One case of Stewart-Treves syndrome successfully treated at two years by chemotherapy and radiation therapy in a 73-year-old woman

Stewart-Treves syndrome: a case report of lymphedema-related angiosarcoma

Stewart-Treves syndrome (STS) is an angiosarcoma associated with lymphedema deriving more often from radical mastectomy and longstanding lymphedema, first described in 1948. Irradiation is also commonly associated with chronic lymphedema of extremities. It generally occurs about 10 years after the mastectomy and/or radiotherapy. The prognosis is very poor with a mean survival of 20 months from the diagnosis especially when radical surgery is not possible. We present the case of STS in an 89-year-old female who underwent left upper outer quadrantectomy for invasive ductal carcinoma in 2009 followed by axillary lymphadenectomy, radiotherapy, and hormonal therapy until 2014. She presented swollen upper left limb associated with hemorrhagic red papular lesions. Skin biopsy revealed the presence of lymphedema-associated angiosarcoma. Radical surgery was not possible, so she underwent conservative therapy with pazopanib, a tyrosine kinase inhibitor, with benefit. Long-term follow-up of these patients is crucial to intercept this condition at an early stage.

Stewart-Treves syndrome in an older woman successfully treated by metronomic chemotherapy: case report and literature survey

The authors present the case of a 94-year-old woman suffering from a right arm angiosarcoma developed after primary breast cancer and treated with success by oral metronomic chemotherapy based on daily low doses of cyclophosphamide and prednisone. The case description is followed by a short review of actual knowledge on the subject.

Unsuspected Stewart-Treves syndrome clinically mimicked by apparent bullous erysipelas and a systematic review of dermatological presentations of the classical Stewart-Treves syndrome

BACKGROUND

Stewart Treves-Syndrome (STS) was first characterized as angiosarcoma in the homolateral limb of a patient with breast cancer and lymphedema. Now, other conditions represent STS. It's a rare condition. The diagnosis is easier in the presence of single or multiple purple nodules. Even though other dermatological aspects have been reported, no study has grouped its characteristics.

AIM

Evaluate the dermatological characteristics of classical STS (c-STS).

METHODS AND RESULTS

We report a patient with chronic lymphedema with a history of recurrent erysipelas that rapidly developed multiple papules in the superior limb. It was initially diagnosed as bullous erysipelas, but unsatisfactory evolution led to biopsy, which demonstrated an unsuspected epithelioid angiosarcoma. We have also performed a review of dermatologic aspects of c-STS using PubMed and Lilacs databases. PICTOS methodology and PRISMA flow chart were considered. The main dermatological aspects associated with c-CTS were summarized. Using a systematic evaluation from 109 articles, 29 were selected and 44 patients were described to whom we added one case. The mean time with lymphedema was 10 years. Of the patients analyzed, 97.2% were female; 95.6% were submitted to radical mastectomy; 81.2% presented with multiple lesions, 67.4% of the lesions were reported as nodules or tumors, 53.4% were purple, 33.4% were associated with an ecchymotic halo, and 33.4% were ulcerated lesions.

CONCLUSION

When evaluating patients with chronic lymphedema with new dermatological abnormalities, clinical suspicion, or unfavorable evolution, the knowledge of clinical signs is important for diagnosis, and a biopsy must be considered. Papules associated with erythematous-wine color and bluish hematoma aspect must raise clinical suspicion.

[Angiosarcoma in primary lymphoedema: A rare complication]

BACKGROUND

Chronic lymphoedema is classically complicated by recurring episodes of cellulitis. Degeneration to the angiosarcoma form (Stewart-Treves syndrome) is much less common. It occurs mainly in the upper limbs following surgery or radiotherapy for mammary neoplasia. Herein we report a rare case of Stewart-Treves syndrome (STS) of the lower limb as a complication of congenital lymphoedema.

PATIENTS AND METHODS

A 69-year-old woman treated for bilateral lower-limb oedema present for 30years developed painful necrotic lesions in her left lower limb. A diagnosis of angiosarcoma was made based on biopsy of a nodular lesion. Since surgical excision was precluded by the extent of the lesions, chemotherapy was initiated with paclitaxel 175mg/m² every 21days. The outcome was rapidly unfavourable and the patient died at her home during the third course of treatment.

DISCUSSION

Angiosarcoma is an extremely rare complication of primary lymphoedema; treatment is poorly codified and the prognosis is unfavourable.

Lymphangiosarcoma: Is Stewart-Treves Syndrome a Preventable Condition?

BACKGROUND

Stewart-Treves syndrome is a rare complication of breast cancer treatment, representing a lymphangiosarcoma commonly associated with lymphedema and severely impacting patient's outcome. The tumor typically develops in the atrophic, pachydermatous, hyperkeratotic skin of limbs affected by long-standing lymphedema. Clinical data associated with Stewart-Treves syndrome and lymphedema management have rarely been published.

METHODS AND RESULTS

In the period between 1980 and 2009, ten patients with Stewart-Treves syndrome were diagnosed and treated at the Foeldiklinik, Hinterzarten, Germany. Nine of the ten patients were female. Five patients had previously suffered from breast cancer (and were treated with mastectomy); two from other malignancies; two patients had primary lymphedema, and one had undergone lower extremity lymphadenectomy. All cancer patients had undergone radiation treatment. In all cases, the sarcoma developed in non-irradiated areas 6-48 years (average 16.3 years) after the onset of lymphedema. None of the patients had received complex decongestive physical therapy (CDT). Two patients had above-elbow amputation, one had shoulder exarticulation, two patients had wide excision and skin grafting, two patients had above-knee amputation procedure, two patients had a below-knee amputation procedure, and one patient had no surgical treatment at all. The time to recurrence after surgery, time to metastasis, patient survival and CDT were recorded.

CONCLUSIONS

Patients with lymphedema should be closely examined starting 5 years from the time of lymphedema onset, paying special attention to those with associated malignancies. Only early diagnosis and treatment by radical ablative surgery confers a reasonable prognosis with this rare but aggressive disease. A potential effect of CDT on lymphangiosarcoma has to be studied in a greater patient cohort.

[Stewart-Treves syndrome complicating chronic idiopathic lymphedema]

Le syndrome de Stewart-Treves (SST) est une entité rare, correspondant à un angiosarcome cutané compliquant un lymphoedème chronique. Il est de mauvais pronostic. Stewart et Treves ont rapportés en 1948, les premiers cas d'angiosarcome secondaire à un traitement du cancer du sein. Ce terme s'est généralisé pour regrouper l'ensemble des cas de lymphangiosarcome sur lymphoedème d'origine congénital héréditaire ou non héréditaire, post-traumatique ou post-infectieux. Le SST sur un lymphoedème idiopathique reste exceptionnel. Nous rapportons le cas rare d'une patiente présentant un lymphoedème chronique primitif idiopathique des quatre membres évoluant depuis l'adolescence et qui a développé un SST du membre supérieur droit. Elle a subi une amputation à mi- bras vu le caractère très évolué de la tumeur

Stewart-Treves syndrome: MR imaging of a postmastectomy upper-limb chronic lymphedema with angiosarcoma

The rare occurrence of angiosarcoma in postmastectomy upper-limb lymphedema with magnetic resonance (MR) imaging is discussed. Unfamiliarity with this aggressive vascular tumor and its harmless appearance often leads to delayed diagnosis. Angiosarcoma complicating chronic lymphedema may be low in signal intensity on T2-weighting and short tau inversion recovery (STIR) imaging reflecting the densely cellular, fibrous stroma, and sparsely vascularized tumor histology. Additional administration of intravenous contrast medium revealed significant enhancement of the tumorous lesions. Awareness of angiosarcoma and its MR imaging appearance in patients with chronic lymphedema may be a key to early diagnosis or allow at least inclusion in the differential diagnosis.

Stewart–Treves syndrome—treatment and outcome in six patients from a single centre

AIMS

Stewart-Treves syndrome is an angiosarcoma associated with long-standing lymphoedema, most commonly seen as a rare complication of breast cancer treatment, and is associated with a poor outcome. We present results from six patients supporting the use of early radical surgery to improve prognosis.

METHODS

Six patients with Stewart-Treves syndrome were diagnosed and treated at our centre over an 11-year period. Five patients had forequarter amputation and the sixth had a through-hip amputation.

RESULTS

Four of the six patients are alive and well following surgery (at 3, 16, 23, and 135 months after amputation); one patient died from metastatic disease at 15 months and the second died due to an unrelated malignancy.

CONCLUSION

Early diagnosis and treatment by radical ablative surgery confers a reasonable prognosis with this rare but aggressive disease. A nihilistic approach is unjustified.

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.

Intra-arterial mitoxantrone and paclitaxel in a patient with Stewart-Treves syndrome: selection of chemotherapy by an ex vivo ATP-based chemosensitivity assay

We report on a 72-year-old patient developing Stewart-Treves syndrome (STS) of the right arm 9 years after curative irradiation for ipsilateral stage III breast cancer. Facing the poor track record of both irradiation and chemotherapy in this highly malignant lymphangiosarcoma, amputation was recommended but refused by the patient. Therefore, limb conserving-therapy using three courses of intra-arterial mitoxantrone (MX) and paclitaxel (PTX) was attempted. This novel chemotherapy protocol was selected by pretherapeutic ex vivo ATP-based chemosensitivity testing of autologous tumor tissue. The patient experienced complete response, which was subsequent histologically confirmed by compartment resection. When developing recurrent STS outside of the perfused area 6 months after primary therapy, the patient was retested and reinduced with three other courses of intraarterial MX/PTX which again produced durable complete remission. This case demonstrates the benefit of indivdualized therapy in this prognostically desperate disease allowing both limb conservation and maintained quality of life.