Hepatic angiosarcoma misdiagnosed in a patient with occupational chemical exposure: A case report and literature review

Background: Primary hepatic angiosarcoma (PHA) is a rare but highly aggressive mesenchymal malignancy which is associated with occupational chemical exposures, particularly vinyl chloride, arsenic, and other industrial agents. Its preoperative diagnosis remains extremely challenging because its imaging features frequently overlap with those of benign hepatic hemangiomas, leading to potential misdiagnosis and catastrophic delays in management. Case presentation: A 65-year-old Han Chinese male with personal history of occupational exposure in a chemical plant for over 10 years presented to the emergency department with acute, persistent, severe right upper quadrant pain accompanied by nausea, pallor, and cold extremities. His blood pressure was 97/47 mmHg, and his heart rate was 103 beats/min. Three months prior, abdominal magnetic resonance imaging performed elsewhere reported a hepatic hemangioma (original records unobtainable). Contrast-enhanced computed tomography revealed a large hepatic mass with intratumoral hemorrhage and a satellite nodule in segment IV, suggestive of a ruptured malignant tumor. Given the patient’s stable hemodynamics, Adequate liver reserve, and resectable anatomy, emergency right hemihepatectomy was performed without perioperative complications. Postoperative immunohistochemistry confirmed the diagnosis of hepatic angiosarcoma, with positive staining for CD31, CD34, and FLI-1; negativity for AFP, CK7, CK19, and CEA; and a Ki-67 proliferation index of approximately 10%, with P53 positivity. The patient initially recovered and was discharged, but telephone follow-up confirmed that he died approximately three months after surgery. Conclusions: This case underscores that in patients with a history of occupational chemical exposure, even remote exposure, a radiologic diagnosis of hepatic hemangioma should be interpreted with great caution. The rapid transition from misdiagnosis to spontaneous rupture and subsequent death within three months despite technically successful emergency resection, illustrates the fulminant clinical course of PHA. Clinicians should maintain a high index of suspicion, consider timely contrast-enhanced imaging and surgical intervention, and thoroughly counsel patients regarding the extremely poor prognosis, even after apparently curative surgery.