The nature of the so-called postmastectomy lymphangiosarcoma

Primary angiosarcoma of the breast in a 21-year-old female: A case report

We present a case of primary angiosarcoma, an exceedingly rare malignant breast lesion, in a 21-year-old female patient with unilateral breast enlargement. Primary angiosarcoma is an aggressive form of breast cancer with variable presentation and limited clinical experience due to the rarity of the disease. Despite an initial diagnostic challenge, this report showcases the importance of a systematic diagnostic approach and multidisciplinary management in the context of uncommon breast lesions in young patients. Our patient underwent a mastectomy followed by breast reconstruction, achieving favourable cosmetic outcomes. This case serves as a contribution to our understanding of the diagnostic considerations surrounding angiosarcoma of the breast in a young patient.

A Case of Postmastectomy Lymphangiosarcoma

A case of postmastectomy lymphangiosarcoma of the arm, arising 13 years after the operation, is described. A singular character of the case was the absence of lymphedema in the affected arm.

Sporadic Case of Breast Angiosarcoma as a Complication of Radiotherapy Following Breast-Conserving Surgery for Invasive Ductal Breast Cancer

BACKGROUND

Angiosarcomas are highly aggressive and malignant blood vessel tumors. Rarely, angiosarcomas develop in the breast following conservative therapy, namely radiotherapy.

CASE REPORT

A 70-year-old female patient presented with dark purple discoloration of the skin of the right breast. 6 years earlier, the patient had undergone conservative surgery for invasive ductal carcinoma of the right breast. According to the breast-conserving surgery protocol, the patient had been treated with radiotherapy to the residual breast tissue. The patient's annual mammograms and ultrasound findings were normal. The skin lesion was superficially localized mostly at the border between the upper and lower medial quadrants of the breast (between 2 and 4 o'clock) and above the areola. The borders were uneven; the dimensions were 7 cm × 4 cm. The mammogram was classified as Breast Imaging Report and Data System (BI-RADS) 2. Ultrasound examination showed a well-vascularized structure, although the etiology was unclear. A tissue biopsy revealed angiosarcoma. The patient underwent radical simplex mastectomy. Following surgery, the patient underwent chemotherapy. Tests excluded metastases for a follow-up period of 5 years.

CONCLUSION

Angiosarcomas that develop after radiotherapy following breast-conserving surgery are sporadic, but it is important to take this possible incident into consideration during treatment.

Radiation induced angiosarcoma a sequela of radiotherapy for breast cancer following conservative surgery

Radiation induced angiosarcomas (RIA) can affect breast cancer patients who had radiotherapy following conservative breast surgery. They are very rare tumors and often their diagnosis is delayed due to their benign appearance and difficulty in differentiation from radiation induced skin changes. Therefore it is very important that clinicians are aware of their existence. We report here a case of RIA followed by discussion and review of literature.

Radiation-Induced Sarcoma Following Treatment of Breast Cancer

BACKGROUND: Radiation therapy (XRT) is an important modality in the treatment of cancer, and XRT is now commonly utilized in the treatment of early-stage breast cancer. However, its use has occasionally resulted in the development of secondary malignancies. We present a critical review of radiation-induced sarcoma (RIS) that develops after irradiation for the treatment of breast cancer. METHODS: The case of a patient who developed sarcoma after radiation for breast cancer is presented, and current literature on RIS is reviewed. The role of XRT in the development of RIS is examined, and the evaluation and treatment of these malignancies are reviewed. Results: RIS occurs in 0.2% of patients following treatment of breast cancer. The role of radiation in the development of RIS has been clearly demonstrated. Clinical presentation varies, and diagnosis is commonly delayed. Treatment consists of wide surgical excision. The role of chemotherapy is controversial. CONCLUSIONS: The occurrence of RIS following treatment of breast cancer is rare. Its development has an average latency of over 10 years and likely correlates with the dose and technique of the radiation treatment. The prognosis of patients with RIS following treatment for breast cancer is poor predominantly due to a delay in diagnosis. However, the benefit derived by breast cancer patients from XRT far outweighs the risk of RIS and should not affect the decision to treat these patients with this modality.

Immunoelectron microscopy shows an atypical pattern and a quantitative shift of collagens type I, III and VI in oral Kaposi's sarcoma of AIDS

The localization of collagen types I, III and VI in normal human alveolar and palatal mucosa and in oral Kaposi's sarcoma (KS) was studied by light microscopy and cryo-immunoelectron microscopy. Normal oral mucosa revealed two different types of organization. The upper connective tissue stroma contained a loose reticular network mainly composed of collagen types III and VI, while collagen type I immunostaining predominated in the deeper stroma. Ultrastructurally, in the KS tumour stroma, a loose pattern of individual thin collagen fibrils was noted. These often fanned out at their ends showing a filamentous substructure. The fibrils consisted predominantly of collagen type I similar to individual fibrils of normal oral mucosa. However, there was a marked loss of thick fibre bundles of collagen types I and III in KS compared with normal oral mucosa, whereas collagen type VI was markedly increased and found preferentially in clusters and strands around cross-striated fibrils that often spanned the distance between single collagen fibres. The abundance of collagen type VI in a pattern similar to early stages of wound healing suggests that the KS stroma resembles an early organizational stage of the interstitial and vascular extracellular matrix subject to a high rate of collagen turnover. This character of the KS stroma appears to result from a continuous auto-and paracrine stimulation of cell growth and collagen synthesis and provides an excellent model to study the structural arrangement of collagen type VI in relation to the fibrillar collagen types I and III.

Lymphangiosarcoma in postmastectomy lymphedema (Stewart-Treves syndrome): ultrastructural and immunohistologic characteristics

Two cases of lymphangiosarcoma arising in a chronic lymphedematous extremity following mastectomy (Stewart-Treves syndrome) were reported with not only standard histology, but also special study on the ultrastructure and immunohistology. These cancers developed as a result of chronic lymphedema of the involved limb following mastectomy 15 and 16 years ago, respectively, for breast carcinoma. Immunohistologic and electron microscopic examinations proved that this tumor originates in the vascular endotheliocytes, even though they are clinically chronic lesions apparently derived from the lymphatic vessels. This sarcoma develops multicentrically in an edematous arm and spreads out rapidly, so prognosis is quite discouraging in those patients. They need to be radically surgically treated without hesitation; hence, amputation, not limb-saving surgery, should be indicated.

Stewart-Treves syndrome: an histogenetic (ultrastructural and immunohistological) study

One case of the so-called "Stewart-Treves syndrome" (STS), appearing on a lymphoedematous arm complicating radical mastectomy for breast cancer, was characterized electronmicroscopically and immunohistologically, in order to elucidate its disputed (epithelial vs endothelial) histogenesis. Epithelial and endothelial differentiation markers used comprised: antibodies against keratin, vimentin, factor VIII-related antigen (F VIII-RA), HLA-DR antigens and the lectin Ulex europeaus agglutinin I (UEA I). At the ultrastructural level, neoplastic cells were found to contain typical Weibel-Palade bodies, whereas by immunohistological techniques they proved to be keratin-negative/vimentin+, F VIII-RA+, UEAI+, HLA-DR+. These results rule out a possible epithelial differentiation and strongly favour an endothelial one for STS.

Histogenesis of post-mastectomy angiosarcoma--an ultrastructural study

An example of post-mastectomy angiosarcoma was studied by electron microscopy to determine its histogenesis. Unequivocal evidence of endothelial differentiation was found in well and poorly differentiated areas. Positive staining for factor VIII related antigen and negative staining for epithelial membrane antigen further confirmed that the tumour was a true angiosarcoma rather than a peculiar form of carcinomatous metastasis.

Angiosarcomas arising in edematous extremities: immunostaining for factor VIII-related antigen and ultrastructural features

Immunostaining for Factor VIII-related antigen was seen in deparaffinized sections from 19 of 20 postmastectomy angiosarcomas and from four of four sarcomas that arose in chronically edematous tissue unrelated to breast carcinoma. Staining was also seen in sections from two malignant hemangioendotheliomas, four capillary hemangiomas, and one granulation tissue specimen. Sections from two lymphangiomas were immunonegative for Factor VIII-related antigen in the endothelium of lymphatic channels, whereas staining was observed in the surrounding normal blood vessels. Electron microscopic study of four postmastectomy angiosarcomas disclosed ultrastructural features (fenestrae, intense pinocytotic activity, cell junctions, and Weibel-Palade bodies) supporting the blood vascular endothelial nature of the neoplastic cells. It is concluded that a neoplastic blood vessel component is present in sarcomas that arise in chronically edematous tissues. It is questionable whether a lymphatic component is also present. These tumors, therefore, should be regarded as angiosarcomas rather than lymphangiosarcomas.

Malignant angiosarcoma of the scalp: a case report with immunohistochemical studies

A case of angiosarcoma of the scalp is reported. The histogenesis of this tumour is discussed in terms of the ultrastructural and immunohistochemical findings. This type of angiosarcoma is uncommon and carries a poor prognosis: the therapeutic alternatives are discussed.

Antibodies to intermediate filament proteins in the diagnosis and classification of human tumors

Immunohistochemistry of intermediate filaments (IF) is a new and important way to evaluate the epithelial, mesenchymal, muscular, glial, or neural differentiation in tumors. This is based on the stable cell-type-specific expression of IF proteins in normal and neoplastic tissues. Immunohistochemical studies with antibodies to intermediate filaments have also given new perspectives in the histogenesis and biologic nature of many tumors. This article reviews both the recent findings and the authors' experience in the use of intermediate filament antibodies in tumor diagnosis and classification.

Angiosarcoma in irradiated post-mastectomy chest wall

A 61-year-old woman developed an angiosarcoma in the irradiated chest wall 2 1/2 and 4 years after mastectomy for a carcinoma of breast. The two sets of tumours were morphologically distinct and differed immunohistochemically. The short interval between post-operative irradiation and presentation of the angiosarcoma is unusual. The case is discussed in relation to others of allied type.

Angiosarcoma of skin and soft tissue: a study of forty-four cases

Forty-four cases of skin and soft tissue angiosarcoma seen at M. D. Anderson Hospital before 1976 were reviewed. The cases fell into six different clinical groups: scalp-face, 17 cases; postmastectomy, 14 cases; postradiation, 5 cases; leg with vascular stasis, 2 cases; breast, 2 cases; and miscellaneous, 4 cases. In all cases in the first four groups, the tumors involved primarily the dermis and subcutis and showed similar blends of vasoformative and solid histologic patterns. Two tumors in the miscellaneous group closely resembled those in the larger groups, but the other two in that group (both located in deeper soft tissue sites) and the two breast angiosarcomas had a somewhat different microscopic appearance. Survival was generally poor in all groups, owing to frequent local recurrence and early metastasis; median survival for the entire series was 20 months. Findings of significantly favorable prognostic importance were tumor size less than 5 cm (in the scalp-face group) and a moderate or marked lymphoid infiltrate in and around the tumor. Less significant favorable factors were a distal location ( in the postmastectomy group) and a low degree of pleomorphism. Only nine patients had long-term, disease-free survival.

Lymphangiosarcoma

Forty-four cases of lymphangiosarcoma treated at Memorial Sloan-Kettering Cancer Center were reviewed. With the exception of four patients with primary lymphangiosarcoma of the scalp, all patients had had chronic lymphedema of the involved limb for many years, usually following mastectomy for breast carcinoma, but occasionally due to other cases. Although chronic lymphedema could be implicated in the etiology of lymphangiosarcoma in all patients with neoplasms of an extremity, a significant number of patients did not have a history of radiation therapy at the site where their tumor developed. Histologically, although there were no differences in the lymphangiosarcomas between any of the groups of patients, the morphology of the tumors was influenced in the individual patient by the size and anatomic site of the sarcoma. Early amputation seemed to give the best chance of long-term survival, with responses to wide resection, chemotherapy, and radiation therapy generally only of short duration. Amputation after local recurrence was ineffective in preventing pulmonary metastases and death. At present, early amputation appears to be the treatment of choice for patients with lymphangiosarcoma.

Postmastectomy lymphangiosarcoma: a reappraisal of the concept--a critical review and report of an illustrative case

The syndrome of postmastectomy lymphangiosarcoma (LAS) has been universally accepted since it was first outlined by Stewart & Treves (1948), except for a small number of authors who concluded that the neoplasms arising in the chronic lymphoedematous arms were in fact due to retrograde spread from the original breast carcinoma (Laffargue, Pinet & le Go 1960, Giannardi, Pelù & Zampi 1960, Giannardi & Pelù 1961, Delarue 1962, Salm 1963, Laugier, Olmos, Hunziker & Orusco 1973), but their views have been largely ignored. A case is reported in whom neoplastic arm lesions appeared 27 years after mastectomy and were due, in our opinion, to recent metastases from a new primary Carcinoma of the lung. The validity of the entire concept of LAS is re-examined.

Stewart-Treves syndrome: the histopathological evolution of epithelial metastases

Clinical, histopathologic, and ultrastructural observations in a patient who developed all the characteristics of the Stewart-Treves syndrome 25 years after mastectomy has convinced the authors that the neoplasm arises as a glandular metastasis after an initial phase of sclerosis and that the neoplastic cells are of myoepithelial type.

Angiosarcoma of the skin. A clinicopathologic and fine structural study

A study of ten cutaneous angiosarcomas is presented. These tumors characteristically involve the scalp or face of elderly individuals, where they present as bluish or violaceous plaques and nodules. They have a marked tendency for local spread in surface and depth, and a third of them eventually give rise to distant metastases, particularly to cervical lymph nodes and lung. Microscopically, angiomatous areas of freely anastomosing channels lined by atypical endothelial cells are seen alternating with Kaposi-like spindle cell areas and undifferentiated foci. By electron microscopy, the tumor cells are seen to have all the features of endothelial cells, including pinocytotic vesicles, tubulated bodies, and in one case closed fenestrations. They also exhibit a cytoplasmic specialization here interpreted as the intracellular formation of a vascular lumen. Pericytes and cells resembling smooth muscle cells are also present. In the differential diagnosis this entity has to be distinguished from other clinical types of angiosarcoma of the skin and from a number of benign and malignant conditions. It is suggested that surgery be used for solitary, well circumscribed tumors and radiation therapy for tumors that either are multicentric or have ill defined margins.

Lymphangiosarcoma arising in chronic congenital and idiopathic lymphoedema

A case of lymphangiosarcoma arising in chronic congenital and idiopathic lymphoedema is presented. The literature is reviewed and the diagnosis discussed.

Lymphangiosarcoma following post-mastectomy lymphedema

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Malignant vascular tumors of the lymphedematous extremity

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