Systemic therapy in primary angiosarcoma of the spleen

Primary splenic angiosarcoma: a case series of a rare oncological entity and diagnostic challenge

BACKGROUND AND PURPOSE

Primary angiosarcoma of the spleen (PAS), an exceptionally rare and aggressive neoplasm with high metastatic risk (70%-85%), is frequently diagnosed in an advanced or metastatic stage. It presents diagnostic challenges due to its nonspecific symptomatology and resemblance to benign vascular lesions in various imaging modalities.

PATIENTS AND METHODS

This case series aims to clarify the diagnostic difficulties by comparing imaging characteristics (CT-scan, MRI, and [18F]FDG-PET/CT) as well as pathological findings of three PAS cases diagnosed in different stages of the diseases (localized, metastatic, and metastatic with organ failure). Furthermore, a brief review on diagnostic and therapeutic features is included.

RESULTS AND INTERPRETATION

We suggest [18F]FDG-PET/CT as a differentiating tool between benign and malignant splenic lesions and propose a flowchart of a diagnostic algorithm for PAS. For treatment, we advocate for early splenectomy and when systemic therapy is warranted, paclitaxel emerges as a viable first-line option. While it is crucial to acknowledge that further trial data is required to evaluate the efficacy of emerging treatment regimens, designing and conducting trials for PAS is challenging given its scarcity and aggressive behavior. Therefore case reporting remains important.

Pancreatic angiosarcoma with synchronous pancreatic ductal adenocarcinoma leading to hemosuccus pancreaticus: A surgical case report and review of literature

Introduction

Angiosarcoma of pancreas is an extremely rare disease with a poor prognosis. The clinical signs and symptoms of pancreatic angiosarcoma are nonspecific, and it is occasionally diagnosed at an advanced stage. Pancreatic angiosarcoma and Pancreatic ductal adenocarcinoma in one patient was never ever known in English literature.

Case presentation

A 56-year-old female was admitted with clinical and laboratory signs of gastrointestinal (GI) bleeding. Upper gastrointestinal endoscopy revealed bleeding from the ampulla of Vater. Besides, abdominal computed tomographic (CT) revealed a solid mass in the region of the pancreatic tail, which was considered the origin of bleeding. Distal pancreatectomy and splenectomy were performed because of persistent GI bleeding, and the final histological diagnosis of tumor in pancreatic tail was pancreatic ductal adenocarcinoma. After 30 days, she developed recurrent bleeding in ampulla and the abdominal CT-scan revealed a huge hematoma in omentum harem. We conducted transcatheter arterial embolization, but anemia continued to worsen. Therefore, pancreaticoduodenectomy was recommended to remove this mass, and based on postoperative histological findings, pancreatic angiosarcoma was diagnosed. After few days, laparotomy was indicated again because of persistent intra-abdominal bleeding. Despite all critical care and surgical therapeutic attempts, the patient died within two weeks after operation.

Discussion

A pancreatic angiosarcomas primary origin is especially rare, with the present case being the tenth accounted in the English literature. Angiosarcomas is creating a disorganized mass of cells with extravasated blood that led to characteristics, extensive amounts of hemorrhage. The clinical manifestations of pancreatic angiosarcoma are variable, and immunohistochemistry staining is mandatory, with positive staining for vascular markers, which include CD31, CD34, von Willebrand factor (vWF), factor-VIII, Ulex europaeus agglutinin 1 (UEA-1), Friend leukemia integration 1 (Fli-1) and vascular endothelial growth factor receptor (VEGFER).

Conclusion

We here present a report of an extremely rare case with had pancreatic angiosarcoma and synchronous pancreatic ductal adenocarcinoma with clinical picture of GI bleeding secondary to hemosuccus pancreaticus (HP).

Case Report: Complete Remission With Anti-PD-1 and Anti-VEGF Combined Therapy of a Patient With Metastatic Primary Splenic Angiosarcoma

Primary splenic angiosarcoma (PSA) is a rare malignancy with poor prognosis. At present, little study is available on immunotherapy in PSA. Here, we report a case of a patient with metastatic PSA who was treated with programmed death-1 (PD-1) inhibitors and vascular endothelial growth factor (VEGF) tyrosine kinase inhibitors combined therapy and achieved complete response (CR). The patient was a 57−year−old woman with three liver metastases. She was treated with seven cycles of toripalimab plus anlotinib. Programmed death-ligand 1 (PD-L1) immunohistochemistry and next-generation sequencing was performed, and the PD-L1 tumor proportion score was 75%. Finally, she achieved CR after six cycles of the combined therapy regimen. No serious adverse events were detected. To the best of our knowledge, this is the first clinical evidence that anti-PD-1 plus anti-VEGF therapy might be a promising option for patients with metastatic PSA. However, more clinical trials are needed to verify this conclusion.

Spleen angiosarcoma: a world review

Introduction: Spleen angiosarcoma (SA) is a rare malignant neoplasm that arises from the splenic vascular endothelium, with only around 300 cases reported to date. Due to a limited number of reported cases, there is a paucity of data and a lack of understanding of its presentation, diagnosis, and management. In this study, we aim to provide a comprehensive review of SA.Areas covered: On 27 February 2021, a literature search was done in PubMed and Embase database. The search yielded 122 articles involving 205 patients. The focus was on patient demographics, risk factors, clinical presentations, investigation results, preliminary diagnoses, therapies provided, and patient outcomes. These factors were analyzed to identify possible risk factors, diagnostic modalities, and therapeutic principles that were not mentioned before.Expert opinion: The clinical presentation or investigation results of patients with SA are often nonspecific. Hence, they may not be sufficient to clinch the diagnosis of SA if used alone. The authors recommend a triple assessment of clinical examination, imaging findings, and pathology to diagnose SA with high accuracy. Splenectomy should be the mainstay of management, with chemotherapy and radiotherapy considered as adjuncts, especially in the presence of metastases.

Long-Term Survival due to Chemotherapy including Paclitaxel in a Patient with Metastatic Primary Splenic Angiosarcoma

A primary splenic angiosarcoma is a rare type of soft tissue sarcoma and is associated with an extremely poor prognosis. In this study, we describe the case of a patient who was diagnosed with metastatic primary splenic angiosarcoma and survived for about 2 years. A 62-year-old female was referred to us for the treatment of splenic angiosarcoma with disseminated intravascular coagulation (DIC) and multiple liver and bone metastases. Paclitaxel therapy resulted in recovery from DIC and enabled her to continue sequential treatment through to sixth-line chemotherapy. We reviewed all splenic angiosarcoma case reports which were described as stage IV to date and compared with our case. From these data, we found that the median overall survival was 105 days, and the prognosis of splenic angiosarcoma of stage IV was worse than conventional case series. Splenectomy was performed in more patients than chemotherapy as a treatment. Moreover, various chemotherapeutic regimens were used. These data suggest that administering chemotherapy including paclitaxel to patients with splenic angiosarcoma might improve their prognosis.

Primary angiosarcoma of the spleen, a rare indication for splenectomy: a case report

INTRODUCTION AND IMPORTANCE

Primary angiosarcoma of the spleen is a rare condition with a nonspecific clinical presentation and is associated with a poor prognosis. We describe two patients with primary splenic angiosarcoma successfully treated with splenectomy and adjuvant chemotherapy.

CASE PRESENTATIONS

Case 1: A 50-year-old female presented with fatigue and left-sided rib, shoulder, and abdominal pain. A CT scan demonstrated a large splenic mass, and biopsy was diagnostic of angiosarcoma. An open en bloc resection of the spleen was performed, and pathologic examination confirmed high-grade angiosarcoma; the surgical margins were negative. The patient received pegylated liposomal doxorubicin (PLD) and ifosfamide; she demonstrated no evidence of recurrence with four years of follow-up. Case 2: A 70-year-old male presented with acute back pain. A CT scan demonstrated a splenic mass; biopsy was diagnostic of angiosarcoma. The patient underwent open splenectomy, and pathology revealed high-grade angiosarcoma; the surgical margins were positive. The patient received PLD and ifosfamide but presented three years later with metastatic tumor to the spine. The patient had a favorable tumor response to pembrolizumab. The patient's tumor burden remains stable at 5 years following splenectomy.

CLINICAL DISCUSSION

Angiosarcoma of the spleen is a rare clinical entity and is often challenging to diagnose early. Moratality is high, especially in the case of metastasis or spontaneous rupture.

CONCLUSION

Due to the rare nature of this tumor, optimal treatment is not known. Here, we show excellent response in two patients to surgery combined with adjuvant therapy.

Relapsing Haemothorax as an Unusual Presentation of Primary Angiosarcoma of the Spleen

Spontaneous haemothorax (SH) is a rare subcategory of haemothorax that involves the accumulation of blood within the pleural space in the absence of trauma. SH especially occurs in middle-aged or elderly patients, but data are usually limited to case reports and case series. Coagulopathy, aneurysm or aortic dissection, Rendu-Osler-Weber syndrome and malignancy have to be considered among the causes of SH.

Aim

We describe a case of primary angiosarcoma of the spleen presenting as relapsing haemothorax.

Results

An 81-year-old woman was referred to our hospital because of a 2-month history of relapsing haemothorax after the performance of urgent splenectomy due to active bleeding from large spleen cysts. No evidence of neoplasm was seen after pathological examination of the spleen. On admission, left haemothorax and 2 new cystic masses in the thoracic wall were documented, both in close relation to the scars of previous surgery and chest tubes. After excision of 1 mass, histological examination revealed angiosarcoma, and a final diagnosis of primary angiosarcoma of the spleen with postsurgical metastatic dissemination to the thorax and pleura was made.

Conclusion

Primary angiosarcoma should be included in the differential diagnosis of haemorrhagic spleen cysts. Clinical diagnosis and management usually requires splenectomy, but it should be carefully planned in order to avoid local metastatic dissemination or haematogenous spread of the tumour.

LEARNING POINTS

The differential diagnosis of spleen cysts must include malignant conditions.Despite its absolute rarity, angiosarcoma is considered the most common primary non-haematolymphoid splenic malignancy and has a poor prognosis.Splenectomy is usually required for a prompt diagnosis of primary angiosarcoma of the spleen, but it needs to be performed with extreme caution to avoid metastatic dissemination.

A Case Report of Splenic Rupture Secondary to Underlying Angiosarcoma

Primary splenic angiosarcoma is a rare type of cancer that has not been well-illustrated due to infrequency and variability in patient presentation. Limited systemic therapy regimens for splenic angiosarcoma make early detection preferable, as management focuses on monitoring for recurrence and metastatic spread or preventing hemorrhagic complications of tumor burden such as splenic rupture. This cancer, in particular, is aggressive, and metastasis is common. Here, we discuss a 68-year-old female who presented with a splenic laceration caused by an underlying primary splenic angiosarcoma. The purpose of this article is to describe a patient who presents with noteworthy clinical features and a rare complication of splenic angiosarcoma to aid in the treatment and diagnosis of future patients.

A primary splenic angiosarcoma hepatic metastasis after splenectomy and its genomic alteration profile

RATIONALE

Primary splenic angiosarcoma (PSA) is a rare mesenchymal malignancy of the splenic vascular origin often with a dismal prognosis. Genomic profile may provide evidence for the solution of therapy.

PATIENT CONCERNS

We reported a case of a 51-year-old woman with splenectomy 4 years ago and the postoperative histopathology diagnosis revealed "splenic hemangioma" with spontaneous rupture. Two years after the operation, the patient's rechecked abdominal computed tomography (CT) showed multiple hepatic occupations.

DIAGNOSES

Pathological test suggested PSA hepatic metastasis.

INTERVENTIONS

The patient was treated with trans-catheter arterial chemoembolization (TACE) and a pathological diagnosis of PSA was highly suspected in the hepatic biopsy. Four somatic alterations, phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA), Fos proto-oncogene, AP-1 transcription factor subunit (FOS), MCL1 apoptosis regulator (MCL1), and phosphoinositide-3-kinase regulatory subunit 1 (PIK3R1) were detected in the tumor tissue using a Next generation sequencing (NGS) technology. The results prompted that the patient may get clinical benefit from using some agents for targeted therapy, Everolimus, Temsirolimus, or Copanlisib.

OUTCOMES

The patient refused targeted therapy. As a result, the patient passed away within 51 months after splenectomy.

LESSONS

PSA is an aggressive disease that often presented with a high propensity for metastasis and rupture hemorrhage. Some of these mutations were first discovered in PSA and these findings added new contents to the genomic mutation profile of PSA.

Splenic Angiosarcoma Diagnosed on Bone Marrow Biopsy: Case Report and Literature Review

Primary splenic angiosarcoma carries a poor prognosis and is among the rarest forms of malignancy. An overwhelming majority of patients with splenic angiosarcoma will develop metastases. However, osseous metastatic disease is rare. We present an 83 year old hispanic female who was diagnosed with primary splenic angiosarcoma on bone marrow biopsy performed for a hematologic workup. We highlight key historical, laboratory, imaging, and pathological features of splenic angiosarcoma. The synthesis of both imaging features and clinical history is essential for establishing early diagnosis in these patients.

Primary splenic angiosarcoma diagnosed after splenectomy for spontaneous rupture

Primary splenic angiosarcoma is a rare abnormality and has a bad prognosis. It has unknown pathogenesis. This abnormality is usually presented by splenic rupture. Surgery is the most promising treatm Surgery is the most accepted and accurate method for diagnosis and treatment. Surgery before rupture increases the life expectancy. A 65-year-old woman who presented to the emergency room with abdominal pain, abdominal distension, and anemia was found to have a splenic mass and massive ascites. After getting a hemorrhagic sample from the abdomen, the patient was operated with splenic rupture prediagnosis. The spleen material was reported as splenic angiosarcoma. The staging 18F-FDG-Positron Emission Tomography-Computed Tomography did not show any metastasis. Five months later, paclitaxel treatment was initiated upon liver and bone metastasis, and the treatment still continues. Splenic angiosarcoma has a place among splenic parenchymal lesions. The splenectomy material names the diagnosis. Pathologic examination of splenectomy material is revealed certain diagnosis.

Primary Splenic Angiosarcoma Presenting as Idiopathic Thrombocytopenic Purpura: A Case Report and Review of the Literature

Angiosarcoma of the spleen is a rare malignancy that arises from vascular endothelial origin. This neoplasm is highly malignant and diagnosis is often delayed due to the vague presentation of clinical symptoms. A case report and concise review of the current diagnostic criteria and surgical treatment are provided to aid in the detection and treatment of this malignancy. We present a case of a 56-year-old female who presented with massive splenomegaly secondary to angiosarcoma of the spleen. The patient suffered from longstanding symptomatic anemia and thrombocytopenia. Diagnosis of a splenic angiosarcoma can be difficult due to the vague presentation and lack of concrete risk factors. Early identification and splenectomy are paramount. However, it is an aggressive malignancy with poor prognosis. We reviewed the literature of the current diagnostic and surgical treatment of primary splenic angiosarcoma.

Spontaneous rupture of primary splenic angiosarcoma: A case report

Primary angiosarcoma of the spleen is an extremely rare malignant neoplasm of vascular origin that often has a poor prognosis. The majority of cases presents with splenic rupture and hemorrhage. The present study retrospectively analyzed the case of 77-year-old female who presented with diffuse abdominal pain and distension. During laparotomy, a huge actively bleeding spleen was identified and a splenectomy was performed. Since an accurate diagnosis could not be achieved by abdominal computed tomography, a pathological examination was performed. The patient and the family refused post-operative adjuvant chemotherapy and radiation therapy. The patient succumbed to uncontrolled hemorrhagic shock and lung metastases at 2 weeks post-surgery.

Delayed diagnosis of angiosarcoma of the spleen: clinically presenting as recurrent haemoperitoneum following embolisation

Angiosarcoma is a highly aggressive and extremely rare neoplasm of the spleen, with a limited number of reported cases worldwide. We report a case of a 69-year-old man who presented with progressive symptoms of fatigue, abdominal and back pain, anaemia and haemoperitoneum 1 year following embolisation of the spleen for splenic rupture. Additional imaging and colonoscopy with biopsy revealed intra-abdominal fluid and a colonic adenocarcinoma. Diagnostic laparoscopy demonstrated a haemoperitoneum and colon carcinoma, after which splenectomy via laparotomy was performed. Pathology report revealed an angiosarcoma of the spleen with peritoneal tumour deposits. Rupturing of a spleen may be due to an underlying disease. Therefore, the differential diagnosis of splenic rupture should include the possibility of a splenic tumour. The definitive diagnosis and treatment of a splenic angiosarcoma may require splenectomy, although prognosis is poor.

Primary angiosarcoma of the spleen: an oncological enigma

Introduction. Primary splenic angiosarcoma is an extremely unusual neoplasm originating from sinusoidal vascular endothelium. Surgical extirpation is the mainstay of treatment of this highly malignant disease. Case Presentation. An 82-year-old woman was admitted with left pleural effusion and a palpable left upper quadrant abdominal mass, secondary to splenomegaly by two large splenic tumors. Classic open splenectomy was performed and angiosarcoma of the spleen was the final histopathological diagnosis, which was primary since no other disease site was revealed. Discussion. The incidence of the disease is 0.14-0.23 cases per million, with slight male predominance. Etiology is not established and clinical presentation may confuse even experienced physicians. Imaging modalities cannot differentiate the lesion from other vascular splenic neoplasms and the correct diagnosis is mainly set after histopathological examination of the resected spleen. As with other sarcomas, surgery is the only curative approach, while chemo- and radiotherapy have poor results. Prognosis remains dismal.

Rupture of splenic angiosarcoma: a rare cause of spontaneous haemoperitoneum

Primary splenic angiosarcoma, a very rare mesenchymal tumour of endothelial cell origin, comprises 2.6% of all cases of angiosarcoma and 10% of all primitive splenic tumours. Clinical presentation is usually unspecific, with abdominal pain and anaemia. Rupture is a rare complication and should prompt emergency splenectomy. Prognosis is usually poor because of liver, lung or bone metastases. We describe the case of an 80-year-old woman admitted to the emergency room with syncope, hypotension and vomiting. She stabilised after fluid resuscitation. Investigations showed anaemia, a large, heterogeneous spleen and free fluid in the abdominal cavity. She underwent emergency splenectomy. Pathology revealed primary splenic angiosarcoma. The postoperative period was complicated by respiratory failure but the patient made an otherwise uneventful course and was discharged 2 weeks after surgery. Six months after the operation she remains free of disease with no adjuvant treatment.