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Pathology of Perivascular epithelioid cell neoplasms   (PEComa) -Infographic

Dr Sampurna Roy MD           


 [Perivascular epithelioid cell neoplasms   (PEComa) -Pathology Infographic posted in LinkedIn]





"Perivascular epithelioid cell neoplasms (PEComas) are defined by the World Health Organisation Classification of Tumors of Soft Tissue and Bone as mesenchymal tumors composed of perivascular epithelioid cells with unique histological properties and immunophenotypes".

Bonetti et al. firstly proposed the descriptive name of Perivascular Epithelioid Cells (PEC) in 1992.  Zamboni et al. introduced the term PEComa in 1996.

"Perivascular Epithelioid Cell tumours (PEComas) represent a family of rare mesenchymal neoplasms, including angiomyolipoma (AML), clear cell "sugar" tumour (CCST) of the lung, lymphangioleiomyomatosis (LAM), clear cell myomelanocytic tumour (of the falciform ligament/ligament teres), and unusual clear cell tumours of the pancreas, rectum, abdominal serosa, uterus, vulva, thigh, and heart. 

The tumour is more frequent in females than in males (6:1) with a median age of 45 years. Some cases are associated with the Tuberous Sclerosis Complex, especially AML, CCST, and LAM"

Lubo I, Fermín I, Massarelli O, Gobbi R, Cossu Rocca P. Perivascular Epithelioid Cell Tumour with Intraorbital Location: Report of a Case and Review of the Literature. Case Reports in Pathology. 2016;2016:1936421. doi:10.1155/2016/1936421.

Renal angiomyolipoma (AML) is the most common PEComa.

Both benign and malignant tumours have been described.

Malignant tumours are diagnosed by histologically confirmed lymph node metastases and radiological evidence of pulmonary metastases.

Histopathological features: 


D’Andrea D, Hanspeter E, D’Elia C, Martini T, Pycha A. Malignant Perivascular Epithelioid Cell Neoplasm (PEComa) of the Pelvis: A Case Report. Urology Case Reports. 2016;6:36-38. doi:10.1016/j.eucr.2016.02.004.

These tumours are closely located to vascular structures and are characterized by spindle to epithelioid cells with clear to pale eosinophilic cytoplasm arranged in fascicular or nested patterns.

Immunohistochemically, the tumour cells expressed HMB45 and smooth muscle actin and micropthalmia transcription factor. 

Over 50% of them stain for melan-A (sometimes in the absence of HMB45), and around 25% are desmin positive.

A subset of cases stain for S-100 protein (may cause confusion with melanoma) and TFE3.

Differential diagnosis:

The differential diagnosis of PEComas  depends on the morphology (epithelioid vs spindled) and location of the neoplasm. 

PEComas must be distinguished from conventional melanoma and clear cell sarcoma.

Gastrointestinal stromal tumor (GIST) and carcinoma (especially clear cell carcinoma) may also be confused with epithelioid PEComas.

Smooth muscle neoplasm (with epithelioid and spindled morphology) is another tumour for which PEComas may be mistaken.

Folpe et al proposed the categorization of PEComas into three groups based on tumor diameter, nuclear grade and cellularity, mitotic rate, necrosis, vascular invasion and infiltrative growth.

Proposed classification of PEComas: Folpe A.L., McKenney J.K., Li Z., Smith S.J., Weiss S.W. Clear cell myomelanocytic tumor of the thigh. Am J Surg Pathol. 2002;26(6):809–812.

Benign <5 cm in diameter
Non-high nuclear grade and cellularity
Mitotic rate ≤1/50 HPF
No necrosis
No vascular invasion


Uncertain malignant potential One or both of the following features:
Nuclear pleomorphism/multinucleated giant cells
>5 cm in diameter


Malignant Two or more of the following features:
>5 cm in diameter
High nuclear grade and cellularity
Mitotic rate ≥1/50 HPF
Vascular invasion


Further reading:

D’Andrea D, Hanspeter E, D’Elia C, Martini T, Pycha A. Malignant Perivascular Epithelioid Cell Neoplasm (PEComa) of the Pelvis: A Case Report. Urology Case Reports. 2016;6:36-38. doi:10.1016/j.eucr.2016.02.004.

Folpe A.L., Mentzel T., Lehr H.-A., Fisher C., Balzer B.L., Weiss S.W. Perivascular epithelioid cell neoplasms of soft tissue and gynecologic origin. Am J Surg Pathol. 2005;29(12):1558–1575.

 Hornick J.L., Fletcher C.D.M. PEComa: what do we know so far? Histopathology. 2006;48(1):75–82. [PubMed]






Dr Sampurna Roy  MD

Consultant  Histopathologist (Kolkata - India)






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