Well-differentiated Angiosarcoma Research Articles

Multiple angiosarcomas of both breasts: a case report

BackgroundPrimary angiosarcomas of the breast are rare and highly aggressive. We herein report a rare case of multiple angiosarcomas detected concurrently in both breasts.Case presentationA 49-year-old woman visited a doctor after noticing a lump in her right breast. At that time, mammography and ultrasonography revealed no abnormal findings in either breast. She was referred to our hospital 5 months later, because screening mammography had revealed a focal asymmetric density in her right breast. Ultrasonography showed ill-defined hyper- and hypo-echoic lesions in both breasts. Magnetic resonance imaging disclosed five heterogeneously enhanced masses (5.8 cm in maximum diameter) in the right breast and six enhanced masses (approximately 1–3 cm in diameter) in the left breast. Histological examination of core needle biopsies revealed proliferation of irregularly shaped vascular channels lined by atypical endothelial cells throughout the adipose tissue and lobules of the breasts, leading to a diagnosis of well-differentiated angiosarcoma. The lesions were assumed to be primary angiosarcomas, because she had neither a history of breast surgery nor of radiation therapy. She underwent bilateral mastectomies and postoperative chest wall irradiation. Computed tomography 11 weeks after the surgery revealed multiple, small, subcutaneous nodules in the chest wall that were suspected of being angiosarcoma metastases. We started chemotherapy (weekly paclitaxel 80 mg/m2), which achieved shrinkage of these nodules within 2 months.ConclusionsEarly diagnosis, immediate initiation of local and systemic therapies, and intensive follow-up are important in improving the prognosis of angiosarcomas.

Radiotherapy for primary angiosarcoma of the breast: a case report

Background: Primary breast angiosarcomas are very rare type malignant breast tumor. It may have an insidious clinical onset, presenting as a painless, often discrete palpable mass that grows rapidly. The ranged age of disease is 20-50 years. Case description: We report a case of a young woman with palpable and painless mass of her left breast. Based on radiological findings with mammography and MRI examination reported as malignant mass of the left breast suspected angiosarcoma. Pathological confirmation post-surgery reported a well-differentiated angiosarcoma that arose primarily in the left breast. Patient treated with simple mastectomy followed by whole breast radiotherapy. External beam radiotherapy delivered using 3DCRT with FIF technique, prescribed dose 60Gy in 30 fractions within 6 weeks. Conclusion: There is no established standard treatment for primary angiosarcoma of the breast. Mastectomy remains the mainstay of treatment. Adjuvant radiotherapy appears to improve local control.

Angiosarcoma-like Kaposi Sarcoma: A Distinctive Histomorphologic Variant Representing an Important Diagnostic Pitfall.

Kaposi sarcoma (KS) is a rare low-grade angioproliferative neoplasm associated with human herpesvirus 8 (HHV-8) infection with multiple clinical subtypes and varying histopathologic patterns. Histologically, many different variants of KS have been reported, yet all can be difficult to recognize and must be differentiated from other vascular tumors. In this report, we studied fourteen cases of a newly described variant of KS reminiscent of a well-differentiated angiosarcoma (angiosarcoma-like KS). All cases showed a diffuse, ill-defined infiltrative dermal-based lesion composed of numerous anastomosing vascular channels of varying caliber lined by a single layer of endothelium with minimal pleomorphism. The vascular proliferation ramified through the dermis and dissected the collagen bundles along with infiltration into the subcutaneous fat and around skin appendages. All cases showed expression of vascular markers (CD31, CD34, and ERG) and were positive for HHV-8. None showed the classic histopathology associated with KS. Without clinical guidance these tumors can be difficult to recognize as KS, creating significant diagnostic challenges. Our study expands on a rare histologic variant of KS that ought to be considered in the differential diagnosis of any cutaneous well-differentiated angiosarcoma. Awareness of this variant of KS is of important for proper diagnosis and management of these patients; thus, careful attention to the histomorphology and clinical history can help lead the pathologist to the correct diagnosis.

Anastomosing Hemangioma Incidentally Found in Kidney or Adrenal Gland: Study of 10 Cases and Review of Literature.

To describe and report a series of renal and adrenal anastomosing hemangioma (AH) and to investigate its distinctive clinicopathologic features and review its clinical data available in the literature. Clinical data of 10 AHs were retrospectively studied. Imaging and histologic features were re-evaluated and summarized. Immunostaining markers were performed include CD31, CD34, ERG, Fil-1, D2-40, AE1/AE3, SMA, CD10, HHV8, S100, Ki-67. A follow-up of all cases was performed. Other AHs published in PubMed and Web of Science were reviewed. All of 10 AHs were found incidentally, containing 5 female and 5 male patients (median, 48.5 years; mean, 51.7 years) and involved unilateral kidney (n=7) and adrenal glands (n=3) respectively. All lesions were well-defined in Imaging and histologic examination. AHs were morphologically characterized by prominent anastomosing vascular channels without evidence of infiltration to surrounding normal tissues and significant cellular atypia. CD31, CD34, ERG were positive and Ki-67 showed typically low (?3%). All Patients underwent a mass resection and none of them had evidence of recurrence. Together with other cases published, the AHs showed distinctive clinicopathologic features with an excellent prognosis. Renal or adrenal AH is a very rare vascular tumor. They have distinctive histologic features and a favorable prognosis. Its frequently mimicking well-differentiated angiosarcomas easily result in unnecessary overtreatment in clinical practice. To be acquainted with this entity serves to avoid misdiagnosis.

2298 Novel Use of N-Acetylcysteine in the Management of Immunotherapy-Induced Acute Liver Injury

INTRODUCTION: There is limited research regarding the use of N-Acetylcysteine (NAC) to manage non-acetaminophen induced acute liver failure (NAI-ALF). NAC has an anti-inflammatory, antioxidant effect, and improves oxygenation by vasodilating microcirculation. A mortality benefit and association with lower hospitalization length has been seen when using NAC in NAI-ALF. Use of immunotherapy to treat cancer has recently increased, and acute liver injury has been reported with many agents. This case examines using NAC to manage immunotherapy induced acute liver injury (ITI-ALI). CASE DESCRIPTION/METHODS: Patient is a 67-year-old Caucasian female with a medical history of hyperlipidemia and well-differentiated angiosarcoma of the right breast, diagnosed in 2011. She had mastectomy and adjuvant chemo-radiotherapy resulting in remission. Surveillance abdominal CT, in 2017 showed new enhancing hepatic lesions. Abdominal MRI confirmed these concerning lesions. A cervical mass was noted, which was biopsied, and diagnostic of metastatic angiosarcoma. She was started on Pazopanib. Two weeks into therapy, she experienced darkened urine, myalgia, and abdominal pain. Labs just prior to admission showed transamninits, ALT of 522 units/L and AST of 456 units/L. Admission labs showed worsening transaminitis, ALT 1377 units/L and AST 1212 units/L. Exam showed jaundice and diffuse abdominal pain. Acetaminophen levels were undetectable. Abdominal ultrasound showed patent hepatic vasculature, normal liver size, appearance, echogenicity, and no intrahepatic ductal dilation or masses. Additionally, serologies for herpes simplex virus, Ebstein Barr virus, cytomegalovirus, viral hepatitis, anti-nuclear antibody, and anti-smooth muscle antibody were negative. Ultimately, her acute liver injury was suspected to be ITI-ALI. NAC was started and Pazopanib was held. Hepatic function was serially monitored, and her acute liver injury rapidly improved. She was discharged and repeat labs on follow-up continued showing improvement in transaminases (Figure 1). DISCUSSION: The use of NAC in NAI-ALF was described in a prospective study by Mumtaz, Azam, et al, and in a randomized, case-control trial by Nabi, et al. Neither studies had patients who had developed ITI-ALI. Both studies were able to conclude that using NAC in NAI-ALF reduced mortality and hospitalization length. Further prospective studies should be conducted to identify if there is a statistically significant effect on mortality and length of hospitalization by using of NAC in ITI-ALI.

Anastomosing Hemangioma: Short Review of a Benign Mimicker of Angiosarcoma.

Anastomosing hemangioma is a rare neoplastic vascular lesion, histologically mimicking angiosarcoma. It is predominantly composed of irregularly anastomosing sinusoidal-like spaces lined by endothelial cells with minimal atypia, a frequently hobnail morphology, and minimally invasive margins. Since its original description in the genitourinary system, an increasing number of anastomosing hemangiomas have been reported, localized deep in the body in various organs, always with similar histologic features. It is more frequently asymptomatic, often discovered incidentally by imaging studies, owing to coexisting benign or malignant tumors. In renal cases, the most frequent clinical context is end-stage renal disease. There is overwhelming evidence of the benign nature of the lesion and an accurate diagnosis could prevent overtreatment. The differential diagnosis includes other benign vascular tumors, well-differentiated angiosarcoma, Kaposi sarcoma, and other vascular-rich neoplasms. We review the clinical and histopathologic characteristics of this peculiar lesion with an emphasis on the differential diagnosis.

A rare case of primary well-differentiated angiosarcoma of the right atrium.

A rare case of primary well-differentiated angiosarcoma of the right atrium.

Anastomosing Hemangiomas Arising in Unusual Locations: A Clinicopathologic Study of 17 Soft Tissue Cases Showing a Predilection for the Paraspinal Region.

Anastomosing hemangioma, a recently recognized benign vascular neoplasm originally described in the kidney, may be confused with well-differentiated angiosarcoma. Rare cases of anastomosing hemangiomas have been described in the liver and in nonrenal genitourinary sites. We report a series of 17 anastomosing hemangiomas occurring in unusual locations, in particular in the paravertebral soft tissues. The 17 tumors occurred in 10 male and 6 female patients, ranging in age from 2 to 85 years. One patient had bilateral, synchronous tumors involving the right paracaval and left para-aortic soft tissues. Thirteen (76%) cases involved the soft tissues near the vertebral column, including the paravertebral region (n=4), the psoas muscle (n=2), the costovertebral angle (n=2), para-aortic soft tissue (n=2), and the paracaval, parasacral, and retroperitoneal soft tissues (n=1 each). Other locations included the anterior mediastinum, uterine cornu, infundibular pelvic ligament, and upper arm (n=1 each). Imaging studies, available in 13 cases, were not felt to be diagnostic of a hemangioma. The tumors ranged from 1.5 to 7.5 cm (median, 3.6 cm) in size and were grossly well demarcated. All cases showed typical morphologic features of anastomosing hemangiomas, including a nonlobular architecture, an anastomosing proliferation of capillary-sized vessels with mild endothelial cell nuclear variability, scattered hobnailed endothelial cells, and small fibrin thrombi. Mitotic activity was rare or absent. Adipocytic metaplasia and extramedullary hematopoiesis were present in subsets of cases. When performed, immunohistochemical studies showed expression of endothelial markers (eg, CD31, CD34). In only 1 case did the submitting pathologist favor a diagnosis of anastomosing hemangioma; 4 cases were submitted specifically to exclude a well-differentiated angiosarcoma. Clinical follow-up available in 13 cases has not revealed any local recurrences or metastases. This series, the first formal description of anastomosing hemangiomas involving soft tissue locations, shows these tumors to have a notable predilection for the paraspinal region. The diagnosis of soft tissue anastomosing hemangioma may be challenging, as imaging studies do not show classical features of hemangioma and as these tumors may be sampled with limited needle biopsies. Awareness of this entity, and appreciation that they may occur in nongenitourinary sites, should allow its confident distinction from potentially more aggressive lesions, in particular angiosarcoma.

Primary Cutaneous Angiosarcoma on the Nose in a Patient with Multiple Nonmelanoma Skin Cancers

Cutaneous angiosarcoma is an uncommon, potentially metastatic and highly aggressive vascular tumor that may arise as de novo or be associated with previous radiotherapy. A 70-year-old female with a solitary lesion on the nose was initially diagnosed as actinic keratosis. However, when the recurring lesion at the same region within 6 months was reexcised, the histological diagnosis was definitively established as well-differentiated angiosarcoma. This case was presented in order to increase awareness of this rare malignancy in an uncommon localisation, especially in the light of pathological findings. Moreover, occurrence of cutaneous angiosarcoma within a short period following a previous excision in a patient with a history of multiple nonmelanoma skin cancers was interestingly pointed out.

Anastomosing Hemangioma of the Liver and Gastrointestinal Tract

Anastomosing hemangioma, a benign vascular neoplasm histologically simulating angiosarcoma, is newly recognized and has been described primarily in the genitourinary tract. We have encountered this lesion in the liver and gastrointestinal tract, where it can be diagnostically challenging, especially in core biopsy. Herein, we described 6 cases of anastomosing hemangioma of the liver and gastrointestinal tract. They occurred in 4 women and 2 men, ranging in age from 48 to 71 years. The tumors ranged from 0.2 to 6 cm (median, 3.1 cm) and were grossly well demarcated with a gray-brown spongy appearance. Microscopically, they had a loosely lobulated architecture. At higher magnification, lesions consisted of anastomosing sinusoidal capillary-sized vessels with scattered hobnail endothelial cells. Mild cytologic atypia occurred in all cases. Mitoses were absent. Vascular thrombi were seen in 4 cases (66.7%) without necrosis. One tumor (16.7%) featured prominent extramedullary hematopoiesis and 1 (16.7%) hyaline globules. Immunohistochemistry results were available for 3 cases, and the lesions stained with CD34 and/or CD31. Five cases had clinical follow-up information; there were no recurrences or metastases (range, 8 to 96 mo; mean, 41 mo), and 1 patient received no follow-up after a benign diagnosis on her colon polyp. In summary, anastomosing hemangioma of the liver and gastrointestinal tract is a rare distinctive vascular neoplasm displaying overlapping features with well-differentiated angiosarcoma. Despite small numbers and limited follow-up information in our series, evidence to date supports that the lesion is benign. Awareness of this entity is essential to avoid overdiagnosis and unnecessary aggressive treatment.

Pancreas-preserving segmental duodenectomy for gastrointestinal stromal tumor of the duodenum and splenectomy for splenic angiosarcoma

Gastrointestinal stromal tumors are the most common mesenchymal tumors of the gastrointestinal tract and occur rarely in the duodenum. Splenic angiosarcoma is an aggressive neoplasm with an extremely poor prognosis. We report a case of a 70-year-old man hospitalized for abdominal pain in the upper quadrants, dyspepsia and nausea, previously treated for Hodgkin lymphoma 30 years ago. Abdominal CT showed a solid nodular lesion in the third portion of the duodenum, the presence of retropancreatic, aortic and caval lymph nodes, and four nodular splenic masses. (111)In-octreotide scintigraphy revealed pathological tissue accumulation in the duodenal region, and in the retropancreatic, retroduodenal, aortic and caval lymph nodes, suggesting a nonfunctioning neuroendocrine peripancreatic tumor. At exploratory laparotomy, an exophytic soft tumor was found originating from the third portion of the duodenum. Pancreas-preserving duodenectomy with duodenojejunostomy, splenectomy and lymphnodectomy of retropancreatic aortic and caval lymph nodes were performed. Pathological evaluation and immunohistochemical studies showed the presence of a duodenal gastrointestinal stromal tumor with low mitotic activity and a well-differentiated angiosarcoma localized to the spleen and invading lymph nodes. We speculated that the angiosarcoma and duodenal gastrointestinal stromal tumors of this patient were due to the treatment of Hodgkin lymphoma with radiotherapy 30 years ago. Pancreas-preserving segmental duodenectomy can be used to treat non-malignant neoplasms of the duodenum and avoid extensive surgery. Splenectomy is the treatment of choice for localized angiosarcomas but a strict follow-up is mandatory because of the possibility of recurrence.

Geriatric high-grade soft tissue sarcoma (G-HG STS): An analysis of 116 patients (pts) evaluating prognostic factors and clinical outcomes stratified by histology.

10051 Background: STS in geriatric pts is not well studied. We evaluated prognostic factors and clinical outcomes in elderly pts with HG STS. Methods: Single centre retrospective study. G-HG STS pts defined as age > 65 yrs seen in our centre from 2002 - 2011 with complete medical records were identified. Charlson age-comorbidity score was assessed for each pt. Results: 116 pts from 4 most common HG STS histo-types representing 69% of pts in the geriatric STS cohort were analysed; leiomyosarcoma (LMS, 14%), non well-differentiated liposarcoma (nWD-LPS, 9%), angiosarcoma (AS, 30%), and undifferentiated pleomorphic sarcoma (UPS, 47%). Median age was 72 yrs, 81% presented with localised disease; of 78% of these localised pts who had curative surgery, 49% received adjuvant therapy, of whom 92% had radiotherapy (RT) only. AS arises more commonly from the head/neck region (p<0.001) and fewer receive curative surgery (p=0.006). In 43 pts who had metastases either at diagnosis or relapse, 33% received first-line palliative chemotherapy with a response rate of 27% in evaluable pts. At a median follow-up of 15.8 mths, overall survival (OS) for the entire cohort was 25.1 mths, 30.5 vs 3.9 mths in pts presenting with localised vs metastatic disease respectively (p<0.0001). In pts who had curative surgery for localised disease, overall relapse-free survival (RFS) was 17.7mths; 26.8 mths vs 16.0 mths vs 7.3 mths vs 12.5 mths in LMS, nWD-LPS, AS and UPS respectively. In univariate analysis, adjuvant RT, non-head/neck primary and sarcoma subtype were associated with improved RFS. In multivariate analysis, adjuvant RT (p<0.001), sarcoma subtypes AS (p=0.011) and UPS (0.012) vs LMS remained significant. In pts with metastatic HG STS either at diagnosis or relapse, overall median OS was 5.9 mths; 5.9 mths (LMS), 30.5 mths (nWD-LPS), 6.4 mths (AS) and 4.3 mths (UPS). In univariate analysis, presence of bone metastases was significantly associated with inferior OS (p=0.0029). Charlson score did not correlate with RFS or OS. Conclusions: Prognosis of G-HG STS appears poor particularly in AS and UPS. Adjuvant RT improves outcomes in this group of pts and should not be omitted based on age alone.

A rare case of rapidly progressing angiosarcoma of the breast with multiple metastases to the bone, liver, ovary, and gingiva

We herein report a rare case of primary angiosarcoma of the breast. A 31-year-old pregnant woman noted a progressing mass in her left breast, and it was suspected to be a phyllodes tumor on the basis of images acquired after the delivery. The histological diagnosis by excisional biopsy was well-differentiated angiosarcoma, so she was referred to our hospital for further treatment. CT and MRI suggested that there was a residual lesion in the remnant breast and multiple bone metastases. She underwent a simple mastectomy, and chemotherapy was performed postoperatively. Four months after surgery, liver, ovary, and mandibular gingival metastases became apparent, although these metastatic lesions had not been distinguished at first. They rapidly progressed, and the regimen of chemotherapy was changed from weekly paclitaxel, MAID (mesna/ifosfamide/doxorubicin/dacarbazine) combination therapy, to docetaxel. Radiation therapy to the gingival tumor was relatively effective. However, the liver and ovary metastases continued to progress under chemotherapy and caused a fatal hemorrhage. Early diagnosis is very important in this highly aggressive disease, and a novel strategy for treatment is needed to prolong the survival and maintain the quality of life of such patients.

Lésions vasculaires atypiques et angiosarcomes post-radiothérapie : 11 cas

Post-radiation atypical vascular lesions of the skin display clinical and morphological overlap with well-differentiated angiosarcomas, and correct diagnosis may be difficult. We studied clinical, histological and immuno-histochemical aspects (CD31, CD34, D2-40 and VEGFR-3) of eight post-radiation atypical vascular lesions comparatively with three post-radiation angiosarcomas. All patients were female and received radiation therapy for breast carcinoma. On average, atypical vascular lesions occurred 4.3 years after radiation therapy and presented as small papulonodules or erythematous plaques. The clinical course after simple excision was benign. Histologically, they were relatively circumscribed lesions and showed slit-like vessels dissecting dermal collagen in all cases. On average, angiosarcomas occurred 5 years after radiation therapy and presented as more extensive lesions with a more aggressive clinical course. The lesions showed histological overlap with atypical vascular lesions, but were poorly circumscribed, with deeper invasion, cytological atypia and mitosis. Although the immuno-histochemical profiles were similar, expression of VEGFR-3 was greater in two cases of angiosarcoma. Post-radiation atypical vascular lesions are benign lesions that display clinical, histological and immuno-phenotypic overlap with well-differentiated angiosarcoma, and diagnosis requires good clinicopathological correlation. VEGFR-3 may be useful for differential diagnosis, as well as amplification of the MYC gene.

Pseudoangiomatous stromal hyperplasia

This report describes five cases of pseudoangiomatous stromal hyperplasia of the breast. The lesion manifested as a discrete palpable slowly growing lumps. The patients ranged in age from 30 to 71 years. The clinical diagnosis was that of fibroadenoma in most cases. Pathologic examination revealed complex vascular like lesions closely resemble mimic well-differentiated angiosarcoma. The accurate diagnosis was established following the application of appropriate immunohistochemical markers.

Molekulare Methoden in der Sarkomdiagnostik

The use of modern molecular techniques has gained importance in the diagnosis of sarcomas in recent years. Each of the analytical methods discussed here has its unique advantages and specific requirements. Cytogenetic screening methods which provide genome-wide information depend on the availability of fresh tissue. With the aid of fluorescence in situ hybridization and RT-polymerase chain reaction, specific events such as translocations in Ewing sarcoma, synovial sarcoma or alveolar rhabdomyosarcoma, as well as gene amplifications in well-differentiated and dedifferentiated liposarcoma or radiation-induced angiosarcoma and deletions in rhabdoid tumors or well-differentiated spindle cell liposarcoma can be detected in fresh and formalin fixed tissues. Molecular methods including Sanger sequencing, pyrosequencing and high resolution melting provide information about specific molecular aberrations on gene level. Here we review the most important molecular techniques currently used in sarcoma diagnosis, describe their relevance for differential diagnosis and point out specific examples.

Angiosarcoma, radiation-associated angiosarcoma, and atypical vascular lesion.

Abstract Angiosarcoma, one of the least common sarcomas, has become increasingly important because of its association with radiation therapy, especially for breast cancer. Most are sporadic, presenting as cutaneous tumors in the scalp/face of elderly patients. However, angiosarcoma has a wide anatomic distribution including soft tissue, visceral organ, and osseous locations. Predisposing conditions include environmental exposures to chemical or radioactive sources. Radiation-associated angiosarcoma typically presents as a cutaneous tumor several years posttherapy. The latency for radiation-associated mammary angiosarcoma is relatively short, sometimes less than 3 years. Atypical vascular lesion refers to a small, usually lymphatic-type vascular proliferation in radiated skin. Although most atypical vascular lesions pursue a benign course, they recur and very rarely progress to angiosarcoma. Distinguishing this lesion from well-differentiated angiosarcoma in a biopsy can be challenging, especially because ...

Angiosarcoma, Radiation-Associated Angiosarcoma, and Atypical Vascular Lesion

Angiosarcoma, one of the least common sarcomas, has become increasingly important because of its association with radiation therapy, especially for breast cancer. Most are sporadic, presenting as cutaneous tumors in the scalp/face of elderly patients. However, angiosarcoma has a wide anatomic distribution including soft tissue, visceral organ, and osseous locations. Predisposing conditions include environmental exposures to chemical or radioactive sources. Radiation-associated angiosarcoma typically presents as a cutaneous tumor several years posttherapy. The latency for radiation-associated mammary angiosarcoma is relatively short, sometimes less than 3 years. Atypical vascular lesion refers to a small, usually lymphatic-type vascular proliferation in radiated skin. Although most atypical vascular lesions pursue a benign course, they recur and very rarely progress to angiosarcoma. Distinguishing this lesion from well-differentiated angiosarcoma in a biopsy can be challenging, especially because areas indistinguishable from atypical vascular lesion are found adjacent to angiosarcoma. Recently, vascular-type atypical vascular lesion, which resembles hemangioma, has been described, thus expanding the definition of this entity.

THOROTRAST-INDUCED PRIMARY CEREBRAL ANGIOSARCOMA

Thorotrast was used as a contrast medium in clinical practice until the 1960s for outlining cerebral abscess cavities and ventricular cavities, and for angiography. Gliosarcomas, meningiomas, and schwannomas have been reported previously, as has Thorotrast-associated angiosarcoma, typically in the liver. A unique case of a primary intracerebral well-differentiated angiosarcoma in a 68-year-old man with a history of colocalized exposure to Thorotrast is described. This may be the first case of a primary angiosarcoma in the brain. The patient presented with a progressive left-sided weakness 62 years after initial surgery for a right parietal cerebral abscess, which included the instillation of Thorotrast into the abscess cavity. Computed tomography showed a right parietal tumor. An explorative craniotomy showed an intrinsic, infiltrating, very vascular tumor with surrounding calcification. The tumor appeared to arise from a benign cavernous vasoformative lesion intimately associated with a Thorotrast-type granuloma. The patient declined further surgery or radiotherapy. The histology, confirmation of radioactivity of the material obtained from within the tumor, and latency period of presentation provide compelling support for tumor induction by the Thorotrast. Primary lesions of the central nervous system associated with Thorotrast are very rarely reported, despite its extensive use in cerebral angiography and management of brain abscess between 1930 and 1960.

Atypical Vascular Lesions After Surgery and Radiation of the Breast

We report the clinicopathologic study of 32 cases of atypical vascular lesions (AVLs) after surgery and radiation of the breast, which were referred to us in consultation over a 17-year period. The patients, all women, ranged in age from 41 to 95 years (mean 61 y). The lesions developed within the radiation field from 1 to 12 years (median 6.0 y) after therapy. They occurred as one (n=18) or more (n=10) flesh-colored papules or erythematous patches/plaques ranging in size from 1 to 60 mm (mean 8.0 mm, median 4.0 mm). Tumors could be divided into 2 histologic types: a lymphatic type (LT) (n=22) and a vascular type (VT) (n=10). LT AVLs consisted predominantly of thin-walled, variably anastomosing lymphatic vessels that were usually confined to the superficial dermis but occasionally extended into the deep dermis and even subcutis. The VT (n=10) typically consisted of small, irregularly dispersed, often blood-filled, pericyte-invested, capillary-sized vessels involving the superficial or deep dermis. VTs were often associated with extravasated erythrocytes, hemosiderin, and a surrounding minor LT component. In 4 cases, endothelial atypia, consisting of nuclear and nucleolar enlargement, was noted. Follow-up of 21 patients with LT AVLs (1 to 106 mo; mean 47 mo) disclosed recurrence/additional lesions in 6, all of whom had additional surgery. Of the 21 patients, 17 are alive without disease, 1 is alive with disease, 1 died of breast carcinoma, 1 died of unknown causes, and 1 showed progressive histologic changes in the AVLs over a period of 5 years resulting in a well-differentiated angiosarcoma. Follow-up in 8 patients with VT AVL (2 to 181 mo; mean 40 mo) disclosed that 6 were alive and well, but 2 of the 4 patients whose lesions displayed endothelial atypia had additional complications. One patient underwent a mastectomy that revealed extensive residual AVL and the second developed a high-grade angiosarcoma after 14 months. We conclude that AVLs encompass a wider spectrum of changes than previously appreciated, ranging from superficial lymphatic proliferations to more complex lymphatic and capillary vascular lesions. There seems to be an association of AVL with angiosarcoma that differs depending on the histologic features, with the VT AVLs having the higher risk. In the 2 patients who developed angiosarcoma, morphologic evidence suggested AVLs to be a precursor rather than simply a risk factor. Future outcome and management studies should take into account these differences.