Imaging features of primary sites and metastatic patterns of angiosarcoma

MRI features of Stewart-Treves syndrome: a case series and systematic review

PURPOSE

To comprehensively summarize the magnetic resonance imaging (MRI) features of angiosarcomas presenting as Stewart-Treves syndrome (STS) through a retrospective case series and systematic review of previous publications.

MATERIALS AND METHODS

We identified five patients with STS from our institutional database and 25 patients with STS from 15 publications through a systemic review. We reviewed the MR features of 30 patients with STS, including five males and 25 females with a mean age of 59.5 years.

RESULTS

The tumors most commonly involved both the cutis and subcutis (17/25, 68.0%); the remaining tumors were limited to the cutis or subcutis. Multiple tumors were observed in more than half of the cases (16/27, 59.3%), and most of the tumors had poorly defined margins (26/28, 92.9%). The most common signal intensities of the tumors on T1-weighted images were intermediate (16/19, 84.2%), and the remainder were a mixture of intermediate and high, with a predominance of intermediate signal intensity. The signal intensities of the tumors on T2-weighted images were intermediate in seven cases (7/13, 53.8%), a mixture of intermediate and high in five cases (5/13, 38.5%), and a mixture of intermediate and low in one case (1/13, 7.7%). Available diffusion-weighted images from four institutional cases showed restricted diffusion of the tumors with mean apparent diffusion coefficient (ADC) values ranging from 0.77 × 10-3 mm2/s to 0.96 × 10-3 mm2/s.

CONCLUSION

Typical MRI features of angiosarcomas in STS were superficially located in multiple masses with ill-defined margins. Internal signal intensity was intermediate on T1-weighted images, and intermediate or a mixture of intermediate and high on T2-weighted images. ADC values obtained from the limited number of cases were low.

Angiosarcoma in the femoral bone: A case report of a rare bone tumor

INTRODUCTION AND IMPORTANCE

Angiosarcoma is a high-grade endothelial sarcoma rarely found in the bones. Challenges lie in its rareness, high mortality, metastasis, and recurrence. The role of radiotherapy and chemotherapy in managing angiosarcoma remains debatable, while surgery stands out as the optimal treatment for local control. We present a patient with angiosarcoma of the bone, managed through a combination of surgery and radiotherapy.

CASE PRESENTATION

A 66-year-old male presented with pain on the right distal femur and was unable to weight bearing after lifting a box. The X-ray showed a fracture and lytic lesion. The patient has lost 5 kg of body weight in the last 3 months. The Clinicopathological Conference (CPC) suspects a malignancy process, prompting us for wide resection, biopsy, and ORIF with cement augmentation. Histopathology and immunohistochemistry results confirmed the diagnosis of angiosarcoma. We decide to manage patients with radiotherapy without chemotherapy and regular monthly monitoring. The patient exhibited clinical improvement.

DISCUSSION

Angiosarcoma of the bone tends to have a bad prognosis. Diagnosis might be challenging as it is a rare condition and could be easily confused with another disease. The routine CPC we held was beneficial for the diagnosis and treatment of the patient. The combination of surgery and radiotherapy is yielding positive outcomes.

CONCLUSION

Angiosarcoma should be considered in patients with osteolytic lesions in the bone. Surgery and radiotherapy are important to local control in patients with angiosarcoma.

ACG Clinical Guideline: Focal Liver Lesions

Focal liver lesions (FLLs) have become an increasingly common finding on abdominal imaging, especially asymptomatic and incidental liver lesions. Gastroenterologists and hepatologists often see these patients in consultation and make recommendations for management of multiple types of liver lesions, including hepatocellular adenoma, focal nodular hyperplasia, hemangioma, and hepatic cystic lesions including polycystic liver disease. Malignancy is important to consider in the differential diagnosis of FLLs, and healthcare providers must be familiar with the diagnosis and management of FLLs. This American College of Gastroenterology practice guideline uses the best evidence available to make diagnosis and management recommendations for the most common FLLs.

Lymph node involvement in secondary breast angiosarcoma - a case presentation

Angiosarcoma represents a group of rare tumors originating from vascular and lymphatic endothelial cells, characterized by marked aggressiveness, rapid growth and poor clinical outcome. The incidence of breast angiosarcoma accounts for approximately 0.05% of all malignant breast tumors and less than 1% of all sarcomas. In this article, we report the case of a 67-year-old female patient who presented to our Clinic due to a rapidly evolving, non-painful, vegetating mass, encompassing almost her entire left breast. Imaging studies revealed diffuse skin thickening in all quadrants and an intensely opaque axillary lymph node (LN). Interestingly, the patient had prior medical history of breast carcinoma treated conservatively in 2007 with limited breast resection and left axillary lymphadenectomy, followed by post-operative chemotherapy and radiotherapy. At the current presentation, we performed a radical mastectomy with ipsilateral lymphadenectomy. The histopathological examination revealed a secondary angiosarcoma with LN involvement mimicking an atypical vascular lesion. In this article, we report the clinicopathological particularities of this case and discuss the challenge of diagnosing LN involvement in angiosarcoma.

A Population-Based Long-Term Follow-Up of Soft Tissue Angiosarcomas: Characteristics, Treatment Outcomes, and Prognostic Factors

Angiosarcoma is a rare aggressive and understudied soft tissue sarcoma with pending evidence-based treatment guidelines due to varying study cohorts and inconsistent outcome measures. Surgery with wide resection is currently considered to be the cornerstone in management. In a population-based cohort identified from Danish National Health Registers between 2000 and 2017, this study aimed to define prognostic factors in patients with newly diagnosed soft tissue angiosarcoma. Kaplan-Meier survival analysis demonstrated 5-year overall survival of 28%. Competing risk analysis demonstrated cumulative incidence of local recurrence of 30% and metastasis of 43%. Multivariable Cox models among 154 included patients demonstrated age above 60 years and metastasis to be independently associated with worse overall survival. Cutaneous tumors, surgery, and negative resection margin were independently associated with improved overall survival. Adjuvant oncological treatment did not improve overall survival, risk of metastasis, or recurrence. Negative margin was not associated with lower risk of recurrence and metastasis. We conclude that, despite demonstrated improved survival after surgery with wide resection, overall survival remains poor.

Etiology, pathogenesis, and management of angiosarcoma associated with implants and foreign body: Clinical cases and research updates

Angiosarcomas are rare and highly malignant soft tissue sarcomas originating from endothelial cells lining the lymphatic or vascular system. While they predominantly emerge from (sub)cutaneous regions, occurrences have been reported throughout the body. The etiology of angiosarcoma remains elusive in most clinical cases. Nevertheless, several prognosis risk factors play a pivotal role, including chronic lymphedema, therapeutic irradiation, environmental carcinogens, familial syndromes, and the presence of foreign materials like metallic objects and biomedical implants. Despite evidence implicating retained foreign material in angiosarcoma development, understanding its prognosis and pathogenesis remains limited. The pathogenesis of angiosarcoma appears to involve a complex interplay of chronic inflammation, tissue remodeling, and genetic factors that create a conducive microenvironment for malignant transformation. Management of these sarcomas remains challenging due to their infiltrative nature owing to the high chance of metastasis and local recurrence. The primary treatment modalities currently include surgery, radiotherapy, and chemotherapy, but recent advances in targeted immunotherapy and gene therapy hold promise for more effective approaches. This comprehensive review delves into the potential etiological and pathogenic roles of foreign materials, such as metallic objects, biomedical implants, and biomaterials, in the development of angiosarcoma. Further research into the underlying molecular mechanisms could provide valuable insights for tailored management and developing novel targeted therapeutic strategies.

Clinical recommendations for treatment of localized angiosarcoma: A consensus paper by the Italian Sarcoma Group

Angiosarcoma (AS) represents a rare and aggressive vascular sarcoma, posing distinct challenges in clinical management compared to other sarcomas. While the current European Society of Medical Oncology (ESMO) clinical practice guidelines for sarcoma treatment are applicable to AS, its unique aggressiveness and diverse tumor presentations necessitate dedicated and detailed clinical recommendations, which are currently lacking. Notably, considerations regarding surgical extent, radiation therapy (RT), and neoadjuvant/adjuvant chemotherapy vary significantly in localized disease, depending on each different site of onset. Indeed, AS are one of the sarcoma types most sensitive to cytotoxic chemotherapy. Despite this, uncertainties persist regarding optimal management across different clinical presentations, highlighting the need for further investigation through clinical trials. The Italian Sarcoma Group (ISG) organized a consensus meeting on April 1st, 2023, in Castel San Pietro, Italy, bringing together Italian sarcoma experts from several disciplines and patient representatives from "Sofia nel Cuore Onlus" and the ISG patient advocacy working group. The objective was to develop specific clinical recommendations for managing localized AS within the existing framework of sarcoma clinical practice guidelines, accounting for potential practice variations among ISG institutions. The aim was to try to standardize and harmonize clinical practices, or at least highlight the open questions in the local management of the disease, to define the best evidence-based practice for the optimal approach of localized AS and generate the recommendations presented herein.

Aortic Angiosarcoma Manifesting as Multiple Musculoskeletal Metastases: A Case Report

Aortic angiosarcomas are rare. Due to its rarity and metastatic presentation, it is difficult to diagnose metastatic aortic angiosarcoma. We describe the clinicopathological and radiologic features of a metastatic aortic angiosarcoma presenting as musculoskeletal metastases. A 59-year-old male patient presented with left thigh pain. Plain radiographs revealed multifocal osteolytic lesions in the left femur shaft. Abdominopelvic computed tomography showed a lobulated osteolytic lesion in the left iliac bone. Magnetic resonance images revealed multifocal soft tissue lesions in the thigh musculature. A positron emission tomography/computed tomography (PET/CT) scan demonstrated multiple foci of increased uptake in the left femur bone, pelvis, left thigh, and calf musculature. Focal increased uptake in the lower abdominal aorta was newly detected. Pelvis biopsy showed tumor cell nests of epithelioid cells. The tumor cells showed vasoformative features. Immunohistochemically, the tumor cells showed positivity for vimentin, CD31, and ERG. The pathologic diagnosis of epithelioid angiosarcoma was established. The origin of the tumor was presumed to be the aorta. This case underscores the importance of PET scans in identifying primary lesions. In terms of the histopathologic diagnosis of biopsy samples with tumor cells exhibiting epithelioid neoplastic morphology, employing appropriate ancillary techniques such as immunocytochemistry with vascular markers may assist in accurately diagnosing metastatic angiosarcoma.

Lenvatinib-associated hemoperitoneum in a patient with primary angiosarcoma of the breast

We highlight the risk of lenvatinib drug toxicity when high-risk anatomic regions are affected by angiosarcoma.

Synchronous Double Primary Angiosarcoma Originating from the Stomach and Rectum: A Case Report and a Literature Review

Angiosarcomas originating from the gastrointestinal tract are rare but highly aggressive tumors with poor prognosis. These tumors can be misdiagnosed as benign and malignant gastrointestinal tract lesions. The definitive histological diagnosis of angiosarcomasis made by pathologists based on immunohistochemical analysis demonstrating cluster of differentiation 31 (CD31), factor VIII-related antigen (FVIIIRAg), erythroblast transformation specific related gene (ERG), and cluster of differentiation 34 (CD34). Angiosarcomas are treated with a single or multimodality approach that may include resection, radiotherapy, chemotherapy, and palliative care, depending on the stage of disease and the condition of the patient. No matter the treatment option, metastasis and death rates are substantially highin patients with angiosarcoma. In this context, a 59-year-old male with synchronous double primary angiosarcoma arising from the gastric and rectum who presented with the complaint of abdominal pain and distention to the outpatient clinic is presented in this case report, along with a brief literature review.

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.

Skin Malignancies: Imaging Review with Radiologic-Histopathologic Correlation

Skin malignancies are commonly encountered as primary or incidental findings. Neoplasms that affect the skin include primary (basal cell carcinoma, squamous cell carcinoma, melanoma, and Merkel cell carcinoma) and secondary (mesenchymal neoplasms, lymphoma, and metastases) tumors. Imaging provides valuable anatomic information (tumor size, depth of involvement, presence of distant metastasis, and data for guiding biopsy) and functional information (metabolic activity and sentinel node mapping data). This information, in addition to biopsy results, improves the histopathologic characterization of tumors and treatment planning. Various histopathologic types of the same entity exhibit different biologic behavior and have different imaging features. Familiarity with the multimodality imaging features, histopathologic characteristics, and various modes of dissemination (direct invasion; perineural, lymphatic, and hematogenous spread) of the most common skin malignancies helps radiologists narrow the differential diagnosis in clinical practice. ©RSNA, 2023 Supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.