Massive bleeding after fine needle aspiration of liver angiosarcoma

A pooled analysis of treatment and prognosis of hepatic angiosarcoma in adults

BACKGROUND

Hepatic angiosarcoma is a rare malignant vascular tumor presenting unique treatment challenges. The aim of the present study was to determine the treatment and prognosis of this entity.

DATA SOURCES

A systematic literature search was conducted using PubMed, Embase and Chinese Biomedical Literature database, to identify articles published from January 1980 to July 2017. Search terms were "hepatic angiosarcoma" and "liver angiosarcoma". Additional articles were retrieved through manual search of bibliographies of the relevant articles. Pooled individual data concerning the prognosis following various therapeutic modalities were analyzed.

RESULTS

A total of 75 articles involving 186 patients were eligible for inclusion. The median overall survival (OS) was 8 months, with 1-, 3-, and 5-year OS rates of 36.6%, 22.3%, and 12.0%, respectively. The median OS after partial hepatectomy (n = 86), chemotherapy (n = 36), liver transplantation (n = 17), and supportive care (n = 46) were 15, 10, 5 and 1.3 months, respectively. Small tumor size (<10 cm) was the only significant favorable factor for OS after partial hepatectomy (P = 0.012).

CONCLUSIONS

Despite the dismal prognosis, partial hepatectomy could prolong the survival of hepatic angiosarcoma patients, particularly those with tumors <10 cm. Chemotherapy could be an option for unresectable disease. Liver transplantation is not a recommendable option for the management of this malignancy.

Clinical courses of primary hepatic angiosarcoma: retrospective analysis of eight cases

BACKGROUND/AIMS

Hepatic angiosarcoma, a rare and aggressive liver malignancy, is difficult to diagnose because of a lack of specific clinical features. The clinical and radiological features of patients with histologically confirmed hepatic angiosarcoma were examined.

METHODS

Among 2,336 patients diagnosed with primary hepatic carcinoma at Keimyung University Dongsan Medical Center (Daegu, Korea) between May 2002 and February 2012, eight (0.03%) with histologically confirmed primary hepatic angiosarcoma were included. The patterns of disease diagnosis, tumor characteristics, treatment responses, and prognoses were reviewed retrospectively.

RESULTS

Median age was 66 years-old (range, 41-80 years). Four patients were male. Five patients were compulsive drinkers. All patients had no HBsAg and anti-HCV. Initial radiologic diagnoses revealed primary hepatic angiosarcoma (n=2), hepatocellular carcinoma (n=2), hemangioma (n=2), and hepatic metastatic carcinoma (n=2). Definitive diagnoses were made by percutaneous needle biopsies in seven patients and surgical resection in one patient. At the time of the initial diagnosis, extrahepatic metastases were detected in three patients (37.5%). Metastatic sites included the spleen and lung, pericardium, and bone, in one patient each. Two patients underwent conservative treatments. The remaining patients underwent surgical resection (n=1), transcatheter arterial chemoembolization (n=1), and systemic chemotherapy (n=4). The median survival period was 214 days (range, 21-431 days).

CONCLUSIONS

Hepatic angiosarcoma is a highly progressive disease with a poor prognosis. Detailed studies including histological examinations are essential to facilitate early diagnosis of the disease.

Primary hepatic angiosarcoma

Primary hepatic angiosarcoma is a rare, aggressive tumor; composed of spindle or pleomorphic cells that line, or grow into, the lumina of pre-existing vascular spaces like sinusoids and terminal hepatic venules; with only about 200 cases diagnosed annually worldwide but it is the most common primary malignant mesenchymal tumor of the liver in adults and accounts for 2% of all primary hepatic malignancies. HAS occurs in association with known chemical carcinogens, but 75% of the tumors have no known etiology. Patients present with vague symptoms like abdominal pain, weight loss, fatigue or an abdominal mass. Hepatic angiosarcoma is usually multicentric and involves both lobes, entire liver may also found to be involved. CD31 is the most reliable marker. These tumors lack specific features on imaging, so, pathological diagnosis is necessary. There are no established treatment guidelines because of low frequency and aggressive nature of tumor, chemotherapy is only palliative, liver resection is indicated for solitary mass and liver transplant is contraindicated. The aim of this article is to comprehensively review all the available literature and to present detailed information and an update on primary hepatic angiosarcoma.

Fulminant hepatic failure secondary to primary hepatic angiosarcoma

Background. Hepatic angiosarcoma is a rare and aggressive tumor that often presents at an advanced stage with nonspecific symptoms. Objective. To report a case of primary hepatic angiosarcoma in an otherwise healthy man with normal liver function tests two months prior to presenting with a short period of jaundice that progressed to fulminant hepatic failure. Methods. Case report and review of literature. Conclusion. This case illustrates the rapidity of progression to death after the onset of symptoms in a patient with hepatic angiosarcoma. Research on early diagnostic strategies and newer therapies are needed to improve prognosis in this rare and poorly understood malignancy with limited treatment options.

Cytopathologic diagnosis of liver mass lesions

The liver is a common site for metastatic malignancies, particularly from the gastrointestinal tract. It also may be involved by primary neoplasms, both benign and malignant. Cytopathologic examination of mass lesions of the liver with pertinent use of ancillary studies is a useful method of establishing a correct diagnosis for patient management. The authors reviewed the literature for articles pertaining to cytologic characteristics of specific tumor types, utility of immunohistochemical markers and pertinent molecular studies, differential diagnoses and pitfalls.

The natural history of a hepatic angiosarcoma that was difficult to differentiate from cavernous hemangioma

A 69-year old man came to our hospital complaining of abdominal pain. Contrast-enhanced computed tomography (CT) showed a 65-mm ruptured mass in Couinaud segment 5 of the liver. The mass was treated with emergent transcatheter arterial embolization (TAE), followed by partial hepatectomy. Microscopically, the mass was determined to be an angiosarcoma. Six months previously, enhanced CT had shown a 15-mm mass diagnosed as a cavernous hemangioma in the same region of the liver. Even when the enhancement pattern of a small hepatic mass resembles that of hemangioma, the mass should be reassessed within several months to exclude a diagnosis of hepatic angiosarcoma.

Mesenchymal tumors of the liver

Primary angiosarcoma of the liver accounts for up to 2% of all primary liver tumors and is the second most common primary malignant neoplasm of the liver. Approximately 10 to 20 new cases are diagnosed every year in the United States and the prevalence varies from 0.14 to 0.25 per million. In an autopsy series from Chicago, one hepatic angiosarcoma was noted for every 30 cases of hepatocellular carcinoma.

Cytology of angiosarcoma. Findings in fourteen fine-needle aspiration biopsy specimens and one pleural fluid specimen

We report the cytologic features of 15 cases of angiosarcoma from various sites and include 14 fine-needle aspiration (FNA) biopsy specimens and 1 pleural fluid specimen. Six were initial diagnoses with histologic confirmation; an additional case in the liver was an initial diagnosis without tissue confirmation. One case represented lymph node metastasis from a primary prostatic epithelioid angiosarcoma. In 10 cases, immunohistochemical staining for factor VIII-related antigen, CD34, CD31, or Ulex europaeus agglutinin I was performed on the cytology or histology specimen. The aspirates varied in cellularity, and the degree of nuclear atypia ranged from relatively bland in a case of low-grade angiosarcoma of the prostate to highly pleomorphic in a lymph node metastasis from a facial cutaneous angiosarcoma. Vasoformative features such as intracellular RBCs, well-formed vessels, attempts at microacinar/lumen formation, and intracytoplasmic lumens were variably present. The background was bloody in all specimens, with necrosis in rare cases. This cytologic series emphasizes that the cytologic features are heterogeneous but that the diagnosis can be suggested by fine-needle aspiration (FNA) when vasoformative features are present. The diagnosis can be made conclusively by FNA with immunocytochemical confirmation of endothelial differentiation.

Two cases of lethal complications following ultrasound-guided percutaneous fine-needle biopsy of the liver

Two cases with lethal complications are reported among 1750 ultrasound (US)-guided percutaneous fine-needle liver biopsies performed in our department. The first patient had angiosarcoma of the liver which was not suspected after computed tomography (CT) and US studies had been performed. The other patient had hepatocellular carcinoma in advanced hepatic cirrhosis. Death was due to bleeding in both cases. Pre-procedure laboratory tests did not reveal the existence of major bleeding disorders in either case. Normal liver tissue was interposed in the needle track between the liver capsule and the lesions which were targeted.

Fine-needle aspiration biopsy of hepatic angiosarcoma: report of a case with immunocytochemical findings

Hepatic angiosarcoma (Kupffer cell sarcoma) is a very rare but ominous malignancy. We report a case diagnosed by fine-needle aspiration biopsy (FNAB). The smear showed malignant spindle cells and a few rounded cells. The diagnosis was made on the cell block by the characteristic scaffolding arrangement of malignant cells along preexisting hepatocytes. This is the first report with immunocytochemical findings. The tumour cells stained positively for vimentin and negatively for keratin, factor VIII, Ulex europaeus agglutinin I (UEA-1), carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP), and lysozyme. This case demonstrates the possibility of a definitive diagnosis by FNAB prior to death without inflicting serious complications.

Imaging-guided and nonimaging-guided fine needle aspiration of liver lesions: experience with 406 patients

The aim of the present study was to determine the diagnostic accuracy of different modes of fine needle aspiration (FNA) of liver lesions. A total of 492 FNAs were performed on 406 patients in order to confirm or to rule out focal or multifocal neoplastic disease: 29% under ultrasound (US) guidance, 3% with computed tomographic (CT) guidance, 67% preoperatively, and 1% intraoperatively without imaging guidance. Based on histologic, cytologic, and clinical findings, final diagnoses were reached in 387 patients, of whom 264 had malignant liver disease and 123 had benign liver disease. Of 321 aspirations performed in patients with malignant liver disease, the cytologic findings suggested malignancy in 225 (70.1%), suspected malignancy in 25 (7.8%), and did not reveal malignancy in 71 aspirations (22.1%). Among the 123 patients with benign liver disease, the cytologic findings were reported as benign in all but two patients, who had false-positive cytologic findings. The overall sensitivity, specificity, positive, and negative predictive values for cytologic findings were 85.6, 98.4, 99.1, and 76.1%, respectively. The overall diagnostic accuracy was 89.7%. In one patient, fatal intraperitoneal bleeding due to chronic intravascular coagulation complicated the FNA procedure. We conclude that imaging-guided FNA as well as nonguided FNA for cytologic diagnosis of liver lesions are highly accurate and only rarely may be associated with a fatal complication.