Clinical course and vascular endothelial growth factor signaling system expression in maxillary angiosarcoma: A case report

Abstract

Maxillary angiosarcoma, an aggressive tumor derived from vascular endothelial cells, is very rare. Recently, antivascular endothelial growth factor (VEGF) therapies have attracted considerable attention. We describe the clinical course of a patient with maxillary angiosarcoma and discuss the expression of VEGF signaling molecules assessed via immunohistological analysis. An 81-year-old man presented with an aggressive tumor in the left maxillary sinus. Biopsy revealed atypical nuclear cell proliferation, and the tumor was suspected to be a sarcoma. The maxillary malignancy was treated using a multidisciplinary approach with a combination of surgery, radiotherapy, and regional chemotherapy. Examination of the specimen obtained in the first surgery revealed maxillary angiosarcoma, found to be positive for CD31, while negative for CD34, D2-40, and factor Ⅷ. Although no pathological residual tumor was observed after the planned wide surgery, cervical lymph node and distant metastases occurred. The patient died 24 months after the first surgery. Staining revealed VEGF receptor (VEGFR) 1, VEGFR2, phosphorylated Ak strain transforming, mitogen-activated protein kinase, and signal transducer and activator of transcription 3 positivity. Although our findings do not indicate that anti-VEGF therapy is beneficial for treating maxillary angiosarcomas, we found that VEGFR signaling pathways were activated in maxillary angiosarcomas similar to angiosarcomas originating at other sites. Herein, we report a case of maxillary angiosarcoma, focused on VEGFR and signaling pathway activation. To our knowledge, this is the first report to describe VEGFR system immunostaining findings in maxillary angiosarcoma.

Introduction

Angiosarcoma, a tumor derived from vascular endothelial cells, accounts for approximately 0.01% to 0.02% of all malignant tumors ¹ ; it is extremely rare even among malignant tumors of the nasal sinuses. ² Angiosarcoma is associated with a poor prognosis, with high rates of local recurrence and distant metastasis, and a standard treatment has not been established. ³ Recently, an association between angiosarcoma and vascular endothelial growth factor (VEGF) was reported, and anti-VEGF therapy has attracted much attention.^4,5 However, no reports have examined the VEGF receptor (VEGFR) and its signaling pathway in patients with maxillary angiosarcoma. Herein, we describe the clinical course of a patient with maxillary angiosarcoma and the immunohistological findings of the tumor related to VEGF, its receptors, and its signaling pathway.

Case report

This case report was approved by the Institutional Review Board of Jichi Medical University (JMUH24-002), and written informed consent for its publication was obtained from the patient's legally authorized representative. An 81-year-old man in good general health with repeated epistaxis and subsequent tingling in the left cheek was referred to the Department of Otolaryngology, Jichi Medical University Hospital. Mass lesions were noted at the middle and common nasal meatus to the nasopharynx, and the middle and inferior turbinate were compressed. Computed tomography (CT) revealed a dense soft tissue mass extending from the left maxillary sinus to the nasal cavity and ethmoid sinus. Bone destruction was observed at the medial and inferior walls of the orbit, with intraorbital extension (Figure 1a). Contrast-enhanced CT revealed heterogeneous enhancement effects in the area (Figure 1b). On magnetic resonance imaging (MRI), the mass showed a signal equal to that of muscle on T1-weighted imaging and a moderate signal on T2-weighted imaging (Figure 1c). Internally, there was a septum-like high signal, and after contrast agent administration, a contrast effect was observed with a predominance of septum-like structures (Figure 1d). The posterior wall of the maxillary sinus was preserved, and the tumor did not extend into the pterygopalatine fossa.

Figure 1.

CT and MRI: (a) coronal noncontrast CT in the bone window; (b) coronal contrast-enhanced CT; (c) axial T2WI; and (d) axial contrast-enhanced fat-suppressed T1WI. Noncontrast CT shows a soft-tissue mass in the left maxillary sinus with bone destruction on the medial and inferior walls of the orbit, with intraorbital extension (a). Contrast-enhanced CT shows heterogeneous enhancement within the mass. The mass shows moderate signal intensity on T2WI (c) and heterogeneous enhancement on contrast-enhanced fat-suppressed T1WI (d). CT: computed tomography; MRI: magnetic resonance imaging; T1WI: T1-weighted image; T2WI: T2-weighted image.

Biopsy results showed atypical nuclear cell proliferation in the stroma with distinct sporulation. The sarcoma type was unconfirmed; however, malignancy was diagnosed. Consequently, the maxillary malignancies were treated by a multidisciplinary approach; the first surgery, radiotherapy, regional chemotherapy, and planned wide surgery. ⁶ Briefly, the primary tumor site was treated with conservative irradiation; subsequently, the first surgery was performed. Intraoperatively, a catheter was placed at the site where the internal maxillary artery branched, and 250 mg of 5-fluorouracil (5-FU) was infused. The maxillary cavity was opened through a gingivobuccal sulcus incision. The lateral wall of the nasal cavity, including the inferior turbinate, was removed through this incision. The necrotic mass in the maxillary sinus was curetted. After the first surgery, an intra-arterial infusion of 250 mg of 5-FU was administered simultaneously with irradiation. Approximately, 3 to 4 weeks later, the mucositis in the oral cavity subsided, and the planned wide surgery was performed; the residual tumor tissue was resected through the gingivobuccal sulcus incision. All residual tumors were carefully resected along with minimal adjacent healthy tissues. ⁶ Figure 2 shows the surgically removed specimen during the first surgery; pathological findings revealed vascular neoplasia with multiple vessels comprised of endothelial cells with prominent nuclei and atypia (Figure 2a). Elongated fusiform nuclei with atypia were observed between the vascular areas. Immunohistochemically, CD31 is stained at the cell membrane (Figure 2b), CD34 is well stained by capillaries, while minimally stained by tumor cells (Figure 2c), D2-40 is stained focally at the membrane and cytoplasm (Figure 2d), and factor Ⅷ is partially stained though often unstained at the cell membrane and cytoplasm (Figure 2e). The tumor cells were positive for CD31, while negative for CD34, D2-40, and factor Ⅷ. The final diagnosis was angiosarcoma, considering CD31 is considered the most specific immunohistochemical indicator of angiosarcoma.

Figure 2.

Histopathological findings: (a) HE staining (×200); (b) CD31 (×200); (c) CD34 (×200); (d) D2-40 (×200); and (e) factor Ⅷ (×200). Vascular neoplasia with multiple vessels comprised of endothelial cells with prominent nuclei and atypia (a). Elongated fusiform nucleus cells with atypia were also observed between the vascular areas. Immunohistochemically, the tumor cells were found to be positive for CD31, while negative for CD34, D2-40, and factor Ⅷ. CD31, cluster of differentiation 31; CD34, cluster of differentiation 34; HE, hematoxylin and eosin.

Pathological examination of the specimen obtained during the planned wide surgery revealed no residual tumor. Two months after the maxillary sinus’ complete removal, metastasis was observed in the left submandibular lymph node, and radical neck dissection was performed. However, the tumor continued to metastasize to the cervical lymph nodes and distant sites. Despite receiving additional irradiation, the patient died 24 months after the first surgery.

Method and results

Considering the VEGF signaling pathway in maxillary angiosarcoma is unreported, we investigated the main signaling molecules in our patient's tumor. We immunohistochemically analyzed molecules related to VEGF and its receptors using specific antibodies against VEGF-A (Abcam PLC, Cambridge, UK: ab46154; 1:800), VEGFR1 (Abcam PLC: ab32152; 1:300), VEGFR2 (Cell Signaling Technology, Danvers, MA: #2479; 1:200), and VEGFR3 (Abcam: ab27278; 1:100). Antibodies against the key signaling molecules of receptor-type tyrosine kinases, including VEGFR, phosphorylated signal transducer and activator of transcription 3 (pStat3; Cell Signaling Technology, #4060; 1:75), phosphorylated mitogen-activated protein kinase (MAPK; pMAPK; Cell Signaling Technology, # 4370; 1:200), and phosphorylated Ak strain transforming (pAkt; Cell Signaling Technology, #9145; 1:75), were used. The pathological pictures were taken using a virtual slide system, NanoZoomer S210 and NDP.view2 U12388-01 (Hamamatsu Photonics K.K. Hamamatsu), instead of a conventional optical microscope. Approximately 30% of the tumor cells were negative for VEGF-A (Figure 3a), over 70% were positive for VEGFR1 (Figure 3b), negative for VEGFR2 (Figure 3c), and 70% were positive for VEGFR3 (Figure 3d). Furthermore, 80% of cells were mildly stained for pAkt (Figure 3e) in the cell membrane and cytoplasm, 60% were strongly stained for pMAPK in the cytoplasm (Figure 3f) and nucleus, and 20% were moderately stained for pStat3 in the nucleus (Figure 3g).

Figure 3.

Results of immunohistochemical staining for VEGF, VEGFR, and signaling molecules. (a) VEGF-A (×200), (b) VEGFR1 (×200), (c) VEGFR2 (×200), (d) VEGFR3 (×200), (e) pAkt (×200), (f) pMAPK (×200), and (g) pStat3 (×200). The tumor cells are positive for VEGFR1, VEGFR3, pAkt, pMAPK, and pStat3. pAkt, phosphorylated Ak strain transforming; pMAPK, phosphorylated mitogen-activated protein kinase; pStat3, phosphorylated signal transducer and activator of transcription 3; VEGF, vascular endothelial growth factor; VEGFR, vascular endothelial growth factor receptor.

Discussion

Angiosarcoma is a very rare disease, accounting for approximately 0.01% to 0.02% of all malignant tumors. ¹ Approximately 30% of angiosarcomas occur on the skin, with the skin of the head and face being the most common site of onset. Angiosarcomas of the head and neck, including the nasal sinuses, are very rare, occurring in 1% to 4% of cases. ⁷ Factors that may induce oncogenesis include radiation, surgery, trauma, and exogenous toxins, such as vinyl chloride, thorium dioxide, and arsenic. ⁸ Nonetheless, no obvious factors were found in this case. There were no characteristic imaging findings on CT, nor MRI, and the diagnosis was confirmed histologically. Imaging findings are useful in evaluating the lesion's extent and distant metastasis. Angiosarcoma has a high rate of metastasis to the lung, liver, kidney, spleen, intestine, bone, and retroperitoneum, making it very aggressive.^1,3,4 This patient developed lymph node and distant metastasis at a relatively early stage, and consequently died.

Previously, histological examination revealed anastomosing vascular channels lined with atypical endothelial cells that protruded into the lumen, neolumen formation, frequent atypical mitotic figures, necrosis, and hemorrhage. Additionally, immunoreactivity for antibodies against factor VIII-RA, CD34, CD31, and smooth muscle actin, but not for antibodies against keratin and S-100 protein, was observed.^3,9 Presently, we observed vascular neoplasia with multiple vessels comprising endothelial cells with prominent nuclei and atypia. Elongated fusiform nuclear cells with atypia were observed between the vascular areas, and CD31 staining was positive.

Angiosarcoma treatments include surgery, radiotherapy, chemotherapy, interleukin-2, and steroids; a combination of these therapies is often provided. Currently, extensive surgical resection is the preferred treatment with the best prognosis. Radiotherapy has been shown to improve prognosis in several case studies. ¹⁰ The best maxillary malignancy treatment comprises wide surgical resection followed by chemotherapy, and the advantages of our multidisciplinary treatment approach are documented. ⁶

Although large-scale clinical studies on the outcome of maxillary angiosarcoma are lacking, Nelson et al. reported that 6 of 10 patients with sinonasal tract angiosarcoma were treated with surgery alone, while the remaining were treated with surgery plus radiation and/or chemotherapy; they recommended radiotherapy with a wide planning target volume in addition to extended surgery. ³ Weekly chemotherapy with paclitaxel ¹¹ and interleukin-2 ¹² have demonstrated efficacy in angiosarcoma treatment; however, an effective chemotherapy regimen remains undetermined.

Recently, multiple gene mutations related to VEGFR and its downstream signal, MAPK, have been identified in patients with angiosarcoma,^4,5 leading to research aimed at suppressing VEGF signaling pathways to obtain therapeutic effects. In this case, immunostaining for VEGFR1, VEGFR3, pMAPK, and phosphorylated Ak strain transforming (pAkt) was positive, suggesting potential involvement of VEGF signaling pathway activation in tumor development. In the initial and diagnostic immunohistochemical procedures, considering CD31 positivity, which can stain both lymphatic and blood endothelial cells, and D2-40 negativity, which indicates lymphatic endothelial cell absence, some results seem controversial. In normal adult tissues, VEGFR3 expression is limited to the lymphatic epithelium. However, VEGFR3 expression is found in the tumor vasculature, and targeting its activity has shown to inhibit angiogenesis and delay tumorigenesis, ¹³ which seems consistent with the current case.

Bevacizumab, a recombinant humanized monoclonal antibody that blocks angiogenesis through VEGF-A, has shown promise. ¹⁴ Reports on the efficacy of pazopanib, a multityrosine kinase inhibitor, have shown it acts as a pan-RAF inhibitor and exerts anticancer effects through the inhibition of VEGF-A and the MAPK signaling pathway in cancer cells when there is no demonstrable antiangiogenic effect. ¹⁵ Kollár et al. ¹⁶ retrospectively evaluated 40 patients with angiosarcoma treated with pazopanib and reported a median progression-free survival and overall survival of 3 and 9.9 months, respectively. In a Japanese study, the progression-free survival was 94 days in patients with cutaneous angiosarcoma treated with pazopanib.^17,18 Wagner et al. observed MAPK signaling activation in over half of the clinical angiosarcoma samples they studied and reported that the combined inhibition of the VEGF and MAPK pathways by cediranib and trametinib reduced angiosarcoma cell survival. ⁵ These results justify clinical studies on the effect of combined VEGFR and MAPK inhibition on angiogenesis in angiosarcoma. Although our findings do not indicate that anti-VEGF therapy is beneficial for treating maxillary angiosarcomas, we found that maxillary sinus angiosarcomas express VEGFR and activate its signaling molecules in the same manner as angiosarcomas originating at other sites.

Conclusion

Herein, we report a very rare case of maxillary angiosarcoma. The patient died of distant metastasis despite multimodal treatment. Activation of VEGFR and its signaling pathway, positive for VEGFR1, VEGFR3, pAkt, and pMAPK was observed. To our knowledge, this is the first report on the immunostaining findings of the VEGFR system in maxillary angiosarcoma.