Multiple hepatic metastases of cardiac angiosarcoma

Abstract

The differential diagnosis of hepatic focal lesions is challenging because the etiology can be inflammatory, infectious, and even neoplastic. A rare cause of metastatic liver nodules is cardiac angiosarcoma. We report a case of this tumor, which was diagnosed only after autopsy. A 26-year-old Caucasian man was admitted for progressive dyspnea and cough over the past 3 weeks. Physical examination showed only hypophonetic heart sounds. Laboratory analysis demonstrated anemia and elevated inflammatory markers, despite normal biochemical parameters and liver function. Transthoracic echocardiography revealed massive pericardial effusion. Abdomen computed tomography (CT) showed multiple hepatic nodules, the largest of which measured 3 cm, but the percutaneous biopsy revealed only lobular necrosis and perisinusoidal fibrosis without granulomas or neoplastic cells. During hospitalization, the patient had fever and night sweats with weight loss, and empiric treatment for extrapulmonary tuberculosis associated with corticosteroids was initiated. The outpatient follow-up revealed complete improvement of the pericardial effusion, but maintenance of the liver lesions. After 2 months of hospital discharge, the patient was readmitted with hemorrhagic shock due to bleeding liver lesions, which were evidenced by CT. Embolization of the right hepatic artery was performed, but the patient soon died. The autopsy revealed a primary cardiac angiosarcoma with multiple hepatic metastases, rupture of the Glisson's capsule and laceration of the liver. The case shows how important and difficult the diagnosis of focal liver lesions is, since it may result in an unexpected fatal outcome.

Keywords: Heart Neoplasms; Neoplasm Metastasis; Sarcoma.

Figure 1. A – Increased cardiac area on chest X-ray. B – Transthoracic echocardiography revealing pericardial effusion but not showing the tumor.

Figure 2. Abdominal CT. A – Axial plane: multiple hypodense hepatic lesions and hemorrhagic ascites. B – Coronal plane: evidence of the right atrial mass. C – Thoracic CT, axial plane: reveals right atrial hypodensity. CT = computed tomography.

Figure 3. A – Gross view of the right atrial angiosarcoma. B – Macroscopic appearance of the hepatic cut surface showing multiple and scattered metastases of the angiosarcoma. C – Photomicrograph of the hepatic fragment with spindle cells delimiting poorly-formed vascular structures, characteristic of angiosarcoma (H&E, 100X). D – Immunohistochemistry: strong and diffuse positivity for CD34 (40X). Ao = aorta; LA = left atrium, PT = pulmonary trunk, RVOT = right ventricle outflow tract, RA = right atrium, T = tumor.