Kütanöz anjiyosarkomda kemik iliği metastazı: bir olgunun manyetik rezonans görüntüleme bulguları

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Introduction
Cutaneous angiosarcoma (CA) is a rare, aggressive endothelium-derived sarcoma that occurs most
frequently in the scalp and facial skin of elderly men.
They rarely occur on the extremities, and a few previous reports interest upper limbs (1,2). In this study,
magnetic resonance (MR) imaging findings of an elderly male who had CA in his cruris with its metastases to bone and bone marrow is reported. In addition
to splenic angiosarcomas in which previous reports
proposed to have a virtually unique propensity for
infiltration in the bone marrow (3), this case shows
that CAs can also metastasize to the bone.
Case Report
An 85-year-old, otherwise healthy male presented
with large blue-purple colored, exophytic, nodular and
fixed masses on his right cruris. The lesions had appeared gradually and grew slowly but continuously in a
relatively short period of time. In order to demonstrate
the likely extension of the tumors to deep soft tissues, an MR imaging was planned. MR images revealed
nodular lesions in cutaneous and subcutaneous tissues, hyperintense on T2 weighted images with contrast
enhancement on T1 weighted sequences. Lesions with
same intensity characteristics and dimensions were
also seen within the medulla of crural bones (Figures
1,2,3). The biopsy of the primary lesion, accomplished
after MR imaging, revealed a malignant mezenchymal
tumor with prominent epitheloid features, and most of
the neoplastic cells showed immunoreactivity against
CD31, a marker of endothelial differentiation (Figure
4). The lesions with the same dimensions and signal
intensity characteristics seen in the bone marrow was
interpreted as metastasis of the CA.
Discussion
CA is most commonly seen on the scalp of elderly men with an average age of 75 years (2). In their
* Department of Radiodiagnostic Radiology, Gulhane Military Medical Faculty
**Department of Pathology, Gulhane Military Medical Faculty
Reprint request: Dr. Hatice Tuba Sanal, Department of Radiodiagnostic
Radiology, Gulhane Military Medical Faculty, Etlik-06018, Ankara, Turkey
E-mail: tubasanal@yahoo.com
Date submitted: February 20, 2009 • Date accepted: June 01, 2009Volume 52 • Issue 1 Cutaneous angiosarcoma • 59
47 case series of CA, Morgan et al. have reported the
most common location as the head and neck region
(a ratio of 96%) with a single case involving the arm
and shoulder (2). Nilles et al. and Bock et. al have separately reported two distinct cases of CA involving
the distal forearm (1,4). In this case the lesions were
involving the distal cruris. Though excessive UV light
exposure to head and neck area has been proposed as
one risk factor (2), this was not completely possible for
our case. These lesions are reported to be clinically prediagnosed as angiosarcoma, metastases, lymphoma,
squamous/basal cell carcinoma, pyogenic granuloma,
and ecchymosis/bruise mistakenly (2). Patients may
present not only with a single lesion but multifocal
or satellite lesions may also be seen as in our case (5).
Studied head and neck CAs are reported to metastasize most commonly to lungs, followed by the liver,
cervical lymph nodes, spleen, and, rarely, the heart
and brain (2). Wang et al. have found that although
metastases occur commonly, bone marrow findings
have been rarely documented (3). In their splenic angiosarcoma case, on observing metastasis to bone with
2 other cases that have been reported previously, they
have concluded that splenic angiosarcomas have a virtually unique propensity for infiltration in the bone
marrow. Nonethless, our case shows that CAs can also
metastasize to bone. MR imaging may define the extent of the tumor (5). Similar to previous reports on
scalp CAs, lesions in our case were hyperintense on
T2-weighted images with distinct borders, enhancing
on postcontrast T1-weighted images. On MR images,
lesions with similar imaging characteristic were revealed also within the bone marrow in our case.
In conclusion, metastasis to bone marrow from a
CA can be observed though previous reports claim
metastasis to bone is unique to splenic angiosarcoma.
Awareness of the disease in spite of the rare location may hinder delay in diagnosis. If CA is diagnosed with histopathology, the probable metastases to
bone should be evaluated either by scintigraphy or
MR imaging.