Angiosarcoma of the Liver: A Radiological Alarm for Radiologists and Hepato-Pancreato-Biliary (HPB) Surgeons

Hepatic angiosarcoma (HA) is a rare and aggressive malignancy. Radiological findings are non-specific and often mimic benign liver pathologies. Patients' rapid clinical deterioration is often alarming, leading clinicians to a late, futile diagnosis. We present two cases of HA in which presenting symptoms, but more importantly, radiological appearances, were misleading, mimicking liver cysts and cavernous haemangiomas, respectively. Rapid clinical deterioration and speedy radiological evolution of disease spread led to a diagnosis of HA with a dismal prognosis. A 77-year-old male was diagnosed with an incidental finding of a cystic lesion in the upper abdomen. On contrast-enhanced computed tomography (CECT), the lesion mimicked a complex liver cyst with atypical radiological features, prompting clinicians to treat it with surgical resection for an otherwise unclear malignant pathology. On repeat CECT prior to surgery, the disease explosion with extensive peritoneal spread was surprising. A 79-year-old female presented with right flank pain, and CECT showed features of a cavernous haemangioma on the right liver lobe. The MRI confirmed atypical features of an otherwise benign entity, not long before the patient presented with spontaneous rupture, treated with embolisation. On repeat CECT, findings of new multiple liver lesions representing disease spread led to a biopsy confirming HA. Radiological appearances of HA are non-specific and may mimic benign liver pathologies, misleading clinicians. Early radiological detection and clinician awareness may lead to timely diagnosis, as complete resection of this aggressive malignancy offers better outcomes. Recognised treatment options appear limited in most cases, and future molecular analyses of this aggressive cancer may help advance systemic therapies.