Pulmonary metastases from angiosarcoma: a spectrum of CT findings

Imaging primary cardiac angiosarcoma: case-based illustrations with multimodality imaging and emphasis on the role of positron emission tomography-CT

Primary cardiac angiosarcomas are extremely rare, highly aggressive tumours with rapid progression and high metastatic capability. More than 60% of tumours are detected after the onset of a metastatic disease. In the two cases presented, we demonstrate the role of muti-modality imaging in the diagnosis of the lesion and provide valuable input in prognosticating the disease burden. In both cases, the diagnosis was suspected initially by imaging, based on radiological observations, before the final histopathology confirmation was made. Positron emission tomography- (PET-CT) was a critical component of the diagnostic workup for the detection of disease extent and volume of total disease burden. Hence, PET-CT imaging should be performed in all aggressive appearing cardiac tumours. In view of misleading clinical presentation, we suggest that aggressive workup to be performed in suspected patients. Young patients presenting with vague symptoms and those with recurrent, unresolving, unexplained pericardial effusion deserves special consideration.

Malignant pleural effusion due to angiosarcoma: A rare entity

ABSTRACT

Angiosarcoma is a rare and aggressive vascular malignancy that typically originates in the skin or soft tissue of the body. It is known to have a propensity for metastasis to the lung parenchyma in the form of pulmonary nodules and cavitary lesions; however, a less commonly described entity is in the form of a malignant pleural effusion. Management of a malignant pleural effusion due to angiosarcoma presents a unique challenge. This article describes the challenges faced during one patient's diagnostic and treatment course, and the anticipated future complications of his aggressive disease.

High-Resolution Computed Tomography of Cystic Lung Disease

The cystic lung diseases (CLD) are characterized by the presence of multiple, thin-walled, air-filled spaces in the pulmonary parenchyma. Cyst formation may occur with congenital, autoimmune, inflammatory, infectious, or neoplastic processes. Recognition of cyst mimics such as emphysema and bronchiectasis is important to prevent diagnostic confusion and unnecessary evaluation. Chest CT can be diagnostic or may guide the workup based on cyst number, distribution, morphology, and associated lung, and extrapulmonary findings. Diffuse CLD (DCLDs) are often considered those presenting with 10 or more cysts. The more commonly encountered DCLDs include lymphangioleiomyomatosis, pulmonary Langerhans' cell histiocytosis, lymphoid interstitial pneumonia, Birt-Hogg-Dubé syndrome, and amyloidosis/light chain deposition disease.

Case report: Primary cardiac angiosarcoma with multiple metastases

This reports outlines a rare case of primary right atrial angiosarcoma with multiple metastases. Multimodality imaging and histopathology confirmed the diagnosis of primary cardiac angiosarcoma and multiple metastases. We present the details of the presentation, multimodality imaging findings, and clinical management. The patient was followed up by cardiac MRI (CMRI) 2 months after therapy, the cardiac tumor and pulmonary metastases decreased markedly. Up to now, the patient has undergone four cycles of chemotherapy and immunotherapy.

Imaging features of primary sites and metastatic patterns of angiosarcoma

Angiosarcomas are rare, aggressive soft tissue sarcomas originating from endothelial cells of lymphatic or vascular origin and associated with a poor prognosis. The clinical and imaging features of angiosarcomas are heterogeneous with a wide spectrum of findings involving any site of the body, but these most commonly present as cutaneous disease in the head and neck of elderly men. MRI and CT are complementary imaging techniques in assessing the extent of disease, focality and involvement of adjacent anatomical structures at the primary site of disease. CT plays an important role in the evaluation of metastatic disease. Given the wide range of imaging findings, correlation with clinical findings, specific risk factors and patterns of metastatic disease can help narrow the differential diagnosis. The final diagnosis should be confirmed with histopathology and immunohistochemistry in combination with clinical and imaging findings in a multidisciplinary setting with specialist sarcoma expertise. The purpose of this review is to describe the clinical and imaging features of primary sites and metastatic patterns of angiosarcomas utilising CT and MRI.

Clinical Detection of Primary Pulmonary Angiosarcoma

Pulmonary angiosarcomas (PAS) are rare malignant vascular tumors that due to their aggressive and metastatic nature, are often diagnosed at a late stage, resulting in a poorer prognosis. Here we present a 53-year-old male who was initially found to have recurring episodes of dyspnea and syncope, with initial workup showing bilateral saddle pulmonary embolisms on computerized tomography, presumed secondary to newly discovered atrial fibrillation with sinus node dysfunction. Further investigation over subsequent months and subsequent biopsy of a potential lung mass ultimately revealed pulmonary angiosarcoma of the spindle cell line. This case emphasizes findings in the current literature, which reveal the time between the onset of symptoms and definitive diagnosis ranges from two to six months, with a median survival time of seven months or two months, with solitary lesions or multiple lesions at the time of diagnosis, respectively. With the limited incidence of PAS, this case suggests benefits in the development of screening and detection criteria for earlier detection and treatment.

Computed tomography features of pulmonary metastases from angiosarcoma: Lessons learned from one case study

A distinctive feature of some angiosarcomas is that two or more atypical forms of pulmonary metastases may be detected concomitantly. In this case report, we present a 37-year-old man diagnosed with angiosarcoma of the neck, with extreme diversity of lung metastases on chest computed tomography (CT). We analyzed CT features of metastases and discussed possible reasons for their pleomorphism, as well as clinical implications of these findings.

CT Findings of Pulmonary Metastases from Primary Cardiac Angiosarcoma

BACKGROUND

Primary cardiac angiosarcoma is a rare malignancy with high predilection to involve surrounding structures such as pulmonary metastases. We analysed the chest computed tomography (CT) imaging features of patients diagnosed with primary cardiac angiosarcoma with pulmonary metastases in this study.

METHODS

This study retrospectively reviewed 12 patients with confirmed primary cardiac angiosarcoma, out of which eight (all men) with pulmonary metastasis were included in the analysis. The patients' age ranged from 17 to 74 (mean: 48) years. CT was performed in all patients with unenhanced, contrast-enhanced, and both scans were done in 1, 3 and 4 patients, respectively.

RESULTS

Nodular lesions were observed in 7 patients with multiple solid nodules observed in 6 out of 7 patients. A solitary solid nodule was found in the remaining patient in the upper lobe and apical segment of the right lung with a diameter of 11.7 mm. All solid nodules were distributed along with bronchovascular bundles in the lungs, and their maximum diameter ranged from 2.3 to 19.9 mm. Nodules larger than 10 mm in diameter were heterogeneously enhanced on contrast-enhanced CT images (5/8 patients), whereas those smaller than 10 mm were homogeneously enhanced (3/8 patients). Other imaging features, namely the tree-in-bud pattern, emphysema, pleural effusion, and mediastinal lymph node enlargement, were observed in 4, 3, 3, and 2 patients, respectively.

CONCLUSION

CT enhancement features of pulmonary metastasis in patients with primary cardiac angiosarcoma depend on the size of pulmonary nodules, with larger ones being heterogeneous and smaller ones homogeneous. Other signs are less noticed.

A Rare Cause of Pulmonary Nodules Diagnosed as Angiosarcoma Was Misdiagnosed as Vasculitis and Wegener's Granuloma in an Elderly Man: A Case Report

Background

Angiosarcoma is a rare, highly malignant tumor prone to recurrence and metastasis. Angiosarcoma is insidious in the initial stage, and its clinical manifestation lacks specificity. The diagnosis is based on histopathology and immunohistochemistry findings.

Case presentation

A 73-year-old man was hospitalized following complaints of persistent cough 6 months and hemoptysis for 2 months. Anti-infective treatment was ineffective. A CT-guided percutaneous core needle biopsy of pulmonary lesions revealed organized pneumonia, and the removed skin of purpuric rash area on the left calf revealed vasculitis. Chest CT was used during the patient follow-up. Hormonal therapy combined with immunoglobulins did not lead to improvement, and there was rapid progression of the lung lesions. Subsequently, the patient underwent a surgery, the diseased tissue was separated and removed completely beside the left submandibular gland under local anaesthesia. The immunohistochemical staining indicated CD31 (+) and CD34 (+) confirming a diagnosis of metastatic angiosarcoma. The expression of PD-L1 was 70%, therefore, anlotinib and pembrolizumab treatments were initiated. The patient eventually died.

Conclusion

Angiosarcoma is a malignant tumor in the clinic that lacks typical and specific signs and symptoms. The diagnosis depends on immunohistochemistry, which requires repeated biopsies of multiple sites in highly suspected cases.

CT Features of Benign Intrapulmonary Lymph Nodes in Pediatric Patients With Known Extrapulmonary Solid Malignancy

OBJECTIVE. The purpose of our study was to determine the CT features of benign intrapulmonary lymph nodes in pediatric patients with known extrapulmonary solid malignancy. MATERIALS AND METHODS. A retrospective review of surgical pathology archives was performed to identify consecutive chest CT studies of pediatric patients (≤ 18 years) with extrapulmonary solid malignancy and histologically confirmed benign intrapulmonary lymph nodes between January 1, 2004, and March 15, 2020. CT features of intrapulmonary lymph nodes-including size, shape, margin, type, associated calcification or fat, and location-were independently evaluated by two pediatric radiologist reviewers. The CT features of benign intrapulmonary lymph nodes in pediatric patients were analyzed using summary statistics. Interobserver agreement was measured with the kappa coefficient. RESULTS. There were 36 pathology-confirmed benign intrapulmonary lymph nodes in 27 pediatric patients (18 boys and nine girls; mean age, 12 years; age range, 1-18.2 years). Twenty-three (63.9%) of the benign intrapulmonary lymph nodes were biopsied from the right lung and 13 (36.1%) from the left lung (p = .03). The mean size, determined from CT studies, of benign intrapulmonary lymph nodes was 3.6 mm (SD, 1.4 mm; range, 1.3-7.8 mm). Triangular shape (25/36, 69.4%) was the most common shape of the benign intrapulmonary lymph nodes. Less commonly seen shapes of benign intrapulmonary lymph nodes were oval (6/36, 16.7%), round (3/36, 8.3%), and trapezoidal (2/36, 5.6%). All benign intrapulmonary lymph nodes were smoothly marginated and solid without associated calcification or fat. Of the 36 benign intrapulmonary lymph nodes, 15 (41.7%) were pleura-based; 11 (30.6%), perifissural; and 10 (27.8%), parenchymal. The kappa value for interobserver agreement between the two reviewers was 0.917 (95% CI, 0.825-1.000; standard error, 0.047), which corresponds to near-perfect agreement. CONCLUSION. In pediatric patients with known extrapulmonary solid malignancy, benign intrapulmonary lymph nodes are subcentimeter (mean size, 3.6 mm), smoothly marginated, and solid without containing calcification or fat on CT. In particular, triangular shape was the most commonly encountered shape of a benign intrapulmonary lymph node.

Rapidly progressive respiratory failure with multiple halo signs on computed tomography in a patient with primary cardiac angiosarcoma derived from the right atrium: a case report

Background

Primary cardiac neoplasms are extremely rare, with an autopsy incidence of 0.0001–0.003%. Primary cardiac sarcoma is usually derived from the right atrium and it manifests as chest pain, arrhythmia, hemoptysis, dyspnea, and fatigue. The most common target organ for metastasis of primary angiosarcoma is the lungs, but the radiological-pathological correlation has been rarely reported.

Case presentation

A 38-year-old healthy Japanese man was admitted to our hospital with persistent hemoptysis, exaggerated dyspnea, and two episodes of loss of consciousness in the past 3 months. Non-enhanced thoracic computed tomography (CT) revealed multiple scattered nodules with halo signs. Contrast-enhanced thoracic CT revealed a filling defect in the right atrium, which corresponded to the inhomogeneously enhancing tumor in the right atrium on enhanced electrocardiogram-gated cardiac CT. On day 2, acute respiratory failure occurred, and the patient was placed on mechanical ventilation. The patient was diagnosed with primary cardiac angiosarcoma based on the urgent transcatheter biopsied specimen of the right atrium mass and was treated with intravenous administration of doxorubicin. However, his respiratory status rapidly deteriorated, and he died on day 20. Postmortem biopsy showed that the multiple lung nodules with the halo signs corresponded to the intratumoral hemorrhagic necrosis and peripheral parenchymal hemorrhage in their background, suggesting the fragility of the lung tissue where the tumor had invaded, which caused hemoptysis. Furthermore, two episodes of loss of consciousness occurred probably due to a decreased cardiac output because of a massive tumor occupying the right atrium, recognized as an inhomogeneous centripetal enhancement on enhanced electrocardiogram-gated cardiac CT.

Conclusions

This case clearly demonstrated that primary cardiac angiosarcoma could expand in the right atrial cavity, which led to a decreased cardiac output resulting in repeated syncope, together with the fragility of lung tissue by tumor invasion, thereby generating a halo sign on thoracic CT.

A Stepwise Diagnostic Approach to Cystic Lung Diseases for Radiologists

Lung cysts are commonly seen on computed tomography (CT), and cystic lung diseases show a wide disease spectrum. Thus, correct diagnosis of cystic lung diseases is a challenge for radiologists. As the first diagnostic step, cysts should be distinguished from cavities, bullae, pneumatocele, emphysema, honeycombing, and cystic bronchiectasis. Second, cysts can be categorized as single/localized versus multiple/diffuse. Solitary/localized cysts include incidental cysts and congenital cystic diseases. Multiple/diffuse cysts can be further categorized according to the presence or absence of associated radiologic findings. Multiple/diffuse cysts without associated findings include lymphangioleiomyomatosis and Birt-Hogg-Dubé syndrome. Multiple/diffuse cysts may be associated with ground-glass opacity or small nodules. Multiple/diffuse cysts with nodules include Langerhans cell histiocytosis, cystic metastasis, and amyloidosis. Multiple/diffuse cysts with ground-glass opacity include pneumocystis pneumonia, desquamative interstitial pneumonia, and lymphocytic interstitial pneumonia. This stepwise radiologic diagnostic approach can be helpful in reaching a correct diagnosis for various cystic lung diseases.

Cystic Interstitial Lung Diseases: A Pictorial Review and a Practical Guide for the Radiologist

A cyst is a round circumscribed area of low attenuation, surrounded by epithelial or fibrous wall. Cysts can frequently occur on chest computed tomography (CT) and high-resolution computed tomography (HRCT); multiple parenchymal cysts of the lungs are the most typical feature of cystic lung interstitial diseases, characterizing a wide spectrum of diseases—ranging from isolated lung disorders up to diffuse pulmonary diseases. The aim of this review is to analyze scientific literature about cystic lung interstitial diseases and to provide a practical guide for radiologists, focusing on the main morphological features of pulmonary cysts: size, shape, borders, wall, location, and distribution. These features are shown on free-hand drawings and related to HRCT images, in order to help radiologists pursue the correct differential diagnosis between similar conditions.

A 27-year-old female presented with diffuse alveolar haemorrhage due to breast angiosarcoma with lung metastasis

Angiosarcomas are rare soft-tissue sarcomas of endothelial cell origin and have a poor prognosis. Diffuse alveolar haemorrhage (DAH) is a syndrome characterized by the accumulation of intra-alveolar red blood cells. However, neoplastic diseases are not commonly considered in the differential diagnosis of DAH. We report a case of a 27-year-old female with the diagnosis of primary breast angiosarcoma developing DAH. This raised our concern that angiosarcoma with lung metastasis may present with DAH and should be considered as an important fatal differential diagnosis of DAH.

Angiosarcoma in the chest: radiologic-pathologic correlation: Case report

RATIONALE

Angiosarcomas are rare, malignant vascular tumors.

PATIENT CONCERNS

They represents about 2% of all soft tissue sarcoma, which can often metastasize through the hematogenous route. The radiological features have been analyzed in 4 patients with metastatic angiosarcoma in the chest.

DIAGNOSES

The main radiologic findings included nodules, cysts, nodules with halo sign, and vascular tree-in-bud. Morphologic features, as observed in the histologic specimen, have been correlated with radiologic appearance.

LESSONS

Metastatic angiosarcomas to the lung are characterized by a wide variety of radiologic appearances that can be very characteristic. Computed tomographic findings observed include bilateral solid nodules, cystic, and bullous lesions sometimes associated with spontaneous hemopneumothoraces.