Angiosarcoma of the breast: report of a case and its findings of MRI

Primary Breast Angiosarcoma: Utilisation of Pre-surgical Magnetic Resonance Imaging (MRI) for Accurate Tumour Characterization and Planning - A Case Report and Literature Review

BACKGROUND

Primary breast angiosarcoma is a rare malignancy with non-specific clinical and radiological findings.

CASE REPORT

A 30-year-old lady presented with left breast pain and lumpiness for over one year. She has had several breast ultrasounds (US) and was treated for acute mastitis and abscess. Subsequently, in view of the rapid growth of the lump and worsening pain, she was re-investigated with US, elastography, digital breast tomosynthesis (DBT) and MRI. MRI raised the suspicion of angiosarcoma. The diagnosis was confirmed after biopsy and she underwent mastectomy.

DISCUSSION

Literature review on imaging findings of breast angiosarcoma, especially on MRI, is discussed. MRI features showed heterogeneous low signal intensity on T1 and high signal intensity on T2. Dynamic contrast enhancement (DCE) features included either early enhancement with or without washout in the delayed phase, and some reported central areas of non-enhancement.

CONCLUSION

This case report emphasises on the importance of MRI in clinching the diagnosis of breast angiosarcoma, and hence, should be offered sooner to prevent diagnostic delay.

Breast Angiosarcoma with a Preoperative Diagnosis of Late Recurrence of Breast Cancer: A Case Report

Angiosarcoma is a malignant mesenchymal tumor characterized by the presence of vascular endothelial cells. Although rare, angiosarcoma developing in the mammary glands has a poor prognosis. We report a case of breast angiosarcoma with a preoperative diagnosis of late recurrence of breast cancer. A 78-year-old woman noticed a tumor in her right breast and visited our hospital. The patient had undergone breast-conserving surgery and axillary lymph node dissection from the right breast 12 years before the visit. The tumor was diagnosed as T4bN0M0, stage IIIB. Anastrozole was administered as postoperative adjuvant therapy for 5 years; the patient also received 50-Gy whole-breast radiation therapy after surgery. Physical examination during her visit revealed an elevated lesion with blue purpura around the nipple in the right breast. We performed breast ultrasound and detected a well-defined 19.6 × 16.4 × 10.7 mm hypoechoic tumor in the left subareolar area. The patient underwent core needle biopsy (CNB). Based on the CNB specimen findings, she was suspected to experience late local recurrence after surgery. Therefore, she underwent total mastectomy after breast-conserving surgery. A dark-red tumor sized 18 × 12 mm was found in a specimen from the nipple. The pathological diagnosis of the specimen revealed short spindle-shaped tumor cells with strong nuclear pleomorphism and a significant interstitial fibrosis. Immunohistochemistry using D2-40 and CD31 antibodies showed irregular luminal proliferation at the anastomosis, infiltration into the surrounding tissue, and massive necrosis, thereby leading to the diagnosis of breast angiosarcoma. We have reported a case of breast angiosarcoma with a preoperative diagnosis of late recurrence of breast cancer.

Neoadjuvant Systemic Treatment of Primary Angiosarcoma

Angiosarcoma is an extremely rare and aggressive malignancy. Standard of care of localized tumors includes surgery ± radiation. Despite this multimodal treatment, >50% of the angiosarcoma patients develop local or distant recurrent disease. The role of neoadjuvant systemic therapy is still controversial and we therefore performed a systematic review of the literature to define the role of neoadjuvant systemic therapy based on available evidence. We focused on the effects of neoadjuvant systemic therapy on: 1. The success of surgical resection and 2. the long-term survival. All articles published before October 2019 on Ovid Medline, Ovid Embase, Cochrane library and Scopus were evaluated. Eighteen case reports and six retrospective cohort studies were included. There were no randomized controlled trials. This literature showed a beneficial role of neoadjuvant chemotherapy on downsizing of the tumor resulting in an improvement of the resection margins, especially in patients with cardiac or cutaneous angiosarcoma. However, no definitive conclusions on survival can be drawn based on the available literature lacking any prospective randomized studies in this setting. We advise that neoadjuvant chemotherapy should be considered, since this could lead to less mutilating resections and a higher rate of free resection margins. An international angiosarcoma registry could help to develop guidelines for this rare disease.

[Radiation-induced breast angiosarcoma: about a case]

Breast angiosarcoma is a rare vascular endothelial connective tissue tumor. It is primitive in young patients and radio-induced in older subjects. It is a malignant tumor and it manifests with polymorphic clinical and radiological features. Its prognosis is poor due to the frequent occurrence of visceral metastases and fast recurrence. We here report a case of breast angiosarcoma in a female patient aged 43 years, with a history of breast cancer, treated by conservative surgery and adjuvant radiotherapy. The purpose of this study is to highlight the epidemiological diagnostic and therapeutic features of these rare aggressive tumors.

Imaging findings of primary breast sarcoma: Results of a first multicenter study

PURPOSE

To investigate imaging findings in patients with primary breast sarcoma (PBS).

MATERIALS AND METHODS

A retrospective search in the databases of 10 radiological departments in Germany from 2000 to 2011 was performed. Only histologically proven cases of PBS were included into the study. Mammography was available in 31 patients (33 lesions), ultrasound images in 24 patients (24 lesions), and for 10 patients (14 lesions) magnetic resonance imaging (MRI) of the breast was performed. The breast findings were classified according to the American College of Radiology Breast Imaging Reporting and Data Systems (BI-RADS) 5th edition categories. Collected data were evaluated by means of descriptive statistics.

RESULTS

Forty-two female patients (mean age 62.0 years, range, 30-86 years) were included in the study. Clinically, all women had painless lumps. Irregular (53.3% [16/30]) or oval (30.0% [9/30]) mass with indistinct (73.3% [22/30]) or microlobulated (10% [3/30]) margins were common findings on mammograms. Ultrasound revealed typically an irregular (79.2% [19/24]), hypoechoic (62.5% [15/24]) mass, with indistinct margins (79.2% [19/24]), and posterior acoustic shadowing (79.2% [19/24]). MRI showed irregular masses (81.8% [9/11]) with irregular or spiculated margins, and a rapid initial signal increase with a delayed washout in kinetic analysis.

CONCLUSION

Overall, PBS has no pathognomonic imaging features and can mimic those of invasive mammary carcinoma. Breast sarcoma should be taken into the differential diagnosis of breast findings described above.

[Breast angiosarcoma: a case report]

The breast angiosarcoma is an endothelial malign tumor. Its prevalence is about 0.04% of all breast malignant tumors. The characteristics of angiosarcoma are its malignancy and its clinical and radiologic polymorphism. The breast angiocarcinoma has a bad prognostic because of the frequency of metastases and recurrence. The purpose of this paper is to report the clinical, imaging and pathological features of breast angiosarcoma, a rare but aggressive tumor, based on a review of one case.

MRI findings of large low-grade angiosarcoma of the breast with subsequent bone metastases: a case report

We describe the magnetic resonance imaging (MRI) findings of 13 cm-sized low-grade angiosarcoma of the breast that occurred in a 23-year-old woman. Magnetic resonance examination revealed an ill-defined mass with marked high-signal intensity on T2-weighted images and persistent heterogeneous enhancement. Thirty months later she developed bone metastases, incidentally found on an MRI performed to evaluate the pelvis. There were well-defined bone lesions with high-signal intensity on T2-weighted images and persistent contrast enhancement on delayed phases. The metastases were not detected on previous computed tomography and fluoro-deoxyglucose positron emission tomography scans because the lesions were subtle osteoblastic type with a low proliferative index.

Bilateral angiosarcoma of breast in a young lady

We report a young lady with bilateral angiosarcoma of breast because of its rarity. A 29 year old unmarried female presented with bilateral breast lump. She underwent bilateral mastectomy with axillary dissection histopathology of which showed low grade angiosarcoma of left breast and high grade angiosarcoma of right breast. CT Thorax revealed right hilar and right mediastenal lymph nodes. She was treated with radiotherapy and chemotherapy postoperatively.

From the archives of the AFIP: breast masses in children and adolescents: radiologic-pathologic correlation

The spectrum of breast lesions in children and adolescents varies markedly from that for adults, with the former lesions being overwhelmingly benign. A breast mass in a young boy or girl may arise from normal and abnormal breast development. Other causes of masses include infection, trauma, and cyst formation. After onset of puberty, most cases of breast enlargement arise from benign fibroadenoma in girls and gynecomastia in boys. These conditions have specific imaging appearances, although juvenile (often giant) fibroadenoma cannot be distinguished from phyllodes tumor, which can be benign or malignant. In children, both conditions usually appear as well-circumscribed, hypoechoic masses at sonography and show diffuse enhancement except for nonenhancing septations at magnetic resonance imaging. A diagnosis of juvenile papillomatosis (a benign lesion) portends later development of breast cancer, and patients with this condition should be closely monitored. Malignant lesions of the breast in children are rare. The most common malignant lesions are metastases and are usually associated with widespread disease. The most common primary breast malignancy is malignant phyllodes tumor. Primary breast carcinoma is exceedingly rare in the pediatric age group, but its imaging appearance in children is the same as seen in adults and is different from that of almost all benign lesions. In girls, diagnostic interventions may injure the developing breast and cause subsequent disfigurement. Given this risk and the low prevalence of malignant disease in this population, a prudent course should be followed in the diagnosis of breast lesions. Imaging findings are very helpful for selecting patients for further diagnostic procedures. Although malignancy is rare, lesions with suspicious imaging findings or progressive growth should be subjected to cytologic or histologic examination.

Angiosarcoma arising in an unirradiated breast with subsequent pituitary metastasis

Angiosarcoma of the breast is a rare condition with known risk factors. The Stewart-Treves syndrome describes angiosarcoma of the arm or breast in the setting of adjuvant radiation therapy (RT) after breast conservation surgery. Angiosarcoma of the breast, in the absence of RT, is rarer still. We present a unique case of angiosarcoma of the breast, diagnosed 6 years after conservative surgery for carcinoma of the breast when no adjuvant RT was given. Chronic postoperative lymphoedema in the breast delayed the investigation of skin changes, with an eventual diagnosis of angiosarcoma. An isolated pituitary metastasis 9 months from the diagnosis, the first such reported case, adds to the complexity of the case. The diagnosis and management of angiosarcoma of the breast is discussed. Angiosarcoma is a rare occurrence after breast conservative surgery. Postoperative lymphoedema can impede early diagnosis. The disease can display unique metastatic potential.

Angiosarcoma of the breast - specific findings of MRI

We present a case of low-grade angiosarcoma of the breast. A 26-year old woman presented with a lump in the left breast. An elastic hard and ill-defined tumor, 80 x 50 mm in size, was palpated in the upper region of her left breast. Mammography showed a dense lesion with poorly defined border. Ultrasonography showed a hyper-and hypo-echoic lesion with an unclear border, but no definite tumor. Fine needle aspiration cytology showed no evidence of malignancy. Therefore, she was followed with a diagnosis of mastopathy. Six months later, the lump got enlarged. A contrast-enhanced MRI of the breast was performed. It showed a 100 x 60 mm enhancing vascular mass. Most parts of the tumor enhanced remarkably at the early phase, and prolonged enhancement was recognized at the late phase. Core needle biopsy was performed, and a possible angiosarcoma was diagnosed. It is not easy to diagnose the mammary angiosarcoma. MRI may contribute to the accurate diagnosis and play an important role regarding this entity.

Mammary angiosarcomas: imaging findings in 24 patients

PURPOSE

To retrospectively evaluate the clinical, imaging, and pathologic findings of mammary angiosarcomas in 24 patients.

MATERIALS AND METHODS

The institutional review board approved this HIPAA-compliant study and waived informed consent. Twenty-four patients with records in the surgical pathology database who had a diagnosis of mammary angiosarcoma (n = 26) and who underwent preoperative imaging with mammography, ultrasonography (US), or magnetic resonance (MR) imaging were included. Mean and median ages at time of diagnosis were 40 and 38 years, respectively (range, 15-77 years). Images were reviewed in consensus by two radiologists with the American College of Radiology Breast Imaging Reporting and Data System lexicon and were compared with pathologic findings. Total length of follow-up (in months) was determined by the interval from the time of diagnosis to the time of last follow-up. Information on overall and disease-free survival was also obtained.

RESULTS

Mean tumor size at time of diagnosis was 5.9 cm (range, 1-12 cm). Nineteen tumors manifested as a palpable mass, four manifested with progressive breast swelling, and three were asymptomatic. Mammograms of 16 tumors showed a noncalcified mass in eight, focal asymmetry in five, and no abnormality in three. All three mammographically occult tumors were visible at US and MR imaging. US images of 21 tumors showed a solid, frequently oval-shaped, and hyperechoic mass in 13 tumors and random mixed hyper- and hypoechogenicity with associated architectural distortion in eight tumors. Dynamic contrast material-enhanced MR imaging of nine tumors showed large, lobular, and intensely and heterogeneously enhancing masses with rapid enhancement and the washout characteristics of a malignant lesion.

CONCLUSION

A mass that shows homogeneous or heterogeneous hyperechogenicity at US (with associated architectural distortion) and has a hypervascular, hemorrhagic, and heterogeneous appearance and typical malignant enhancement characteristics at MR imaging should alert the radiologist to a possible diagnosis of angiosarcoma.

Primary Angiosarcoma of the Breast: Do Enlarged Axillary Nodes Matter?

Primary angiosarcoma of the breast is a rare and aggressive malignancy that is typically seen in premenopausal patients. The tumor's spread occurs predominantly through the bloodstream; involvement of the lymphatics is unusual. We present a case of breast angiosarcoma presenting with enlarged axillary lymph nodes treated with a modified mastectomy and axillary lymph node dissection. Pathology found no tumor in the lymph nodes. Based on this experience and data from the literature, we suggest evaluation of the sentinel nodes prior to potentially morbid standard level 1 and 2 axillary lymph node clearance.

Radiological Reasoning:Male Breast Mass with Calcifications

OBJECTIVE

We encountered a mammographically calcified breast mass in a 30-year-old man. It was initially thought to be comedo-type ductal carcinoma in situ because of the dense calcifications, but sonography and MRI suggested a highly vascular lesion. The final pathologic diagnosis was hemangioma.

CONCLUSION

Vascular tumors of the breast occur infrequently and are even more rare in males. The clinical and radiologic diagnosis of breast hemangioma is often difficult, but different imaging techniques, when used together, can provide important information for differential diagnosis and management. A biopsy is required.

[Breast angiosarcoma: sonographic, mammographic and MRI features]

The purpose of this paper is to report the clinical, imaging (sonographic, mammographic and MRI) and pathological features of breast angiosarcoma, a rare but aggressive tumor, based on a review of two cases.

[Breast angiosarcomas: three case reports]

Angiosarcoma is a rare type of breast cancer, it has the worst prognosis of all breast malignancies. We report three cases of breast angiosarcoma observed at the National Oncology Institute and the Maternity of Orangers. A preoperative diagnosis was evoked in one case only, after a local recurrence in the second one and histological in the last one. Mastectomy is the reference treatment. The development is distinguished by general metastasis. Based on review of literature, we analysed the different aspects of this disease.