Diagnostic Challenge of a Vascular Liver Tumor With Pulmonary Hemorrhagic Metastases: A Case Report.

We report the case of a 64-year-old man with chronic liver disease who presented with abdominal discomfort, anorexia, and progressive weight loss, initially suspected to have hepatocellular carcinoma based on a large hepatic mass lacking definitive radiologic hallmarks. Multiphase CT demonstrated heterogeneous peripheral enhancement without classical washout, while thoracic imaging revealed numerous bilateral pulmonary nodules surrounded by ground-glass halos, indicating hemorrhagic metastases. These thoracic findings proved pivotal in directing diagnostic suspicion toward a vascular neoplasm. Ultrasound-guided liver biopsy confirmed high-grade hepatic angiosarcoma, with tumor cells showing ERG positivity and weak CD31 expression, and lacking hepatocellular or epithelial markers. The patient experienced rapid clinical deterioration with intrapulmonary hemorrhage, multiorgan dysfunction, and refractory shock, culminating in death shortly after diagnosis. This case highlights the diagnostic complexity of hepatic angiosarcoma and underscores the importance of integrating thoracic imaging with hepatic evaluation, particularly when liver findings are atypical.