What are these lesions?

(Marcelo Hochman, MD)

Arteriovenous

malformation Infantile hemangioma Congenital hemangioma

Page 3: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Outline

Clinical presentation, histopathology and

molecular genetics

• Congenital hemangioma (NICH/RICH)

• Kaposiform hemangioendothelioma

• Angiosarcoma

Page 4: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

ISSVA classification for vascular

anomalies(Approved at the 20th ISSVA Workshop, Melbourne, April 2014)

Vascular anomalies

Vascular tumors Vascular malformations

Benign

Locally aggressive or

borderline

Malignant

Simple Combined ° of major named

vessels

associated with

other anomalies

Capillary malformations

Lymphatic malformations

Venous malformations

Arteriovenous malformations*

Arteriovenous fistula*

CVM, CLM LVM,

CLVM CAVM*

CLAVM*

others

See details See list

Page 5: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

ISSVA Classification of Vascular Tumors

Benign vascular tumors

Infantile hemangioma / Hemangioma of infancy see details

Congenital hemangioma

Rapidly involuting (RICH) *

Non-involuting (NICH)

Partially involuting (PICH)

Tufted angioma * °

Spindle-cell hemangioma

Epithelioid hemangioma

Pyogenic granuloma (aka lobular capillary hemangioma)

Others

Locally aggressive or borderline vascular tumors

Kaposiform hemangioendothelioma * °

Retiform hemangioendothelioma

Papillary intralymphatic angioendothelioma (PILA), Dabska tumor

Composite hemangioendothelioma

Kaposi sarcoma

Others

Malignant vascular tumors

Angiosarcoma

Epithelioid hemangioendothelioma

Others

Page 6: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Congenital Hemangiomas

Page 7: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Congenital Hemangiomas

(distinct from infantile hemangiomas)

• Fully formed at birth

• More common in males

• Can occur at any body site,

commonly on head and neck

• Rapidly involuting congenital

hemangiomas (RICH) -can be

gone by 12-18 months of age

• Non-involuting congenital

hemangiomas (NICH)

• GLUT 1 negative

Page 8: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

(Michele Ramien, MD,

University of Ottawa)

Soon after birth 8 months old

Neck mass

23 weeks in utero

17 months old

Rapidly-involuting congenital hemangioma

(RICH)

Page 9: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Rapidly involuting congenital

hemangioma (RICH)

•Distinct hypercellular

lobules with slit-like

channels and enlarged

central draining veins

•Fibrous tissue

separating lobules

Page 10: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Rapidly involuting congenital

hemangioma (RICH)

•Lobules with enlarged central draining vessels•Slit-like channels

•Fibrous tissue separating lobules

Page 11: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

RICH

Small vessels surrounding enlarged central draining vessels

Hobnail nuclei

Page 12: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Non-involuting congenital

hemangioma (NICH)

• Lesion is fully formed at birth

• Does NOT involute as the child grows

In Utero ultrasound Newborn

Page 13: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Non-involuting congenital

hemangioma (NICH)

Firm rubbery swelling with telangiectasia and a blue halo,

warm to touch, non-compressible, non-tender mass

Blue halo

Page 14: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

NICH: Ultrasound Imaging

Color Doppler shows pulsatile arteries and veins within a

well-circumscribed, non-compressible soft tissue mass

Page 15: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

NICH

•Large lobules with enlarged stellate central

draining vessels and curvelinear channels

•Fibrous tissue separating large lobules

Page 16: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Non-involuting congenital hemangioma

(NICH)

Lobules of cells with dilated central vessels

Page 17: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

NICH

Lobules of cells with dilated central vessels

Page 18: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

NICH

Lobules of small vessels and large central draining vessels

Hobnail nuclei

Page 19: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Congenital hemangioma

GLUT-1 negative

Infantile hemangioma

GLUT-1 positive

Page 20: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Congenital hemangioma vs. Infantile

hemangioma – Growth curves

Infantile hemangioma

NICH

RICH

BirthPrenatal Post-natal

Lesio

n s

ize

(Wassef et al., Pediatrics. 2015 Jul;136(1):e203-14)

NICH

RICH

Page 21: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Kaposiform

hemangioendothelioma

(KHE)

Page 22: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Kaposiform hemangioendothelioma

• Solitary firm tumor in the skin or soft

tissue with red-purple ecchymosis

• Presents during infancy (58%) or

early childhood (32%); rare in adults

• Present in head and neck,

extremities, trunk, and extra-

cutaneous sites (bone, mediastinum

and retroperitoneum)

• A locally aggressive, borderline-

malignant tumor; metastasis is very

rare

• Major clinical complication is

Kasabach-Merritt phenomenon –

a severe DIC-like consumptive

coagulopathy

Page 23: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Kaposiform

hemangioendothelioma

Page 24: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Kaposiform

hemangioendothelioma

Page 25: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Kaposiform

hemangioendothelioma

Page 26: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Kaposiform hemangioendothelioma

CD31

Page 27: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Kaposiform hemangioendothelioma

D2-40

Page 28: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Angiosarcoma

Page 29: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Angiosarcoma

• Four groups

1. Primary sporadic angiosarcoma -

the head & neck in elderly men

2. Post-radiation angiosarcoma

3. Chronic lymphedema-associated

angiosarcoma (Stewart-Treves

syndrome)

4. Exposure to vinyl chloride – liver

angiosarcoma

• Poor prognosis, 5-year survival rate

is 30-50%

• Epithelioid angiosarcoma has worse

prognosis

Page 30: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Angiosarcoma

Page 31: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Angiosarcoma

Page 32: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Angiosarcoma

Page 33: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Angiosarcoma

Page 34: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

AngiosarcomaCD31+, ERG+, WT1+

Page 35: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

AngiosarcomaLarge hemorrhagic zones

Page 36: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Congenital hemangioma

GNAQ, GNA11

KHE and tufted angioma

GNA14

G-protein coupled receptor

γ

αβ

Genetic Mutations in Vascular Tumors

PI3-K

RAS/RAF

Infantile hemangioma

VEGFR-2/TEM8

Angiosarcoma

VEGFR-2

Angiosarcoma

• KRAS, PTPRB, PLCG1

• TP53

• NUP160-SLC43A3 gene fusion

• MYC amplification (in 90% of post-

radiation angiosarcoma)

PTEN

MAPK

Receptor tyrosine kinase (VEGF, Tie2, PDGF)

Akt

S6K

mTOR

Infantile hemangioma

Angiosarcoma

Akt/mTOR/S6K

Page 37: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Take Home Points

• Vascular malformations and tumors in children and

adults represent a number of unique entities with diverse

etiologies, many with distinctive clinical, imaging and

histologic features.

• Some lesions continue to defy classification and are best

viewed as complex biological processes yet to be

defined. For these, it is best not to pigeon hole the

lesion as a “hemangioma” but to describe it as

accurately as possible and correlate the clinical, imaging

and histologic features of the lesion.

Page 38: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Global Health Outreach in Southeast

Asia

Page 39: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Vietnam Vascular Anomalies Center

Ho Chi Minh City, Vietnam

Since 2009, we have helped over 5,000 children in Vietnam!

www.VietnamVAC.org

Infantile hemangioma - Treatment with pulsed dye

laser and topical timolol

Page 40: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Global Pathology, Ho Chi Minh City, Vietnam

Surgical pathology and dermatopathology

CME conference

Slide review

Page 41: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Telepathology – Multiple pathologists share skin

biopsies in weekly video conference (Zoom)

7 AM, Vietnam

Funding: AAD “Skin Care in Developing Countries” Grant

Global Pathology Program, Texas Children’s Hospital

Video conference each Wednesday

7 PM, Houston, USA

Page 42: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies
Page 43: Vascular Tumors in Children and Adults - Thuy Phung HSCP talk...ISSVA classification for vascular anomalies (Approved at the 20th ISSVA Workshop, Melbourne, April 2014) Vascular anomalies

Thank You !


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