Intracranial invasion from recurrent angiosarcoma of the scalp

Case report: cranial angiosarcoma with multiple hemorrhagic brain metastasis in a child

BACKGROUND AND IMPORTANCE

Angiosarcoma is a rare malignant tumor with an aggressive course and poor prognosis. It is typically seen in adults but very rarely seen in children. Angiosarcoma of the skull with brain metastasis is exceptionally rare. Due to the rare nature of these tumors, much is left unknown about clinical progression and treatment guidelines are not well established.

CLINICAL PRESENTATION AND COURSE

A 14-year-old male patient presented with an enlarging mass on the parietal region of the head. Further investigations revealed a mass lesion involving scalp and skull tissue. Biopsy result showed angiosarcoma and the patient underwent multiple surgical interventions including scalp excision, craniectomy on tumor site, and excision of brain metastases. He also received chemotherapy and radiation therapy. Despite aggressive treatment, disease progression could not be controlled.

CONCLUSION

Here we report a pediatric patient with intracranially invasive angiosarcoma of the scalp and skull, with recurrent hemorrhagic metastases to the brain. This is a very rare case in pediatric age group with very poor prognosis. Our patient had impressively longer survival than those reported in the literature despite multiple hemorrhagic brain metastasis and this is most likely related to our aggressive treatment strategy that includes multiple craniotomies for metastatic tumor resection in addition to neoadjuvant chemotherapy and radiation therapy. We believe optimal treatment of skull angiosarcoma in children should aim gross total resection of the skull tumor including involving scalp and dura as well as neoadjuvant chemotherapy and radiation therapy, and the patient should be followed closely with repeated brain MRI studies to pursue additional surgeries to remove brain metastasis if feasible.

Extra-axial brain tumors

Extra-axial brain tumors are the most common adult intracranial neoplasms and encompass a broad spectrum of pathologic subtypes. Meningiomas are the most common extra-axial brain tumor (approximately one-third of all intracranial neoplasms) and typically present as slowly growing dural-based masses. Benign meningiomas are very common, and may occasionally be difficult to differentiate from more aggressive subtypes (i.e., atypical or malignant varieties) or other dural-based masses with more aggressive biologic behavior (e.g., hemangiopericytoma or dural-based metastases). Many neoplasms that typically affect the brain parenchyma (intra-axial), such as gliomas, may also present with primary or secondary extra-axial involvement. This chapter provides a general and concise overview of the common types of extra-axial tumors and their typical imaging features.

Diffuse alveolar hemorrhage due to metastatic angiosarcoma of the lung: A case report

Angiosarcoma is a rare, heterogeneous malignant tumor that derives from endothelial cells, and it has aggressive characteristics with a marked tendency for distant metastasis. Diffuse alveolar hemorrhage (DAH) is a catastrophic clinical syndrome, however, it is rare as the presentation of pulmonary angiosarcoma. To increase awareness with regard to angiosarcoma and DAH, the current study presents a case of angiosarcoma that originated from the subcutaneous soft tissue of the mastoid process, but was subject to a delayed diagnosis and rapid invasion into the brain and lung. The metastatic angiosarcoma of the lung presented with DAH as the initial manifestation. The pathological examination of a biopsy of the subcutaneous mass and pulmonary lesions confirmed the diagnosis of angiosarcoma. The patient succumbed to respiratory failure at 1 month post-diagnosis.

Metastatic angiosarcoma: a vascular tumour or an intracranial haemorrhage?

A 64-year-old man presented with weakness of his right arm and leg. He had previously had mitral valve replacement, tricuspid annuloplasty, leg deep vein thrombosis (DVT) and femoral embolism. Computed tomography (CT) scan of the brain showed an acute left thalamic haemorrhage. Repeat CT brain showed resolution of the original haemorrhage, but the apparent development of new areas of haemorrhage. Warfarin continued due to high risk of thromboembolism. He was readmitted with the rapid development of a visible swelling at the sternum and on the scalp. Ultrasound scan of the sternum revealed a vascular tumour. Suspected haemorrhages in the past were reported as the metastatic deposits. Biopsy and immunohistochemical staining confirmed angiosarcoma of the scalp. Being vascular tumours, angiosarcoma can mimic a brain haemorrhage. Our case illustrates a clinical conundrum. Diagnosing metastatic angiosarcoma of the brain proved difficult without visible primary and histology. The rapid clinical course of the disease and problems with anticoagulation therapy made treatment options limited and the prognosis worse.