Man with a Bleeding Wound on the Scalp

A 60-year-old man presented with bruising and a bleeding wound on the scalp for 2 weeks without trauma history, and the wound was sutured at the emergency department. However, it continued bleeding 2 days later, and the dermatologist was consulted. Physical examination showed purpuric patches on the scalp with an oozing sutured wound (Figure 1). Laboratory examination did not show anemia, thrombocytopenia, or coagulation abnormalities. Histopathologic examination of skin biopsy samples showed diffuse infiltrates of pleomorphic, dysplastic endothelial cells ramifying the dermis and subcutaneous tissues with extensive hemorrhage (Figure 2) and positive CD31/ERG staining.Figure 2Histopathologic features (hematoxylin–eosin stain). A, Diffuse infiltrates of atypical endothelial cells dissecting the dermis and intercalating through dermal collagen with extensive hemorrhage (original magnification ×100). B, Irregularly shaped anastomosing vascular channels lined by pleomorphic atypical endothelial cells (original magnification ×4).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Angiosarcoma. Angiosarcoma was diagnosed, and a positron emission tomography–computed tomography scan revealed no metastases. The tumor resolved after chemotherapy with paclitaxel. Angiosarcoma is an aggressive endothelial cell malignancy associated with old age, radiation exposure, and chronic lymphedema. Angiosarcoma mostly involves the head and neck area, especially the scalp. Typically, 48.3% of angiosarcomas initially manifest with bruise-like maculopatches before growing into tumor nodules, mimicking bruising or hematoma.1Pawlik T.M. Paulino A.F. McGinn C.J. et al.Cutaneous angiosarcoma of the scalp: a multidisciplinary approach.Cancer. 2003; 98: 1716-1726Crossref PubMed Scopus (298) Google Scholar Diagnosis is often delayed up to 5 months.1Pawlik T.M. Paulino A.F. McGinn C.J. et al.Cutaneous angiosarcoma of the scalp: a multidisciplinary approach.Cancer. 2003; 98: 1716-1726Crossref PubMed Scopus (298) Google Scholar Distant metastases can occur in the early stage, and tumor size is the most important determinant of prognosis.2Wen S. Zhang W. Yang Y. et al.Angiosarcoma of the scalp and face associated with Kasabach-Merritt syndrome and disseminated intravascular coagulation.Indian J Dermatol Venereol Leprol. 2016; 82: 96-97Crossref Scopus (5) Google Scholar,3Buehler D. Rice S.R. Moody J.S. et al.Angiosarcoma outcomes and prognostic factors: a 25-year single institution experience.Am J Clin Oncol. 2014; 37: 473-479Crossref PubMed Scopus (127) Google Scholar Early diagnosis is emphasized but relies on the clinician's alertness, especially for the scalp where hairs can cover early lesions. The prognosis of angiosarcoma of the scalp is worse than other regions, with a 5-year survival rate of 9%.4Bernstein J.M. Irish J.C. Brown D.H. et al.Survival outcomes for cutaneous angiosarcoma of the scalp versus face.Head Neck. 2017; 39: 1205-1211Crossref PubMed Scopus (42) Google Scholar Skin biopsy is suggested for a suspicion of angiosarcoma in the elderly without a history of trauma or coagulopathy presenting with spontaneous ecchymosis and refractory bleeding wounds.