Lower Gastrointestinal Bleeding in a Patient With a History of Breast Cancer
Article Outline
- Answer to the Clinical Challenges and Images in GI Question: Image 2: Hemangiosarcoma of the Ileum and Liver
- References
- Copyright
Question: A 43-year-old woman with history of breast cancer successfully treated with surgery and chemotherapy in 2003 was admitted because of hematochezia. The patient was well until 1 month ago, when she presented intermittent episodes of abdominal pain and vomiting. An abdominal mass in the right upper quadrant and in the pelvis was evident by palpation. Blood tests showed hemoglobin of 9 g/dL; white blood cells count and platelet count were within normal ranges.. Bilirubin and transaminases were also normal. Alkaline phosphatase was 216 IU/L; γ-glutamyltransferase, 323 IU/L; and albumin, 2.5 g/dL. Abdominal computed tomography showed centripetal-enhanced, hypodense tumors in the liver and ileum (Figure A). On colonoscopy, deformation of the ileocecal valve did not allow the evaluation of the ileum; therefore, surgery was performed. Grossly, there were a bleeding, dark-red tumor in the ileum and another 2 in the liver.
Histologic analysis by hematoxylin and eosin (Figure B) showed a tumor with an angioformative appearance. Immunohistochemical staining (positivity for CD31 and CD34, and negativity for epithelial marker keratin) confirmed its vascular origin. Patient died after 1 month of follow-up.
What is the diagnosis?
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Answer to the Clinical Challenges and Images in GI Question: Image 2: Hemangiosarcoma of the Ileum and Liver
Computed tomographic images suggested a vascular tumor of the intestine and liver. The diagnosis of hemangiosarcoma was made histologically. Microscopically, the tumor is characterized by sheets of polygonal cells and many spaces suggestive of vascular differentiation, with positive immunohistochemical staining for vimentin, factor VIII-related antigen and endothelial markers (UEA-I, CD31, CD34) and negative for epithelial marker keratin and epithelial membrane antigen. This is an extremely uncommon neoplasm of the gastrointestinal tract; until now, <20 cases have been reported to affect the small bowel.1, 2, 3 Few cases of extraintestinal angiosarcomas have been associated with breast cancer; however, the meaning of this relationship has not been elucidated. This is the first report of intestinal angiosarcoma in a patient with history of breast cancer. The prognosis of metastatic angiosarcoma is poor and most patients die within 6 months. Treatment usually involves operative resection of the bleeding lesion; unfortunately, because of its infiltrative and multifocal nature, complete operative excision is often not possible.3 The role of adjuvant radiation or chemotherapy in the treatment of this tumor remains unknown.
References
- Epithelioid angiosarcoma of the small bowel. Gastrointest Endosc. 2006;64:1018–1021
- Angiosarcoma involving the gastrointestinal tract: a series of primary and metastatic cases. Am J Surg Pathol. 2004;28:298–307
- Rapidly progressive metastatic multicentric epithelioid angiosarcoma of the small bowel: a case report and a review of literature. Int J Colorectal Dis. 2008;23:745–756
Conflicts of interest The authors disclose no conflicts.
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PII: S0016-5085(09)01968-4
doi:10.1053/j.gastro.2009.09.071
© 2010 AGA Institute. Published by Elsevier Inc. All rights reserved.
