Extracutaneous angiosarcomas metastatic to the lungs: clinical and pathologic features of twenty-one cases

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.

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.

Metastatic angiosarcoma of the scalp presented as posttraumatic subgaleal hematoma: The many faces of a diagnostic challenge

Angiosarcomas represent highly-aggressive malignant lesions of the endothelial cells of blood vessels, affecting mostly the elderly population, and usually located in the scalp or face. As cutaneous angiosarcomas often metastasize to the lung, they can manifest in various forms. We report a case of a 77-year-old male who presented after a posttraumatic blunt scalp lump that was initially diagnosed as infected subgaleal hematoma. This was later found to be an angiosarcoma. Further workup revealed that the tumor was invading the dura, with a rare pattern of mixed concomitant cystic and solid lung metastasis with ground-glass infiltrates. The patient underwent soft tissue reconstruction with split-thickness skin graft for the scalp lesion and palliative chemotherapy. We are discussing the common manifestations of scalp angiosarcomas and their potential pulmonary metastatic patterns. Also, a review of the differential diagnoses that may mimic cutaneous scalp angiosarcoma will be demonstrated.

Case Report: Thromboembolism and Hemorrhagic Pericardial Effusion-The Janus Face of Primary Pericardial Angiosarcoma

Background: Primary cardiac angiosarcomas, especially those originating in the pericardium, are extremely rare and aggressive tumors with poor prognosis. These types of malignant tumors have diverse clinical presentations and are often masked by other comorbidities. Case Summary: Our hospital reported a 59-year-old woman who initially presented with pulmonary thromboembolism (PTE) and was subsequently treated with low-molecular-weight heparin. However, she experienced acute pericardial tamponade after anticoagulation therapy, where no obvious mass was primarily identified upon imaging, both in the pericardium or within the heart. Emergency pericardiocentesis and drainage were performed, where a total of 210 mL of bloody effusion was drained. Four months later, she was hospitalized with progressive hemoptysis and dyspnea. A large mixed mass occupying the right pericardium was later identified by coronary computed tomography angiography (CCTA). The mass was consistent with the right atrium, with heterogeneous thickened pericardium and localized moderate pericardial effusion. CCTA and positron emission tomography scans later showed metastases in both lungs and bilateral pleura. Nodules in hilar and mediastinal lymph nodes were also significant. Ultrasound-guided biopsy was performed, and the patient was ultimately diagnosed with an angiosarcoma based on final positive results for both CD31 and CD34 markers. The patient refused chemotherapy and passed away while waiting for her pathology results. The patient survived for 6 months since the first reported episode of PTE. Conclusions: Our case indicates that patients presenting with both embolism and hemorrhage should urgently be channeled to a clinical specialist to confirm any malignant etiology. This would be beneficial to confirm an early diagnosis and lengthen the duration of patient survival. However, the diagnosis of primary cardiac angiosarcoma is still challenging and requires multiple imaging modalities and biopsies in order to assist the accurate diagnosis of disease and achieve effective patient management.

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.

Pulmonary epithelioid angiosarcoma responsive to chemotherapy: A case report

Primary pulmonary epithelioid angiosarcoma (AS) is an extremely rare cancer with a poor prognosis. The presenting symptoms and imaging results are nonspecific and hold similarities with more common lung pathology, contributing to missed or delayed diagnosis. Complementing radiological imaging with patient information, such as presenting symptoms and exposures, is important for early consideration of pulmonary epithelioid AS. Even with supportive imaging findings and clinical suspicion for pulmonary epithelioid AS, the most reliable and definitive method for diagnosis is through immunohistochemistry. We describe the case of a 65-year-old patient who presented with dyspnea, cough, and hemoptysis in whom pauci-immune vasculitis was initially suspected before immunohistochemical diagnosis of primary pulmonary epithelioid AS. Due to the rarity of this disease, treatment options have not been well-studied and consist of any combination of surgical resection, chemotherapy, and radiation therapy. Although typically poorly responsive to chemotherapy, our patient achieved a reduction in size of his pulmonary nodules after a course of steroids followed by cyclophosphamide and was later maintained with gemcitabine and docetaxel until his death nearly a year after presentation.

Clinical and diagnostic features of angiosarcoma with pulmonary metastases: A retrospective observational study

Angiosarcoma with pulmonary metastasis is a rare, fatal disease that often presents with multiple pulmonary nodules and diffuse alveolar hemorrhage. We herein review the detailed clinical characteristics of pulmonary metastatic angiosarcoma and determine a reasonable diagnostic strategy.The medical records of 11 patients with pulmonary angiosarcoma were reviewed.The mean age of the patients was 45.7 years (range, 30-71 years). All patients were male. The most common symptom was hemoptysis (8/11). Common initial misdiagnoses were tuberculosis (5/11), vasculitis (2/11), nontuberculous infectious disease (1/11), and constrictive pericarditis (1/11). Chest computed tomography (CT) of patients with hemoptysis showed bilateral, randomly distributed, variably shaped, and differently sized nodules, as well as ground-glass opacities (GGO) (8/11). The right heart was the most common primary tumor site (8/11), but the sensitivity of echocardiography was limited; CT angiography and cardiac magnetic resonance imaging (MRI) revealed more atrial masses. CT-guided needle biopsy was difficult to perform in most patients because of the small size of the nodules. The diagnosis was made by surgical biopsy of either the lung (3/9) or heart (6/9). The median overall survival of patients who underwent lung biopsy and those who underwent cardiac/pericardiac biopsy was 4.1 and 1.4 months, respectively (P = .098). The median overall survival of the 9 available patients was 5.0 months (95% confidence interval, 0.500-8.544).Angiosarcoma with pulmonary metastases should be considered in patients with hemoptysis and concurrent GGO and nodules on their chest CT scan. Careful cardiologic monitoring is necessary for these patients, even without any cardiac symptoms or signs, and enhanced cardiac MRI is the first recommendation. Surgical biopsy is reliable for histological diagnosis, but the safety of the lung biopsy should be carefully assessed. When primary cardiac tumors are identified, heart biopsy should be preferentially considered.

Primary pulmonary artery sarcoma masquerading as pulmonary thromboembolism: a rare diagnosis unveiled

BACKGROUND

Primary pulmonary artery sarcomas are rare malignant vascular tumors and carry a very poor prognosis. Due to overlapping clinical and radiological features, the differentiation between pulmonary artery thromboembolism and pulmonary artery sarcoma can be challenging.

CASE PRESENTATION

We herein present clinical, radiological and pathological features of primary pulmonary artery high grade sarcoma (angiosarcoma) in a 59-year-old male. The patient presented with a history of breathlessness on exertion of 2-months duration and was misdiagnosed as massive pulmonary thromboembolism on initial CT imaging.

CONCLUSION

Great similarity with significant degree of overlap in clinical and radiologic presentation makes differentiation of pulmonary artery sarcomas and thromboembolism a diagnostic challenge. Even though they are exceptionally rare, one should always consider it as differential diagnosis especially in cases with atypical clinical or imaging presentation.

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.

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.

The lung metastatic niche

Cancer cells that succeed in forming lung metastases need to survive in a foreign microenvironment and to protect themselves against immune surveillance. Lung metastatic niches facilitate this process. They can develop as pre-metastatic niches by inflammatory events that are provoked by primary tumors before tumor cell arrival, and/or they can be post-formed by reciprocal signaling between metastasizing tumor cells and local non-tumor cells. Primary tumor-derived factors induce expression of chemokines in the lungs to which bone marrow-derived myeloid cells are recruited. These cells work in concert with lung-specific resident cells to establish pre-metastatic niches. The role of the endogenous TLR4-dependent innate immune system in pre-metastatic niche formation illustrates this point. During lung infection, endotoxin induces inflammation by increasing vascular permeability and leukocyte mobilization to the lungs through the endotoxin receptor TLR4 that is expressed in endothelial cells and leukocytes, respectively. This innate immune system can be hijacked by primary tumors to generate a pre-metastatic niche. Specifically, primary tumor-produced chemokine CCL2 works in an endocrine manner to induce pulmonary overexpression of endogenous TLR4 ligands such as S100A8 and SAA3 resulting in lung inflammation similar to that caused by endotoxin. An endotoxin analog Eritoran inhibits pre-metastatic niche formation in this system.

Pulmonary metastases from angiosarcoma: a spectrum of CT findings

BACKGROUND

Though a few reports have summarized the computed tomography (CT) findings of pulmonary metastases from angiosarcoma, the detailed CT findings of cysts are not well known, except for their characteristic thin walls.

PURPOSE

To retrospectively summarize the CT findings of pulmonary metastases from angiosarcoma, focusing mainly on the CT findings of cysts.

MATERIAL AND METHODS

Thirty-three patients with pulmonary metastases from angiosarcoma were selected retrospectively. Two radiologists reviewed and assessed patients' chest CT images on a consensus basis for nodules, cysts, the CT halo sign, pneumothorax, pleural effusion, and enlarged lymph nodes. Cysts were also evaluated by wall thickness and smoothness, air-fluid levels, and vessels or bronchi penetrating the cysts. The relationship between cysts and pneumothorax was assessed using the Chi-square test.

RESULTS

Nodules were found in 28 (85%) patients. Cysts were found in 19 (58%) patients; 17 had thin and smooth walls, 10 had thin and irregular walls, and four had thick and irregular walls. In addition, 12 patients showed vessels or bronchi penetrating the cysts, and six showed air-fluid levels. The CT halo sign, pneumothorax, pleural effusion, and mediastinal lymphadenopathy were seen in 19 (58%), 16 (48%), 26 (78.8%), and five (15.2%) patients, respectively. Pneumothorax occurred significantly more frequently in patients with cysts (P = 0.002).

CONCLUSION

Cysts showed variability in their walls, and air-fluid levels and vessels or bronchi penetrating the cysts appeared to be characteristic findings, which may be useful for detection and accurate diagnosis in patients with pulmonary metastases from angiosarcoma.

A rare cause of hemoptysis

Angiosarcomas are rare, malignant, endothelial-cell tumors of vascular origin that can arise at any body site. They frequently metastasize to the lung, heralded by dyspnea, hemoptysis, chest pain, pneumothoraces, and diffuse pulmonary hemorrhage. However, in most cases lung metastases are discovered after the diagnosis of a primary angiosarcoma has already been established. Very rarely will an undiagnosed metastatic angiosarcoma present as diffuse pulmonary hemorrhage. We describe the case of a 59-year-old male who presented to hospital with dyspnea and hemoptysis. CT chest revealed rapidly progressing nodular changes and broncho-alveolar lavage returns were progressively bloody. Open lung wedge biopsy ultimately revealed metastatic angiosarcoma and extensive pulmonary hemorrhage. Our case highlights the key clinical, radiological, and pathological features of this rare malignancy that frequently metastasizes to the lung and reminds clinicians to consider it as a cause of hemoptysis and pulmonary hemorrhage.

Pulmonary tumor thrombotic microangiopathy from metastatic epithelioid angiosarcoma

The lung is most common site for metastatic disease via hematogenous route. Tumor emboli of the vessels of the lung induces fibrocellular and fibromuscular intimal proliferation. These histopathological changes may cause pulmonary tumor trombotic microangiopaty. Few cases are diagnosed antemortem. We report a 60 year old woman with by metastatic epithelioid angiosarcoma involving the lung. Tumor cells were positive for VEGF and topoisomerase II. VEGF may be involved in the pathogenesis pulmonary tumor trombotic microangioapy and topoisomerase II positivity showed sensitivity against catalytic topoisomerase II inhibitors.

Diffuse primary angiosarcoma of the pleura: a case report and review of the literature

Primary pleural angiosarcoma is an extremely rare tumor. We report the case of a patient who presented with recurrent massive bilateral hemothoraxes. Although thoracoscopy was performed, biopsy samples of the pleura were inconclusive. The delayed onset of skin metastases led to the diagnosis of angiosarcoma, however the patient died from pleuropulmonary progression before treatment could be started. We review the literature of primary pleuropulmonary angiosarcoma and discuss its treatment modalities.

Diffuse primary angiosarcoma of the pleura: a case report and review of the literature

Primary pleural angiosarcoma is an extremely rare tumor. We report the case of a patient who presented with recurrent massive bilateral hemothoraxes. Although thoracoscopy was performed, biopsy samples of the pleura were inconclusive. The delayed onset of skin metastases led to the diagnosis of angiosarcoma, however the patient died from pleuropulmonary progression before treatment could be started. We review the literature of primary pleuropulmonary angiosarcoma and discuss its treatment modalities.

Metastatic angiosarcoma of the lung with alveolar hemorrhage

A case of metastatic angiosarcoma of the lung with alveolar hemorrhage was experienced. A 76-year-old woman was diagnosed as stage IIb uterine cervical cancer. The cancer disappeared after radiotherapy. Five years later, she was readmitted because of severe pain around the right hip joint. Fracture of the neck of the right femur was found on roentgenogram. On chest CT and roentgenogram, spotted or restiform shadows with uncertain margins were found in the peripheral regions of the bilateral lung field. The lesions reached just underneath the pleura, and interstitial shadows such as ground-glass-like shadows and thickening of the interlobular walls were also found. These lesions were rapidly aggravated in the course of 1-2 weeks. She died after a short period of hospitalization (2 months) with pathological fracture. In autopsy, metastases of the tumor were found to bones, lungs, heart, and other organs that mainly occurred hematogenously. No recurrence of the uterine cervical cancer was detected. Tumor cells were polymorphic or ovoid, and occurred scattered individually or showed growth-forming small aggregates. By immunohistochemical staining, CD31, CD34 and Factor VIII were found to be positive, and the tumor was diagnosed as epithelioid angiosarcoma. The main findings in the lungs were intraalveolar hemorrhage consequent to tumor embolization.

Establishment and Characterization of an Angiosarcoma-Derived Cell Line, AS-M

A novel human endothelial cell line, AS-M, has been established from a cutaneous angiosarcoma on the scalp. The cells expressing platelet endothelial cell adhesion molecule-1 (CD31) were isolated using magnetic beads and subsequently cultured for a year. To date, the cells have undergone more than 100 population doublings (PDs). The AS-M cells manifested endothelial characteristics, such as active uptake of acetylated low-density lipoprotein labeled with 1,1'-dioctadecyl 3,3,3',3'-tetramethylindocarbocyanine perchlorate (Dil-Ac-LDL), capacity to bind the Ulex europeaus agglutin-I (UEA-I), and expression of von Willebrand factor (vWF) and CD31. The single cell-derived clone, AS-M.5, showed a constitutive expression of CD31, vWF, angiotensin-converting enzyme (ACE), endoglin (CD105), and the endothelial cell receptor tyrosine kinases KDR and Tie-1. Similarly to freshly isolated endothelial cells, the AS-M.5 responded to induction by bacterial lipopolysaccharide (LPS) by increased transcription of cell adhesion molecules and cytokines. The AS-M.5 cultures required endothelial growth supplements for optimal growth and long-term propagation in vitro. However, in contrast to normal endothelial cells, p53 gene products were detected in nuclei of AS-M.5 cells. Cytogenetic analyses consistently revealed a hypodiploid karyotype with complete loss of one homologue of several chromosomes and a homogeneous pattern of distinct karyotypic changes. Although the AS-M.5 presented characteristics suggestive of tumor cells, they did not develop into tumors when inoculated subcutaneously into nude mice. The cell line AS-M.5 could be a useful model system to study endothelial pathobiology in vitro.

Detection and characterization of vascular endothelial growth factors and their receptors in a series of angiosarcomas

BACKGROUND

Angiosarcomas are malignant mesenchymal neoplasms, including sarcomas of presumptive vascular endothelial origin and sarcomas of probable lymphatic origin. It is, however, often difficult to determine whether they are from blood vascular or lymphatic endothelium. The majority of angiosarcomas are thought to originate from vascular endothelia and spread via bloodstream to lung, but lymphatic metastases can occur.

METHODS

We investigated immunohistochemical expression of vascular endothelial growth factors (VEGF-A, VEGF-C) and their receptors (VEGFR-1, VEGFR-2, VEGFR-3) in a series of 34 angiosarcomas.

RESULTS

VEGF-A was expressed by 32/34 (94%), VEGF-C by 4/34 (12%), VEGFR-1 by 32/34 (94%), VEGFR-2 by 22/34 (65%), and VEGFR-3 by 27/34 (79%). Patients who expressed low or no VEGFR-2 showed a significantly unfavorable prognosis by log-rank test (P = 0.010) and multivariate analysis (hazard ratio, 5.16; 95% CI, 1.40-19.04; P = 0.014). VEGFR-1 and VEGFR-3 were not significantly associated with patients' prognosis.

CONCLUSIONS

VEGF-A and VEGFR-1 were detected in diverse subtypes of angiosarcomas. In cooperation, VEGF-A and VEGF-C are likely to be involved in the development of angiosarcoma associated with lymphedema. VEGF-C expression may cause susceptibility to lymphatic metastasis through tumor lymphangiogenesis. Angiosarcoma of the scalp, which is traditionally considered as a true hemangiosarcoma, may include some cases of lymphatic origin.

Pathology of the Pleura

The pleura and lung are intimately associated and share many pathologic conditions. Nevertheless, they represent two separate organs of different embryonic derivation and with different yet often symbiotic functions. In this article, the authors explore the pathologic manifestations of the many conditions that primarily or secondarily affect the pleura.

The frequency of ipsilateral second tumors after breast-conserving surgery for DCIS

BACKGROUND

The diagnosis of ductal carcinoma in situ (DCIS) is increasing, although to the authors' knowledge there is no consensus regarding optimal treatment. This analysis of women treated with breast-conserving surgery (BCS) evaluated the impact of radiation therapy (RT) in patient outcomes.

METHODS

The current study included a population-based sample of 1103 women residing in selected Surveillance, Epidemiology, and End Results (SEER) registries who were diagnosed with DCIS between 1991-1992. Data were obtained from the registry, physician follow-up, and pathology reports. Physicians were contacted in 1999 to determine whether the patient had developed a second event in the ipsilateral breast. For second events, pathology reports were reviewed to determine the presence of in situ or invasive disease. Registry data through 2001 were used to assess death rates and cause of death. Cox proportional hazards and logistic regression models were used to evaluate the rates of second events and breast carcinoma deaths between women treated with and without RT.

RESULTS

Over an average of 91 months, 13.2% of women developed a second event. Rates of second events were 11% for women treated with BCS and RT compared with 15% for women treated with BCS only (adjusted hazards ratio, 0.64; 95% confidence interval, 0.44-0.92). Women receiving RT were significantly less likely to develop invasive breast carcinoma in the ipsilateral breast (adjusted odds ratio, 0.40). By 2001, the rate of death from breast carcinoma was 2.7%; in the group of women treated with BCS only compared with 0.8% in the group of women treated with BCS with RT.

CONCLUSIONS

Among a population-based cohort, RT was found to significantly reduce the risk of second events in the ipsilateral breast, particularly invasive tumors, although not to the extent reported in clinical trials.

Epithelioid Angiosarcoma Involving the Lungs

Diffuse lung involvement by metastatic tumor from an unknown primary site often constitutes a diagnostic dilemma. Although cytologic features and pattern of metastatic spread can guide in narrowing the list of possible primary neoplasms, immunohistochemistry remains pivotal in determining the phenotype of metastatic disease. We report a case with extensive involvement of lung parenchyma by a metastatic epithelioid neoplasm exhibiting a variety of distinctive patterns with a predominance of intra-arterial and lymphangitic spread. Immunohistochemical studies showed no evidence of epithelial, melanocytic, or lymphoid differentiation. The neoplastic cells were strongly positive for vimentin and CD31 but negative for CD34 and factor VIIIR:Ag. Electron microscopy of formalin-fixed tissue revealed multiple Weibel-Palade bodies and pinocytosis, supporting the diagnosis of epithelioid angiosarcoma. Doppler studies performed after pathologic diagnosis was rendered demonstrated 2 discrete hypoechoic masses within the medial aspect of the left proximal calf musculature, suggestive of solid soft tissue neoplasm—a possible source of pulmonary metastatic disease.

Metastatic angiosarcoma of the lung: spectrum of CT findings

OBJECTIVE

The purpose of our study was to summarize the CT features of pulmonary metastases in angiosarcoma in 24 patients.

CONCLUSION

A variety of CT features were associated with metastatic angiosarcoma of the lung. The common CT manifestations of metastatic angiosarcoma were multiple solid nodular lesions and multiple thin-walled cysts that were often accompanied by hemorrhagic change.

Angiosarcoma of the head and neck with intra-oral presentation. A clinico-pathological study of four cases

Angiosarcoma of the head and neck is a rare malignant tumour that most commonly involves the skin and subcutis, particularly of the scalp. It has been reported in intra-oral locations very rarely. This study reports on the clinico-pathological features of four such cases, in elderly patients and manifesting an aggressive course. All patients were admitted for rapidly enlarging masses involving the hard palate, alveolar crest and retromolar trigone and displaying bone destruction in three cases. Morphologically, three cases were composed by bundles of spindle cells admixed with variably sized abortive vascular channels which only showed slit-like spaces separating large clusters of epithelioid cells. In all instances, intra-cytoplasmic vacuoles containing intact or fragmented red blood cells were distinctly evident. All neoplasms showed consistent CD 31 immunoreactivity and variable degrees of CD 34 and Factor VIII related antigen positivity and were responsible for the death of the patients, for local progression or lung metastases, within 6 months from the original diagnosis. Due to their rarity, angiosarcomas with intra-oral presentation may be diagnosed with difficulty, especially on small incisional biopsies. and their differentiation from spindle cell carcinoma, malignant melanoma, anaplastic lymphoma, malignant myoepithelioma and other sarcomas that more commonly arise at this site should be based on accurate immunohistochemical characterisation.