대한흉부영상의학회 Weekly Chest Cases

Case No : 769 Date 2012-07-23

Courtesy of Hyun Ju Seon, Daun Lee, Yun-Hyeon Kim / Chonnam National University Hospital
Age/Sex 57 / M
Chief ComplaintRUQ pain (D: 4 days), current smoker (1 pack x 40 years)

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Diagnosis With Brief Discussion

Diagnosis: Hemorrhagic and cystic lung metastases from hepatic angiosarcoma
Radiologic Findings: Unenhanced chest CT shows a large mass-like lesion containing amorphous hyperattenuation area in right mid lung. On contrast-enhanced chest CT, the mass does not show definite enhancement, which is suggestive of hemorrhagic cystic mass.
Serial HRCT from apical lungs to basal lungs shows multiple cystic nodules and masses with some internal air-fluid levels and/or hemorrhagic debris and surrounding ground glass attenuation. Also, there is pneumothorax in left hemithorax.
Unenhanced abdomen CT shows about 5.0 cm round low attenuation mass containing amorphous hyperattenuation portion in right hepatic lobe. On contrast-enhanced abdomen CT, the mass does not show definite enhancement, which is suggestive of hemorrhagic cystic mass.
Brief Review: Angiosarcoma is a rare malignant neoplasm of the the vascular or lymphatic endothelim that accounts for 2% of all soft-tsisue arcomas and the most common primary sarcoma in the liver. It commonly affects patients 60-70 years of age. The lung is one of the most common sites of metastatic involvement, along with liver and lymph nodules. It is frequently accompanied by thin-walled cavitary pulmonary metastasis and is often obscured on chest radiograph. Imperfect vessel-like structures of the cavitary metastasis in this disease are likely to break down and finally grow up to large thin-walled cavities. The Secondary pneumothorax is also known as a characteristic complication in this disease due to lung metastasis. A study reported that secondary pneumothorax was observed in 10 of 17 patients with scalp angiosarcoma. Characteristic findings on chest CT were multiple thin-wall cavities and ground-glass attenuation around the cavity, located in bilateral subpleural lung fields. It is suggested that the subpleural thin-wall cavities cause pneumothorax. Secondary pneumothorax caused by this disease was intractable, resulting in an unfavorable outcome. It is necessary to develop a proper treatment strategy for secondary pneumothorax to create a favorable prognosis in this disease. Diffuse alveolar hemorrhage (DAH) is rarely the presenting manifestation of angiosarcoma. The finding of alveolar hemorrhage without identifiable tumor was considered supportive of a nonneoplastic DAH syndrome but subsequently some of these patients are discovered to have metastatic angiosarcoma. The open lung biopsy remains the gold standard for the diagnosis. None of the described patients with metastatic angiosarcoma who presented with DPH were known to have malignancy prior to lung biopsy or autopsy.
References: 1. Chen W, Shih CS, Wang YT, Tseng GC, Hsu WH. Angiosarcoma with pulmonary metastasis presenting with spontaneous bilateral pneumothorax in an elderly man. J Formos Med Assoc. 2006;105(3):238-241
2. Nomura M, Nakaya Y, Saito K, Miyoshi H, Kishi F et al. Hemopneumothorax secondary to multiple cavitary metastasis in angiosarcoma of the scalp. Respiration. 194;61(2):109-121.
3. Goto H, Watanuki Y, Miyazawa N, Kudo M, Inoue S, Kobayashi N, et al. Clinical and pathological analysis of 10 cases of secondary pneumothorax due to angiosarcoma of the scalp. Nihon Kokyuki Gakkai Zasshi. 2008 Feb;46(2):85-91.
4. SP Rai, MS Barthwal, P Bhattacharya, S Bhargava, M Pethe. Metastatic angiosarcoma presenting as diffuse alveloar hemorrhage. Lung India. 2008;25(1):14-16.
Keywords: lung, malignant tumor, metastasis,

No. of Applicants : 69

▶ Correct Answer : 21/69, 30.4%

- Kurashiki Seijin-byo Center , Japan Akihiro Tada
- University of British Columbia , Canada Amr Ajlan
- CHRU lille , France manuel toledano
- Onomichi municipal hospital , Japan Hirofumi Mifune
- Chonnam National University Hospital , Korea (South) So yeon Ki
- Vitalife Clinics , Pune , India. , India Rahul Deshmukh
- Chonnam national univ. hospital , Korea (South) Choi Seul-Gi
- CHU Poitiers , France CHAN paul
- Asan Medical Center , Korea (South) Hye Jeon Hwang
- XiangYa hospital , China Xia Yu
- Toranomon Hospital , Japan Takana Yamakawa
- Fortis hospital , Mohali , India Shaleen Rana
- Kizawa Memorial Hospital , Japan Yo Kaneko
- HUEC , Brazil Diogo Pinheiro
- GM InHospital , Korea (South) Ju Won Lee
- IRSA La Rochelle France , France Denis Chabassiere
- Zaid Alsheriti hospital- Alsweida , Syria jehad alakabani
- Mallinckrodt Institute of Radiology , United States Naganathan Mani
- Asan Medical Center , Korea (South) Eunyoung Kim
- Chonnam national university hospital , Korea (South) seo yeon Park
- Okayama university , Japan Mayu Uka

▶ Correct Answer as Differential Diagnosis : 16/69, 23.2%

- Kyung Hee Universitiy Hospital at Gangdong , Korea (South) Seong Jong Yun
- Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
- McGill University Health Center , Canada Alexandre Semionov
- Kyungpook National University Hospital , Korea (South) Jaekwang Lim
- Kyung Hee University Medical center , Korea (South) Myung You
- Goa Medical College , India Paresh Desai
- Auckland hospital , New Zealand (Aotearoa) Yuranga Weerakkody
- Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
- Hanyang University Hospital , Korea (South) Yo Won Choi
- James Paget Hospital , U.K , United Kingdom nabil mahmood
- China Medical University , Chia-Yi Christian Hospital ,Taiwan, R.O.C. , Taiwan Jun Jun Yeh
- CHRU Lille , France Paul Lebert
- Homs National Hospital , Syria Rami Abou Zalaf
- Kohka Public Hospital , Japan Akitoshi Inoue
- NDMVP Nashik , India Imran Jindani
- jaslok hospital & research centre mumbai , India JAINENDRA JAIN

▶ Semi-Correct Answer : 5/69, 7.2%

- Oita University, Faculty of Medicine , Japan Fumito Okada
- Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
- Ishikawa Matto Central Hospital , Japan Manabu Akimoto
- Centre Hospitalier Lyon Sud , France matthieu ROUSSET
- IRSA , France, Metropolitan BIGOT

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 769 Date 2012-07-23

Discussion

No. of Applicants : 69