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

Magnetic resonance findings of Stewart-Treves Syndrome in primary limb lymphedema compared with pathology: A retrospective single-center study

Background

Stewart-Treves Syndrome in Primary Limb Lymphedema (STS-PLE) is an extremely rare malignant tumor. A retrospective analysis was conducted to elucidate the relationship between magnetic resonance imaging (MRI) findings and signs compared to pathology.

Methods

Seven patients with STS-PLE were enrolled at Beijing Shijitan Hospital, Capital Medical University, from June 2008 to March 2022. All cases were examined by MRI. The surgical specimens were subjected to histopathological and immunohistochemical staining for CD31, CD34, D2-40, and Ki-67.

Results

There were two different types of MRI findings. One was mass shape (STS-PLE I type) in three male patients, and the other was the "trash ice" d sign (STS-PLE II type) observed in four female patients. The average duration of lymphedema (DL) of STS-PLE I type (18 months) was shorter than that of STS-PLE II type (31 months). The prognosis for the STS-PLE I type was worse than that for the STS-PLE II type. Regarding overall survival (OS), the STS-PLE I type (17.3 months) was three times shorter than that of the STS-PLE II type (54.5 months). For STS-PLE I type, the older the STS-PLE onset, the shorter the OS. However, there was no significant correlation in STS-PLE II type. MRI was compared to histological results to provide an explanation for the differences in MR signal changes, especially on T2WI. Against a background of dense tumor cells, the richer the lumen of immature vessels and clefts, the higher the T2WI MRI signal (taking muscle signal as the internal reference standard) and the worse the prognosis, and vice versa. We also found that younger patients with a lower Ki-67 index (<16%) had better OS, especially for the STS-PLE I type. Those with stronger positive expression of CD31 or CD34 had shorter OS. However, the expression of D2-40 was positive in nearly all cases, and seemed not to be associated with prognosis.

Conclusions

In lymphedema, the richer the lumen of immature vessels and clefts based on dense tumor cells, the higher the T2WI signal on the MRI. In adolescent patients, the tumor often showed a "trash ice" sign (STS-PLE II-type) and prognosis was better than for the STS-PLE I type. While in middle-aged and older patients, tumors showed a mass shape (STS-PLE I type). The expression of immunohistochemical indicators (CD31, CD34, and KI-67) correlated with clinical prognosis, especially decreased Ki-67 expression. In this study, we determined it was possible to predict prognosis comparing MRI findings with pathological results.

Imaging features of primary sites and metastatic patterns of angiosarcoma

Angiosarcomas are rare, aggressive soft tissue sarcomas originating from endothelial cells of lymphatic or vascular origin and associated with a poor prognosis. The clinical and imaging features of angiosarcomas are heterogeneous with a wide spectrum of findings involving any site of the body, but these most commonly present as cutaneous disease in the head and neck of elderly men. MRI and CT are complementary imaging techniques in assessing the extent of disease, focality and involvement of adjacent anatomical structures at the primary site of disease. CT plays an important role in the evaluation of metastatic disease. Given the wide range of imaging findings, correlation with clinical findings, specific risk factors and patterns of metastatic disease can help narrow the differential diagnosis. The final diagnosis should be confirmed with histopathology and immunohistochemistry in combination with clinical and imaging findings in a multidisciplinary setting with specialist sarcoma expertise. The purpose of this review is to describe the clinical and imaging features of primary sites and metastatic patterns of angiosarcomas utilising CT and MRI.

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.

Stewart-Treves syndrome: Magnetic resonance imaging data compared with pathological results from a single center

The aim of the present study was to evaluate the magnetic resonance imaging (MRI) data of patients with Stewart-Treves Syndrome (STS), and to compare them with the corresponding pathological data. A total of 4,289 cases of secondary upper limb lymphedema (LE) from a single center, including 5 female cases of STS who underwent modified-radical post mastectomy, were included in the study. All cases were diagnosed pathologically, and by conventional and contrast-enhanced (ce)MRI scans. A total of 43 tumor nodules (Φ ≥4 mm) were examined. According to the immunohistochemical results, the 5 cases of STS were divided into 2 types; 4 patients exhibited STS type I [angiosarcoma (AS)] and 1 patient exhibited STS type 2 [mixed lymphangiosarcoma (mLAS)]. The MRI signal intensity (SI) of all the nodules was compared with the pathological results. In the T1WI sequences, all nodules showed isointensity compared with normal muscle tissues in the same image. However, in the T2WI sequences, there were the visually recognizable differences in the SI compared with the LE tissues in the two STS types. The SI of mLAS was more markedly decreased compared with that of AS. The SI of mLAS was closer to that of normal muscle tissues compared with the SI of AS. In the ceMRI, the SI of the tumor nodules was markedly increased in the two STS types, compared with non-enhancement imaging. Overall, MRI is a useful tool for the evaluation and diagnosis of STS. A chronic case of LE, in which MRI examination demonstrates nodules within the LE, may suggest a diagnosis of STS.

Stewart-Treves Syndrome Involving Chronic Lymphedema after Mastectomy of Breast Cancer

Steward-Treves syndrome is a cutaneous angiosarcoma that usually appears after long evolution of a lymphoedema after mastectomy for mammary neoplasia associated with an axillary dissection. This is a rare disease develop most of the time in upper arm and often confounded with cutaneous metastasis. Only the biopsy and immunohistochemical study confirm the diagnosis. The treatment is surgical and consists of large cutaneous excision, an amputation of the limb or even its disarticulation and will be followed by chemotherapy. Despite the treatment, the prognosis remains severe with poor survival. We report the case of a patient who had a Steward-Treves syndrome 20 years after lymphoedema following a left mastectomy with axillary dissection.

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.

Radiology-pathology conference: cutaneous angiosarcoma of the leg

Cutaneous angiosarcoma is a rare aggressive vascular neoplasm with a poor prognosis, seen usually in the elderly population in a background of chronic lymphedema. We present a case of cutaneous angiosarcoma of the leg without any chronic lymphedema with clinicoradiological and histological correlation.

Imaging of the most frequent superficial soft-tissue sarcomas

Superficial soft-tissue sarcomas are malignant mesenchymal tumors located within the cutaneous and/or subcutaneous layers. Most superficial soft-tissue sarcomas are low-grade tumors; yet, the risk of local recurrence is high, and initial wide surgery is the main prognostic factor. Some of these superficial sarcomas may grow, following an infiltrative pattern, and their real extent may be underestimated clinically. Imaging techniques are useful to determine precisely the real margins of the tumor, especially in cases of clinically doubtful or recurrent or large superficial lesions. Imaging tools enable one to determine the relationship with the superficial fascia separating the subcutaneous layer from the underlying muscle. In our institution ultrasonographic examination is followed by magnetic resonance (MR) imaging when the size of the lesion exceeds 3-5 cm. Imaging assessment is performed prior to biopsy, enabling optimal surgical management. Imaging features of the main superficial sarcomas are detailed in the following article, according to their major locations: those arising in the epidermis and/or dermis, which are most often diagnosed by dermatologists, and the subcutaneous sarcomas.

Malignant vascular tumors: clinical presentation, surgical therapy, and long-term prognosis

BACKGROUND

The aim of this study was to analyze the presentation of, surgery for, and prognosis of malignant vascular tumors (MVTs).

METHODS

This was an observational single-center study. Patients who underwent operation for MVTs between 1988 and 2004 were included. Data were gathered prospectively in a computerized registry.

RESULTS

Of 568 adult patients with soft tissue malignancies, 43 (7.6%) were treated for MVTs. Twenty-four men and 19 women (median age, 55.3 years) were referred for 30 primary tumors and 13 recurrences. Symptoms were observed in 90.7% of the cases (swelling [37.2%], pain [34.9%], extrusion [11.6%], hemorrhage [7%], weight loss [4.7%], loss of energy [4.7%], impaired function [4.7%], and others [30.2%]). Tumors were located in the extremities (n = 16), trunk (n = 3), abdomen (n = 15), retroperitoneum (n = 7), and thyroid gland (n = 2). Twenty-two (51.2%) angiosarcomas, nine (20.9%) malignant hemangiopericytomas, eight (18.6%) malignant epithelioid hemangioendotheliomas, and four (9.3%) lymphangiosarcomas were seen. The median overall survival after surgery was 21.4 months, with 2-, 5-, and 10-year overall survival rates of 41.5%, 38.3%, and 18.8%, respectively. MVTs of the extremities and trunk and localized disease indicated a better prognosis than abdominal or retroperitoneal MVTs (univariate and multivariate analyses: P = .0122 and P = .0287) and metastasized stages (univariate and multivariate analyses: P = .0187 and P = .0287).

CONCLUSIONS

A considerable number of patients with soft tissue malignancies undergo surgery for MVT. Various symptoms and a multilocular occurrence are typical. The course of MVTs is aggressive. Tumor site and stage are important prognostic factors. Surgery is potentially curative, especially for localized disease of the extremities and trunk.