Primary hepatic angiosarcoma: multi-institutional comprehensive cancer centre review of multiphasic CT and MR imaging in 35 patients

Rare Malignant Liver Tumors: Current Insights and Imaging Challenges

Rare malignant liver tumors (RMLTs) comprise a diverse group of neoplasms with distinct imaging features and significant diagnostic challenges due to their low prevalence and overlap with more common hepatic lesions. This review highlights the main radiologic characteristics of selected rare malignant liver tumors-including fibrolamellar hepatocellular carcinoma, hepatic lymphoma, hepatocellular carcinoma in non-cirrhotic liver, mucinous cystic neoplasm, intraductal papillary neoplasm of the bile duct, epithelioid hemangioendothelioma, angiosarcoma, malignant hepatic adenoma, neuroendocrine tumor, hepatocholangiocarcinoma, hepatoblastoma, undifferentiated embryonal sarcoma, and infantile hepatic hemangioendothelioma-focusing on their presentation in computed tomography and magnetic resonance imaging. Recognizing specific imaging findings, such as arterial hyperenhancement, biliary communication, target and lollipop signs, and tumor morphology, can help narrow differential diagnoses and guide appropriate clinical management. Despite advancements in imaging, histopathologic confirmation is often required due to nonspecific features. Improved radiologic awareness of these rare entities is essential to facilitate early diagnosis and individualized treatment planning.

Magnetic resonance imaging and clinicopathological findings of primary hepatic angiosarcoma

PURPOSE

To investigate the magnetic resonance imaging (MRI) and clinicopathological features of primary hepatic angiosarcoma (PHA) and enhance preoperative diagnosis.

METHODS

MRI and clinicopathological information of 12 cases proved PHA were reviewed. Summarize the MRI characteristics of PHA combined with literature reviews.

RESULTS

Among 12 cases (6 males and 6 females; age range, 23-70 years; mean, 53.3 years), one presented as a large mass, two as a diffuse infiltrating tumor, and nine as a mixed pattern of large masses with multiple nodules, all involving both lobes of the liver and ranging from 0.1 cm to 11 cm in diameter. A total of 63 lesions were analyzed, including 21 masses and 42 nodules. 13 masses (61.9%) demonstrated intratumoral hemorrhage. 18 masses (85.7%) demonstrated heterogeneous patchy, ring-shaped, septate, or irregular shaped enhancing foci on late arterial phase (LAP). On dynamic contrast-enhanced MRI (DCE-MRI), 14 masses (66.7%) showed a centripetal or centrifugal pattern of incomplete progressive enhancement. 6 nodules (14.3%) appeared intratumoral hemorrhage. 31 nodules (73.8%) showed no enhancing foci on LAP images and 27 nodules (64.3%) showed enhancement pattern of complete filling, either centripetal or centrifugal pattern. Moreover, 12 cases (100%) exhibited prominent vessels within or adjacent to at least one lesion.

CONCLUSION

PHA exhibits diverse appearances on MRI. Typical MRI signs include multifoci with intratumoral hemorrhage, prominent vessels within or adjacent to the foci, as well as varied degrees of progressive enhancement with incomplete filling in dominant masses of PHA.

Comparison of clinical and MRI features of hepatic angiosarcoma and epithelioid hemangioendothelioma

OBJECTIVE

Differentiating hepatic epithelioid hemangioendothelioma (EHE) and angiosarcoma (AS), the two most common vascular tumors in the liver, is important due to disparities in their prognosis and treatment. We aimed to compare clinical and MRI features of the two tumors.

METHODS

This retrospective study included patients with pathologically-confirmed AS or EHE who underwent MRI using gadoxetate disodium between 2008 and 2023. Two radiologists independently reviewed MR images. Wilcoxon rank sum and Fisher's exact tests were used to compare clinical and imaging features. Overall survival was compared using restricted mean survival time at 3 years.

RESULTS

32 patients with AS (18 women [56.3%]; median age, 68 years) and 38 with EHE (24 women [63.2%]; 51 years) were included. Patients with AS were generally older (81.3% ≥ 60 years; P < 0.001), had more frequent laboratory abnormalities (P ≤ 0.018), and poorer overall survival (11.2 vs. 31.8 months; P < 0.001) than those with EHE. On MRI, a large dominant mass accompanied by smaller nodules (14/32, 43.8%), often with ill-defined margins (15/32, 46.9%) was prevalent in AS; compared with nodules of similar sizes (24/38, 63.2%; P = 0.015) with well-defined margin (30/38, 78.9%; P = 0.002) in EHE. Cirrhotic appearance of the liver was more frequent in AS (62.5%, P < 0.001), along with decreased parenchymal enhancement on hepatobiliary phase (31.3%, P < 0.001) and ascites (37.5%, P = 0.010). AS frequently presented with avid enhancement of bizarrely-shaped foci, with a centrifugal enhancement pattern. In comparison, targetoid appearance was characteristic of EHE (78.9% on T2-weighted, 54.1% on diffusion-weighted, 65.8% on multiphase images) (P ≤ 0.002), with enhancement degree typically lower than that of the aorta. On hepatobiliary phase, all the AS exhibited hypointensity, while 39.5% of EHE showed targetoid appearance (P < 0.001).

CONCLUSION

Patients aged ≥ 60 years presenting with laboratory abnormalities, typically with a large dominant mass accompanied by smaller nodules, exhibiting avid, bizarre, and centrifugal enhancement-particularly in the cirrhotic-appearing liver-suggests the likelihood of AS over EHE.

Discontinuous peripheral enhancement of focal liver lesions on CT and MRI: outside the box of typical cavernous hemangioma

The discontinuous peripheral enhancement is a pattern of enhancement usually attributed to typical cavernous hemangioma, that is the most common benign solid lesion of the liver. The discontinuous peripheral enhancement, however, may be encountered in many other benign and malignant focal liver lesions as an atypical presentation or evolution, and hemangiomas with discontinuous peripheral hyperenhancement on hepatic arterial phase may not always have the typical post-contrast pattern on portal venous and delayed phases. Therefore, abdominal radiologists may be challenged in their practice by lesions with discontinuous peripheral enhancement. This pictorial essay aims to review the spectrum of benign and malignant focal liver lesions that may show discontinuous peripheral enhancement. A particular point of interest is the diagnostic tree pathway that may guide the radiologists in the differential diagnosis.

Demographics, Prognostic Factors, and Survival Outcomes in Hepatic Angiosarcoma: A Retrospective Analysis

BACKGROUND

Hepatic angiosarcoma (HA) is a rare malignant vascular neoplasm. Currently, there are no standardized protocols for treating HA. This study aims to understand clinicopathologic analysis, prognostic factors, and treatment outcomes comprehensively.

METHODS

The data retrieved from the SEER database was reviewed for hepatic angiosarcoma cases between 2000 and 2021.

RESULTS

A total of 389 patients with hepatic angiosarcoma were identified with a mean age of 63.9 years (SD ± 16). Most patients were male (64%), and per US census data, non-Hispanic Asians or Pacific Islanders were the most common race (17%). In known cases of tumor stage (61%), the most common tumor stage was distant (22%), and most were grade III (18%) tumors. Overall, the 3-year survival rate was 6.7% with a 95% confidence interval (95% CI 0.044-0.100), disease-specific survival at a 1-year survival rate was 4.43% (95% CI 0.023-0.083), and no patients survived by 3 years. The best overall survival rate was the 1-year rate for surgical resection, 18.20% (95% CI 0.075-0.441). Chemotherapy had a 1-year survival rate of 11% (95% CI 0.057-0.211), and radiation therapy had no survival significance (p = 0.2). Multivariate analysis shows age above 70 years (H.R. 1.67 (95% CI 1.181-2.381), p < 0.05), no surgical intervention (H.R. 2.29 (95% CI 1.585-3.336) p < 0.001), and distant stage (H.R. 2.54 (95% CI 1.696-3.805) p < 0.001) are negative prognostic factors, whereas female sex (H.R. 0.68 (95% CI 0.536-0.875) p < 0.05) is a positive prognostic factor.

CONCLUSION

Increasing age (> 70 years), male sex, and distant stage were found to be strong predictors of poor survival outcomes. Patients had better outcomes when surgical resection and chemotherapy were included in their treatment. These results can provide continued evidence in the future management of patients with hepatic angiosarcoma.

An Infiltrative Case of Angiosarcoma Causing Portal Hypertension

Hepatic angiosarcoma is a rare and aggressive liver tumor. We report a case study of an 82-year-old elderly gentleman who presented with failure to thrive and ascites. Initially suspected to be cirrhosis, biopsy results eventually concluded angiosarcoma of the liver. Our patient presented with an infiltrative form, rather than distinct masses, which led to portal hypertension and ascites. The variance in symptomatology and radiology presentations make a diagnosis of hepatic angiosarcoma challenging and require a high index of suspicion.

Acute respiratory distress syndrome as the initial symptom of hepatic angiosarcoma with Kasabach-Merritt syndrome: A case report

RATIONALE

Hepatic angiosarcoma (HSA) has a poor prognosis. Our understanding of its clinical features, diagnosis, treatment, and prognosis remains limited. In certain cases, vascular tumors such as HSA can induce bleeding complications due to thrombocytopenia, known as Kasabach-Merritt syndrome (KMS). When KMS symptoms occur in the lungs, its clinical manifestations closely resemble those of ARDS, leading to misdiagnosis and poor outcomes. Unfortunately, this condition is extremely rare and there is a lack of relevant case reports, which further adds to the difficulty of its diagnosis and treatment.

PATIENT CONCERNS

This case report describes a patient who initially presented with symptoms of ARDS. Due to the unique nature of these symptoms, the patient underwent a complex diagnostic and treatment process before finally being diagnosed with HSA complicated by KMS through pathological examination.

DIAGNOSES

The patient was eventually diagnosed with HSA by pathology and KMS with multiorgan hemorrhage.

INTERVENTIONS

Highly misleading clinical manifestations were recorded during the diagnosis and treatment, which, to our knowledge, have not been previously reported.

OUTCOMES

The patient died from a massive pulmonary hemorrhage.

LESSONS

Dysfunction of a single organ or system may be the external manifestation of a multi-system clinical disease. Therefore, in the clinical diagnosis and treatment process, especially during early diagnosis, while it is important to focus on the primary or typical clinical symptoms, it is equally crucial not to underestimate or ignore accompanying symptoms that lack specificity. When diagnosis and treatment reach an impasse, these "atypical" symptoms often prove to be key in solving the puzzle.

Hepatic Sinusoidal Disorders

Hepatic sinusoids are highly specialized microcirculatory conduits within the hepatic lobules that facilitate liver functions. The sinusoids can be affected by various disorders, including sinusoidal dilatation, sinusoidal obstruction syndrome (SOS), sinusoidal cellular infiltration, perisinusoidal infiltration, and endothelial neoplasms, such as hemangioendothelioma and angiosarcoma. While these disorders, particularly SOS and neoplasms, can be life threatening, their clinical manifestation is often nonspecific. Patients may present with right upper quadrant pain, jaundice, hepatomegaly, ascites, splenomegaly, and unexplained weight gain, although the exact manifestation depends on the cause, severity, and duration of the disease. Ultimately, invasive tests may be necessary to establish the diagnosis. A comprehensive understanding of imaging manifestations of various sinusoidal disorders contributes to early diagnosis and can help radiologists detect subclinical disease. Additionally, specific imaging features may assist in identifying the cause of the disorder, leading to a more focused and quicker workup. For example, a mosaic pattern of enhancement of the liver parenchyma is suggestive of sinusoidal dilatation; peripheral and patchy reticular hypointensity of the liver parenchyma on hepatobiliary MR images is characteristic of SOS; and associated diffuse multiple hyperintensities on diffusion-weighted images may be specific for malignant sinusoidal cellular infiltration. The authors provide an overview of the pathogenesis, clinical features, and imaging appearances of various hepatic sinusoidal disorders, with a special emphasis on SOS. ©RSNA, 2024 Supplemental material is available for this article.

Rare infiltrative primary hepatic angiosarcoma: A case report and review of literature

BACKGROUND

The most primary sites of angiosarcoma are the skin, breast gland, and soft tissues. Primary hepatic angiosarcoma (PHA) is a rare malignant tumor of mesothelial tissue originating from the liver. PHA often presents with multiple intrahepatic foci or metastasis at the time of presentation due to its nonspecific clinical presentation and highly aggressive nature. There are no established or effective treatment guidelines for PHA, so early detection and early treatment are of great value for patient survival. Unfortunately, there is a paucity of literature on the imaging features of PHA, making the diagnosis and treatment of this disease a considerable challenge.

CASE SUMMARY

In this case report, we present a 59-year-old man who initially presented with abdominal pain and radiating pain in the right shoulder. Magnetic resonance imaging and positron emission tomography-computed tomography revealed multiple intrahepatic nodules that needed to be differentiated from tumors of vascular epithelial origin and tumors with progressive enhancement features, and signs of tumor metastasis were assessed. The patient was then subjected to contrast-enhanced ultrasonography (CEUS) to further clarify the extent of tumor infiltration and the state of microcirculatory perfusion. The manifestations observed on CEUS were similar to the classical characteristic presentation of hepatocellular carcinoma, called "quick wash-in and quick wash-out". In addition, CEUS showed that the lesion exhibited gradual infiltration and growth along the liver pedicle structures with no invading blood vessels. Finally, based on pathological and immunohistochemical tests and the above imaging manifestations, it was confirmed that the patient had infiltrating PHA, which is a rare pathological type of PHA. The patient underwent transcatheter arterial chemoembolization and chemotherapy. Four months after the onset of symptoms, the follow-up radiological examination revealed poor treatment efficacy and rapid deterioration.

CONCLUSION

This case report complements the imaging modalities of a rare infiltrative PHA, in which CEUS and quantitative analysis are found to offer substantial advantages in characterizing the microcirculatory perfusion of the lesion, providing clinicians with diagnostic information at the earliest opportunity to make a diagnosis and develop a treatment strategy to prolong the patient survival.

Better 90 Minutes Late than Never: Differential Diagnosis on MRI Scanning in a Case of Hepatic Angiosarcoma

Primary hepatic angiosarcoma (PHA) is a rare liver malignancy with few studies describing its radiological characteristics. This article aims to assess the imaging features of each of the multiple delayed contrast-enhanced magnetic resonance imaging (MRI) scans, in addition to the conventional MRI protocol, in a patient with PHA. Standard MRI sequences and a liver protocol were used in the examination of a 71 year-old male with pathologically proven PHA after current imaging evaluation. In addition, the patient underwent transversal and coronal MRI T1-weighted scans at 10 min, 20 min and 90 min after intravenous (IV) administration of gadobenatedimeglumine (Gd-BOPTA). The PHA revealed a variable appearance on MRI, with classic imaging being insufficient in making a reliable diagnosis. Lesions have increased vascularity, which translates into increased IV contrast uptake in the MRI arterial phase, showing progressive and globular enhancement in the portal and parenchymatous phases. On delayed scans, at 10 min after IV administration, the lesions maintained no washout, but slightly began to washout at 20 min post-contrast. However, in the hepatobiliary phase (90 min post-contrast injection), on an MRI T1-weighted sequence, PHA lesions were hypointense, suggesting the absence of hepatocytes, thus indicating high-grade malignancy. This approach proved the conclusion that in a patient with PHA, an extra MRI T1-weighted scan at 90 min post-gadobenatedimeglumine injection can provide helpful information in differential diagnosis.

Paediatric hepatic angiosarcoma with consumptive hypothyroidism-an important diagnostic pitfall to avoid during evaluation of hepatic vascular tumours

Hepatic angiosarcoma is an extremely rare primary malignant vascular tumour in children with very poor prognosis. Radiological diagnosis of hepatic angiosarcoma is challenging due to overlapping imaging features with other benign vascular hepatic tumours, particularly infantile hepatic haemangioma. Consumptive hypothyroidism is a condition that is almost exclusively associated with infantile hepatic haemangioma and has never been reported in angiosarcoma. We present a case of hepatic angiosarcoma in a 20-month-old girl, associated with consumptive hypothyroidism and, as a result, initially misdiagnosed as infantile hepatic haemangioma. Radiologists should be aware that consumptive hypothyroidism is not a reliable feature to use in excluding paediatric hepatic angiosarcoma. Biopsy should be performed in patients older than 1 year of age or with atypical imaging features.

Characteristic findings of primary perirenal angiosarcoma on chemical shift subtraction magnetic resonance imaging (CSS-MRI): A case report

A 70-year-old man with supraglottic carcinoma underwent computed tomography (CT) for staging purposes. A tumor measuring approximately 7 × 10 cm was found incidentally in the left perirenal space. The tumor showed homogeneous high signal intensity on chemical shift subtraction magnetic resonance imaging (CSS-MRI) suggesting the presence of minimal amounts of fat. Five months later, the tumor had grown to approximately 10 × 12 cm with indistinct margins. CSS-MRI showed high signal intensity in the tumor periphery only. The tumor was resected and the pathological diagnosis was angiosarcoma. Angiosarcomas are malignant endothelial vascular neoplasms that are highly invasive to their surroundings. Here we report a case of primary perirenal angiosarcoma that was difficult to differentiate from a dedifferentiated liposarcoma. On CSS-MRI, high signal intensity within a tumor may be a characteristic feature of primary perirenal angiosarcoma.

Update on the Pathology of Pediatric Liver Tumors: A Pictorial Review

Liver tumors in children are uncommon and show remarkable morphologic heterogeneity. Pediatric tumors may arise from either the epithelial or mesenchymal component of the liver and rarely may also show both lines of differentiation. Both benign and malignant liver tumors have been reported in children. The most common pediatric liver tumors by age are benign hepatic infantile hemangiomas in neonates and infants, malignant hepatoblastoma in infants and toddlers, and malignant hepatocellular carcinoma in teenagers. Here, we provide an up-to-date review of pediatric liver tumors. We discuss the clinical presentation, imaging findings, pathology, and relevant molecular features that can help in the correct identification of these tumors, which is important in managing these children.

Diagnosis, Prognosis, and Treatment of Canine Hemangiosarcoma: A Review Based on a Consensus Organized by the Brazilian Association of Veterinary Oncology, ABROVET

Hemangiosarcoma is a mesenchymal neoplasm originating in the endothelial cells of blood vessels; they can be classified as non-visceral and visceral types. Non-visceral hemangiosarcomas can affect the skin, subcutaneous tissues, and muscle tissues; visceral hemangiosarcomas can affect the spleen, liver, heart, lungs, kidneys, oral cavity, bones, bladder, uterus, tongue, and retroperitoneum. Among domestic species, dogs are most affected by cutaneous HSA. Cutaneous HSA represents approximately 14% of all HSA diagnosed in this species and less than 5% of dermal tumors, according to North American studies. However, Brazilian epidemiological data demonstrate a higher prevalence, which may represent 27 to 80% of all canine HSAs and 13.9% of all skin neoplasms diagnosed in this species. Cutaneous HSA most commonly affects middle-aged to elderly dogs (between 8 and 15 years old), with no gender predisposition for either the actinic or non-actinic forms. The higher prevalence of cutaneous HSA in some canine breeds is related to lower protection from solar radiation, as low skin pigmentation and hair coverage lead to greater sun exposure. Actinic changes, such as solar dermatosis, are frequent in these patients, confirming the influence of solar radiation on the development of this neoplasm. There are multiple clinical manifestations of hemangiosarcoma in canines. The diagnostic approach and staging classification of cutaneous HSAs are similar between the different subtypes. The definitive diagnosis is obtained through histopathological analysis of incisional or excisional biopsies. Cytology can be used as a presurgical screening test; however, it has little diagnostic utility in cases of HSA because there is a high risk of blood contamination and sample hemodilution. Surgery is generally the treatment of choice for dogs with localized non-visceral HSA without evidence of metastatic disease. Recently, electrochemotherapy (ECT) has emerged as an alternative therapy for the local ablative treatment of different neoplastic types; the use of radiotherapy for the treatment of dogs with cutaneous HSA is uncommon. There is greater consensus in the literature regarding the indications for adjuvant chemotherapy in subcutaneous and muscular HSA; doxorubicin is the most frequently used antineoplastic agent for subcutaneous and muscular subtypes and can be administered alone or in combination with other drugs. Other therapies include antiangiogenic therapy, photodynamic therapy, the association of chemotherapy with the metronomic dose, targeted therapies, and natural products. The benefits of these therapies are presented and discussed. In general, the prognosis of splenic and cardiac HSA is unfavorable. As a challenging neoplasm, studies of new protocols and treatment modalities are necessary to control this aggressive disease.

Primary hepatic angiosarcoma: A case report

BACKGROUND

Primary hepatic angiosarcoma (PHA) is a rare malignant tumor of the vascular endothelium. Clinical manifestations and laboratory and imaging examinations often lack specificity for PHA. We report a case of PHA, and describe the ultrasound characteristics and characteristic changes in laboratory values associated with PHA.

CASE SUMMARY

A 75-year-old woman presented with right upper quadrant abdominal pain for half a month. Magnetic resonance imaging (MRI) at a local hospital revealed multiple liver space-occupying lesions, and she was admitted to our hospital for further diagnosis. Contrast-enhanced ultrasound (CEUS) revealed multiple slightly hyperechoic nodules in the liver, which were suspected to be of malignant vascular origin. Contrast-enhanced computed tomography revealed multiple low-density nodules in the liver, considered to be metastatic hematopoietic malignancies. Contrast-enhanced MRI showed that the multiple liver nodules shared features with infectious lesions. Laboratory examination revealed normal alpha-fetoprotein levels, slightly increased other liver enzymes, decreased platelets, and significantly increased D-dimer levels. Liver biopsy and histopathology confirmed the presence of PHA.

CONCLUSION

CEUS can provide valuable clues for the diagnosis of PHA and greatly improve the success rate of puncture biopsy.

Primary Hepatic Angiosarcoma Having FDG Uptake at the Similar Level of the Normal Liver Parenchyma

ABSTRACT

Primary hepatic angiosarcoma is a rare but aggressive malignancy. A 60-year-old woman presented with multiple liver lesions with progressive enhancement detected with multiphasic CT. FDG PET did not show any FDG-avid lesions, and the uptake of hepatic lesions was similar to that of the normal liver parenchyma. Subsequently, pathological examination revealed hepatic angiosarcoma.

Long-term 14-year survival with primary hepatic angiosarcoma

Primary hepatic angiosarcomas (PHAs) are rare primary liver malignancies with poor outcomes due to their aggressive nature and the difficulty it presents in terms of diagnosis and management. However, early diagnosis and aggressive surgical resection combined with ongoing surveillance can confer prolonged survival in patients with PHA. Additionally, adjuvant radiotherapy may be of benefit in cases of involved surgical margins. Here we report the longest surviving patient with PHA in literature to date. The patient had an initial right hemihepatectomy 14 years ago and 10 years later had a segment III segmentectomy for recurrence on surveillance imaging. This was followed with adjuvant radiotherapy for involved margins. There has been no further recurrence noted on imaging to date, and the patient is continuing to thrive in the community.

Hemorrhagic shock after contrast-enhanced ultrasound-guided liver biopsy: A case report of primary hepatic angiosarcoma

Primary hepatic angiosarcoma (PHA) is a rare, highly aggressive malignancy. There is no specificity in clinical manifestations, laboratory examinations and imaging examinations. The definitive diagnosis of PHA depends on pathological analysis. The gold standard method to obtain specimens is percutaneous transhepatic biopsy under the guidance of contrast-enhanced ultrasound (CEUS). However, CEUS-guided biopsy for PHA is controversial. If a biopsy is necessary, a comprehensive preoperative evaluation is essential. In addition, CEUS has an auxiliary value in diagnosing PHA. In this case, we present an elderly woman who underwent CEUS-guided liver mass biopsy. The patient developed hemorrhagic shock after biopsy.

Treatment Outcomes for Primary Hepatic Angiosarcoma: National Cancer Database Analysis 2004-2014

Background: To determine the risk of mortality and factors associated with survival amongst patients diagnosed with primary hepatic angiosarcoma (PHA). Methods: All patients diagnosed with hepatocellular carcinoma (HCC) or PHA from 2004 to 2014 were identified from the National Cancer Database (NCDB). Further analysis was performed within the cohort of patients with PHA to assess the impact of surgery, chemotherapy, radiation, and facility type on overall survival (OS). A multivariable analysis using the Cox proportional methods and a survival analysis using the Kaplan−Meier method were used. Results: A total of 117,633 patients with HCC were identified, out of whom 346 patients had PHA. Patients with PHA had a mean age of 62.9 years (SD 13.7), the majority were men (64.7%), white (85.8%), and had a Charlson comorbidity index (CCI) of zero (66.2%). A third of the patients with PHA (35.7%) received chemotherapy, and 14.6% underwent a surgical resection. The median survival was 1.9 months (1.8−2.4 months) compared to patients with HCC (10.4 months, 10.2−10.5) (aHR-2.41, 95% CI: 2.10−2.77, p < 0.0001). Surgical resection was associated with a higher median survival (7.7 versus 1.8 months, aHR-0.23, 95% CI: 0.15−0.37, p < 0.0001). A receipt of chemotherapy was associated with a higher median survival than no chemotherapy (5.1 versus 1.2 months, aHR-0.44, 95% CI: 0.32−0.60, p < 0.0001), although the survival benefit did not persist long term. Conclusion: PHA is associated with poor outcomes. A surgical resection and chemotherapy are associated with improved survival outcomes; however, the long-term benefits of chemotherapy are limited.

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.

Role of 3D Volumetric and Perfusion Imaging for Detecting Early Changes in Pancreatic Adenocarcinoma

Purpose

There is a major shortage of reliable early detection methods for pancreatic cancer in high-risk groups. The focus of this preliminary study was to use Time Intensity-Density Curve (TIDC) and Marley Equation analyses, in conjunction with 3D volumetric and perfusion imaging to demonstrate their potential as imaging biomarkers to assist in the early detection of Pancreatic Ductal Adenocarcinoma (PDAC).

Experimental Designs

A quantitative retrospective and prospective study was done by analyzing multi-phase Computed Tomography (CT) images of 28 patients undergoing treatment at different stages of pancreatic adenocarcinoma using advanced 3D imaging software to identify the perfusion and radio density of tumors.

Results

TIDC and the Marley Equation proved useful in quantifying tumor aggressiveness. Perfusion delays in the venous phase can be linked to Vascular Endothelial Growth Factor (VEGF)-related activity which represents the active part of the tumor. 3D volume analysis of the multiphase CT scan of the patient showed clear changes in arterial and venous perfusion indicating the aggressive state of the tumor.

Conclusion

TIDC and 3D volumetric analysis can play a significant role in defining the response of the tumor to treatment and identifying early-stage aggressiveness.

Hepatic angiosarcoma: Pitfalls in establishing a diagnosis

Hepatic angiosarcomas are rare, deceptive and aggressive malignancies that remain notoriously difficult to diagnose and treat. This case report discusses some of the common challenges faced by clinicians, and potential clinical, radiological and histological clues to this often elusive diagnosis.

Tumor Biology Impacts Survival in Surgically Managed Primary Hepatic Vascular Malignancies

BACKGROUND

Hepatic angiosarcoma (AS) and hepatic epithelioid hemangioendothelioma (HEHE) are rare primary hepatic vascular malignancies (PHVM) that remain poorly understood. To guide management, we sought to identify factors and trends predicting survival after surgical intervention using a national database.

MATERIALS AND METHODS

In a retrospective analysis of the National Cancer Database patients with a diagnosis of PHVM were identified. Clinicopathologic factors were extracted and compared. Overall survival (OS) was estimated and predictors of survival were identified.

RESULTS

Three hundred ninty patients with AS and 216 with HEHE were identified. Only 16% of AS and 36% of HEHE patients underwent surgery. The median OS for patients who underwent surgical intervention was 97 months, with 5-year OS of 30% for AS versus 69% for HEHE patients (P< 0.001). Tumor biology strongly impacted OS, with AS histology (Hazard Ratio [HR] of 3.61 [1.55-8.42]), moderate/poor tumor differentiation (HR = 3.86 [1.03-14.46]) and tumor size (HR = 1.01 [1.00-1.01]) conferring worse prognosis. The presence of metastatic disease in the surgically managed cohort (HR = 5.22 [2.01-13.57]) and involved surgical margins (HR = 3.87 [1.59-9.42]), were independently associated with worse survival.

CONCLUSIONS

In this national cohort of PHVM, tumor biology, in the form of angiosarcoma histology, tumor differentiation and tumor size, was strongly associated with worse survival after surgery. Additionally, residual tumor burden after resection, in the form of positive surgical margins or the presence of metastasis, was also negatively associated with survival. Long-term clinical outcomes remain poor for patients with the above high-risk features, emphasizing the need to develop effective forms of adjuvant systemic therapies for this group of malignancies.

Clinical characteristics and surgical treatments of primary hepatic angiosarcoma

PURPOSE

Primary hepatic angiosarcoma is a very rare and highly malignant tumor with poor prognosis. It is difficult to diagnose because of the lack of typical clinical features, and the treatment protocols for PHA are also not clear. Therefore, this study wants to find out the clinical characteristics and surgical treatments of primary hepatic angiosarcoma.

METHODS

Among 8990 patients diagnosed with primary malignant tumor of the liver from January 2000 to December 2019 in our hospital, only four patients were diagnosed with primary hepatic angiosarcoma. The demographics, clinical manifestation, past history, serology test results, MRI features, pathology, treatment modality and prognosis of four patients were collected and analyzed.

RESULTS

Three of four patients had no clinical symptoms, while one patient's symptom was abdominal pain. The levels of tumor markers of all four patients were within the normal reference range and serological tests were negative for hepatitis B and C virus. The MRI imaging findings of all four patients were mixed mass with highly disordered vascular characteristics. All four patients were misdiagnosed preoperatively. One patient who underwent hepatic lobectomy was still alive for about 18 months after surgery. One patient who underwent hepatic lobectomy has survived for only 6 months due to severe pneumonia. The other two patients who received transarterial chemoembolization survived 16 months and 11 months respectively.

CONCLUSION

The clinical symptoms of primary hepatic angiosarcoma are not typical, and primary hepatic angiosarcoma is easily misdiagnosed. The typical imaging manifestations are structural disorder and heterogeneous tumor. Hepatic lobectomy and transarterial chemoembolization may be important surgical treatments to improve the prognosis of patients.

New insights into the pathophysiology and clinical care of rare primary liver cancers

Hepatocholangiocarcinoma, fibrolamellar carcinoma, hepatic haemangioendothelioma and hepatic angiosarcoma represent less than 5% of primary liver cancers. Fibrolamellar carcinoma and hepatic haemangioendothelioma are driven by unique somatic genetic alterations (DNAJB1-PRKCA and CAMTA1-WWTR1 fusions, respectively), while the pathogenesis of hepatocholangiocarcinoma remains more complex, as suggested by its histological diversity. Histology is the gold standard for diagnosis, which remains challenging even in an expert centre because of the low incidences of these liver cancers. Resection, when feasible, is the cornerstone of treatment, together with liver transplantation for hepatic haemangioendothelioma. The role of locoregional therapies and systemic treatments remains poorly studied. In this review, we aim to describe the recent advances in terms of diagnosis and clinical management of these rare primary liver cancers.

Overview of spontaneous intraabdominal tumor hemorrhage: etiologies, imaging findings, and management

Hemorrhage is a potential complication of benign and malignant tumors and tumor-like conditions in the abdomen. Patients often have non-specific presentations, although they may present critically ill and hemodynamically unstable. Imaging plays an important role not only in the diagnosis of hemorrhage but also in the detection and characterization of an underlying mass. Ultrasound, computed tomography, and magnetic resonance imaging are utilized in evaluating these patients, with each having particular strengths and limitations. Spontaneous tumor hemorrhage is most commonly seen in hepatic and renal lesions, although it can arise from nearly every abdominal organ. In this article, we will review principles of tumor hemorrhage, illustrate common and uncommon imaging features, and highlight different options for management.

The humbling hemangioma: uncommon CT and MRI imaging features and mimickers of hepatic hemangiomas

Cavernous hemangiomas are among the most common liver lesions encountered in abdominal imaging. While classical imaging characteristics usually aid the radiologist in confidently arriving at its diagnosis, atypical hemangiomas can prove to be difficult to distinguish from other more worrisome hepatic lesions such as metastases and hepatocellular carcinoma. Furthermore, some malignant lesions can display features that simulate hemangiomas. The radiologist must be aware of these pitfalls to make an accurate diagnosis, when possible.

Unexpected death due to spontaneous splenic rupture: A rare case in splenic angiosarcoma

Splenic angiosarcoma (SA) is a rare disease that can cause spontaneous splenic rupture leading to unexpected death. The rare incidence and non-specific clinical presentations made the early correct diagnosis of SA impossible in clinical practice. Even with medical intervention, 80% of patients died within 6 months after diagnosis. Here, we report a man who had complained of abdominal distension for 2 weeks and succumbed to the disease nine hours after admission. Diagnosis of hepatic and splenic angiosarcomas was based on post-mortem histopathological examination and immunohistochemistry, and the cause of death was hemorrhagic shock caused by spontaneous splenic rupture secondary to SA. This present case was the first forensic autopsy of spontaneous splenic rupture secondary to SA, which can highlight the diagnosis of rare diseases in forensic practice, and forensic pathologists should bear in mind these rare diseases even in routine practice.

Clinical and imaging characteristics of primary hepatic sarcomatoid carcinoma and sarcoma: a comparative study

Background

Primary hepatic sarcomatous carcinoma (PHSC) and primary hepatic sarcoma (PHS) are rare malignancies with frequent overlap in both the clinic and radiology. No comparative study of these tumors for the restricted cases has previously been undertaken. The purpose of our study was to analyze the clinical and imaging features of PHSCs and PHSs, with an emphasis on particularities and similarities through a comparison of the two tumors.

Methods

We retrospectively analyzed the clinical and imaging features of 39 patients with pathologically proven PHSCs (n = 23) and PHSs (n = 16) from four university centers over a 9-year period from 2010 to 2019. Univariate analyses were performed to determine the consistent and distinctive features.

Results

The background of chronic hepatitis or cirrhosis was observed with a high frequency in both of PHSCs (73.7%) and PHSs (62.5%). Tumors with a diameter greater than 10 cm were significantly more common in PHSs than PHSCs (p = 0.043) and cystic masses were more detected in PHSs (P = 0.041). Both PHSCs and PHSs mainly presented hypovascularity (78.3% vs 81.3%). The ring hyper enhancement on the arterial phase (AP) and wash out were more frequently seen in PHSCs and the iso-hypo enhancement on the AP followed persistent or progressive enhancement was more commonly detected in PHSs (all, p < 0.05).

Conclusion

PHSC and PHS generally present as mass lesions with hypovascularity. The ring hyper enhancement on the AP and wash out favor the diagnosis of PHSC. The large size greater than 10 cm, cystic lesion, iso-hypo persistent or progressive enhancement pattern might suggest the possibility of PHSs.

Primary hepatic malignant vascular tumors: a follow-up study of imaging characteristics and clinicopathological features

Background

Owing to its low incidence, there is insufficient clinical awareness and diagnostic experience with primary hepatic malignant vascular tumors (PHMVTs). The aim of our study was to investigate the imaging and clinicopathological features of patients with PHMVTs and analyze the clinicopathological correlations.

Methods

We retrospectively analyzed 42 patients who had pathologically confirmed PHMVT during the period from June 2012 to December 2019 and enrolled them in our study. The computed tomography (CT) and magnetic resonance (MR) images and pathological findings of each patient were recorded.

Results

There were more female (29/42) than male patients. The imaging features of primary hepatic angiosarcoma (PHA) (n = 11) included ill-defined margins (11/11, 100%), necrosis (5/11, 45%), calcification (3/11, 27%) and “slow in-slow out” centripetal enhancement (7/11, 64%). Patients with epithelioid hemangioendothelioma (EHE) (n = 15) presented with ill-defined margins (15/15, 100%), necrosis (6/15, 40%), calcification (2/15, 13%), “fast in-slow out” centripetal enhancement (10/15, 67%), halo sign (15/15, 100%), pseudocapsule sign (4/15, 27%), lollipop sign (2/15, 13%) and capsule retraction sign (2/15, 13%). Patients with malignant hemangiopericytoma (MHP) (n = 3) showed ill-defined margins (3/3, 100%), necrosis (3/3, 100%) and “fast in-slow out” progressive enhancement (3/3, 100%). Infantile hemangioendotheliomas (IHEs) (n = 13) were defined by ill-defined margins (7/13, 54%), necrosis (8/13, 62%), calcification (5/13, 38%) and “fast in-slow out” centripetal enhancement (13/13, 100%). Immunohistochemistry showed strong positive expression of CD31, CD34, ERG, FaVIII and FLI-1. Patients with IHE (96 months) and EHE (88 months) had the longest survival times, followed by those with MHP (23 months), while patients with PHA (15 months) had the shortest survival time.

Conclusion

On CT and MR images, most PHMVTs were ill-defined, heterogeneous, hypervascular masses with centripetal progressive enhancement and possibly calcification, especially in female patients. The prognosis of patients with PHMVT was associated with the pathological type of the tumor.

Primary Hepatic Angiosarcoma: A Rare Liver Malignancy - Varying Manifestations but Grave Prognosis

Primary hepatic angiosarcoma (PHA) is a rare mesenchymal liver tumor, accounting for 0.1–2% of primary liver malignancies. The clinical presentations of PHA are variable, from asymptomatic to liver failure or complicated with tumor rupture. The diagnosis of PHA is difficult due to the lack of specific clinical manifestation and investigation results, which can be confused with other liver tumors resulting in late diagnosis. However, there is currently a paucity of effective therapeutic approaches. We advocate early diagnosis with radiological imaging and histopathology because most of them are diagnosed in late-stage and carry a grave prognosis. Surgical resection remains the mainstay of treatment, which can significantly prolong survival. Chemotherapy, including transarterial chemoembolization, is an option for palliative treatment. Unfortunately, molecular treatment has limited efficacy and liver transplantation is also not recommended due to high rate of recurrence. We present a case series of four patients with biopsy-proven PHA which had distinct presentations and clinical courses.

Diffused hepatic angiosarcoma with Kasabach-Merritt syndrome-case report and literature review

Background

Hepatic angiosarcoma is a rare malignant tumor featured by highly aggressive behavior and poor prognosis. There are few reports about diffused hepatic angiosarcoma with Kasabach-Merritt syndrome till now.

Case presentation

A male patient with the chief complain of hepatic space-occupying lesion accompanied by disturbance of consciousness and jaundice. Hyperbilirubinemia, anemia, thrombocytopenia, prolonged prothrombin time, hypofibrinogenemia, decreased prothrombin activity, and increased fibrinogen degradation product and D-dimer were confirmed by blood analysis; multiple focal hypodense lesions in liver was detected by abdominal computed tomography. Liver failure and Kasabach-Merritt syndrome induced by hepatic hemangioma was diagnosed before operation and liver transplantation was performed. Hepatic angiosarcoma was finally proven by postoperative pathology. This patient died of tumor metastasis 2 months after operation.

Conclusions

Hepatic angiosarcoma which can generate Kasabach-Merritt syndrome and even liver failure has an extremely poor prognosis; liver transplantation option should not be considered in hepatic angiosarcoma regardless of the reason.

Initial clinical radiological findings and staging to predict prognosis of primary hepatic angiosarcoma: A retrospective analysis

OBJECTIVE

Primary hepatic angiosarcoma (PHA) is extremely rare and most patients die within 12 months of diagnosis. The object of the study is to determine the association of initial clinical-radiological features and staging with outcomes in patients with PHA.

METHODS

The medical records of adult patients with PHA were retrieved from an electronic medical record database and a pathology database and retrospectively reviewed. During 10 years, 22 eligible patients were included. Data extracted focused on the information before the first formal treatment with a pathological proof, including demographic characteristics, medical history, laboratory data, preliminary images, histopathological records, treatment, and follow-up survival period. Two radiologists blindly re-analyzed preliminary images of all 22 patients together and recorded tumor features and imaging stage based on the American Joint Committee on Cancer (AJCC) 8th edition tumor-node-metastasis (TNM) Staging System for hepatocellular carcinoma. A radiologist compiled the initial clinical data and preliminary image stage to analyze the association with patients' survival outcome.

RESULTS

Higher aspartate aminotransferase (AST), higher total bilirubin (TB), lower albumin (ALB), longer prothrombin time (PT) and lower platelet count of serum relative to the normal reference range were more common in patients who survived ≤ 90 days (all P < 0.05). Overall survival was much better in patients with single PHA than in those with other tumor patterns of multiple PHA (all P < 0.05). Overall survival determined by preliminary imaging showed significant differences between stage I and stage III (P = 0.044), stage I and stage IV (P = 0.011), and stage III and IV (P = 0.047). No patients were at stage II.

CONCLUSIONS

Initial serum levels of ALT, TB, ALB, and PT, platelet count, single mass in liver, and preliminary imaging staging could help predict survival outcomes of patients with PHA.

Bleeding Liver Masses: Imaging Features With Pathologic Correlation and Impact on Management

OBJECTIVE. The purposes of this article are to discuss a variety of liver masses that can present with hemorrhage, including their characteristic imaging features, and to propose a diagnostic approach. CONCLUSION. A broad spectrum of pathologic conditions can present as spontaneous hemorrhage within or surrounding the liver and may present acutely or as a chronic or incidental finding. Imaging characteristics and clinical history can often narrow the differential diagnosis and guide management.

CT and MRI studies of hepatic angiosarcoma

AIM

To analyse the computed tomography (CT) and magnetic resonance imaging (MRI) manifestations of hepatic angiosarcoma.

MATERIALS AND METHODS

Nineteen patients with hepatic angiosarcoma underwent preoperative abdominal unenhanced and contrast-enhanced CT (11 cases) or (eight cases) MRI.

RESULTS

The results of a coagulation examination showed varying degrees of abnormalities in 12 (63.16%) cases (most were prolonged prothrombin time and an increased proportion of prothrombin time), which were the most common abnormalities on the laboratory tests. Unenhanced CT of the lesions showed homogeneous or heterogeneous hypointense with hyperintense haemorrhagic lesions, contrast-enhanced CT was performed for six cases (6/11, 54.5%) with centripetal heterogeneous filling. All lesions showed heterogeneous intensity at MRI, including heterogeneous hypointense T1WI and homogeneous or heterogeneous hyperintense T2WI. Haemorrhage lesions showed higher hyperintensity with spot or patchy signals. Centripetal enhancement was found in six cases using contrast-enhanced imaging. Flaky patches of contrast enhancement were seen in the lesions.

CONCLUSION

The CT and MRI features of most of the hepatic angiosarcomas in the present study were relatively characteristic: the border of the mass was indistinct, the density was heterogeneous, and haemorrhage was frequently seen, with secondary calcification in a few cases, whereas enhanced imaging showed typical centripetal heterogeneous enhancement. In addition, highly malignant angiosarcoma could not be enhanced.

Vascular tumours of the liver: a particular story

Vascular tumours of the liver represent an underrated chapter of medical and surgical hepatology. These tumours cover a wide spectrum ranging from the frequent and most benign hepatic haemangioma (HH), via the rare and intermediately aggressive hepatic epithelioid haemangioendothelioma (HEHE) to the rare and most malignant hepatic haemangiosarcoma (HHS). In contrast to the treatment algorithms for hepatocellular and cholangiocellular cancer, the diagnostic and therapeutic approaches to HEHE and HHS are not well developed. The related uncertainty is explained by their rare occurrence and their protean clinical, morphological (imaging) and histopathological presentation and behaviour. This article gives an update about these particular tumours based on the analysis of the recent literature and of the studies on vascular tumours published by the European Liver Intestine Transplantation Association (ELITA)-European Liver Transplant Registry (ELTR). It focuses also on the place of liver transplantation (LT) in the respective therapeutic algorithms. The differential diagnosis between these vascular and other tumour types may be very difficult. Correct diagnosis is of utmost importance and is based on a high index of clinical suspicion and on the integration of clinical, radiological, histological [including immunohistochemistry (IHC) and molecular biology findings]. Surgery, be it partial or total hepatectomy (LT), should be proposed whenever possible, because it is the therapeutic mainstay. In HEHE, LT provides excellent results, with long-term disease-free survivals (DFS) reaching 75%. Good results can be obtained even in case of (frequent) extrahepatic spread. Based on the extensive ELITA-ELTR study a HEHE-LT prognostic score has been proposed in order to estimate the risk of recurrence after LT. In contrast, results of surgery and LT are extremely poor for HHS, for the almost invariably rapid recurrence (within 6 months) and related death within 2 years. LT remains a contraindication for HHS. Due to the still important recurrence rate after surgical resection (25% in HEHE and almost 100% in HHS), there is an urgent need to develop pharmacological treatments targeting angiogenic and non-VEGF angiogenic pathways. To date, some prospective pilot studies and case reports have shown some short-term stabilisation of the disease in small groups of patients. In order to make progress, combination of surgery, anti-angiogenic and immunotherapy seems worthwhile. To complete the panel of vascular liver tumours, infantile haemangioendothelioma, haemangiopericytoma, nodular regenerative hyperplasia (NRH) and hepatic small vessel neoplasms (HSVN) are also discussed.

Hepatic tumors of vascular origin: imaging appearances

A number of benign and malignant neoplasms may arise from the vascular elements within the liver parenchyma. Lesions discussed in this article include angiosarcoma, epithelioid hemangioendothelioma, solitary fibrous tumor (hemangiopericytoma), infantile, and cavernous hemangiomas. Despite a common theme of vascular origin, the pathologic and imaging appearance of these entities can be heterogeneous. Angiosarcomas are bizarrely enhancing, highly aggressive tumors, which often present with metastatic disease. When solitary, epithelioid hemangioendothelioma lesions can exhibit a concentric ring or target appearance on contrast-enhanced CT and at MR and when numerous may be indistinguishable from angiosarcoma except for a more slowly advancing course. Primary solitary fibrous tumors of the liver are exceedingly rare solid masses and most often initially diagnosed on imaging as other entities such as cholangiocarcinoma. Infantile hemangiomas consist of benign proliferation of the vascular endothelium and in the absence of flow-related complications, are usually clinically silent, and may be detected incidentally as T1 hypointense, T2 hyperintense, centripetally enhancing lesions. Cavernous hemangiomas are extremely common hepatic lesions and when classic rarely offer a challenge in diagnosis, though atypical variants may mimic more serious diseases. The purpose of this review is to provide an overview of important vascular tumors of the liver in order to aid the radiologist in providing a broad differential diagnosis for focal liver lesions, and when classic, suggest specific uncommonly seen diagnoses in order to more accurately guide clinical management.

Primary hepatic angiosarcoma and liver transplantation: Radiological, surgical, histological findings and clinical outcome

Angiosarcoma is a rare type of soft tissue sarcoma that accounts for less than 1% of all sarcomas and only 2% of all primary hepatic tumours. Thorotrast, arsenic, and vinyl chloride monomer are frequently listed as occupational exposure risks. The estimated latency is long (10-40 years) in occupational cases and very long (60 years or more) in non-occupational cases. The symptoms and CT-scan appearance of hepatic angiosarcoma (HAS) are non-specific. We present a case of a 65-year-old Caucasian male with history of cryptogenic cirrhosis, low alpha-foetoprotein levels and a single, 4-cm nodule of potential atypical hepatocellular carcinoma (no washout at MRI and CT-scan) in segment VIII. Laparoscopic radiofrequency ablation (a biopsy of the neoplastic lesion was technically impossible) was performed, followed by liver transplantation (LT) 6 months later. High-grade multifocal HAS was found in the explanted liver, with extensive involvement of the venous portal structures. No complications were observed during the postoperative course, and initial immunosuppression included tacrolimus, mycophenolate mofetil and corticosteroids. Because of the histological findings, tacrolimus was switched to everolimus as the main immunosuppressive drug one month after LT. Despite this conversion, the patient developed bone metastases 3 months after LT and peritoneal carcinosis one month later. This case report suggests that everolimus conversion does not inhibit the development of tumour metastases. Consequently, HAS remains an absolute contraindication to LT because of the poor outcome. If LT has been performed for incidental HAS, new molecular therapies (e.g. vascular endothelial growth factor antagonists) should be considered immediately after LT to improve the outcome.

Contrast uptake in primary hepatic angiosarcoma on gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging in the hepatobiliary phase

Primary hepatic angiosarcoma is the most common malignant mesenchymal tumor of the liver. It has a poor prognosis and various appearances on magnetic resonance (MR) images. We report a case of hepatic angiosarcoma with a characteristic appearance on gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced MR imaging in the hepatobiliary phase. A 72-year-old man was admitted with a complaint of abdominal pain. Gd-EOB-DTPA-enhanced MR imaging revealed a liver tumor that showed slight hyperintensity in the hepatobiliary phase. These findings suggested Gd-EOB-DTPA uptake in the tumor. An autopsy revealed the solid proliferation and sinusoidal spreading of hepatic angiosarcoma cells. Immunohistochemistry indicated that the tumor was negative for OATP1B3. Gd-EOB-DTPA uptake in the liver tumor in the hepatobiliary phase suggested sinusoidal tumor invasion with residual normal hepatocytes.

Imaging features of rare mesenychmal liver tumours: beyond haemangiomas

Tumours arising from mesenchymal tissue components such as vascular, fibrous and adipose tissue can manifest in the liver. Although histopathology is often necessary for definitive diagnosis, many of these lesions exhibit characteristic imaging features. The radiologist plays an important role in suggesting the diagnosis, which can direct appropriate immunohistochemical staining at histology. The aim of this review is to present clinical and imaging findings of a spectrum of mesenchymal liver tumours such as haemangioma, epithelioid haemangioendothelioma, lipoma, PEComa, angiosarcoma, inflammatory myofibroblastic tumour, solitary fibrous tumour, leiomyoma, leiomyosarcoma, Kaposi sarcoma, mesenchymal hamartoma, undifferentiated embryonal sarcoma, rhabdomyosarcoma and hepatic metastases. Knowledge of the characteristic features of these tumours will aid in guiding the radiologic diagnosis and appropriate patient management.

Primary Hepatic Neoplasms of Vascular Origin: Key Imaging Features and Differential Diagnoses With Radiology-Pathology Correlation

OBJECTIVE

This article describes, illustrates, and correlates imaging and pathologic features of primary vascular mesenchymal neoplasms of the liver, which arise from the vascular endothelium and perivascular epithelioid cells.

CONCLUSION

Familiarity with the spectrum of benign, malignant-potential and malignant vascular neoplasms, and nonneoplastic mimickers allows consideration in the differential diagnosis of enhancing hepatic masses. Understanding relevant pathologic features facilitates recognition of key imaging features, specifically dynamic contrast enhancement patterns on CT and MRI, which provide a useful classification system.

Primary Hepatic Angiosarcoma: A Case Report with 10-Year Patient Medical Data

In the current study, we report a case of a 46-year-old man who presented with sudden abdominal pain and was diagnosed with rupture of hepatic angiosarcoma (HAS). He underwent surgery, but died 13 days after the onset of the abdominal pain. Chronic exposure to carcinogens, such as thorium dioxide, arsenic, vinyl chloride, and radium, is associated with HAS. However, our patient had not been exposed to such carcinogens. He had submitted himself for annual medical checkups since he was employed. His liver was cirrhotic, and medical history data showed that he had had fatty liver for at least 10 years before HAS onset. Although liver cirrhosis may play a role in the occurrence of HAS, the connection of chronic fatty liver in the tumorigenesis remains unclear. Case reports regarding HAS with fatty liver are few. To the best of our knowledge, this is the first case of HAS occurring in a cirrhotic liver that advanced from persistent fatty stage. Given that HAS is a rare tumor, data collection is important for investigating its pathophysiology. Case presentations considering health conditions before HAS onset are limited; therefore, we present a case of HAS with annual health checkup data before disease onset.

Magnetic Resonance Imaging of Primary Hepatic Malignancies in Patients With and Without Chronic Liver Disease: A Pictorial Review

Primary hepatic malignancies are less common than metastatic diseases, but a recognition of these lesions is important for diagnosis and treatment planning. Magnetic resonance imaging (MRI) provides the most imaging information to diagnose lesions noninvasively and to narrow differential diagnoses. This paper reviews the imaging findings of chronic liver disease and primary hepatic malignancies, including hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (CCA), epithelioid hemangioendothelioma, hepatic angiosarcoma, and primary hepatic lymphoma. Clinical and MRI features are reviewed to improve the readers’ recognition of these tumors, allowing for a narrower differential diagnosis when liver masses are encountered on abdominal imaging.

Contrast-enhanced ultrasound in diagnosis of primary hepatic angiosarcoma

Primary hepatic angiosarcoma (PHA) is a rare malignant tumor that occurs mainly in the elderly, with almost no specific symptoms or tumor markers. Information on the imaging characteristics of this tumor is limited due to its rarity. Therefore, it is difficult to diagnose PHA. So far, its definite diagnosis depends on histopathologic examination combined with immunohistochemical results. Patients with PHA have a poor prognosis in spite of surgical resection of this tumor. In this case report, we present a 72-year-old woman with PHA, focusing on the imaging features of this tumor, especially its enhancement pattern on contrast-enhanced ultrasound images. Contrast-enhanced ultrasound provided helpful information for diagnosis.

Primary Hepatic Angiosarcoma Mimicking Multifocal Liver Abscess with Disseminated Intravascular Coagulation and Hemoperitoneum

Primary hepatic angiosarcoma (PHA), a rare and aggressive malignancy, has rarely been reported to present with disseminated intravascular coagulation with liver hemorrhage. Incidence is estimated at 0.5–2.5 cases per 10,000,000. To our knowledge, it has not been reported to mimic liver abscess with a septic presentation. Advanced imaging techniques may aid in the diagnosis, though biopsy with microscopy and immunohistochemistry is the mainstay. Prognosis is very poor, with a 5-year survival rate estimated at 6.4%. We present the case of a 70-year-old man who presented with sepsis thought to be due to a multifocal liver abscess, who did not respond to drainage and antibiotics. This atypical course led to further workup which subsequently revealed a diagnosis of PHA.

Angiosarcoma: clinical and imaging features from head to toe

Angiosarcoma is a rare, aggressive subtype of soft-tissue sarcoma with a propensity for local recurrence and metastasis associated with a generally poor prognosis, unless diagnosed early. Given the vascular endothelial cell origin of angiosarcoma, tumours may develop in essentially any organ; however, there is a predilection for the skin where half of all tumours arise, increasing in prevalence with age. The most common risk factors are chronic lymphoedema and history of radiation. We review the most important radiological findings along the spectrum of angiosarcoma from head to toe throughout the body, including uncommon and rare locations. Key imaging features of angiosarcoma across multiple organ systems will be described, as well as the impact on management and prognosis.