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Address correspondence to:Department of Plastic Surgery, Istanbul Training and Research Hospital, Kavakli sk. Eksioglu sit B blok D: 54 Atasehir, Istanbul, Turkey.
A case of intravascular papillary endothelial hyperplasia is presented. This proliferation usually forms inside thrombotic processes. It is critical to be able distinguish these lesions from low-grade angiosarcomas because they can have similar pathologic findings.
). It is a rare vascular lesion and usually not considered neoplastic. One of the most important aspects of this lesion is that it has histopathologic features similar to those of angiosarcoma. The mean age at representation is approximately 40 years. It has been reported in various locations, including the fingers (
). In the present report, we describe a case of IPEH of the dorsum of the foot.
Case Report
A 60-year-old male patient with history of heavy smoking, type 2 diabetes, hypertension, and renal calculus presented to our clinic with a mass on the dorsum of the foot. The patient had no history of trauma or thrombophilias. The physical examination revealed a well-defined, nonmobile mass on the dorsum of the foot approximately 2 cm in diameter (Fig. 1). Magnetic resonance imaging revealed a localized uniloculed cystic mass at the medial side of the medial cuneiform bone adjacent to the tarsometatarsal joint. In addition, soft tissue edema was present surrounding the neck of the anterior talus. The lesion was excised under local anesthesia with the patient in a supine position using a 3-cm-long vertical incision along the skin. The mass was carefully dissected from the surrounding tissues. After hemostasis was achieved, skin closure was performed with 4-0 polypropylene sutures. The resected specimen was sent for histopathologic examination. No complications developed in the postoperative period. The patient was released from the clinic the same day. No additional treatment was performed. At 9 months after surgery, the patient was feeling well with no signs of recurrence. Ongoing surveillance follow-up visits are planned.
Gross examination of the specimen revealed a cystic formation containing gray-white septas. Histopathologic examination revealed papillary endothelial hyperplasia along a thrombosis inside a small dilated vein (Fig. 2, Fig. 3). The endothelial hyperplasia was characterized by papillary formations, which were covered with a layer of endothelial cells. No anaplasia, necrosis, or mitosis was present. The endothelial cells were stained with CD31 to reveal the papillary structures (Fig. 4).
IPEH is a process of vascular hyperplasia. It is considered a reactive process of endothelial cells induced by thrombosis and inflammation. This process can result secondary to other pathologic processes. Most of the cases were associated with thrombus formation, which was also found in our patient. IPEH has also been reported secondary to other vascular pathologies, including hemangiomas (
), lymphangiomas, and pyogenic granulomas. In some cases, no evidence of other vascular pathology or thrombus has been found. This could have been because thrombus will disappear after a certain period.
It has been suggested that thrombus that leads to IPEH could be related to trauma (
). In the present case, the patient had no history of trauma. However, he did have vascular complications caused by smoking, diabetes, and hypertension, which might have resulted in the vascular pathology.
In conclusion, the lack of features such as anaplasia, necrosis, and atypical mitosis is the main differentiating point between IPEH and angiosarcoma. Other findings such as an intraluminal location, association of papillary formations with the thrombotic material, and piling up of endothelium have also been reported to aid in the differential diagnosis (
). In our case, the findings of the magnetic resonance imaging scan were more consistent with a ganglion cyst. Inconsistency between the radiologic and pathologic findings could also be an important point in differentiating IPEH from angiosarcoma.
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