A Rare Case of Pulmonary Epithelioid Hemangioendothelioma Presenting with Skin Metastasis

Epithelioid hemangioendothelioma (EHE) is a well-differentiated and rare vascular tumor. Systemic metastases are uncommon. Herein, we present a patient with skin metastasis of pulmonary EHE (PEH) that was treated by wide excision. A 76-year-old male was evaluated due to pulmonary thromboembolism and a solitary pulmonary nodule. A biopsy was performed and pathological examination of the mass confirmed EHE. No metastasis was observed. The patient returned to care approximately two years later due to a painful nodule in the right lower leg. A skin biopsy showed metastatic EHE from the lung. We used a safety margin of 1 cm based on clinical experience, because no prior case had been reported regarding the resection margin appropriate for primary cutaneous EHE and skin metastases of PEH. At four months after surgery, the patient recovered without complications or recurrence. Skin metastasis of PEH is extremely rare, and only two cases have been reported in the literature. In this case, we report a rare case of PEH with histologically diagnosed skin metastasis that was successfully treated by curative resection. It is expected that this case report will provide a helpful contribution to the extant data regarding PEH metastases.

Anticoagulantes y antiplaquetarios en cirugía dermatológica / Anticoagulants and antiplatelet in cutaneous surgery

Introducción: Un porcentaje importante de pacientes sometidos a cirugía cutánea están en tratamiento anticoagulante o antiplaquetario. Las cirugías cutáneas tienen bajo riesgo de sangrado, pero los tratamientos antitrombóticos podrían causar mayor riesgo, lo que ha llevado a los cirujanos dermatólogos a suspender estas terapias antes de la cirugía. Por otro lado, un inadecuado manejo de estas terapias puede tener graves consecuencias tromboembólicas. Objetivo: Establecer los riesgos y beneficios de continuar o suspender el tratamiento antitrombótico antes de una cirugía dermatológica, con el fin de establecer una conducta preoperatoria segura. Materiales y métodos: Se realizó una revisión de la literatura médica bajo los términos anticoagulants, anticoagulation y anticoagulation therapy in dermatologic surgery o in cutaneous surgery. Se seleccionaron los 20 artículos que mejor respondían al objetivo del estudio, dando prioridad a los más recientes. Resultados: En los estudios analizados no se observó evidencia que sustente la suspensión de lo warfarina, clopidogrel o ácido acetilsalicilico antes de una cirugía cutánea, pero sí se reportan casos de complicaciones tromboembólicas asociadas a la suspensión de la terapia antitrombótica. No existe consenso respecto al valor del INR sobre el cual existe mayor riesgo de sangrado perioperatorio en la cirugía cutánea ni del mejor momento para controlarla. Conclusiones: La cirugía cutánea con anticoagulantes y antiplaquetarios es segura, pero la suspensión de estas terapias se puede asociar a complicaciones vasculares con riesgo vital. Sugerimos tomar un INR de control dentro de las 24 horas previos a la cirugía; en caso de valores mayores a 4, derivar al médico tratante para ajustar los niveles.

Introduction: A significant percentage of patients undergoing cutaneous surgery are on anticoagulants or antiplatelet therapy. Cutaneous surgery are at low risk of bleeding but antithrombotic treatments may cause increased risk which has led to dermatologic surgeons to discontinue these therapies before surgery. Moreover, inadequate management of these therapies can have serious thromboembolic consequences Objective: To establish the risks and benefits to continue or suspend the therapy prior to a dermatologic surgery in order to have o reliable preoperative behavior. Materials and methods: A search was conducted by the authors on medical literature under the terms anticoagulants, anticoagulation and anticoagulation therapy in dermatologic surgery or in cutaneous surgery. A total of 20 articles were selected giving priority to the most recent ones. Results: In the studies reviewed there was no evidence to support the suspension of warfarin, clopidogrel or aspirin before skin surgery but reported cases of thromboembolic complications associated with the suspension of antithrombotic therapy were found. There is no consensus on the INR value related with increased risk of perioperative bleeding in cutaneous surgery or the best time to control it Conclusions: Perform o cutaneous surgery under anticoagulant and antiplatelet treatment is safe; the suspension of these therapies may be associated with life-threatening vascular complications. An INR control within 24 hours prior to surgery is suggested. In case of an INR over 4 o recommendation of control with the physician to adjust levels seem reasonable.