Distinguishing papillary endothelial hyperplasia and angiosarcoma on core needle biopsy of the breast: The importance of clinical and radiologic correlation

Papillary endothelial hyperplasia (Masson's tumor) of the breast: A diagnostic challenge

Papillary endothelial hyperplasia (PEH) or Masson's tumor is a rare benign vascular tumor that usually appears in the soft tissues of the head and neck, trunk and extremities, being extremely rare in the breast. Its diagnosis can be a challenge, especially in the follow-up of patients with previous disease of breast carcinoma. We present the case of a 65-year-old patient, with a history of bilateral breast cancer and reconstruction with implants, who presented a Masson's tumor during follow-up. An ultrasound scan was performed, showing a well-circumscribed mass in the left breast, located in the posterior contour of the implant. Subsequently, magnetic resonance imaging (MR) depicted an enhancing tumor, without infiltration of adjacent structures. Finally, the definitive anatomopathological diagnosis was obtained after surgical excision.

Breast Hemangiomas: Imaging Features With Histopathology Correlation

Breast hemangiomas are rare benign vascular lesions. In a previously performed review of approximately 10,000 breast surgical pathology results, roughly 0.15% (15/~10 000) were hemangiomas. Hemangiomas are more frequent in women and have a documented age distribution of 1.5 to 82 years. They are most often subcutaneous or subdermal and anterior to the anterior mammary fascia but may rarely be seen in the pectoralis muscles or chest wall. On imaging, breast hemangiomas typically present as oval or round masses, often measuring less than 2.5 cm, with circumscribed or mostly circumscribed, focally microlobulated margins, equal or high density on mammography, and variable echogenicity on US. Calcifications, including phleboliths, can be seen. Color Doppler US often shows hypovascularity or avascularity. MRI appearance can vary, although hemangiomas are generally T2 hyperintense and T1 hypointense with variable enhancement. Pathologic findings vary by subtype, which include perilobular, capillary, cavernous, and venous hemangiomas. If core biopsy pathology results are benign, without atypia, and concordant with imaging and clinical findings, surgical excision is not routinely indicated. Because of histopathologic overlap with well-differentiated or low-grade angiosarcomas, surgical excision may be necessary for definitive diagnosis. Findings that are more common with angiosarcomas include size greater than 2 cm, hypervascularity on Doppler US, irregular shape, and invasive growth pattern.

Primary Angiosarcoma of the Breast Diagnosed on Core Needle Biopsy: A Diagnostic Challenge

Primary angiosarcoma of the breast is very rare and difficult to pathologically diagnose especially on core needle biopsy. Only 11 cases of breast primary angiosarcoma diagnosed on core needle biopsy have been reported in English literature of last 5 years. We reported a case of primary angiosarcoma of the breast diagnosed on core needle biopsy and summarized the useful morphological clues in literature which prompted the diagnosis of angiosarcoma. A 50-year-old woman presented with a palpable mass in her left breast for a year. She never received breast surgery or radiotherapy before. Microscopically, the core needle biopsy specimen displayed interanastomosing vascular spaces that dissected through the mammary stroma and adipose tissue. The vascular channels were mostly lined by a single layer of endothelial cells with a mild degree of nuclear atypia, whereas focally, the endothelia were multilayered, with tufting and formation of glomerulus-like structures. CD31, CD34, and ERG immunochemical stain highlighted the endothelial cells lining on the vascular spaces. The Ki67 index was about 10%, and MYC was negative. Primary angiosarcomas have significant overlaps of morphological features with benign and borderline vascular lesions. Anastomosing vascular spaces, cytologic atypia, endothelial mitotic activity, infiltration of glandular parenchyma, elevated Ki-67, and high cellularity are all useful clues to diagnose angiosarcomas. Among them, anastomosing vascular spaces with infiltrated growth pattern especially invasion into the breast intralobular stroma and adipose tissue was the most common character of angiosarcomas which alert the possibility of malignancy in core needle biopsy. However, an accurate diagnosis demands integration of various histological clues and multidisciplinary discussion.

Breast Angiosarcoma: Imaging Features With Histopathologic Correlation

Breast angiosarcoma is a rare malignancy of endothelial origin that can be categorized as primary angiosarcoma (PAS) or secondary angiosarcoma (SAS) based on etiology. Primary angiosarcoma typically affects younger women with no known risk factors, whereas SAS of the breast typically develops in older women who have undergone breast cancer treatment. There are two types of SAS, one that develops in the setting of chronic lymphedema and one that develops as a radiation-associated neoplasm after breast-conserving therapy (BCT). Clinically, PAS often presents as a palpable mass that may be rapidly growing, whereas SAS presents with skin changes such as erythematous plaques or nodules or with areas of skin discoloration. Mammographically, the appearance of PAS can be nonspecific and may be obscured by the dense tissue that is characteristic of the young patient population it typically affects. Cases of mammographically occult PAS have been visible at US and MRI. Mammography and US have been found to be less sensitive than MRI for the diagnosis of secondary radiation-associated angiosarcoma. Angiosarcomas, both PAS and SAS, are graded, depending on degree of differentiation, as low, intermediate, or high grade. Endothelial markers such as ERG and CD31 immunohistochemical stains are used to support the diagnosis of angiosarcomas. In this article, we review the clinical presentation, imaging findings, associated histopathology, and treatment of primary and secondary breast angiosarcoma.

Masson's tumor of the reconstructed breast

Intravascular papillary endothelial hyperplasia (Masson's Tumor) is a rare benign endothelial vascular lesion that can mimic angiosarcoma if not properly recognized. It represents less than 2% of all vascular tumors, but has been seen in the postradiation setting, which also makes differentiating it from angiosarcoma crucial. It is classically characterized as a circumscribed, intravascular mass that is hypoechoic on ultrasound, and T1 isointense and T2 heterogenous on MRI with variable enhancement. Histologically, it demonstrates papillary architecture without significant atypia, and associated vascular thrombus. Although it typically occurs in the soft tissues of the trunk and neck, a very small percentage of cases have been found in the breast. The following case will involve a 64-year-old female with a Masson's tumor involving the capsule of her left breast implant, in the setting of previously treated ductal carcinoma in situ, which was surgically excised and irradiated over 20 years prior.

Radiologic and Pathologic Correlation for Angiolipomas of the Breast

Angiolipomas of the breast are rare; however, they are an important entity for the radiologist who determines radiologic-pathologic concordance and recommends appropriate management. They can present as a palpable concern, prompting diagnostic workup, or can be detected on screening breast examinations. They often present as a circumscribed low-density mass on mammography, which is hyperechoic on sonography; associated fibrin thrombi can produce soft tissue density and/or hypoechoic foci that appear hypointense on T1-weighted MRI. Due to the nonspecific radiographic appearance, tissue sampling is often required for definitive diagnosis. Pathologically, angiolipomas can be difficult to distinguish from angiosarcomas; however, scattered microthrombi in small blood vessels are a typical feature of angiolipomas. Generally, in the setting of radiologic-pathologic concordance, angiolipomas do not need to be excised and can be followed clinically when palpable. Surgical excision can be pursued when certain high-risk features, such as nuclear enlargement, an infiltrative pattern, endothelial mitoses, and a high proliferation rate, are present in the core-needle biopsy specimen.

Papillary endothelial hyperplasia (Masson's tumor) developed in the capsule of the implant in a breast cancer patient treated with mastectomy and radiation therapy

Papillary endothelial hyperplasia (PEH) is an uncommon benign vascular proliferation appearing in soft tissues in different body areas including the breast, which may be related to radiation therapy. A 48-year-old woman previously treated for breast cancer with mastectomy followed by radiation therapy and reconstruction with an implant presented with a newly developing mass in the implant capsule. Pathological diagnosis was PEH. Imaging features of this rare entity are described, and lesions included in differential diagnosis are discussed.

Primary and secondary breast angiosarcoma: single center report and a meta-analysis

Background

Primary and secondary breast angiosarcoma is a rare and aggressive malignancy with limited published literature. Optimal management is mostly based on expert opinion. Our study aims to describe a single institution experience with breast angiosarcoma and evaluate other publications on this topic to further clarify prognostic outcomes and treatment modalities in this disease.

Methods

Twenty two cases of breast angiosarcoma from Roswell Park Comprehensive Cancer Center were retrospectively analyzed. Additionally, a systemic review and meta-analysis was conducted to study the association between survival outcomes, overall survival (OS), and recurrence-free survival (RFS) in both primary (PAS) and secondary breast angiosarcoma (SAS).

Results

9 PAS patients (41%) and 13 SAS patients (59%) were retrospectively analyzed. No significant differences were noted in tumor characteristics and survival outcomes between PAS and SAS. Treatment modality had no significant effects on survival outcomes although adjuvant chemotherapy demonstrated a trend towards improved RFS in high grade tumors. 380 PAS and 595 SAS patients were included in the outcome meta-analysis. Survival outcomes were significantly worse with high grade tumors and tumor size of > 5 cm. Adjuvant radiation therapy demonstrated significantly better RFS, while adjuvant chemotherapy had no effect on survival outcomes.

Conclusion

Tumor size and grade seem to be reliable predictors of survival in both PAS and SAS. Mastectomy does not seem to be adding any additional benefit to BCS. Adjuvant radiation therapy showed statistically significant RFS benefit, while adjuvant chemotherapy can be beneficial in high grade tumors.

Repeated resection-associated breast angiosarcoma: A case report

RATIONALE

As a very rare vascular tumor, breast angiosarcoma (AS) can be divided into primary and second breast AS. However, the latter is slightly more commonly detected in clinical practice. Radiation post mastectomy is the common cause for the secondary breast AS, and although there are other reasons, it is still quite rare. In the present study, we reported a rare case of breast AS and summarized the relevant literatures so that to conduce to diagnose AS.

PATIENT CONCERNS

A 50-year-old female with a history of right breast neoplasm was treated with repeat lumpectomy for 4 times during 8 years.

DIAGNOSES

Mammogram and ultrasound examination demonstrated a possible malignancy (BIRADS-4B and BI-RADS-4C, respectively). Immunohistochemically positive for endothelial markers CD31, CD34, ERG, and FVIII-R-Ag.

INTERVENTIONS

The patient underwent a right mastectomy with sentinel lymph node biopsy by our multidisciplinary team and no other therapy was given postsurgery.

OUTCOMES

The patient had no recurrence after 3 months.

LESSONS

Based on our findings, we concluded that repeated resection might be a risk factor for the breast AS, especially for a gradual pathological evolution from benign to malignant. This case showed a very rare cause for angiomatosis of breast, and the patient had a successful outcome after a simple mastectomy.