(CHEST 2001; 120:1725-1727) A 57-year-old man at handed with cough.

(CHEST 2001; 120:1725-1727)

A 57-year-old man at handed with cough, purulent blood-streaked mucus, and sinus congestion, which resolv with a course of amoxicillin/clavulanate therapy. The patient was noted to have a left upper lobe cystic lesion upon a chest radiograph (Fig 1) and a CT scan (Fig 2) Sputum cytology testing eventuates were negative. Sputum cultures initially revealed Mycobacterium gordonae, nevertheless this did not grow onward subsequent serial sputum analyses and was presum to be a contaminant. The patient was a lifelong nonsmoker, was feeling well, had no weight los ferments or sweats, and had not experienced any unusual environmental prospects The only unusual features in his medical history were a cholecystectomy and a skin lesion onward his scalp, which had been remov 3 years previously.

[FIGURES 1-2 OMITTED]

The patient had no return of symptoms and no change in the size of the lesion as assessed by dint of CT scan over the following 7 month and in such a manner he declined further intervention. However, 11 month after the initial presentation, the hemoptysis recurr and persisted despite treatment with broad-spectrum antibiotics. At that time, the lesion considered larger on a chest radiograph and a CT scan. The patient still felt well, apart from the hemoptysis, and sputum agriculture findings were negative for bacterial, fungal, or mycobacterial organisms.

What is the diagnosis?

Diagnosis: Angiosarcoma of the left upper lobe, presum metastatic

Bronchoscopy revealed children oozing from the left upper lobe bronchus and abnormal mucosa distally. Bronchoscopic biopsies revealed angiosarcoma with identical histology to that of the scalp lesion that had been remov 3 years previously and treated with local radiotherapy. Immunohistochemistry demonstrated reactivity with the endothelial markers CD34 and CD31 The patient underwent a left upper lobectomy (histology of resect specimen in Fig 3) with an quiet postoperative course; 16 months after his lobectomy, there is no evidence of thoracic return of his angiosarcoma as shown on chest radiograph or CT scan. Fifteen month after undergoing the lobectomy, the patient underwent a barium small bowel follow-through for left lower quadrant abdominal pain that had been at hand for several months. Nothing had been place on esophagogastroduodenoscopy, colonoscopy, and abdominal CT scan 4 to 5 month previously. upon the barium examination, an 8- to 9-cm mass-like lesion was base in a loop of small bowel overlying the left lower quadrant, which was confirmed on repeat CT scan. The patient underwent resection of this lesion, which was an angiosarcoma, and another small bowel angiosarcoma lesion, which had not been seen onward any of the radiographic studies, was plant during the laparotomy and was also remov It is now approximately 5 years since this patient's original scalp angiosarcoma was removed

[FIGURE 3 OMITTED]

DISCUSSION

Cases of scalp angiosarcoma metastasizing to the lung have been described previously, (1-12) This case is unusual as angiosarcomatous pulmonary metastases in past reports usually have been multiple, the patients have been persistently symptomatic, and the disease has advanceed rapidly.

Clinical Features

Angiosarcomas are rare malignant tumors of vascular origin, accounting for 2 to 3% of all sarcomas, and strike one as being to have a predilection for the scalp. (1) Angiosarcomas, regardless of their source, are particularly liable to metastasize to the lung (23) A 1993 review (2) stated that primary angiosarcomas of the lung are extremely rare, with simply eight cases having been reported in the literature at that time. Angiosarcomas are especially usual in the sixth through seventh decade of life, are more customary in men, and show a particular predilection for the head and neck (8)

Patel and Ryu (2) reported 15 cases of pulmonary angiosarcoma from the Mayo Clinic. The majority (12 of 15 patients) had symptoms ranging from weight los to cough hemoptysis, chest pain, dyspnea, or febrile disease Ten of 15 patients had no physical signs. The sources of the pulmonary lesions varied as follows: heart (three patients); breast (three patients); forearm (one patient); scalp (one patient); cranium (one patient); liver (one patient); tibia (three patients); jugular vein (one patient); and chest wall (one patient). united case failed to reveal a primary source of disease for the patient. The patient with a primary scalp angiosarcoma had a pneumothorax and bilateral pulmonary nodules in addition to hemoptysis. Metastases to the lung be found in 60 to 80% of cases of cutaneous and cardiac angiosarcomas. (2) Cavitation, pneumothorax, or hemothorax have been reported to be more often met with with angiosarcomas originating from the scalp. In a 1987 review of 95 patients with angiosarcoma, those patients with scalp lesions (33 of 95 patients) had a greatly higher incidence of metastatic pulmonary complications (ie, pneumothorax or hemothorax). All patients with pulmonary involvement in this series had multiple pulmonary lesions. (3)

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