Abstract:

Graft-versus-host disease-associated angiomatosis (GVHD-AA) is a rare complication of chronic GVHD (cGVHD) characterized by vascular proliferation. We present a case of GVHD-AA and discuss implications for clinical sampling and histologic diagnosis. A 69 year-old man with a history of acute myelogenous leukemia in remission after stem cell transplant 6 years prior complicated by cGVHD was seen in dermatology clinic for spontaneously bleeding leg lesions. These had been present for several years and were being treated in wound care clinic but had recently grown in size. Biopsy of a similar lesion 2 years prior had shown granulation tissue. Physical exam revealed several 3-6 cm hyperkeratotic bleeding papules and plaques in sclerotic regions on the bilateral legs. The differential diagnosis included squamous cell carcinoma (SCC), granulation tissue, and infection. After a punch biopsy showed ulceration without malignancy, the patient underwent a debulking shave biopsy from the left shin. Histologic examination showed large, dilated, thin-walled vessels in the papillary dermis with ulceration and epidermal hyperplasia, compatible with GVHD-AA. The biopsy site healed without recurrence, and in subsequent months the patient underwent two incisional biopsies and two excisions, which showed similar histologic findings. Our case provides several examples of the histologic features of GVHD-AA. Further, it underscores the importance of adequately sampling hyperkeratotic lesions in patients with cGVHD. After punch biopsies showed non-specific features, a large debulking shave biopsy finally revealed diagnostic features. If hyperkeratotic areas had been superficially sampled, histologic exclusion of SCC would have been difficult. Familiarity with the histologic features of GVHD-AA is important for pathologists to suggest this diagnosis in patients with cGVHD. Adequate sampling is essential to aid in preventing misdiagnosis or underdiagnosis of this rare entity.

Financial Disclosure:
No current or relevant financial relationships exist.

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Ronald Yang, BS