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Frequent FOS Gene Rearrangements in Epithelioid Hemangioma

A Molecular Study of 58 Cases With Morphologic Reappraisal

Huang, Shih-Chiang MD*,†; Zhang, Lei MD; Sung, Yun-Shao MSc; Chen, Chun-Liang MSc; Krausz, Thomas MD; Dickson, Brendan C. MD§; Kao, Yu-Chien MD; Agaram, Narasimhan P. MBBS; Fletcher, Christopher D.M. MD, FRCPath; Antonescu, Cristina R. MD

The American Journal of Surgical Pathology: October 2015 - Volume 39 - Issue 10 - p 1313–1321
doi: 10.1097/PAS.0000000000000469
Original Articles

Epithelioid hemangioma (EH) is a unique benign vasoformative tumor composed of epithelioid endothelial cells. Although a small subset of EHs with atypical features harbor ZFP36-FOSB fusions, no additional genetic abnormalities have been found to date in the remaining cases. On the basis of a novel FOS-LMNA gene fusion identified by RNA sequencing in an index case of a skeletal EH with typical morphology, we sought to investigate the prevalence of FOS rearrangement in a large cohort of EHs. Thus 57 additional EH cases lacking FOSB rearrangements were studied for FOS gene abnormalities by fluorescence in situ hybridization, and results were correlated with morphologic appearance and clinical presentation. The EHs were subclassified as typical (n=25), cellular (n=21), and angiolymphoid hyperplasia with eosinophilia (ALHE) (n=12) variants. The ALHE was defined as an EH with a vascular “blow-out” pattern associated with a variable degree of inflammation. There were 17 (29%) cases bearing FOS gene rearrangements among 58 cases tested, including 12 male and 5 female patients, with a mean age of 42 years. Most FOS-rearranged EHs occurred in the bone (10) and soft tissue (6), whereas only 1 case was cutaneous. The predominant anatomic site was the extremity (12), followed by trunk (3), head and neck (1), and penis (1). The incidence of FOS rearrangement was significantly higher in bone (59%, P=0.006) and lower in head and neck (5%, P=0.009). Twelve of the FOS-rearranged cases were cellular EH (P=0.001) associated with moderate mitotic activity (2 to 5/10 HPF) and milder inflammatory background. All 12 ALHE cases lacked FOS gene abnormalities, suggesting different pathogenesis. In conclusion, FOS rearrangement was present in a third of EHs across different locations and histologic variants; however, it was more prevalent in cellular EH and intraosseous lesions, compared with those in skin, soft tissue, and head and neck. This genetic abnormality can be useful in challenging cases, to distinguish cellular EHs from malignant epithelioid vascular tumors. These results also suggest that dysregulation of the FOS family of transcription factors through chromosomal translocation is as a key event in the tumorigenesis of EH except for the ALHE variant.

*Department of Pathology, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan

Department of Pathology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan

Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY

Department of Pathology, University of Chicago, Chicago, IL

Department of Pathology, Brigham and Women’s Hospital, Boston, MA

§Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, ON, Canada

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Conflicts of Interest and Source of Funding: Supported in part by: P01CA47179 (C.R.A.), P50CA140146-01 (C.R.A.), Cycle for Survival (C.R.A.). The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Correspondence: Cristina R. Antonescu, MD, Department of Pathology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065 (e-mail:

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