Primary Pulmonary Angiosarcoma Presenting with Hemoptysis and Ground-Glass Opacity: A Case Report and Literature Review

Diffuse Alveolar Hemorrhage Associated with Epithelioid Angiosarcoma of the Lung: A Challenging Diagnosis

A 68-year-old patient presented with persistent hemoptysis and weight loss. A CT scan showing diffuse bilateral ground-glass opacities and nodules was followed by bronchoscopy. While diffuse alveolar hemorrhage (DAH) could be seen, specimens obtained during bronchoscopy did not provide conclusive histological findings. The decision was made to conduct video-assisted wedge resection, after which histological examinations revealed the diagnosis of bifocal nodular manifestation of an epithelioid angiosarcoma in the lung. Being a rare entity even among sarcomas, these kinds of tumors can be primary lung tissue angiosarcomas or metastatic lesions with primaries in places like the skin, breast, and heart. Treatment usually includes chemotherapy, but prognosis remains grim. This case highlights that in DAH, uncommon causes should be considered, and sufficient probe gathering is the key to early diagnosis and treatment.

Bilateral pneumothorax in a patient with angiosarcoma of the scalp: a case report

BACKGROUND

Angiosarcoma is a rare, vascular malignancy that arises from endothelial cells of blood vessels. This case report aims to create the awareness of its existence in the region and its mode of presentation.

CASE PRESENTATION

A 63-year-old Pakistani man presented to the emergency department with sudden bilateral chest pain and shortness of breath for 2 days. On examination, a scalp lesion was seen which had been increasing in size over the last 6 weeks. The lesion was 8 × 10 cm in size with an irregular border, non-tender, violet and dome-shaped in elevation on the right occipito-parietal lobe of the skull. Chest computed tomography (CT) showed multiple cystic lesions on both lungs, patchy areas of ground-glass opacities, nodules of variable sizes and bilateral pneumothorax. Bilateral tube thoracostomy was performed which provided symptomatic relief for shortness of breath. His bronchoalveolar lavage (BAL) was negative for infection. He underwent biopsy of scalp lesion which was positive for aggressive angiosarcoma.

CONCLUSION

Bilateral spontaneous pneumothorax can be the initial manifestation of aggressive cutaneous angiosarcoma and frequently leads to respiratory failure. Early recognition is essential to prevent delay in diagnosis and management.

Pulmonary Angiosarcoma With Synchronous Invasive Aspergillosis Presenting as Diffuse Alveolar Hemorrhage and Acute Kidney Injury: A Case Report of a Previously Unreported Combination Posing a Diagnostic Challenge

Angiosarcoma is a rare soft tissue sarcoma originating from endothelial cells. It can occur anywhere when there is a blood vessel or lymphatic channel, making highly perfused cutaneous sites their usual location, though they can also develop within visceral structures. Pulmonary angiosarcoma is usually caused by metastasis from other primary sites. The clinical course of pulmonary angiosarcoma is very aggressive, and the prognosis is poor. We present a case of a 55-year-old man who presented to the hospital with progressive exertional dyspnea and right-sided pleuritic chest pain for the past few days. He was found to have recurrent anemia and acute kidney injury. His hospital course was complicated by the development of hypoxia and hemoptysis. Computed tomography of the chest without contrast revealed bilateral nodular, ground-glass opacities compatible with diffuse alveolar hemorrhage. Further investigation with a lung biopsy revealed epithelioid angiosarcoma with extensive microvascular tumor emboli and invasive pulmonary aspergillosis (Aspergillus fumigatus) with patchy necrotizing pneumonia. He later developed acute hypoxic respiratory failure and worsening kidney failure, so he was transferred to the intensive care unit. Upon discussing with the family, the patient was put on comfort measures, and he passed away the following day. We present a rare presentation of concurrence of pulmonary angiosarcoma and invasive aspergillosis. Upon searching the literature, our case is one of the first to report such concurrence. Because of its rarity, the non-specific clinical presentation makes the diagnosis challenging.

Primary pulmonary epithelioid angiosarcoma with thyroid tumor history: A case report and literature review

Primary pulmonary epithelioid angiosarcoma is a rare tumor type without any specific clinical and imaging features. Therefore, it is associated with high rates of misdiagnosis. The present study reports the case of a 54-year-old female patient who was admitted after complaining of cough, expectoration and bloody sputum for >5 months in May 2021. The patient reported a previous history of papillary thyroid carcinoma in 2003 and had undergone treatment through surgery, postoperative chemotherapy and iodine¹³¹ therapy. Chest computed tomography (CT) was performed in May 2021, which indicated that the disease had progressed rapidly since February 2021. CT-guided lung biopsy and immunohistochemical staining of the tumor indicated positivity for CD31, CD34 and E26 transformation-specific-related gene markers. The tumor was negative for thyroid cancer-associated antibodies; thus, a diagnosis of primary pulmonary epithelioid angiosarcoma was made. The patient died 3 months after the diagnosis. Primary pulmonary epithelioid angiosarcoma is a rare tumor type with high recurrence and metastasis rates. This tumor has no specific clinical symptoms and signs and is thus easily misdiagnosed. Biopsy is essential for diagnosis of the disease, particularly if patients have a tumor history.

Rare primary pulmonary angiosarcoma with aberrant neuroendocrine differentiation

Angiosarcomas are aggressive, malignant endothelial cell tumors derived from the vascular or lymphatic epithelium. Angiosarcomas makes up less than 1% of all soft tissue sarcomas. Primary pulmonary angiosarcoma is a rare tumor that most commonly presents as metastatic disease and carries a grim prognosis. The disease rarity and low index of suspicion make the diagnosis problematic. In this report, we present a case of primary pulmonary angiosarcoma with aberrant neuroendocrine differentiation. The diagnostic images, pathology and management strategy are discussed in this case with overall longer survival. The unique neuroendocrine pathologic subtype may contribute to the overall longer survival, however, there are only a few limited cases published. Further recognition and investigation of primary pulmonary angiosarcoma with aberrant neuroendocrine differentiation is warranted to further characterize diagnostic markers, determine more effective treatment strategies, and establish a possible link to improved survival.

Primary pulmonary arterial sarcoma treated with endostar injection and radiotherapy

We present a case of primary pulmonary arterial sarcoma (PPAS) treated with endostatin (endostar) injection and radiotherapy  discuss the diagnosis, clinical manifestations, and pathology of PPAS. The patient complained of cough with sputum, fever, and chest pain with hemoptysis. Numerous nodules were observed in the computed tomography (CT) scan. The patient was diagnosed with pulmonary embolism (PE) by computed tomography pulmonary angiography (CTPA). The pathology and immunohistochemistry results indicated soft tissue sarcomas, indicative of angiosarcoma. The nodules shrunk after 5 courses of endostatin and one course of radiotherapy, as determined in the CT scan. Primary pulmonary arterial sarcoma is clinically rare with nonspecific symptoms. Hence, it can be easily misdiagnosed as PE, and biopsy must be performed for confirmation. Current treatment methods, including surgery, are limited. Therefore, administration of endostatin injection combined with other therapies may be an alternative treatment methods.

Metastatic angiosarcoma of unknown primary site misdiagnosed as tuberculosis

Tuberculosis in endemic areas is likely to be overdiagnosed in patients with atypical clinical and imaging findings mimicking tuberculosis, as in our case of angiosarcoma. Detailed history, physical examination, imaging, and histopathology avert diagnosis of tumors as tuberculosis in resource-limited settings, where countless diseases have common clinical and imaging presentations.

Primary Pulmonary Epithelioid Angiosarcoma: A Rare Case Presentation of Bilateral Pneumothoraces

Angiosarcoma is a rare malignant neoplasm with a very poor prognosis that originates from the vascular endothelium and accounts for only 1%-2% of all sarcomatous malignancies. It is most commonly present in the deep soft tissues. Still, a wide range of primary sites, including the adrenals, thyroid, skin, and bone, are encountered. Here, we report a 52-year-old female with a past medical history of hypertension who presented with chest pain. Her chest images showed bilateral pneumothoraces with diffuse cystic lung disease. She underwent bilateral video-assisted thoracoscopy with a tissue biopsy, which was consistent with epithelioid angiosarcoma.

Angiosarcoma-related cerebral metastases: a systematic review of the literature

Angiosarcoma-related cerebral metastases have only been recorded in a few case reports and case series and have not been systematically reviewed to date. Our objective was therefore to perform a systematic literature review on cases of angiosarcomas metastasizing to the brain to inform current practice. All three major libraries-PubMed/MEDLINE, Embase, and Cochrane-were systematically searched, until January 2019. Articles in English reporting angiosarcoma-related cerebral metastases via hematogenous route were included. Our search yielded 45 articles (38 case reports, 5 retrospective studies, 1 case series and 1 letter to the editor), totaling 48 patients (mean age 47.9 years). The main primary site was the heart. The mean time of diagnosis of cerebral metastases following primary tumor identification was 4.9 months. In 15 cases, the brain was the only metastatic site. In cases of multiple extracerebral metastases, the most common sites were the lung and bone. Acute intracerebral supratentorial hemorrhage was the most common presenting radiological feature. Treatment strategies were almost equally divided between the surgical (with or without adjuvant treatment) and the medical arm. Mean overall survival was 7.2 months while progression-free survival was 1.5 months. To our knowledge, this is the first systematic literature review on angiosarcoma-related cerebral metastases. This pathology proves to be an extremely rare clinical entity and carries a poor prognosis, and no consensus has been reached regarding treatment.

Correlations between computed tomography and positron emission tomography/computed tomography findings and pathology in 6 cases of pulmonary epithelioid angiosarcoma

Previous studies on primary pulmonary epithelioid angiosarcoma (PEA) have been mostly clinical or pathological case reports. We here summarize findings from computed tomography (CT) and positron emission tomography/computed tomography (PET/CT) analyses of PEA to improve the diagnosis and differentiation of this rare tumor.We conducted a retrospective analysis of the clinical findings, radiological imaging, and pathological findings of 6 cases of primary PEA confirmed by surgery, biopsy, and pathology. All cases were evaluated by CT and x-ray prior to surgery, and 2 cases were further examined by PET/CT.CT images indicated maximum tumor diameters of 2.4 to 9.8 cm and inhomogeneous density, with 1 case exhibiting nodular calcification. Contrast-enhanced CT revealed inhomogeneous enhancement with visible necrosis in all 6 cases, while 3 cases had hilar and mediastinal lymph node metastasis. Five cases displayed extensive tumor involvement with extension into the chest wall, mild-to-moderate levels of pleural effusion, and varying degrees of volume loss in the corresponding hemithorax. One case had limited pleural thickening and invasion. Preoperative PET/CT of 1 case revealed abnormal fluorine-18 fluorodeoxyglucose (F-FDG) uptake by the tumor and multiple enlarged right hilar and mediastinal lymph nodes, right diffuse pleural thickening, and systemic multiple bone metastasis. In the other case, PET/CT scan at 7 months after surgery revealed pleural thickening and mediastinal lymph nodes with increased F-FDG uptake on the surgical side. Immunohistochemistry analyses determined that all 6 tumors were positive for CD34, CD31, ERG, and vimentin.CT and PET/CT findings reveal that malignant characteristics, including extensive pleural thickening, invasion and metastasis, and pleural effusion, are common in PEA. Imaging data are only supportive; therefore, the final diagnosis should be based on pathology and immunohistochemistry analyses.

Radiologic findings of primary pulmonary angiosarcoma: A case report

RATIONALE

Primary pulmonary angiosarcoma is a rare disease. Here, we report the case of primary pulmonary angiosarcoma diagnosed computed tomographic pulmonary angiography (CTPA) and discuss its specific imaging characteristics.

PATIENT CONCERNS

A 46-year-old man was admitted for cough and shortness of breath. Thoracic CTPA images demonstrated a high-attenuation lesion surrounding by a halo sign in upper lobe of right lung, and the dilated vessel was also seen in lower lobe of right lung. The sign of "hillside sign" was observed on CTPA.

DIAGNOSES

It was diagnosed with primary pulmonary angiosarcoma.

INTERVENTIONS

Right thoracotomy and right upper lobe lobectomy were performed.

OUTCOMES

Five years later, the patient dead of complete occlusion of the pulmonary artery owing to tumor recurrence.

LESSONS

Although primary pulmonary angiosarcoma is a rare disease with atypical early clinical symptoms, and it is often misdiagnosed as pulmonary embolism and pulmonary infection. Therefore, it is important to recognize the CTPA imaging characteristics of primary pulmonary angiosarcoma and Surgical resection should be performed to prolong the patients' lifetime.

Angiosarcoma of the lung

Angiosarcoma is a rare malignant vascular tumor. Pulmonary involvement is usually attributable to metastasis from other primary sites, primary pulmonary angiosarcoma therefore being quite uncommon. We report a case of angiosarcoma with pulmonary involvement, probably primary to the lung, which had gone untreated for more than two years. We describe this rare neoplasm and its growth, as well as the extensive local invasion and hematogenous metastasis at presentation. We also discuss its poor prognosis.

Primary pulmonary angiosarcoma: Three case reports and literature review

Primary pulmonary angiosarcoma is a rare type of malignant vascular tumor with a very aggressive clinical course and a grim prognosis. To date, only a handful of cases have been reported in English literature. Its rarity and consequent low index of suspicion makes clinical diagnosis difficult. In this report we present three cases of primary pulmonary angiosarcoma with cough, hemoptysis, and progressive dyspnea to contribute to the sparse literature on this disease. A review is made of previous reports of primary pulmonary angiosarcomas, and the clinical characteristics, diagnosed method, treatment options, and prognosis of pulmonary angiosarcoma are also discussed.