Postirradiation Angiosarcoma Research Articles

Atypical Vascular Lesions of the Breast: Clinicopathological and Immunohistochemical Study of 24 Cases from a Single Institution

INTRODUCTION: Atypical Vascular Lesions (AVL) of the breast after radiation exposure show heterogeneous clinical and histopathologic features. Most data on outcomes reported previously favored a benign process, but some studies have challenged this concept, suggesting that AVL and post-radiation angiosarcoma represent a morphologic continuum, implying AVL as a precursor to angiosarcoma. However, the risk of malignancy is still undefined due to small number of reported cases with follow-up information. OBJECTIVES: To characterize AVL of the breast clinically and histopathologically, and to study their behavior, trying to establish whether they are a true benign process or a risk factor for developing angiosarcoma. MATERIAL AND METHODS: All cases of AVL of the breast diagnosed at the Department of Anatomic Pathology at the European Institute of Oncology (EIO), Milan, from 1999 to 2009 were selected. Histo-pathologic review and immunohistochemical studies for podoplanin (D2-40), CD31, Ki67 and endoglin (CD105) were performed. RESULTS: Twenty-four female patients treated at the EIO were diagnosed with AVL of the breast after radiotherapy for breast carcinoma. The median age was 58 years old (range: 36-81 years), and AVL size ranged from 0.3cm to 1.1cm (median, 0.5cm). The latency interval between radiotherapy and AVL diagnosis was 49 months (range: 17-124 months). The most common clinical presentation of AVL was an erythematous or violet unique papule in the irradiation field (62.5% of the cases). Microscopically, AVL did not infiltrate the subcutaneous tissue and did not have endothelial multilayering, prominent nucleoli, mitoses or lakes of blood. A patchy chronic inflammatory infiltrate accompanied all AVL to varying degrees. Thirteen cases were classified as lymphatic type (LT) AVL and 11 cases as vascular type (VT) AVL, according to positive staining for D2-40. The endothelial cells stained for CD31 (18 cases), Ki-67 (5 cases), and CD105 (12 cases). One patient with VT-AVL with positive margin developed local recurrence. Two patients, one with VT-AVL, and the other with LT-AVL with compromised margin, developed high grade angiosarcoma in the previous biopsy site, 19 and 89 months later, respectively. Both cases showed overexpression of Ki-67 in the endothelial cells of the AVL. Margin involvement was associated to unfavorable outcome. DISCUSSION: Our data indicate that post-radiation angiosarcoma and AVL may represent a morphologic continuum. AVL cases of both types, VT and LT-AVL, showed similar risk of progressing to angiosarcoma, as well as AVL with high Ki-67 expression. CONCLUSION: Although our data are not conclusive, the development of local recurrence and subsequent angiosarcoma indicate that AVL must be completely excised, with free surgical margins, and patients must be accompanied by clinical exams and imaging until the natural history of the AVL is better explained.

Primary and secondary angiosarcomas of the breast: a single institution experience

Angiosarcomas of the breast (ASB) are rare, representing <1% of breast malignancies. They can develop as a primary or secondary malignancy, also called post-radiation angiosarcoma. The aim of the this study is to discuss diagnosis, treatment, and outcome of primary and secondary ASB patients, diagnosed and treated in a single institution, over a 10-year period and to further compare the two conditions. We retrieved 28 consecutive cases of ASB, diagnosed from 1999 to 2009 at the European Institute of Oncology. Clinical and pathologic findings and survival analyses were performed. Of the 28 cases (27 women and 1 man), eight were primary breast angiosarcomas (PBA) and 20 were secondary breast angiosarcomas (SBA). Median follow-up was 23 months (range 1-112 months). Type of treatment (conservative or radical surgery) did not affect survival in both types of angiosarcomas. The clinical course observed was characterized by a high rate of local recurrence rather than distant metastasis or death from disease. There was a correlation between histological grade and prognosis of angiosarcomas with high-grade tumors presenting worse prognosis. SBA had a poorer prognosis compared to PBA. Our data indicate that primary and secondary ASB are distinct clinical and pathological features. SBA showed worse prognosis and was more often diagnosed in the study period compared to PBA. Physicians who care for patients who have been treated with radiation must be aware of its potential to induce angiosarcoma and stay vigilant in its detection.

Angiosarcoma of the Prostate

No AccessJournal of UrologyPathology Page1 Feb 2012Angiosarcoma of the Prostate Peter A. Humphrey Peter A. HumphreyPeter A. Humphrey More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.11.007AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Angiosarcoma of the Prostate." The Journal of Urology, 187(2), pp. 684–685 References 1 : Adult prostate sarcoma: The M.D. Anderson Cancer Center experience. J Urol2011; 166: 521. Google Scholar 2 : Prostate Pathology. Chicago: ASCP Press2003: 440. Google Scholar 3 : Postradiation angiosarcoma of the prostate. Arch Pathol Lab Med2003; 127: 876. Google Scholar Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri© 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 2February 2012Page: 684-685 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Peter A. Humphrey More articles by this author Expand All Advertisement PDF downloadLoading ...

A case of postirradiation angiosarcoma of the greater omentum with hemorrhage.

Angiosarcoma, one of the least common sarcomas, occurs most commonly in the skin and soft tissues, and postirradiation angiosarcoma of the greater omentum is extremely rare. Only one reported case of postirradiation angiosarcoma involved the greater omentum. We describe the case of 74-year-old female with a history of cervical cancer treated with abdominal irradiation 5years before. On admission, she had nausea, vomiting anorexia, and fatigue. She underwent an abdominal computed tomography scan that revealed an irregularly shaped tumor bounded by transverse colon. The patient died on the 34th hospital day. Autopsy revealed that the tumor was composed of anastomosing irregular vascular channels of variable calibers, involving the adipose tissue of the omentum. Histological studies suggested angiosarcoma. The definitive diagnosis was postirradiation angiosarcoma of the greater omentum, which is an extremely rare condition with an overall dismal prognosis.

Angiosarcoma With Pseudoepidermotropism in a Patient With Breast Cancer: A Mimic of Epidermotropic Metastatic Adenocarcinoma

We report a case of cutaneous postradiation angiosarcoma of the breast exhibiting pseudoepidermotropism that resembled metastatic adenocarcinoma on hematoxylin and eosin. The patient is a 74-year-old woman with history of breast carcinoma treated with mastectomy, chemotherapy, and radiotherapy who complained of an erythematous "rash" along the central portion of the mastectomy scar. Radiography showed widespread osseous metastasis. Biopsy revealed an infiltrative tumor with single file growth and tumor cells obscuring the dermal--epidermal junction in multiple foci, imparting an appearance of epidermotropism. The tumor cells were positive for CD31, CD34, and D2-40 and negative for Cam 5.2. This novel case of pseudoepidermotropic angiosarcoma highlights a potential pitfall in the histomorphologic assessment of poorly differentiated angiosarcoma.

1. Post-radiation breast angiosarcoma: clinical and imaging findings to be known

1. Post-radiation breast angiosarcoma: clinical and imaging findings to be known

Angiosarcoma of the breast: a clinicopathologic analysis of cases from the last 10 years

Breast angiosarcoma may occur de novo, or as a complication of radiation therapy, or chronic lymphedema secondary to axillary lymph node dissection for mammary carcinoma. In our effort to characterize the clinicopathologic features of breast angiosarcoma, we reviewed all breast angiosarcoma cases in the University of Kansas Medical Center and Ohio State University Medical Center archives from 1997 to 2007. Clinical histories and follow-up data for identified patients were reviewed. The tumors were graded histologically according to Rosen's method. Only 11 angiosarcomas were identified among more than 5000 malignant breast neoplasms (0.1%-0.2% incidence) for the last 10 years. Eight cases (6 high grade, 1 intermediate grade, 1 low grade) were identified as postradiation angiosarcoma (postradiation time interval, 4-12 years), and 3 cases were identified as primary angiosarcomas (1 high grade, 2 low grade). Follow-up (median, 36 months) revealed that 3 cases of postradiation angiosarcoma recurred as skin and/or chest wall lesions and 1 case of primary angiosarcoma developed liver metastases (all high-grade). In conclusion, breast angiosarcoma remains a rare disease. Rosen's method for grading breast angiosarcoma is easy to implement and correlates well with clinical outcome. There are no distinct clinical or histologic differences between primary and postradiation breast angiosarcomas.

Recurrence of secondary angiosarcoma in a patient with post-radiated breast for breast cancer

Angiosarcoma of the breast is a rare finding. Two different subtypes of angiosarcomas have been described: (a) the Stewart-Treves syndrome and (b) the cutaneous post-radiation angiosarcoma. We report a case where both types of angiosarcoma occurred. At first, an angiosarcoma affecting parenchyma of the breast was observed after radiotherapy following breast conserving therapy and a history of lymphoedema of the radiated area. Additionally, a subsequent local recurrence of the angiosarcoma of the skin after mastectomy and complete resection of the primary angiosarcoma was diagnosed. This case is distinguished by a short latency period after primary therapy (less than 4 years) and a rapid recurrence after complete resection (14 weeks). Patients should be pointed to this possible complication of radiotherapy and transferred to seek medical advice immediately in case of skin lesion in the irradiated area: even many years after radiotherapy. Additionally, every oncologist should be aware of this rare complication as quick diagnosis and prompt surgical treatment is indispensable due to the aggressive entity of angiosarcoma.

Angiosarcoma of the Breast

This article describes the imaging findings, pathologic correlation, and clinical presentation of rare primary and secondary angiosarcomas of the breast. With the increasing use of breast conservation therapy for breast cancer, reports of postirradiation angiosarcoma have increased. Both primary and secondary angiosarcomas may present with bruiselike skin discoloration, which may delay the diagnosis. Imaging findings are nonspecific. MRI may be used to determine lesion extent by showing rapid enhancement and washout in high-grade tumors.

Pseudolymphomatous Cutaneous Angiosarcoma: A Rare Variant of Cutaneous Angiosarcoma Readily Mistaken for Cutaneous Lymphoma

Cutaneous angiosarcoma is probably the most malignant neoplasm involving the skin. Three clinical variants of cutaneous angiosarcoma are recognized, including angiosarcoma of the scalp and face of elderly patients, angiosarcoma associated with chronic lymphedema, and postirradiation angiosarcoma. Histopathologically, these three variants of angiosarcoma show similar features, which consist of poorly circumscribed, irregularly dilated, and anastomosing vascular channels lined by prominent endothelial cells that dissect through the dermis. Focally, neoplastic endothelial cells show large, hyperchromatic, and pleomorphic nuclei, protruding within vascular lumina and creating small papillations. Usually, inflammatory infiltrate is sparse and consists of a patchy, perivascular lymphoid infiltrate around the neoformed vessels. In rare instances, cutaneous angiosarcomas may exhibit prominent inflammatory infiltrate, and the neoplasm may be mistaken for an inflammatory process, both from clinical and histopathologic points of view. We describe four examples of cutaneous angiosarcomas with dense lymphocytic infiltrates involving the neoplasm. Immunohistochemically, lymphocytes expressed immunoreactivity for CD3, CD5, and CD45 markers, whereas the germinal centers were positive for CD20, CD79a, and Bcl-6. The neoplastic endothelial cells expressed immunoreactivity for the CD31, CD34, podoplanin, Prox-1, Lyve-1, and D2-40. We discuss the possible relationship between neoplastic endothelial lymphatic cells and reactive lymphocytes. Cutaneous angiosarcoma with prominent lymphocytic infiltrate may be readily mistaken for cutaneous follicle center cell lymphoma or cutaneous pseudolymphoma.

Post-irradiation angiosarcoma of bone

Radiation therapy is extensively used for treatment of malignancies, but angiosarcomas occurring in an irradiated area are uncommon. We report a rare case of high-grade epithelioid angiosarcoma of upper end of right humerus in a 67-year-old male occurring ten years following irradiation for giant cell tumor of the same anatomical site. The patient presented with progressive painful swelling over right shoulder and his X-ray showed erosion of medial cortex with lytic areas at upper end of humerus. He underwent excision of affected part of humerus followed by cemented hemiarthroplasty and bone grafting. After initial histopathological diagnostic dilemma the final report was given as post-radiation angiosarcoma. Disease recurred at the end of one-year follow-up period where upon he underwent wide resection with prosthesis replacement. He received four cycles of combination chemotherapy with doxorubicin and ifosfamide and currently is free of recurrence after six months follow-up.

Ｈｏｄｇｋｉｎ病の放射線治療から２０年後に発生した血管肉腫の１例

Ｈｏｄｇｋｉｎ病の放射線治療から２０年後に発生した血管肉腫の１例

Postradiation angiosarcoma of the small intestine: a case report and review of literature

Postradiation angiosarcoma is typically a high-grade sarcoma that presents mainly in the skin and superficial tissues. Postradiation angiosarcoma arising in the small intestine is rare with only 11 cases documented in the English-language literature. Herein, we report a postradiation angiosarcoma of the small intestine 9 years after radiotherapy for uterine cervical adenocarcinoma. The patient presented with symptoms of intestinal obstruction. At exploratory laparotomy, tumor nodules involved the small bowel. Microscopically, the neoplasm was composed of spindled and epithelioid cells arranged in solid aggregates and focally forming vascular channels. The diagnosis of angiosarcoma was confirmed immunohistochemically by tumor cell expression of CD31, CD34, and factor VIII-related antigen. The patient died 10 months after laparotomy. The diagnosis of PRA should be entertained for any poorly differentiated neoplasm arising in a previously irradiated site. The correct diagnosis of PRA depends upon histomorphologic identification of vascular differentiation, coupled with immunohistochemical expression of endothelial-related markers.

Postradiation Angiosarcoma of the Skin Featuring Capillary Lobules

To the Editor: With reference to the article entitled “the capillary lobule: a deceptively benign feature of postradiation angiosarcoma of the skin: report of 3 cases” by Di Tommaso and Rosai,1 we encountered an identical postradiation angiosarcoma of the skin characterized by capillary lobules. The patient was a 49-year-old woman who had a lumpectomy followed by radiation therapy for invasive ductal carcinoma of the left breast. Two and a half years later, she developed a 0.6 cm pink-purple lesion in the skin of the irradiated area, which was excised. Microscopically, the most striking feature was the presence of multiple round to oval capillary lobules throughout the dermis, suggestive of a hemangioma. The capillary lobules varied in size and were composed of compact vascular channels lined by slightly hyperchromatic endothelial cells (Fig. 1A). In addition to the capillary lobules, there were some areas with features typical of angiosarcoma, namely, anastomosing thin-wall vascular channels lined by plump hyperchromatic endothelial cells, intraluminal micropapillary formations, ill-formed vascular channels interposed between collagen bundles, and mitotic figures (Fig. 1B). We interpreted the lesion as an unusual angiosarcoma with features resembling hemangioma. A simple mastectomy was performed and revealed a 1.5 cm tumor with identical histopathologic features. The tumor was present 0.3 mm from the closest margin and 1 mm from the closest margin in a reexcision specimen. Six months later, the patient had a recurrent lesion in the same area with the same morphology. It was widely excised with negative margins. The patient is alive with no evidence of recurrence or metastasis 4 months later.FIGURE 1.: The tumor was mainly composed of round to oval capillary lobules scattered in the dermis, mimicking a hemangioma (A). However, some areas showed the typical features of angiosarcoma (B).In summary, the presence of capillary lobules in a postradiation angiosarcoma of the skin may present a diagnostic pitfall as it can readily be mistaken for a benign lesion. We agree with Di Tommaso and Rosai who state that “the detection of capillary lobules in irradiated skin ought to be regarded with great suspicion, and other morphologic signs suggestive of angiosarcoma should be sought in the specimen.” Zhenqiang Gao, MD, PhD Sheng Chen, MD, PhD Department of Pathology, Albert Einstein College of Medicine Long Island Jewish Medical Center, 270-05 76th Avenue New Hyde Park, NY

Cutaneous Angiosarcoma of the Breast on MRI

WEB This is a Web exclusive article. ngiosarcoma of the breast is a rare malignant tumor. First described as a large intraparenchymal tumor of the breast, a subtype has emerged in the irradiated breast termed “cutaneous postirradiation angiosarcoma of the breast.” The angiosarcomas described in the radiology literature are of the large intraparenchymal variety. We report the clinical history and MRI findings in two patients with this cutaneous subtype.

The Capillary Lobule: A Deceptively Benign Feature of Post-Radiation Angiosarcoma of the Skin

Three cases are presented of a proliferative vascular lesion of the skin developing in the chest wall of women who had received radiation therapy for breast carcinoma. All 3 lesions were characterized microscopically by the presence of the so-called capillary lobule, a formation generally regarded as a sign of benignancy but that in this setting proved to be a forerunner or indicator of angiosarcoma (malignant hemangioendothelioma). Therefore, the detection of capillary lobules in irradiated skin ought to be regarded with great suspicion, and other morphologic signs suggestive of angiosarcoma should be sought in the specimen.

Risk of Angiosarcoma Following Breast Conservation: A Clinical Alert

Approximately 100 cases of angiosarcoma following breast-conserving therapy have been reported. The prevalence of angiosarcoma following breast conservation has not been accurately established and optimal treatment has not been defined. The goal of this article is to clarify both issues. The Fisher's exact test was used to compare the prevalence of postirradiation angiosarcoma seen in our private practice to the prevalence reported from the two largest national database studies. A literature review was performed to determine optimal treatment guidelines. The results of the comparison indicated that the prevalence of postirradiation angiosarcoma seen in our practice was significantly higher than that reported in the two national database studies at p-values of 0.0124 and 0.0080. Also, results from the literature review suggest that early detection and aggressive treatment lead to improved outcomes. The data are insufficient to draw firm conclusions, but suggest that the current literature underestimates the prevalence of angiosarcoma following breast-conserving therapy. Since elderly women derive less benefit from radiation and may be more prone to develop postirradiation angiosarcoma, confirmation of our findings could lead to a reappraisal of the management of elderly patients with early stage breast cancer.

Radiation-Induced Angiosarcoma After Mastectomy and TRAM Flap Breast Reconstruction

Radiation-induced angiosarcoma of the breast is being reported with increasing frequency as a result of the increased use of radiation therapy in conjunction with breast conservation surgery. However, this entity has not been well documented in patients undergoing mastectomy. The authors present a case of angiosarcoma occurring in a patient 6 years after undergoing mastectomy for invasive duct carcinoma with immediate transverse rectus abdominis musculocutaneous flap reconstruction followed by postoperative radiation therapy. The diagnosis of angiosarcoma was made by skin biopsy performed by the patient's reconstructive surgeon on routine follow-up examination. This is the first reported case of postradiation angiosarcoma occurring in a postmastectomy breast reconstructed with autogenous tissue and it is unusual in that the cancer invaded the musculocutaneous flap. Diagnosis and management recommendations for radiation-induced angiosarcoma are discussed.

Cutaneous angiosarcoma following breast-conserving surgery and radiation: an analysis of 27 cases.

Iatrogenic angiosarcomas (AS), following treatment of breast carcinomas and attributed to chronic lymphedema, were first described by Stewart and Treves. With emphasis on breast-conserving therapy combined with adjuvant radiation, a recently recognized form of cutaneous postradiation angiosarcoma of the breast (CPRASB) has emerged. To more completely characterize CPRASB, 27 cases were analyzed. Histologic features studied included pattern of growth (vasoformative, sieve-like, or solid), nuclear grade, necrosis, and mitotic rate. Clinical and follow-up information was obtained. The patients received relatively standard radiation treatment. The median interval to diagnosis of CPRASB was 59 months; 5 occurred in less than 3 years. Lymphedema was largely absent, and when present was only mild in nature. CPRASB was frequently multifocal at presentation (13 of 27). All tumors had a vasoformative pattern of growth; the majority (16 of 27) had areas with a sieve-like pattern. The solid pattern was less frequent (7 of 27). The majority had high-grade nuclear features (16 grade 3, 8 grade 2, 3 grade1). The mean mitotic rate was 9/10 HPF. Necrosis was rare (2 of 27). All were treated with wide excision or mastectomy. Follow-up was available on 22 of 27 cases (median 44 months). Fourteen experienced local recurrence and 6 had multiple recurrences. Metastasis was documented in 9 of 22 patients and involved lungs (6), contralateral breast (3), skeleton (2), lymph nodes (1), and soft tissue (1). Eight patients died of disease, 2 died with disease, 4 were alive with disease, and 8 are alive without disease. The median interval to death was 33.5 months. All 4 patients with disease have documented metastasis. CPRASB differs from Stewart-Treves AS by its shorter latency period and lack of association with lymphedema.

Low Grade Cutaneous Angiosarcoma Of Chest Wall Skin Following Mastectomy 20 Months Postradiation

Angiosarcoma of the skin of the chest wall or breast following radiation treatment after breast lumpectomy or mastectomy for breast carcinoma is a rare condition. The majority of cases of post radiation angiosarcoma occur in the upper extremities and are associated with edema. The latent period of postradiation angiosarcoma of chest wall or breast skin varies from 37 months to 13 years. Few cases are reported and most have high-grade angiosarcoma. The latent period in the case we are reporting was 21 months and the tumor histologically was low grade. The clinical history and histological findings are compared with cases found in a review of the literature.