A Solitary Red Nodule on the Back: A Quiz

Nobuyuki Kikuchi, Tatsuhiko Mori, Tomoko Hiraiwa, Takenobu Ohashi, Yuka Hanami, Masataka Satoh, Mikio Ohtsuka and Toshiyuki Yamamoto

Department of Dermatology, Fukushima Medical University, Fukushima 960-1295, Japan. E-mail: nobuyuk@fmu.ac.jp

A 57-year-old woman received surgical resection of a nodule on the left lateral abdomen in another hospital, which had appeared 6 months previously. Histological features showed atypical endothelial cell proliferation, and she was further treated with surgical re-excision with 2 cm wide margins, followed by radiation and recombinant IL-2 administration. Five years later, she developed haemorrhagic nodules and macular purpura on the scalp, and histological examination was consistent with the features of the previously excised nodule from the abdomen. Detailed investigation revealed distant metastasis to the lung and bone. She was subsequently treated with chemotherapy consisting of weekly low-dose docetaxel (40 mg/day) followed by paclitaxel (80 mg/day); however, 6 months later, a 5 mm red nodule appeared on her back (Fig. 1a). Histopathology of the totally resected nodule revealed prominent proliferation of atypical endothelial cells with many mitotic figures, and a number of irregular vascular channels filled with erythrocytes (Fig. 1b).

Fig. 1. (a) Red nodule on the back. Histological features showing proliferation of atypical endothelial cells (b) (H&E × 200).

doi: 10.2340/00015555-1919

What is your diagnosis? See next page for answer.

A Solitary Red Nodule on the Back: A Comment

Acta Derm Venereol

Diagnosis: Cutaneous angiosarcoma

Angiosarcoma usually occurs on the head and neck of elderly people, and shows a poor prognosis with metastasis to the lymph nodes and lung. We herein describe a rare case of angiosarcoma initially arising on the abdomen, that metastasised to the back as well as multiple organs including the brain, liver, kidney, and pharynx 6 years later. Histological examination of the nodule on the back demonstrated that the tumour cells were immunoreactive for CD31, CD34, and Factor VIII-related antigen, but negative for D2-40 (not shown). Thereafter, she was treated with chemotherapy with paclitaxel, however CT examination revealed metastases to the brain, kidney, liver, and pharynx. She ultimately died of multiple organ failure 4 months later.

Our case is uncommon in that the initial angiosarcoma arose on the lateral abdomen, which then metastasised to the lung and bone 5 years later, and further metastasised to the back skin. Moreover, multiple metastases to internal organs such as brain, liver, kidney, and pharynx appeared the following year.

To date, only 6 cases of distant skin metastasis have been reported (1–6), of which 3 were not primary cutaneous angiosarcoma. Our patient did not have a previous history of either chronic lymphoedema or prior treatment with radiotherapy radiation therapy on this site. Previously, a case of cutaneous angiosarcoma which metastasised to the skin graft donor site (buttock), with recurrence at the radiation field to the primary site (head), after the radical operation for angiosarcoma was reported (6). The authors speculated the role of the Koebner phenomenon in their case.

Metastasis of angiosarcoma usually occurs to the lymph nodes of the head and neck, as well as the lung, and with less frequency, the spleen, liver, and spine. To date, there have been a few reports of mucous membrane metastasis of cutaneous angiosaroma (7), however metastasis to the pharynx is extremely rare (8). Although the prognosis of angiosarcoma is poor, postmortem examination is not always carried out. The possibility of more cases of angiosarcoma with metastasis to the pharynx or larynx may exist. In our department, we experienced 17 cases of angiosarcoma over these 10 years period. Among those cases, metastases to either skin or pharynx occurred in the presented case only.

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