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a large collection of blood with many clots was observed&#46; Soft tissue mass&#8217; histological findings were&#58; necrotic-haemorrhagic material and occasional atypical cells&#44; without any tumour cells in resected ribs&#46; Furthermore&#44; a mycobacterium tuberculosis complex was isolated in parietal pleura culture&#44; which supported our initial suspected diagnosis&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the first postoperative month&#44; the patient had mild self-limited bleeding in the thoracostomy&#46; In the third month&#44; he suffered a massive haemorrhage&#44; requiring hospital admission and emergency haemostatic surgery &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; During admission&#44; protruding lesions prone to bleeding were observed&#44; causing anaemia in the transfusion range &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46; Due to torpid evolution&#44; the mass was biopsied two more times and the final result was epithelioid angiosarcoma&#46; The patient was not a candidate for resective surgical treatment&#44; choosing radical radiotherapy and chemotherapy &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41;&#46; He died of bilateral pneumonia two months after diagnosis&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Epithelioid angiosarcoma is an uncommon subtype of soft tissue sarcoma that is rare in the chest wall&#46; Its prognosis is poor&#46; This pathology is a major diagnostic challenge due to its low incidence &#40;few cases have been published in the literature&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> nonspecific clinical features and complex differential diagnosis &#40;empyema necessitatis&#44; haematoma&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2&#44;3</span></a> Biopsy may be inconclusive because of diffuse haemorrhagic and necrotic areas&#46; Immunohistochemistry is important in the definitive diagnosis with positivity for CD31&#44; CD34&#44; ERG and Factor VIII&#46; It is thought the origin of epithelioid angiosarcoma of the chest wall could be related to chronic pleuropulmonary inflammation&#44; because this pathology has been described in patients with a previous history of pulmonary-pleural tuberculosis and empyema&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> In conclusion&#44; this tumour should be suspected in patients with soft tissue mass&#44; a previous history of chronic tuberculous empyema&#44; and poor evolution in spite of tuberculostatic drugs and inconclusive biopsies&#44; in order to achieve an early-stage diagnosis and to be a candidate for resective surgical treatment&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Con&#64258;ict of Interests</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors state that they have no con&#64258;ict of interests&#46;</p></span></span>"
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Case Report
Everything is not Always What it Seems: Epithelioid Angiosarcoma of the Chest Wall
Inmaculada Sabariego-Arenas
Corresponding author
isa_122716@live.com

Corresponding author.
, Fernando Cózar-Bernal, Marta López-Porras
Hospital Universitario Virgen Macarena, Seville, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 62-year-old man with a previous history of pulmonary tuberculosis from 15 years earlier was complaining of persistent left rib pain&#46; Chest computed tomography showed encapsulated pleural effusion&#44; pleural calcification and heterogeneous soft tissue mass &#40;85<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>110<span class="elsevierStyleHsp" style=""></span>mm&#41; destroying the 9th and 10th ribs &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; A diagnostic-therapeutic thoracocentesis was performed&#44; which revealed purulent pleural effusion and elevated lactate dehydrogenase &#40;639&#41;&#46; In addition&#44; an ultrasound-guided fine needle aspiration of soft tissue mass was carried out without detecting any malignant cells&#44; only material consisting of blood&#46; Previous radiological images were also reviewed&#44; in which the patient already had a mild pleural effusion and chronic pleural thickening&#46; Due to his previous history of tuberculosis&#44; his pleuritic pain and complementary tests&#8217; results&#44; our suspected diagnosis was tuberculous empyema necessitatis&#44; and tuberculostatic drugs were started&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Two months later&#44; because of the lack of response to tuberculostatic treatment without any clinical-radiological improvement and the increase in size of the soft tissue mass&#44; we decided to perform a diagnostic-therapeutic surgery&#46; Due to the extend period of infection&#44; as well as the patient&#39;s morbidity&#44; we thought that lung re-expansion would not be achieved&#44; and an open thoracostomy would be an appropriate surgical option&#46; During surgery&#44; a large collection of blood with many clots was observed&#46; Soft tissue mass&#8217; histological findings were&#58; necrotic-haemorrhagic material and occasional atypical cells&#44; without any tumour cells in resected ribs&#46; Furthermore&#44; a mycobacterium tuberculosis complex was isolated in parietal pleura culture&#44; which supported our initial suspected diagnosis&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the first postoperative month&#44; the patient had mild self-limited bleeding in the thoracostomy&#46; In the third month&#44; he suffered a massive haemorrhage&#44; requiring hospital admission and emergency haemostatic surgery &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; During admission&#44; protruding lesions prone to bleeding were observed&#44; causing anaemia in the transfusion range &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46; Due to torpid evolution&#44; the mass was biopsied two more times and the final result was epithelioid angiosarcoma&#46; The patient was not a candidate for resective surgical treatment&#44; choosing radical radiotherapy and chemotherapy &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41;&#46; He died of bilateral pneumonia two months after diagnosis&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Epithelioid angiosarcoma is an uncommon subtype of soft tissue sarcoma that is rare in the chest wall&#46; Its prognosis is poor&#46; This pathology is a major diagnostic challenge due to its low incidence &#40;few cases have been published in the literature&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> nonspecific clinical features and complex differential diagnosis &#40;empyema necessitatis&#44; haematoma&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2&#44;3</span></a> Biopsy may be inconclusive because of diffuse haemorrhagic and necrotic areas&#46; Immunohistochemistry is important in the definitive diagnosis with positivity for CD31&#44; CD34&#44; ERG and Factor VIII&#46; It is thought the origin of epithelioid angiosarcoma of the chest wall could be related to chronic pleuropulmonary inflammation&#44; because this pathology has been described in patients with a previous history of pulmonary-pleural tuberculosis and empyema&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> In conclusion&#44; this tumour should be suspected in patients with soft tissue mass&#44; a previous history of chronic tuberculous empyema&#44; and poor evolution in spite of tuberculostatic drugs and inconclusive biopsies&#44; in order to achieve an early-stage diagnosis and to be a candidate for resective surgical treatment&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Con&#64258;ict of Interests</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors state that they have no con&#64258;ict of interests&#46;</p></span></span>"
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ISSN: 03002896
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