Angiosarcoma after tylectomy and radiation therapy for carcinoma of the breast

Ovarian epithelioid angiosarcoma complicating pregnancy: a case report and review of the literature

Epithelioid angiosarcoma is a rare and highly aggressive soft tissue angiosarcoma most commonly arising in the deep soft tissues. Given that abundant vascular cavities anastomose with each other, most angiosarcomas prone to metastasis recur quickly, and the overall prognosis is poor. We report a 25-year-old woman at 24 weeks’ gestation who presented with a 1-month history of abdominal distension. Ultrasonography suggested a mass in the right adnexa, and she underwent two operations owing to uncontrolled intraperitoneal bleeding with progressive anemia. The right ovarian tumor and right adnexa were removed successively. Biopsy yielded a diagnosis of primary epithelioid angiosarcoma with mature cystic teratoma. The patient died from uncontrolled progressive bleeding 1 week after the second operation. This case revealed that epithelial angiosarcoma is a highly malignant endothelial cell tumor. The results of surgery and chemoradiotherapy tend to be poor, and the recurrence rate is high. The purpose of this study is to raise clinical awareness of epithelial angiosarcoma and its adverse events and to provide new ideas for the treatment of these adverse events. Immunohistochemical staining of pathological specimens can facilitate diagnosis. Pregnancy with malignant tumors may lead to rapid disease progression, extensive lesions, and a poor prognosis.

Radiation-associated sarcoma after breast cancer in a nationwide population: Increasing risk of angiosarcoma

Radiation‐associated sarcoma (RAS) is a rare complication of radiation therapy (RT) to breast cancer (BC). This study explored RAS after RT to BC in a nationwide population‐based material. The Finnish Cancer Registry was queried for patients with BC treated during 1953‐2014 who were later diagnosed with a secondary sarcoma in 1953‐2014. Registry data, patient files, and sarcoma specimens were  analyzed to confirm diagnosis and location of RAS at or close to the RT target volume. A total of 132 512 patients were diagnosed with invasive BC during the study period. A subsequent sarcoma was diagnosed in 355 patients. After exclusion, 96 RAS were identified. Angiosarcoma (AS) was the most prevalent histology in 50 (52%) of 96 patients. However, the first radiation‐associated AS was diagnosed in a patient treated for BC with breast‐conserving surgery in 1984, and thereafter, the proportion of AS continuously increased. The 5‐year sarcoma‐specific survival was 75.1% for RAS treated with a curative intent. The distribution of histologic subtypes of RAS has changed during the 60 years of this registry study. The first radiation‐associated AS was diagnosed in 1989, and presently, AS is the most common histologic subtype of RAS. It is possible that changes in BC treatment strategies are influencing the characteristics of RAS.

Post-Radiation Angiosarcoma of the Breast: A Clinical Case

After conservative treatment of breast carcinoma (quadran-tectomy and axillary dissection, plus radiotherapy), the growth of an angiosarcoma in the irradiated skin is a very rare event. We report a case, developed in the breast skin 62 months after the irradiation, and discuss the therapeutic possibilities and the role of follow-up in these patients.

Lymphangiosarcoma in a Chronic Lymphedematous Limb: A Case Report

A 69-year-old-woman developed a lymphangiosarcoma of the limb on chronic lymphedema after radical mastectomy and radiotherapy for primary breast cancer 12 years before. Since 1948, when Stewart and Treves described this entity, 200 cases have been described. We report this case because of its extremely rare frequency. Concepts of etiology, treatment and prognosis are reviewed.

Cutaneous Malignant Vascular Neoplasms

Accurate diagnosis of cutaneous malignant vascular tumors, including angiosarcoma and epithelioid hemangioendothelioma, is critical for determination of appropriate clinical management and prognosis. Although there have been significant advances in understanding genetic aspects of cutaneous vascular biology, differential diagnosis of malignant vascular tumor involving skin and superficial soft tissue is a frequent source of difficulty. This brief overview highlights the clinicopathologic features of primary and secondary cutaneous angiosarcoma and epithelioid hemangioendothelioma and also provides a short summary of newer molecular data.

Radiation-induced sarcoma of the breast: a systematic review

INTRODUCTION

Radiation-induced sarcoma (RIS) is a rare, aggressive malignancy. Breast cancer survivors treated with radiotherapy constitute a large fraction of RIS patients. To evaluate evidenced-based practices for RIS treatment, we performed a systematic review of the published English-language literature.

METHODS

We performed a systematic keyword search of PubMed for original research articles pertaining to RIS of the breast. We classified and evaluated the articles based on hierarchical levels of scientific evidence.

RESULTS

We identified 124 original articles available for analysis, which included 1,831 patients. No randomized controlled trials involving RIS patients were found. We present the best available evidence for the etiology, comparative biology to primary sarcoma, prognostic factors, and treatment options for RIS of the breast.

CONCLUSION

Although the evidence to guide clinical practice is limited to single institutional cohort studies, registry studies, case-control studies, and case reports, we applied the available evidence to address clinically relevant questions related to best practice in patient management. Surgery with widely negative margins remains the primary treatment of RIS. Unfortunately, the role of adjuvant and neoadjuvant chemotherapy remains uncertain. This systematic review highlights the need for additional well-designed studies to inform the management of RIS.

angiosarcoma arising in the breast following breast-conserving surgery with radiation for breast carcinoma

We report a case of angiosarcoma arising in the breast following breast-conserving surgery with radiation therapy for breast carcinoma. The patient, a 49-year-old postmenopausal woman, had undergone breast-conserving surgery for invasive ductal carcinoma of the left breast (pT2 pN0 M0 Stage IIA). Adjuvant radiotherapy (50 Gy with a booster dose to the tumor bed of 10 Gy) was then performed for the residual breast tissue and the patient was treated with hormone therapy (tamoxifen, 20 mg daily) for 5 years. She presented with skin erosion with bleeding 10 years after the initial operation. Incisional biopsy revealed angiosarcoma of the breast, and total mastectomy was subsequently performed. The patient was the treated with chemotherapy (weekly paclitaxel, 80 mg/m2 x cycles) and has remained well without evidence of local or distant recurrence.

Complications in Breast Surgery

Most breast operations are categorized as low-morbidity procedures, but a variety of complications can occur in association with diagnostic and multidisciplinary management procedures. Some of these complications are related to the breast itself, and others are associated with axillary staging procedures. This article first addresses some general, nonspecific complications (wound infections, seroma formation, hematoma). It then discusses complications that are specific to particular breast-related procedures: lumpectomy (including both diagnostic open biopsy and breast-conservation therapy for cancer), mastectomy; axillary lymph node dissection, lymphatic mapping/sentinel lymph node biopsy, and reconstruction.

Skin Angiosarcoma Arising in an Irradiated Breast: Case-Report and Literature Review

BACKGROUND

Angiosarcoma (AS) is a rare, invasive malignancy originating from endothelial cells caused by many different clinical situations. AS following radiotherapy for breast cancer after conservative surgery is a rare but well-known association.

OBJECTIVE

The aim of this article is to describe a case of AS after breast conserving surgery and to review the literature to date.

RESULTS

We report the case of an 84-year-old woman who developed AS four years after she was subjected to quadrantectomy for invasive ductal cancer, followed by 30 tangent field radiotherapy sessions. She presented with a one-month history or red papular skin eruptions on the operated breast. Skin lesions were submitted for biopsy, and they were positive for AS. The patients was subjected to surgical excision of the remaining breast including all AS lesions. She is alive with no evidence of disease after 10 months follow-up.

CONCLUSION

Post-radiotherapy AS is rare neoplasm, but it should be considered in the case of patients with red lesions after breast conserving surgery and adjuvant radiotherapy.

Cutaneous Angiosarcoma Following Breast-conserving Surgery and Radiation: An Analysis of 27 Cases

Iatrogenic angiosarcomas (AS), following treatment of breast carcinomas and attributed to chronic lymphedema, were first described by Stewart and Treves. With emphasis on breast-conserving therapy combined with adjuvant radiation, a recently recognized form of cutaneous postradiation angiosarcoma of the breast (CPRASB) has emerged. To more completely characterize CPRASB, 27 cases were analyzed. Histologic features studied included pattern of growth (vasoformative, sieve-like, or solid), nuclear grade, necrosis, and mitotic rate. Clinical and follow-up information was obtained. The patients received relatively standard radiation treatment. The median interval to diagnosis of CPRASB was 59 months; 5 occurred in less than 3 years. Lymphedema was largely absent, and when present was only mild in nature. CPRASB was frequently multifocal at presentation (13 of 27). All tumors had a vasoformative pattern of growth; the majority (16 of 27) had areas with a sieve-like pattern. The solid pattern was less frequent (7 of 27). The majority had high-grade nuclear features (16 grade 3, 8 grade 2, 3 grade1). The mean mitotic rate was 9/10 HPF. Necrosis was rare (2 of 27). All were treated with wide excision or mastectomy. Follow-up was available on 22 of 27 cases (median 44 months). Fourteen experienced local recurrence and 6 had multiple recurrences. Metastasis was documented in 9 of 22 patients and involved lungs (6), contralateral breast (3), skeleton (2), lymph nodes (1), and soft tissue (1). Eight patients died of disease, 2 died with disease, 4 were alive with disease, and 8 are alive without disease. The median interval to death was 33.5 months. All 4 patients with disease have documented metastasis. CPRASB differs from Stewart-Treves AS by its shorter latency period and lack of association with lymphedema.

Cutaneous angiosarcoma as a delayed complication of radiation therapy for carcinoma of the breast

Three cases of cutaneous angiosarcoma of the breast that arose in irradiated skin tissue in women who had previously undergone treatment for breast carcinoma are reported. A review of the literature identified 55 cases of cutaneous angiosarcoma following radiation therapy as part of the treatment of carcinoma of the breast. For all 58 assembled cases, the mean age at the time of adjuvant radiation therapy for breast carcinoma was 64 years (range 42-83). The mean time to subsequent diagnosis in irradiated skin was 75 months (range 12-192). The estimated 3-year overall survival for all 58 patients was only 20%, similar to that of patients with the general form of angiosarcoma. Postirradiation angiosarcoma of the breast has a variety of presentations; thus diagnosis is often delayed. Early diagnosis relies on a high index of suspicion and appropriate histopathologic studies, as the clinical and histopathologic findings may be confused with other conditions. Treatment should be aggressive and include local surgery with consideration of adjuvant systemic chemotherapy.

An unusual case of metastatic post-irradiation breast sarcoma

A 71-year-old lady developed a left breast angiosarcoma 10 years after a wide local excision and external beam radiotherapy for invasive breast cancer. Three years after a left simple mastectomy for the angiosarcoma, she presented with metastatic angiosarcoma in the contralateral axilla. There were no local or distant metastases. This is the first reported case of isolated contralateral axillary metastases from post-irradiation angiosarcoma of the breast. A previous study has reported ipsilateral axillary metastases in relation to secondary breast angiosarcoma. Contralateral axillary metastases have always been associated with extensive distant metastases. We present a review of the available literature on radiation-associated breast angiosarcomas.

Is radiotherapy needed after breast conservation for small invasive breast cancers?

AIMS

The purpose of this study was to determine the rate of local recurrence in patients with small invasive breast cancers (<1 cm) who had been treated with breast-conserving surgery either with (group 1) or without (group 2) adjuvant radiotherapy.

METHODS

This is a retrospective study of 110 patients with an invasive breast cancer less than 1 cm in size, treated in our centre by breast-conserving surgery. Parameters examined included age at and mode of presentation, histopathological features, adjuvant therapy, length of follow-up and outcome in terms of local recurrence rate and death.

RESULTS

In group 1 there were 59 women of median age 57 (38-80) years. The median tumour size was 9 (1-10) mm and median follow-up was 74 (15-110) months. There were no local recurrences. In group 2 the median age at presentation was 59 (48-81) years. The median tumour size was 7 (2-10) mm and median follow-up was 47 (14-93) months. There were three non-breast-cancer related deaths and three local recurrences (6%).

CONCLUSIONS

A local recurrence rate of 6% at almost 4 years median follow-up suggests that it may be possible to avoid adjuvant radiotherapy in a subgroup of largely screen-detected, node-negative patients with invasive tumours less than 1 cm, in whom adequate local excision is performed. Further follow-up is required to substantiate this.

Benign vascular proliferations in irradiated skin

Several types of cutaneous vascular proliferations have been described in areas of irradiated skin, including both benign lesions, such as benign lymphangiomatous papules, atypical vascular lesions, or benign lymphangioendothelioma, and malignant neoplasms such as high-grade angiosarcomas. This report describes the clinicopathologic features of 15 cases of different types of benign cutaneous vascular proliferations arisen within irradiated skin. All patients were female ranging in age from 33 to 72 years, and they had received postoperative external radiotherapy for treatment of breast carcinoma (14 cases) or ovarian carcinoma (one case). In those cases in which the latency interval period between radiotherapy and the development of the vascular lesion was known from the clinical records, the latency interval period elapsed between radiotherapy and diagnosis of the vascular lesion ranged from 3 to 20 years. The most common clinical presentation of the cutaneous lesions consisted of papules, small vesicles, or erythematous plaques on the irradiated field. Histopathologically, most lesions consisted of irregular dilated vascular spaces, with a branching and anastomosing pattern, thin walls, and lymphatic appearance involving the superficial dermis. A discontinuous single layer of endothelial cells with flattened nuclei lined these vascular channels, and numerous small stromal papillary formations also lined by endothelial cells projected into the lumina of the dilated lymphatic vessels. These cases were classified as benign lymphangiomatous papules or plaques. Two cases showed different histopathologic findings because they consisted of poorly circumscribed and focally infiltrating irregular jagged vascular spaces involving the entire dermis and lined by inconspicuous endothelial cells. In some areas these irregular slit-like vascular spaces dissected collagen bundles of the dermis. These cases were classified as atypical vascular proliferations mimicking benign lymphangioendothelioma or patch-stage Kaposi's sarcoma. All cases showed similar immunohistochemical findings and the endothelial cells lining the vascular spaces expressed immunoreactivity for CD31, but they stained only focally positive for CD34 or were negative for this marker. Immunohistochemical investigations for alpha-smooth muscle actin failed to demonstrate a complete peripheral ring of actin-positive pericytes in most of the neoformed vascular structures. This immunohistochemical profile also supported the lymphatic nature of these vascular proliferations developed in irradiated skin. Although some of these lesions may mimic histopathologically patch-stage Kaposi's sarcoma or well-differentiated angiosarcoma, the follow-up of the patients of this series demonstrated that the vascular proliferations arisen in irradiated skin invariably showed a benign biologic behavior.

Angiosarcoma after breast-conserving therapy: experience with hyperfractionated radiotherapy

PURPOSE

To report our promising results of hyperfractionated radiotherapy (RT) in conjunction with surgery for angiosarcoma occurring after breast-conserving therapy for early-stage breast cancer.

METHODS AND MATERIALS

Since 1997, 3 cases of angiosarcoma after breast-conserving therapy have been managed at the University of Florida. The histologic specimens in each case were reviewed and graded by one of us (J.D.R.).

RESULTS

Explosive growth of discolored skin lesions coincident with histologic evidence of angiosarcoma characterized all 3 cases but was preceded by a fairly indolent period (almost 2 years) of atypical vascular hyperplasia in 2 patients. All 3 patients were treated initially with radical surgery for the angiosarcoma, but extensive recurrences were noted within 1 to 2 months of surgery. Because of the extremely rapid growth noted before and after surgery, hyperfractionated RT was used. Two of the patients underwent planned resection after RT, and neither specimen demonstrated any evidence of high-grade angiosarcoma. All 3 patients were alive without any recurrent disease 22, 38, and 39 months after treatment.

CONCLUSIONS

Hyperfractionated irradiation appears to be effective treatment for rapidly proliferating angiosarcoma. For previously untreated angiosarcoma, we now recommend hyperfractionated RT followed by surgery to enhance disease control and remove as much reirradiated tissue as possible.

Lymphangiosarcoma (Stewart-Treves syndrome) in postmastectomy patients

Stewart-Treves syndrome (STS) is a rare but aggressive upper extremity lymphangiosarcoma in postmastectomy patients. Unfamiliarity with this disease and the innocuous appearance of the tumor often lead to delayed diagnosis. A comprehensive search of the databases at a single tertiary-care academic institution revealed only 3 cases of STS in the last 63 years. The latency time between breast cancer treatment and diagnosis of STS was 11 to 21 years. Survival after diagnosis of STS ranged from 8 to 15 months. One patient underwent radical surgery. The extensive lymphangiosarcoma in the other 2 patients precluded surgical resection and they underwent chemotherapy. All patients had adjuvant radiation therapy at the time of the original breast cancer resection. This report includes a discussion of the epidemiology, etiology, presentation, treatment, and prognosis of STS.

Cutaneous angiosarcoma in an irradiated breast after breast conservation therapy for cancer: association with chronic breast lymphedema

The authors report a rare case of cutaneous angiosarcoma arising more than 5 years after excision of a 1.5 cm invasive ductal cancer of the breast. All lymph nodes were negative for metastatic breast cancer in this 68-year-old female. The patient had postoperative therapy consisting of 5040 cGy over a 5 week period using a 6 Megavolt linear accelerator. After radiation therapy to the breast and axillae, the patient developed chronic hard, taut edema of the irradiated right breast. Tamoxifen was administered for 5 years and then stopped. Three months after the cessation of tamoxifen, cutaneous angiosarcoma was found by skin biopsy. A complete mastectomy removed all tumor with clear margins. There are less than 60 cases of radiation associated breast angiosarcoma found in the literature. The presence of chronic lymphedema in the breast after radiation therapy possibly contributes to the development and is an early warning sign for later development of secondary angiosarcoma. The characteristic purple nodules and discoloration of the irradiated skin is the hallmark to suspect the diagnosis. The authors recommend long-term clinical surveillance for this tumor for all patients who have received breast conservative surgical therapy with concomitant radiation therapy for primary breast cancer.

Fine-needle aspiration biopsy of postradiation epithelioid angiosarcoma of breast

Angiosarcoma of breast skin and parenchyma is a rarely reported complication of irradiation for breast carcinoma. We report a case of a subareolar epithelioid angiosarcoma arising 8 years subsequent to lumpectomy and irradiation of the ipsilateral breast for infiltrating carcinoma. The epithelioid appearance of the neoplastic cells on fine-needle aspiration biopsy (FNA) biopsy suggested a recurrence of the primary carcinoma. Careful attention to certain cytomorphologic features and cell block immunohistochemistry were useful in the distinction from recurrent carcinoma. Cytologic features that identified this neoplasm as an angiosarcoma included marked cell discohesiveness, elongate cytoplasmic processes or "pseudopodia," heterogeneous cell size, large nucleoli or macronucleoli, and cytoplasmic lumina. Immunohistochemical markers, including Factor VIII antigen, CD31, and CD34, were positive, confirming the vascular nature of the neoplasm. Other markers ruled out morphologically similar neoplasms such as recurrent carcinoma and melanoma. Epithelioid angiosarcoma should be included in the differential diagnosis of a suspected recurrence of breast carcinoma several years postirradiation therapy. Diagn. Cytopathol. 2000;22:172-175.

A case of malignant fibrous histiocytoma after breast conserving therapy for breast cancer

A 45-year-old woman with malignant fibrous histiocytoma (MFH) of the breast following breast conserving therapy (BCT) is described. She noticed a lump in her left breast 52 months after BCT for breast cancer. The lump was excised and nodular fasciitis was initially diagnosed. However, the tumor recurred locally 4 times in the next 18 months. MFH was finally diagnosed. This case is considered to be radiation-induced sarcoma. The risk of radiation-induced sarcoma after BCT seems to be very low, however careful follow-up is necessary.

Nine breast angiosarcomas after conservative treatment for breast carcinoma: a survey from French comprehensive Cancer Centers

OBJECTIVES

To conduct a survey of the angiosarcomas developing after breast conservation for carcinoma in the French Cancer Centers, to study the evolution of these cases in detail, and to review literature in an attempt to propose an optimal treatment scheme.

MATERIAL AND METHODS

Eleven of the 20 French Cancer Centers agreed to research and retrospectively analyze all angiosarcomas discovered in patients previously treated by conservative treatment. The majority of the patients were node negative, T1N0M0. The mean age of the patients at the time of primary breast cancer treatment was 62.5 years, and 69 years at the diagnosis of the angiosarcoma.

RESULTS

During the last two decades, nearly 20,000 patients have been treated conservatively in these 11 centers, and only 9 cases of angiosarcoma were found. The median latency period between the treatment of the breast carcinoma and the diagnosis of the breast angiosarcoma was approximately 74 months, with a range of 57-108 months. Mastectomy was performed as the main treatment of this angiosarcoma. All recurrences after mastectomy for the angiosarcoma appeared within 16 months after the mastectomy. A median time of recurrence was found to be 7.5 months, regardless of the treatment. The angiosarcomas appeared to be very aggressive, and chemotherapy, radiotherapy, and sometimes hyperthermia could only palliate the condition for a short time. After the diagnosis of angiosarcoma, the median survival was 15.5 months, showing a particularly poor prognosis. Only 1 patient of 9 is alive without progressive disease at 32 months after salvage mastectomy for the recurrence of the angiosarcoma. Precise data obtained from 11 centers show that, of 18115 breast carcinomas treated conservatively, only 9 breast angiosarcomas are reported, which represents a prevalence of 5 cases of angiosarcoma per 10,000, which is the same prevalence for primary breast angiosarcomas occurring in healthy breasts.

CONCLUSION

Angiosarcoma developing after breast conserving therapy for carcinoma is a rare event, and induction of it by treatment is controversial. However, early diagnosis is essential and it appears that radical mastectomy gives the highest chance of cure and the best long-term survival.

Unusual cutaneous malignancies

The most commonly occurring cutaneous malignancies are basal cell and squamous cell carcinoma. There are, however, other rare malignancies that are encountered and should be included in the differential, in which both the clinical and the histological diagnosis may be difficult. Here, the clinical and histological features, management, and prognostic factors of merkel cell carcinoma, microcystic adnexal carcinoma, leiomyosarcoma, dermatofibrosarcoma protuberans, and angiosarcoma are reviewed.

Metastatic angiosarcoma of the spleen after accidental radiation exposure: a case report

Angiosarcoma is a rare malignant tumor arising from endothelial cells of blood vessels or lymphatic channels. Therapeutic irradiation, thoriumdioxide administration, pyothorax, and polyvinyl chloride exposure have been shown to be predisposing factors for developing angiosarcoma. Accidental radiation exposure has not been associated with angiosarcoma. We present an unusual case of angiosarcoma of the spleen, with metastases to bone, liver, breast, and bone marrow, in a woman who lived near the Chernobyl nuclear facility in the former Soviet Union at the time of the reactor accident in 1986. To the best of our knowledge, this is the first report of metastatic angiosarcoma after accidental radiation exposure.

Cutaneous vascular proliferations. Part III. Malignant neoplasms, other cutaneous neoplasms with significant vascular component, and disorders erroneously considered as vascular neoplasms

In this third and last part of our review of cutaneous vascular proliferations we include malignant vascular neoplasms and a group of heterogeneous cutaneous neoplasms characterized by a significant vascular component. We also review some disorders that, in our opinion, have been erroneously considered as vascular neoplasms. We review the epidemiologic, histogenetic, clinical, and histopathologic aspects of Kaposi's sarcoma in its four distinctive variants (classic, African-endemic, immunosuppressive drug-associated, and AIDS-associated Kaposi's sarcoma). There is still controversy about whether Kaposi's sarcoma represents a reactive vascular proliferation or a true neoplastic proliferation. In any event, most authors believe that Kaposi's sarcoma does not produce metastatic disease, but rather develops in multifocal fashion. However, Kaposi's sarcoma may cause death, especially in immunosuppressed patients. Epithelioid hemangioendothelioma, Dabska's tumor, and retiform hemangioendothelioma are examples of low-grade angiosarcoma. In contrast, cutaneous angiosarcomas, including the clinical variants of angiosarcoma of face and scalp in elderly patients, angiosarcoma associated with lymphedema, and radiation-induced angiosarcoma are highly aggressive neoplasms with poor prognosis and most patients die within a short period after presentation. A group of benign and relatively frequent cutaneous neoplasms, including multinucleate cell angiohistiocytoma, angiofibroma, angioleiomyoma, angiolipoma, cutaneous angiolipoleiomyoma, and cutaneous angiomyxoma are here covered because of their significant vascular component. Finally, we review briefly a series of cutaneous disorders that have been erroneously considered as vascular neoplasms. Kimura's disease is an inflammatory reactive condition of unknown origin, "benign" angioendotheliomatosis is a reactive intravascular proliferation of endothelial cells that occurs in the skin as a response to a variety of stimuli, "malignant" angioendotheliomatosis is an intravascular lymphoma, and acral pseudolymphomatous angiokeratoma of children (APACHE) is better interpreted as a pseudolymphoma.

Angiosarcoma of the breast after conservation therapy for invasive cancer, the incidence and outcome. An unforseen sequela

PURPOSE

In the past 15 years breast conserving therapy (BCT) has become an important treatment option for primary breast cancer. Thirty three angiosarcomas (AS) after BCT have been described in a total of 20 published reports. Limited follow-up data and the lack of information on incidence of AS prompted the authors to review the comprehensive experience in the Netherlands.

METHODS

Between 1987 and 1995 twenty-one patients with BCT-associated AS were diagnosed in the Netherlands. Follow-up after diagnosis of AS ranged from 6 to 82 months with a median of 24 months. Information on the total number of patients treated with BCT and on the numbers of angiosarcoma in the breast was obtained.

RESULTS

The median interval between BCT and AS was 74 months (range: 29-106) and appeared to decrease with higher age. Detection of skin changes followed by incisional biopsy provided the diagnosis. Two year overall (OS) and disease free survivals were 72% (s.e. 10.9) and 35% (s.e. 10.7), respectively. Two year OS after initial complete surgical resection was 86% (s.e. 9.3) compared to 0% after incomplete resection of the AS (P = 0.04). The estimated incidence of AS after BCT is 0.16%.

CONCLUSIONS

BCT-associated AS arises after a relatively short interval. Although the incidence of AS is low, the absolute number of patients at risk is increasing. This calls for vigilance concerning skin changes occurring after BCT. An incisional biopsy provides the only reliable diagnosis. The prognosis appears to be related to the completeness of surgical resection.

Radiation-associated angiosarcoma: diagnostic and therapeutic implications--two case reports and a review of the literature

BACKGROUND

Angiosarcoma (AS) accounts for 1 to 2% of all soft tissue sarcoma. Both primary and secondary AS may occur, the latter being reported in the upper extremity with lymphedema after extended radical mastectomy for breast cancer (postmastectomy AS) or following radiotherapy of the breast, the thoracic wall, or other sites (radiation-associated AS). The authors report two cases of cutaneous radiation-associated AS and review literature regarding treatment planning and follow-up data to define the most appropriate therapy for cutaneous and noncutaneous radiation-associated AS.

METHODS

The clinical records of two patients with radiation-associated AS were analyzed and previously reported cases were reviewed.

RESULTS

Case 1: a female age 67 years developed cutaneous AS in the residual breast 27 months after breast-conserving therapy and conventional external beam radiotherapy (EBR). She underwent chemotherapy followed by simple mastectomy and chemotherapy with the same regimen but developed early recurrence that was treated with hyperthermia and EBR, wide excision, and second-line chemotherapy. She died 30 months after primary diagnosis of AS with multiple metastases. Case 2: a male age 59 years developed cutaneous AS in the left groin, 10 years after conservative surgery and EBR for a penile carcinoma. Early recurrence following wide excision was treated with chemotherapy, re-excision, and immunochemotherapy but the patient died 24 months after the primary diagnosis of cutaneous AS with local progression and distant metastases.

CONCLUSIONS

The prognosis of radiation-associated AS is dismal, due mostly to its poor differentiation and frequent diagnostic delay. Simple mastectomy is advised for patients with cutaneous AS after breast-conserving surgery with wide tumor-free margins. If primary surgery fails, survival is seriously compromised because adjuvant or palliative treatments are not effective.

A case of malignant transformation in thoracic vertebral hemangioma following repetitive irradiation and extraction

We report a rare case of thoracic vertebral hemangioma which developed into angiosarcoma during the course of repetitive operations and irradiation. A 44 year old female was operated on for hemangioma of the first thoracic vertebra. The diagnosis of hemangioma was confirmed histopathologically with the specimen from the first operation. The tumor developed multiple lesions later in the clinical course after the first operation, these lesions were removed in four consecutive operations and each histological diagnosis was that of hemangioma. Throughout the period of these operations, the patient was treated with steroid, and with radiotherapy simultaneously. The patient underwent the fifth operation for the recurrence of the tumor on 26 March 1990, and the histopathological diagnosis was not hemangioma but hemangiosarcoma which was considered a malignant transformation. The tumor cells immunohistochemically revealed positive staining with UEA-I, Factor-VIII, as the tumor immunohistochemically showed a vascular endothelioid nature.

Cutaneous angiosarcoma arising in the radiation site of a congenital hemangioma

We describe a patient in whom angiosarcoma developed at the site of a hemangioma that was treated during infancy with radiation for refractory thrombocytopenia. Our findings, along with those of the 10 reported cases from the world literature, are summarized. One third of angiosarcomas arise in the skin. They most often show one of three clinical patterns. First and most common is occurrence as a bruiselike lesion on the scalp or face of an elderly person. Second in frequency is the Stewart-Treves syndrome. Third and least common is angiosarcoma developing as a sequela of previous radiation therapy. The prognosis in general is poor, with a mean survival length of 24 months and a 5-year survival rate of 10%. Effective treatment relies on early diagnosis and wide-margin surgical excision.

Cutaneous metastatic angiosarcoma with a lethal outcome, following radiotherapy for a cervical carcinoma

A cutaneous metastatic angiosarcoma was diagnosed in a 79-year-old woman 19 years after radiotherapy for a carcinoma of the uterine cervix. The diagnosis was confirmed by immunohistochemical staining (factor VIII-related antigen and BMA 120) and electron microscopic examination. Surgical treatment of the large tumour, which was situated in the gluteal region, was not feasible, but electron beam therapy resulted in complete remission. However, a further metastasis occurred in the inguinal region, and management by total excision, radiotherapy, and interferon-alpha treatment was unsuccessful. The patient died 28 months after the initial diagnosis of the neoplasm.

Breast cancer

BACKGROUND

Breast cancer is the most common cancer and the second leading cause of cancer death among women in the United States; annual breast cancer deaths are exceeded only by those for lung cancer.

METHODS

Data from the Surveillance, Epidemiology, and End Results (SEER) program registry of the National Cancer Institute comprising 158,621 invasive and 10,639 in situ cases of microscopically confirmed breast carcinomas registered for the years 1973-1987 have been analyzed. Relative frequencies, incidence rates, and 5-year relative survival rates were examined by selected variables of interest. Invasive and in situ breast carcinomas and sarcomas were analyzed separately.

RESULTS

Infiltrating duct carcinoma was the largest group of female breast cancer, constituting 67.9% of the total with a 5-year relative survival of 79%. All other invasive carcinomas were compared with this group. Lobular carcinoma was the second largest group, only 6.3%, and a 5-year relative survival of 84%. Medullary carcinoma was the third most common with 2.8% and a 5-year relative survival of 82%. Other types included mucinous (colloid) adenocarcinoma, 2.2%, 5-year relative survival of 95%; comedocarcinoma, 1.4%, 5-year relative survival of 87%; Paget's disease (nipple and other breast), 1.1%, 5-year relative survival of 79%; papillary carcinoma, 0.9%, 5-year relative survival of 95%; tubular adenocarcinoma, 0.7%, 5-year relative survival of 96% and inflammatory carcinoma, 0.5%, 5-year relative survival of 18%. Carcinoma in situ was registered as intraductal, lobular, combined ductal and lobular, papillary, and carcinoma in situ, not otherwise specified. The relative survival for all forms of carcinomas in situ was approximately 100%. Sarcomas and malignant tumors not further classified are also considered.

CONCLUSIONS

The various histologic types of breast cancer exhibit differences in regard to relative frequency, site pattern within the breast, and patient survival. The SEER program data base of breast cancer is the largest single population-based reference source for breast cancer in the United States. This program is a valuable resource for information on frequency, percentage, and incidence rates by histologic type as well as survival rates of patients with breast cancer.

Cytogenetic study of angiosarcoma of the breast

Angiosarcoma of the breast is quite rare, and the development of cutaneous angiosarcoma after segmental mastectomy and radiation therapy is even less common. A cytogenetic analysis of a mammary angiosarcoma arising in a breast after previous irradiation and segmental mastectomy for infiltrating ductal carcinoma revealed multiple clonal rearrangements involving chromosomes X, 1, 2, 3, 4, 5, 6, 7, 8, 9, 15, 17, 20, and 22. No cytogenetically analyzed angiosarcomas of the breast have been reported before.

Soft tissue sarcoma of the breast after conservative surgery and irradiation for early mammary cancer

At Istituto Tumori of Milano in a series of 3295 patients treated with conservative surgery and radiotherapy for breast cancer from 1973 to 1989 three cases of soft tissue sarcoma were observed in irradiated breasts. One patient developed a fibrosarcoma of the breast stroma, 16 months after irradiation. A grade II bulky angiosarcoma was diagnosed in the breast of a patient treated 59 months previously. The third was a grade II angiosarcoma detected 41 months after therapy. At present, the risk of a second primary in the irradiated breast seems too low to justify modification of our present policy of conservative therapy of breast cancer, but a careful and longer follow-up is needed.

Angiosarcoma of the residual breast after conservative surgery and radiotherapy for primary carcinoma

BACKGROUND

Angiosarcoma of residual breast, arising after conservative surgery and radiotherapy for early breast cancer, is a rare tumor, with only 14 cases having so far been documented. The first was observed in 1987 and 7 of the 14 were reported in 1992 alone.

METHODS

Here, we present an additional case developing in residual breast 3.3 years after lumpectomy and radiotherapy. The other fourteen are reviewed.

RESULTS

Review of data from this series of patients reveals a higher incidence of breast oedema (67%) than that reported in the literature (4%). Another unusual finding is the shorter mean latency period (time interval from radiotherapy to onset of angiosarcoma) noted here (6 years) compared to the more than 10 years reported for other secondary angiosarcomas.

CONCLUSIONS

In view of the widespread use of radiotherapy after breast-conserving surgery, and also its lack of benefit in terms of overall survival, every novel complication should be investigated. Given the apparent rise in incidence of this rare tumor over the last few years, doctors should be aware of the phenomenon in order to recognize and define it.

Angiosarcoma of the breast following lumpectomy, axillary lymph node dissection, and radiotherapy for primary breast cancer: three case reports and a review of the literature

INTRODUCTION

One of the risks of therapeutic irradiation is the development of secondary malignant tumors. In this paper three cases are reported of angiosarcoma of the breast following breast-conserving surgery and irradiation for primary breast cancer, and the literature is reviewed.

METHODS AND MATERIALS

Until now, 13 other cases of postirradiation angiosarcoma of the breast have been reported. The mean interval between treatment of primary breast cancer and the development of angiosarcoma in these 16 patients is 76 months. The clinical aspect is typical with multiple bluish or purple nodules of the skin, purple discolorations, erythematous maculas or areas, sometimes combined with ulceration, edema, or a palpable mass. Mammography does not necessarily raise suspicion and the interpretation of fine-needle aspiration or biopsy may be difficult.

RESULTS

In all patients mastectomy was performed, Follow-up data are available for 12 cases. Two patients died of extensive local recurrences and one of distant metastases.

CONCLUSION

Angiosarcoma of the previously irradiated breast is an extremely rare tumor and diagnosis may be difficult. The number of patients with long-term follow-up after breast-conserving therapy is growing fast. Therefore, the authors advise to pay special attention to uncommon skin changes of the treated breast, since clinical suspicion is the main clue to the diagnosis of postirradiation angiosarcoma. The primary therapy is (simple) mastectomy if wide tumor-free margins can be achieved. There is no indication for standard adjuvant chemotherapy or irradiation.