Contrast-Enhanced Ultrasound-Guided Liver Tumor Biopsy for Primary Hepatic Angiosarcoma: A Case Series

Primary hepatic angiosarcoma (PHA) is a rare and aggressive malignant liver tumor that is often difficult to diagnose due to its nonspecific clinical presentation and imaging findings. This case series aimed to illustrate the utility of contrast-enhanced ultrasound (CEUS)-guided percutaneous liver biopsy for the definitive diagnosis of unresectable PHA. We report three patients who presented with nonspecific symptoms and hepatic masses. Imaging findings were inconclusive for a definitive diagnosis, and histopathological evaluation was required. All patients underwent CEUS-guided percutaneous liver tumor biopsy. CEUS enabled real-time visualization of viable tumor regions, facilitating accurate needle placement and minimizing sampling from necrotic or hemorrhagic areas. In Case one, multiple punctures were needed to obtain viable tissue due to extensive necrosis. In Cases two and three, CEUS was particularly useful for demarcating poorly defined lesions, resulting in successful tissue sampling with fewer punctures. Biopsies were performed during the post-vascular phase, enhancing diagnostic yield. Histopathological analysis revealed CD31-positive spindle-shaped cells and a high Ki-67 index, confirming the diagnosis of PHA in all cases. All patients died within six months of diagnosis despite chemotherapy, underscoring the poor prognosis and clinical urgency. CEUS-guided percutaneous liver biopsy is a minimally invasive and reliable technique for the diagnosis of PHA, especially in patients who are not candidates for surgery. This approach enables targeted tissue acquisition, potentially improves diagnostic accuracy, and may contribute to the earlier management of this rare malignancy.