Case Report

Juvenile hemangioma (infantile hemangioendothelioma) of theparotid gland associated with cytomegalovirus infection

Yasushi Horie and Masako Kato

Department of Pathology, Tottori University Hospital, Yonago, Japan

CLINICAL SUMMARY

No clinical abnormalities were detected in a male infantduring the perinatal period. At 1 month of age, a mass wasnoted in the left preauricular region. As the mass hadenlarged, the patient was admitted to Tottori UniversityHospital. Sonography and magnetic resonance imagingshowed a lobulated tumor in the left parotid gland region. Theright parotid gland was normal. Laboratory examinations onadmission revealed that the white blood cell (5.8 3 103/mL)and red blood cell (4.27 3 106/mL) counts were withinnormal limits, while that of platelets (480 3 103/mL) waselevated. The counts of serum aspartate aminotransferase(AST; 57 IU/L), alanine aminotransferase (ALT; 64 IU/L) andlactate dehydrogenase (LDH; 333 IU/L) were also elevated.The parotid tumor was extirpated at 4 months of age inJanuary 1997. His postoperative course was uneventful 2years after surgery.

PATHOLOGICAL FINDINGS

Macroscopically, a lobulated elastic-hard tumor, measuring30 3 20 mm, was located in the superficial lobe of theparotid gland. There were no cystic or necrotic changes in thelesion. Capsular formation was absent.

Microscopically, the border between the tumor and theparotid gland was indistinct in most areas (Fig. 1). The lesionconsisted of cellular plump endothelial cells of capillary typeand stromal cells including fibroblasts and pericytes (Figs2,3). Residual ductal and acinar elements of the parotid glandwere distributed throughout the lesion. Red blood cells werefocally present in mature capillary vessels but were absent inmost inconspicuous vascular lumina. Numerous mast cellswere intermingled in the stroma. Mitotic figures were easilyobserved in the endothelial cells and ten/ten high-poweredfields were counted on average. The vascular lumina wasenhanced by small-sized fibers using reticulin stain. In theparenchymal part of the parotid gland, lymphocyte infiltration

Pathology International 1999; 49: 668–671

A case of parotid juvenile hemangioma associated withcytomegalovirus infection is reported. A growing lobulatedmass, measuring 30 3 20 mm, was extirpated from the leftparotid gland in a 4-month-old male. Histologically, thetumor consisted of cellular plump endothelial cells, stromalcells and residual ductal and acinar elements of the parotidgland. Numerous intranuclear and cytoplasmic inclusionswere observed in the ductal cells of the whole parenchymalpart of the parotid gland and the residual part of the tumor.Immunohistochemically, some nuclei of the ductal cellspossessing these inclusions were positive for the anti-cytomegalovirus antibody but there were no positivefindings in the endothelial or stromal cells. Although the present lesion may suggest that the human cyto-megalovirus plays some role in the etiology of juvenilehemangioma, it is unknown whether or not this associationis incidental.

Key words: cytomegalic inclusion disease, cytomegalovirus,infantile hemangioendothelioma, juvenile hemangioma, parotidgland, salivary gland, tumorigenicity, virus

Juvenile hemangioma (benign infantile hemangioendothe-lioma, cellular hemangioma of infancy) is the commonesttumor of the parotid gland in children.1–7 Cytomegalovirus(CMV) infection has also been observed in the parotid glandof infants.8–10 To our knowledge, however, the associationbetween juvenile hemangioma and human CMV in theparotid gland has not been previously described. Therefore, acase of parotid juvenile hemangioma associated with CMVinfection is presented and its pathologic implications arediscussed.

Correspondence: Yasushi Horie, MD, Department of Pathology,Tottori University Hospital, 36-1 Nishimachi, Yonago, Tottori 683-8504, Japan. Email: yhorie-ttr@umin.ac.jp

Received 19 January 1999. Accepted for publication 5 March1999.

Juvenile hemangioma and cytomegalovirus 669

was prominent in and around the ductal cells (Fig. 4).Enlarged ductal cells possessing huge eosinophilic intranu-clear inclusions with halos were scattered, not only in thewhole parenchymal part of the parotid gland (Fig. 5), but alsoin the residual ductal part of the tumor. Cytoplasmic granularbasophilic inclusions were also observed in these ductalcells.

Immunohistochemically, 10% formalin-fixed, paraffin-embedded specimens were examined by the streptavidin–biotin complex method. Most endothelial cells were positivefor vimentin, Factor VIII-related antigen, CD31 and CD34(Table 1). Most stromal cells were immunoreactive forvimentin and α-smooth muscle actin and muscle-specificactin, while they were negative for Factor VIII-related antigen,

Figure 1 Low-power microscopy of a parotid gland tumor. Theborder between the tumor and parotid gland is indistinct in mostareas.

Figure 3 High-power microscopy of the tumor cells forming matureand immature capillary vessels.

Figure 4 Parenchymal part of the parotid gland showing prominentlymphoid cell infiltration around the ducts.

Figure 2 Parotid gland tumor lesion is composed of cellular plumpendothelial cells and stromal cells. Note some residual ductalelements of the parotid gland.

CD31, CD34, desmin, S-100 protein, cytokeratin and epithe-lial membrane antigen. Some nuclei of ductal cells with hugeintranuclear inclusions were positive for anti-CMV antibodybut there were no positive findings in the endothelial orstromal cells of the tumor.

Based on these findings, the lesion was diagnosed asjuvenile hemangioma associated with CMV infection.

DISCUSSION

Juvenile hemangioma is a distinctive neoplasm that occurs ininfancy.1–7 Clinically, it may be located on any body surfacebut most commonly occurs in the head and neck region,

particularly the parotid gland. The lesion usually develops by6 months of age and 70–95% of the cases show spontaneousregression by the age of 7 years. The association ofextensive hemangioma with thrombocytopenia and purpurais well known as Kasabach–Merritt syndrome.

Histologically, juvenile hemangioma exhibits an immatureform of capillary hemangioma and is also referred to asbenign infantile hemangioendothelioma, cellular heman-gioma of infancy, immature hemangioma and strawberrynevus.1–3 It is necessary to distinguish between juvenilehemangioma and tufted angioma (so-called angioblastoma).Tufted angioma and juvenile hemangioma are variants ofcapillary hemangioma, but in cases of tufted angioma, theangiomatous aggregates are much smaller and a distinctive‘cannonball’ pattern is usually observed.1 Immunohis-tochemically, tumor cells of juvenile hemangioma mayexpress heterogeneous cell markers, including vimentin,Factor VIII-related antigen, Factor XIIIa, ulex europaeus I lectin, thrombomodulin, smooth muscle actin and anti-macrophage antibody HAM56.1–3,5,6 The histologic andimmunohistochemical findings of the present lesion werecompatible with those of previously reported cases.

Cytomegalovirus is a DNA virus in the herpes group.8–10

Numerous infections occur congenitally and perinatally, butonly 10% of congenitally infected infants exhibit acutecytomegalic inclusion disease.9 The possible significance ofCMV parotitis was suggested in infant and early childhooddeaths.8 Pena-Alonso et al. reported that CMV infection wasidentified in 49 cases (2.9%) of 1618 children autopsies andthe lung (78%) was the most commonly affected organ,followed by the kidney (41%), adrenals (27%), liver (22%),pancreas (20%), salivary glands (16%) and the centralnervous system (14%).10

Regarding the relationship between hemangioma andCMV infection, Pozzati and Musiani found CMV DNA in thematrix of cerebral cavernous angiomas using in situhybridization.11 They suggested that CMV infection playedsome role in the biologic behavior of these tumors. Chiu et al.

670 Y. Horie and M. Kato

Figure 5 High-power microscopy of cytomegalovirus-infectedductal cells possessing intranuclear and cytoplasmic inclusions inthe parotid gland.

Table 1 Summary of immunohistochemical findings of the parotid lesion

ReactivityEndothelial Stromal Ductal

Antibody Clone Dilution Source cells cells cells

Vimentin V9 Prediluted Nichirei (Tokyo, Japan) 11 11 –Factor VIII-RA Polyclonal 1 : 100 Nichirei 11 – –CD31 JC/70A Prediluted Dakopatts (Glostrup, Denmark) 11 – –CD34 NU-4A1 1 : 100 Nichirei 11 – –α-SMA 1A4 1 : 50 Dakopatts – 11 –Muscle-specific actin HHF35 Prediluted Dakopatts – 11 –Desmin ZC18 Prediluted Nichirei – – –S-100 protein Polyclonal Prediluted Nichirei – – –Cytokeratin AE1/AE3 1 : 50 Dakopatts – – 11

EMA E29 Prediluted Nichirei – – 11

Anti-CMV CCH2 1 : 30 Dakopatts – – 1 Focal

RA, related antigen; SMA, smooth muscle actin; EMA, epithelial membrane antigen; CMV, cytomegalovirus; –, negative; 1, positive cells in 1–49%;11, positive cells in 50–100% in total population.

2 Ellis GL, Auclair PL. Hemangioma. In: Tumors of SalivaryGlands. Atlas of Tumor Pathology, 3rd series. Armed ForcesInstitute of Pathology, Washington, DC, 1996; 375–377.

3 Enzinger FM, Weiss SW. Capillary hemangioma. In: Soft TissueTumors, 3rd edn. Mosby, St Louis, 1995; 581–585.

4 Mantravadi J, Roth LM, Kafrawy AH. Vascular neoplasms of theparotid gland. Parotid vascular tumors. Oral Surg. Oral Med.Oral Pathol. 1993; 75: 70–75.

5 Gonzalez-Crussi F, Reyes-Mugica M. Cellular hemangiomas(‘hemangioendotheliomas’) in infants: Light microscopic,immunohistochemical, and ultrastructural observations. Am. J.Surg. Pathol. 1991; 15: 769–778.

6 Yasunaga C, Sueishi K, Ohgami H, Suita S, Kawanami T.Heterogeneous expression of endothelial cell markers ininfantile hemangioendothelioma: Immunohistochemical studyof two solitary cases and one multiple one. Am. J. Clin. Pathol.1989; 91: 673–681.

7 Nagao K, Matsuzaki O, Shigematsu H, Kaneko T, Katoh T,Kitamura T. Histopathologic studies of benign infantilehemangioendothelioma of the parotid gland. Cancer 1980; 46:2250–2256.

8 Variend S, O’Neill D, Arnold P. The possible significance ofcytomegaloviral parotitis in infant and early childhood deaths.Arch. Pathol. Lab. Med. 1997; 121: 1272–1276.

9 Gnepp DR, El-Mofty SK. Viral sialadenitis. In: Damjanov I,Linder J, eds. Anderson’s Pathology, 10th edn. Mosby, St Louis,1996; 1620.

10 Pena-Alonso R, Navarrete-Navarro S, Ramon-Garcia G,Hernandez-Mote R, Rodriguez-Jurado R. Cytomegalovirusinfection in children: Frequency, anatomopathologic character-istics and underlying risk factors in 1618 autopsies. Arch. Med.Res. 1996; 27: 25–30.

11 Pozzati E, Musiani M. Cavernous hemangioma. J. Neurosurg.1998; 89: 498–499.

12 Chiu HH, Chen RL, Lin KH, Lin DT, Lin KS. Recombinant α-interferon treatment of intracranial hemangioma andKasabach–Merritt syndrome in an infant with cytomegalovirus.J. Formos Med. Assoc. 1995; 94: 261–266.

13 Shen Y, Zhu H, Shenk T. Human cytomegalovirus IE1 and IE2proteins are mutagenic and mediated ‘hit-and-run’ oncogenictransformation in cooperation with the adenovirus E1A proteins.Proc. Natl Acad. Sci. USA 1997; 94: 3341–3345.

14 Legrand A, Mayer EP, Dalvi SS, Nachtigal M. Transformation ofrabbit vascular smooth muscle cells by human cytomegalovirusmorphological transforming region I. Am. J. Pathol. 1997; 151:1387–1395.

15 Alcami J, Barzu T, Michelson S. Induction of an endothelial cellgrowth factor by human cytomegalovirus infection of fibroblasts.J. Gen. Virol. 1991; 72: 2765–2770.

16 Cannistra C, Standoli L. Viral implication in immature angiomas.Etiopathogenical hypothesis and immunohistopathologicalstudy about eleven patients. Pathol. Biol. 1994; 42: 150–155.

17 Dupin N, Enjolras O, Wassef M et al. Lack of evidence of anyassociation between HHV-8 and hemangioma of the infancy.Ann. Dermatol. Venereol. 1998; 125: 98–99.

18 Smoller BR, Chang PP, Kamel OW. No role for human herpesvirus 8 in the etiology of infantile capillary hemangioma. Mod.Pathol. 1997; 10: 675–678.

Juvenile hemangioma and cytomegalovirus 671

reported an unusual case of hemangioma associated withCMV infection.12 A 2-month-old girl presented with anenlarged head girth, generalized petechiae, anemia, coag-ulopathy and hepatosplenomegaly. Imaging examinationsshowed a large, dumbbell-shaped intracranial hemangioma.Cytomegalovirus infection was demonstrated by urineculture. After α-interferon treatment, the hemangiomaremarkably regressed.

Several experimental studies have examined the tumori-genicity of human CMV.13–15 Shen et al. found that humanCMV-related proteins were mutagenic and mediated ‘hit-and-run’ oncogenic transformation in cooperation withadenovirus-related proteins.13 Legrand et al. suggested thatthe morphologic transformation by human CMV DNAsequences enhanced the mitogenic response of rabbitvascular smooth muscle cells to fibroblast growth factors.14

Alcami et al. demonstrated that human CMV infectioninduced a type II heparin-binding growth factor that stimu-lated human endothelial cell proliferation.15

Based on these clinical and experimental findings, weinitially considered that the association between juvenilehemangioma and CMV infection was non-incidental and thatCMV had the potential to induce juvenile hemangioma.Several laboratory abnormalities (high levels of ALT, AST andLDH) of the present patient were considered to be caused byCMV infection. However, we were unable to obtain directpathologic evidence of tumorigenicity of human CMV,because the present tumor cells were immunohistochem-ically negative for the anti-CMV antibody. Furthermore, it wasnecessary to examine the relationship between the parotidlesion and other viruses including papilloma virus and humanherpes virus (HHV) 8.16–18 Cannistra et al. proved thatpapilloma virus was involved in the tissues of immatureangiomas by use of an immunohistochemical method,16

whereas recent studies suggested that no causative role ofHHV8 was detected in juvenile hemangioma.17,18 Therefore, itis unclear whether the association between juvenile heman-gioma and CMV infection is an incidental event. Furtherstudies using molecular and epidemiological methods arenecessary to elucidate the pathologic significance of thisassociation.

REFERENCES

1 Calonje E, Wilson-Jones E. Capillary hemangioma variants. In:Elder D, ed. Lever’s Histopathology of the Skin, 8th edn.Lippincott-Raven, Philadelphia, 1997; 901–903.