Liver angiosarcoma

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Liver angiosarcoma
Other namesHepatic angiosarcoma, angiosarcoma of the liver
Gross specimen of liver angiosarcoma.jpg
Specimen of a surgically removed and dissected liver angiosarcoma with visible necrosis and bleeding
Specialty Oncology
Symptoms Asymptomatic, abdominal pain, weight loss, anorexia, fatigue
Complications Disseminated intravascular coagulation, tumor rupture
Usual onsetAge 60-70
CausesUnknown, exposure to arsenic, thorotrast, vinyl chloride
Diagnostic method Biopsy, imaging
Differential diagnosis Hemangioma, hepatocellular carcinoma [1]
Treatment Surgery, chemotherapy
Prognosis Poor, most die within 6 months [2] [3]
Frequency200 new diagnoses per year worldwide

Liver angiosarcoma also known as angiosarcoma of the liver or hepatic angiosarcoma is a rare and rapidly fatal cancer arising from endothelial that line the blood vessels of the liver. It is a type of angiosarcoma. Although very rare with around 200 cases diagnosed each year, it is still considered the third most common primary liver cancer, making up around 2% of all primary liver cancers. Liver angiosarcoma can be primary (referred to in literature as PHA or primary hepatic angiosarcoma), meaning it arose in the liver, or secondary, meaning the angiosarcoma arose elsewhere and metastasized to the liver. [2] This article covers PHA, however much is also applicable to secondary tumors.

Contents

Signs and symptoms

Liver angiosarcoma usually presents with vague and non-specific symptoms such as abdominal pain, abdominal distension (which are the two most common symptoms, occurring in around 60% of individuals [3] ), weight loss, fatigue or abdominal masses and liver disease like symptoms such as fever, malaise, anorexia and vomiting. [2]

Paradoxically, liver function is generally maintained until the final stages of the disease, further complicating diagnosis. [4]

Complications

Spontaneous tumor rupture resulting in severe intra-abdominal bleeding and hemoperitoneum is a possibly fatal complication of liver angiosarcoma and is reported in 15–27% of patients. Thrombocytopenia, anemia and the vascular nature of the tumor may contribute to this. Tumor rupture generally carries a very poor prognosis even when bleeding is stopped by means of emergency transcathether arterial embolization (TAE), an analysis of four patients showed a median survival of 23 days following tumor rupture. [5] [6] [2] [7] Due to the close and similarly vascular nature of the spleen, metastasis to it is common and therefore intra-abdominal bleeding may also be caused by splenic rupture. [4]

Liver angiosarcoma may also result in liver failure, a potentially fatal complication. [8]

Like many cancers, liver angiosarcoma can also cause disseminated intravascular coagulation (DIC). [2] [9] [10] [11] [12]

Causes

Most liver angiosarcoma cases are of unknown etiology, making up around 75% of cases. [2]

Despite this, several things are associated with liver angiosarcoma. Exposure to vinyl chloride, arsenic, thorotrast, radium, phenylhydrazine and use of androgens is known to contribute to the pathogenesis of liver angiosarcoma. [2] Cyclophosphamide, [4] diethylstilbestrol and oral contraceptives use are also associated with liver angiosarcoma. [13] [2]

In addition liver angiosarcoma is associated with hemochromatosis (iron overload) [14] and neurofibromatosis. [2] [15]

A 2007 case report suggests a possible link between Schistosoma japonicum liver fibrosis and liver angiosarcoma. [4] [16]

A study in Taiwan found no evidence to suggest that viral hepatitis a significant role in the pathogenesis of liver angiosarcoma. [2] [17]

Diagnosis

CD31 is considered the most reliable tumor marker for liver angiosarcoma. [2]

Differential diagnosis

Differential diagnosis includes hemangioma, [1] Kaposi's sarcoma, metastatic angiosarcoma of non liver origin, secondary liver cancer from any origin and hepatocellular carcinoma. [2]

Treatment

Complete surgical resection combined with adjuvant chemotherapy is considered to be the most effective treatment of liver angiosarcoma. [13]

Transcathether arterial embolization (TAE), blocking an artery with the help of a catheter to prevent further bleeding or limit blood supply to the tumor, resulting in suppressed growth, is the most effective treatment for spontaneous rupture of the tumor resulting in intra-abdominal bleeding. Transcatheter arterial chemoembolization (TACE), which is the same as TAE, but also involves the regional injection of chemotherapy drugs, has shown effectiveness at increasing survival, particularly in individuals with few dominant masses rather than several smaller. [2] [4] [5] TACE allows for simultaneously increasing regional (and therefore also tumor) exposure to chemotherapy while reducing systemic exposure, which both allows for an increased dose, as systemic exposure is generally the limiting factor, and also reduced side effects of chemotherapy. TACE and TAE are both generally performed on the hepatic artery. [18]

Liver angiosarcomas are generally reported to be radioresistant and therefore radiation therapy is not considered an effective treatment. [5] [2] [7]

Although previously considered a viable treatment option, liver transplantation is no longer considered for liver angiosarcoma, due to its high reoccurrence rate and poor post transplantation survival. [14] The European Liver Transplant Registry considers liver angiosarcoma an absolute contraindication to liver transplantation, [15] reporting that the median survival following liver transplantation is less than 7 months with no one surviving more than 23 months, showing very little difference from no treatment at all. [2] [6]

Prognosis

Due to the aggressive nature and high recurrence rate, the prognosis for liver angiosarcoma is generally very poor. Most patients die within six months and only 3% live more than two years. [2]

A recent case report suggest that the prognosis of liver angiosarcoma may be improving. [19]

Epidemiology

Although liver angiosarcoma can affect anyone, most people affected are 60–70 years old. Males are affected more often than women at a ratio of 3-4:1, [14] [20] although in children, girls are affected more commonly than boys. [2]

Related Research Articles

<span class="mw-page-title-main">Hepatocellular carcinoma</span> Medical condition

Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer in adults and is currently the most common cause of death in people with cirrhosis. HCC is the third leading cause of cancer-related deaths worldwide.

Liver tumors are abnormal growth of liver cells on or in the liver. Several distinct types of tumors can develop in the liver because the liver is made up of various cell types. Liver tumors can be classified as benign (non-cancerous) or malignant (cancerous) growths. They may be discovered on medical imaging, and the diagnosis is often confirmed with liver biopsy. Signs and symptoms of liver masses vary from being asymptomatic to patients presenting with an abdominal mass, hepatomegaly, abdominal pain, jaundice, or some other liver dysfunction. Treatment varies and is highly specific to the type of liver tumor.

<span class="mw-page-title-main">Hemangiosarcoma</span> Medical condition

Hemangiosarcoma is a rapidly growing, highly invasive variety of cancer that occurs almost exclusively in dogs, and only rarely in cats, horses, mice, or humans. It is a sarcoma arising from the lining of blood vessels; that is, blood-filled channels and spaces are commonly observed microscopically. A frequent cause of death is the rupturing of this tumor, causing the patient to rapidly bleed to death.

<span class="mw-page-title-main">Interventional radiology</span> Medical subspecialty

Interventional radiology (IR) is a medical specialty that performs various minimally-invasive procedures using medical imaging guidance, such as x-ray fluoroscopy, computed tomography, magnetic resonance imaging, or ultrasound. IR performs both diagnostic and therapeutic procedures through very small incisions or body orifices. Diagnostic IR procedures are those intended to help make a diagnosis or guide further medical treatment, and include image-guided biopsy of a tumor or injection of an imaging contrast agent into a hollow structure, such as a blood vessel or a duct. By contrast, therapeutic IR procedures provide direct treatment—they include catheter-based medicine delivery, medical device placement, and angioplasty of narrowed structures.

<span class="mw-page-title-main">Budd–Chiari syndrome</span> Medical condition

Budd–Chiari syndrome is a very rare condition, affecting one in a million adults. The condition is caused by occlusion of the hepatic veins that drain the liver. The symptoms are non-specific and vary widely, but it may present with the classical triad of abdominal pain, ascites, and liver enlargement. It is usually seen in younger adults, with the median age at diagnosis between the ages of 35 and 40, and it has a similar incidence in males and females. The syndrome can be fulminant, acute, chronic, or asymptomatic. Subacute presentation is the most common form.

<span class="mw-page-title-main">Klatskin tumor</span> Medical condition

A Klatskin tumor is a cholangiocarcinoma occurring at the confluence of the right and left hepatic bile ducts. The disease was named after Gerald Klatskin, who in 1965 described 15 cases and found some characteristics for this type of cholangiocarcinoma

<span class="mw-page-title-main">Cholangiocarcinoma</span> Bile duct adenocarcinoma

Cholangiocarcinoma, also known as bile duct cancer, is a type of cancer that forms in the bile ducts. Symptoms of cholangiocarcinoma may include abdominal pain, yellowish skin, weight loss, generalized itching, and fever. Light colored stool or dark urine may also occur. Other biliary tract cancers include gallbladder cancer and cancer of the ampulla of Vater.

<span class="mw-page-title-main">Angiosarcoma</span> Cancer of the lining of the blood or lymphatic vessels

Angiosarcoma is a rare and aggressive cancer that starts in the endothelial cells that line the walls of blood vessels or lymphatic vessels. Since they are made from vascular lining, they can appear anywhere and at any age, but older people are more commonly affected, and the skin is the most affected area, with approximately 60% of cases being cutaneous. Specifically, the scalp makes up ~50% of angiosarcoma cases, but this is still <0.1% of all head and neck tumors. Since angiosarcoma is an umbrella term for many types of tumor that vary greatly in origin and location, many symptoms may occur, from completely asymptomatic to non-specific symptoms like skin lesions, ulceration, shortness of breath and abdominal pain. Multiple-organ involvement at time of diagnosis is common and makes it difficult to ascertain origin and how to treat it.

Transcatheter arterial chemoembolization (TACE) is a minimally invasive procedure performed in interventional radiology to restrict a tumor's blood supply. Small embolic particles coated with chemotherapeutic drugs are injected selectively through a catheter into an artery directly supplying the tumor. These particles both block the blood supply and induce cytotoxicity, attacking the tumor in several ways.

<span class="mw-page-title-main">Hemangioendothelioma</span> Medical condition

Hemangioendotheliomas are a family of vascular neoplasms of intermediate malignancy.

Autotransplantation is the transplantation of organs, tissues, or even particular proteins from one part of the body to another in the same person.

Acute fatty liver of pregnancy is a rare life-threatening complication of pregnancy that occurs in the third trimester or the immediate period after delivery. It is thought to be caused by a disordered metabolism of fatty acids by mitochondria in the fetus, caused by long-chain 3-hydroxyacyl-coenzyme A dehydrogenase deficiency. This leads to decreased metabolism of long chain fatty acids by the feto-placental unit, causing subsequent rise in hepatotoxic fatty acids in maternal plasma. The condition was previously thought to be universally fatal, but aggressive treatment by stabilizing the mother with intravenous fluids and blood products in anticipation of early delivery has improved prognosis.

<span class="mw-page-title-main">Liver cancer</span> Medical condition

Liver cancer is cancer that starts in the liver. Liver cancer can be primary or secondary. Liver metastasis is more common than that which starts in the liver. Liver cancer is increasing globally.

<span class="mw-page-title-main">Signet ring cell carcinoma</span> Medical condition

Signet ring cell carcinoma (SRCC) is a rare form of highly malignant adenocarcinoma that produces mucin. It is an epithelial malignancy characterized by the histologic appearance of signet ring cells.

<span class="mw-page-title-main">Selective internal radiation therapy</span>

Selective internal radiation therapy (SIRT), also known as transarterial radioembolization (TARE), radioembolization or intra-arterial microbrachytherapy is a form of radiation therapy used in interventional radiology to treat cancer. It is generally for selected patients with surgically unresectable cancers, especially hepatocellular carcinoma or metastasis to the liver. The treatment involves injecting tiny microspheres of radioactive material into the arteries that supply the tumor, where the spheres lodge in the small vessels of the tumor. Because this treatment combines radiotherapy with embolization, it is also called radioembolization. The chemotherapeutic analogue is called chemoembolization, of which transcatheter arterial chemoembolization (TACE) is the usual form.

<span class="mw-page-title-main">Cirrhosis</span> Chronic disease of the liver, characterized by fibrosis

Cirrhosis, also known as liver cirrhosis or hepatic cirrhosis, and end-stage liver disease, is the impaired liver function caused by the formation of scar tissue known as fibrosis due to damage caused by liver disease. Damage to the liver leads to repair of liver tissue and subsequent formation of scar tissue. Over time, scar tissue can replace normal functioning tissue, leading to the impaired liver function of cirrhosis. The disease typically develops slowly over months or years. Early symptoms may include tiredness, weakness, loss of appetite, unexplained weight loss, nausea and vomiting, and discomfort in the right upper quadrant of the abdomen. As the disease worsens, symptoms may include itchiness, swelling in the lower legs, fluid build-up in the abdomen, jaundice, bruising easily, and the development of spider-like blood vessels in the skin. The fluid build-up in the abdomen may develop into spontaneous infections. More serious complications include hepatic encephalopathy, bleeding from dilated veins in the esophagus, stomach, or intestines, and liver cancer.

Hepatic artery embolization, also known as trans-arterial embolization (TAE), is one of the several therapeutic methods to treat primary liver tumors or metastases to the liver. The embolization therapy can reduce the size of the tumor, and decrease the tumor's impact such its hormone production, effectively decreasing symptoms. The treatment was initially developed in the early 1970s. The several types of hepatic artery treatments are based on the observation that tumor cells get nearly all their nutrients from the hepatic artery, while the normal cells of the liver get about 70-80 percent of their nutrients and 50% their oxygen supply from the portal vein, and thus can survive with the hepatic artery effectively blocked. In practice, hepatic artery embolization occludes the blood flow to the tumors, achieving significant tumor shrinkage in over 80% of people. Shrinkage rates vary.

Interventional oncology is a subspecialty field of interventional radiology that deals with the diagnosis and treatment of cancer and cancer-related problems using targeted minimally invasive procedures performed under image guidance. Interventional oncology has developed to a separate pillar of modern oncology and it employs X-ray, ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI) to help guide miniaturized instruments to allow targeted and precise treatment of solid tumours located in various organs of the human body, including but not limited to the liver, kidneys, lungs, and bones. Interventional oncology treatments are routinely carried out by interventional radiologists in appropriate settings and facilities.

Radiation lobectomy is a form of radiation therapy used in interventional radiology to treat liver cancer. It is performed in patients that would be surgical candidates for resection, but cannot undergo surgery due to insufficient remaining liver tissue. It consists of injecting small radioactive beads loaded with yttrium-90 into the hepatic artery feeding the hepatic lobe in which the tumor is located. This is done with the intent of inducing growth in the contralateral hepatic lobe, not dissimilarly from portal vein embolization (PVE).

Transarterial bland embolization is a catheter-based tumor treatment of the liver. In this procedure, embolizing agents can be delivered through the tumor’s feeding artery in order to completely occlude the tumor’s blood supply. The anti-tumor effects are solely based on tumor ischemia and infarction of tumor tissue, as no chemotherapeutic agents are administered. The rationale for the use of bland embolization for hepatocellular carcinoma (HCC) and/or other hyper-vascular tumors is based on the fact that a normal liver receives a dual blood supply from the hepatic artery (25%) and the portal vein (75%). As the tumor grows, it becomes increasingly dependent on the hepatic artery for blood supply. Once a tumor nodule reaches a diameter of 2 cm or more, most of the blood supply is derived from the hepatic artery. Therefore, bland embolization and transarterial chemoembolization (TACE) consist of the selective angiographic occlusion of the tumor arterial blood supply with a variety of embolizing agents, with or without the precedence of local chemotherapy infusion. The occlusion by embolic particles results in tumor hypoxia and necrosis, without affecting the normal hepatic parenchyma.

References

  1. 1 2 Yasir, Saba; Torbenson, Michael S. (May 2019). "Angiosarcoma of the Liver: Clinicopathologic Features and Morphologic Patterns". The American Journal of Surgical Pathology. 43 (5): 581–590. doi:10.1097/PAS.0000000000001228. ISSN   1532-0979. PMID   30986799. S2CID   86577531. Archived from the original on 2021-08-11. Retrieved 2021-08-11.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Chaudhary, P.; Bhadana, U.; Singh, R. a. K.; Ahuja, A. (September 2015). "Primary hepatic angiosarcoma". European Journal of Surgical Oncology: The Journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology. 41 (9): 1137–1143. doi:10.1016/j.ejso.2015.04.022. ISSN   1532-2157. PMID   26008857. Archived from the original on 2021-08-11. Retrieved 2021-08-11.
  3. 1 2 Zeng, Dong; Cheng, Jianan; Gong, Zhihua; Chen, Jianghong; Long, Haixia; Zhu, Bo (2020-05-05). "A pooled analysis of primary hepatic angiosarcoma". Japanese Journal of Clinical Oncology. 50 (5): 556–567. doi: 10.1093/jjco/hyaa017 . ISSN   1465-3621. PMID   32083280.
  4. 1 2 3 4 5 Zheng, Ya-Wen; Zhang, Xin-Wei; Zhang, Jia-Li; Hui, Zhen-Zhen; Du, Wei-Jiao; Li, Run-Mei; Ren, Xiu-Bao (May 2014). "Primary hepatic angiosarcoma and potential treatment options". Journal of Gastroenterology and Hepatology. 29 (5): 906–911. doi: 10.1111/jgh.12506 . ISSN   1440-1746. PMID   24372769. S2CID   12049352.
  5. 1 2 3 Zhu, Yi-Ping; Chen, Yan-Min; Matro, Erik; Chen, Ren-Biao; Jiang, Zhi-Nong; Mou, Yi-Ping; Hu, Hong-Jie; Huang, Chao-Jie; Wang, Guan-Yu (2015-05-21). "Primary hepatic angiosarcoma: A report of two cases and literature review". World Journal of Gastroenterology. 21 (19): 6088–6096. doi: 10.3748/wjg.v21.i19.6088 . ISSN   1007-9327. PMC   4438048 . PMID   26019478.
  6. 1 2 Schueler, Samuel A.; Hwang, Daniel G.; Twaddell, William; Raufman, Jean-Pierre; Urrunaga, Nathalie H. (February 2020). "Angiosarcoma: A rare cause of acute liver failure". Clinics and Research in Hepatology and Gastroenterology. 44 (1): e14–e16. doi:10.1016/j.clinre.2019.06.014. ISSN   2210-741X. PMID   31296397. S2CID   195893978. Archived from the original on 2021-10-10. Retrieved 2021-10-10.
  7. 1 2 Chien, Chin-Ying; Hwang, Cheng-Cheng; Yeh, Chun-Nan; Chen, Huang-Yang; Wu, Jui-Teng; Cheung, Chan-Siu; Lin, Chih-Lang; Yen, Cho-Li; Wang, Wen-Yen; Chiang, Kun-Chun (2012-01-26). "Liver angiosarcoma, a rare liver malignancy, presented with intraabdominal bleeding due to rupture--a case report". World Journal of Surgical Oncology. 10: 23. doi: 10.1186/1477-7819-10-23 . ISSN   1477-7819. PMC   3292925 . PMID   22280556.
  8. ↑ Abegunde, Ayokunle T.; Aisien, Efe; Mba, Benjamin; Chennuri, Rohini; Sekosan, Marin (2015). "Fulminant Hepatic Failure Secondary to Primary Hepatic Angiosarcoma". Case Reports in Gastrointestinal Medicine. 2015: 869746. doi: 10.1155/2015/869746 . ISSN   2090-6528. PMC   4359886 . PMID   25815217.
  9. ↑ Wadhwa, Sanya; Kim, Tae Hun; Lin, Leah; Kanel, Gary; Saito, Takeshi (2017-04-07). "Hepatic angiosarcoma with clinical and histological features of Kasabach-Merritt syndrome". World Journal of Gastroenterology. 23 (13): 2443–2447. doi: 10.3748/wjg.v23.i13.2443 . ISSN   2219-2840. PMC   5385411 . PMID   28428724.
  10. ↑ Fernando, Nadeeshani; Butcherine, Kylie; Harle, Robin; Ritchey, Donald (August 2019). "Mysterious abdominal pain and disseminated intravascular coagulation due to hepatic angiosarcoma". Internal Medicine Journal. 49 (8): 1053–1054. doi:10.1111/imj.14382. ISSN   1445-5994. PMID   31387140. S2CID   199467800. Archived from the original on 2021-10-27. Retrieved 2021-10-11.
  11. ↑ Mazharuddin, Samir; Podduturi, Varsha; Guileyardo, Joseph M.; Cooper, Barry (January 2015). "Hepatic angiosarcoma associated with disseminated intravascular coagulation". Proceedings (Baylor University. Medical Center). 28 (1): 54–56. doi:10.1080/08998280.2015.11929186. ISSN   0899-8280. PMC   4264711 . PMID   25552799.
  12. ↑ Rosen, Emily A.; Vallurupalli, Mounica; Choy, Edwin; Lennerz, Jochen K.; Kuter, David J. (2018-11-21). "Management of disseminated intravascular coagulation in a patient with hepatic angiosarcoma". Medicine. 97 (47): e13321. doi:10.1097/MD.0000000000013321. ISSN   0025-7974. PMC   6392710 . PMID   30461646.
  13. 1 2 Millan, Mauricio; Delgado, Alejandro; Caicedo, Luis A.; Arrunategui, Ana M.; Meneses, Carlos A.; Villegas, Jorge I.; Serrano, Oscar; Caicedo, Liliana; Duque, Mauricio; Echeverri, Gabriel J. (2016-09-29). "Liver Angiosarcoma: Rare tumour associated with a poor prognosis, literature review and case report". International Journal of Surgery Case Reports. 28: 165–168. doi:10.1016/j.ijscr.2016.09.044. ISSN   2210-2612. PMC   5061303 . PMID   27718433.
  14. 1 2 3 Maluf, D.; Cotterell, A.; Clark, B.; Stravitz, T.; Kauffman, H. M.; Fisher, R. A. (June 2005). "Hepatic angiosarcoma and liver transplantation: case report and literature review". Transplantation Proceedings. 37 (5): 2195–2199. doi:10.1016/j.transproceed.2005.03.060. ISSN   0041-1345. PMID   15964377. Archived from the original on 2021-10-10. Retrieved 2021-10-10.
  15. 1 2 Orlando, Giuseppe; Adam, Rene; Mirza, Darius; Soderdahl, Goran; Porte, Robert J.; Paul, Andreas; Burroughs, Andrew K.; Seiler, Christian A.; Colledan, Michele; Graziadei, Ivo; Garcia Valdecasas, Juan-Carlos (2013-03-27). "Hepatic hemangiosarcoma: an absolute contraindication to liver transplantation--the European Liver Transplant Registry experience". Transplantation. 95 (6): 872–877. doi: 10.1097/TP.0b013e318281b902 . ISSN   1534-6080. PMID   23354302. S2CID   2375015.
  16. ↑ Wang, Ze-Sheng; Wang, Wei-Xing; Xiong, Cheng-Long; Zhan, Na; Li, Hui (July 2007). "Spontaneous ruptured primary hepatic angiosarcoma coincident with Schistosoma Japonica liver fibrosis". Hepatology Research. 37 (7): 572–576. doi:10.1111/j.1872-034X.2007.00067.x. ISSN   1386-6346. PMID   17540001. S2CID   43274169. Archived from the original on 2021-10-10. Retrieved 2021-10-10.
  17. ↑ Huang, Neng-Chyan; Wann, Shue-Ren; Chang, Hong-Tai; Lin, Shoa-Lin; Wang, Jyh-Seng; Guo, How-Ran (2011-12-26). "Arsenic, vinyl chloride, viral hepatitis, and hepatic angiosarcoma: a hospital-based study and review of literature in Taiwan". BMC Gastroenterology. 11: 142. doi: 10.1186/1471-230X-11-142 . ISSN   1471-230X. PMC   3280174 . PMID   22200164.
  18. ↑ Guan, Yong-Song; He, Qing; Wang, Ming-Quan (2012-08-26). "Transcatheter Arterial Chemoembolization: History for More than 30 Years". ISRN Gastroenterology. 2012: 480650. doi: 10.5402/2012/480650 . ISSN   2090-4398. PMC   3433134 . PMID   22966466.
  19. ↑ Huang, Neng-Chyan; Kuo, Yau-Chang; Chiang, Jui-Chin; Hung, Shih-Yuan; Wang, Huay-Min; Hung, Yao-Min; Chang, Yun-Te; Wann, Shue-Ren; Chang, Hong-Tai; Wang, Jyh-Seng; Ho, Sheng-Yow (May 2015). "Hepatic angiosarcoma may have fair survival nowadays". Medicine. 94 (19): e816. doi:10.1097/MD.0000000000000816. ISSN   1536-5964. PMC   4602568 . PMID   25984668.
  20. ↑ Averbukh, Leon D.; Mavilia, Marianna G.; Einstein, Michael M. (2018-09-11). "Hepatic Angiosarcoma: A Challenging Diagnosis". Cureus. 10 (9): e3283. doi: 10.7759/cureus.3283 . ISSN   2168-8184. PMC   6235643 . PMID   30443453.
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