Angiosarcoma of skin and soft tissue: a study of forty-four cases

The hanging manoeuver to complete liver resection for a locally advanced angiosarcoma: A case report

INTRODUCTION

Angiosarcomas arising in the liver are rare tumours in the Western world. We report a case of a locally advanced primary hepatic angiosarcoma and also describe the manoeuvres used to achieve operative resection.

PRESENTATION OF A CASE

A 52-year old woman presented with vague right upper quadrant pain. Abdominal imaging revealed a heterogenous tumour in the right liver measuring 15centimetres in maximal diameter. Although the tumour was deemed to be resectable, there was free fluid in the right paracolic gutter suggestive of rupture. Intra-operatively, the peritoneal cavity was noted to be free of metastatic disease. However, tumour was adherent to the diaphragm precluding traditional mobilization of the liver. Therefore, a modified hanging manoeuvre was performed using a nasogastric tube. This allowed controlled mobilization of the right liver, parenchymal transection and en-bloc resection of the diaphragm with good hemostasis. Histologic examination revealed a primary angiosarcoma with uninvolved margins.

DISCUSSION

When they occur, primary hepatic angiosarcomas are most often locally advanced. Nevertheless, surgeons should be aggressive in the pursuit of complete resections because this is the only therapeutic modality that has been shown to have a survival advantage.

CONCLUSION

Hepatobiliary surgeons should keep the hanging manoeuver in their armamentarium when performing complex liver resections for locally advanced angiosarcomas.

Angiosarcoma of penis: Case report of an aggressive penile cancer

Angiosarcoma is a very rare mesenchymal tumor of penis. Though extremely unusual, it should be considered in the differential diagnosis in patients presenting with a penile growth or a localized subcutaneous penile lesions as they are very aggressive and there is a high chance of recurrence. One such case is reported here, which was aggressively treated with total penectomy and the patient did not show any recurrence in 2 years of follow-up.

Cutaneous angiosarcoma of the foot: a case report and review of the literature

Primary Angiosarcoma of the skin of the foot is very rare. Angiosarcoma is typically treated with resection and wide-field postoperative radiation therapy. Chemotherapy and radiation therapy have also been used. Regardless of the treatment, the risk of local and distant relapse remains high for this disease. We present a case of an elderly patient who developed cutaneous angiosarcoma of the foot. It posed as a diagnostic dilemma at presentation. Chronic lymphedema was a possible predisposing factor. Given his age, preexisting renal dysfunction, refusal of surgery, and preference not to receive chemotherapy, the patient was ultimately treated with definitive radiotherapy. We present this case because of its rare site, unique presentation and delay in diagnosis of the condition, and attainment of an excellent response to radiation at the time of follow-up. We also review the current literature on this topic.

Cutaneous angiosarcoma of head and neck

Cutaneous angiosarcoma is a rare aggressive tumor of capillary and lymphatic endothelial cell origin. Cutaneous angiosarcoma of the head and neck regions seems to be a distinctive neoplasm with characteristic clinicopathologic features that differ from angiosarcoma in other anatomic locations. Angiosarcoma, regardless of their setting, has a bad prognosis. We presented here a case of 80 years old male, with multiple nontender grouped purple to red hemorrhagic vesicular and bullous lesions over left lower cheek and upper neck area, with bilateral cervical lymph nodes since 1 month. Computed tomography thorax showed nodular opacities in the right upper and midzones. Excisional biopsy showed characterstic “dissection of collagen” with mild nuclear atypia. Immunohistochemistry showed tumor cell positive for CD-31 and Fli-1. Patient died within 1 month of presentation.

Angiosarcoma of the liver: imaging of a rare salient entity

Hepatic angiosarcomas are rare mesenchymal tumors with few case series and reports describing their imaging findings in the last two decades. The computed tomography and magnetic resonance imaging findings are variable and may appear like hemangioma at one end of the spectrum and hepatoma at the other end. The use of hepatocyte specific contrast on magnetic resonance imaging may also be insufficient in making a reliable imaging diagnosis. These tumors can easily mimic hypervascular liver cancer, atypical hemangioma or metastases. This case report highlights the imaging features of this entity and also underlines that, this tumor should always be considered as a differential diagnosis for hypervascular tumors in cirrhotic patients. The current imaging paradigms for its diagnosis are also discussed.

Angiosarcoma of the scalp: a case report

Purpose

The aim of this paper is to report the treatment of angiosarcoma of the scalp. High-dose-rate (HDR) brachytherapy with an individual mold applicator is presented.

Case description

A case of a 75-year-old male will be presented with multicentric lesions over the scalp in the temple and crown region. Biopsy diagnosis was angiosarcoma of the scalp, nonoperable. The patient was qualified for chemotherapy combined with radiotherapy.

Discussion

Angiosarcoma of the scalp is a very aggressive tumor. The main aim of the treatment of angiosarcoma is local control of the tumor. Most cases are treated with wide excision surgery. The use of surgery with adjuvant radiotherapy or chemotherapy is recommended in some cases. Chemotherapy and radiotherapy are suggested in the recurrent or extensive lesions with regional or distant metastasis. Radiation therapy can be realized with external beam therapy or brachytherapy. High-dose-rate brachytherapy is an effective, adequate, well tolerated by patients treatment method. In every case, an individual approach is needed.

Conclusions

The HDR brachytherapy technique is useful and practicable. The advantages of brachytherapy are: targeted dose distribution, low integral dose, and short time of treatment. The mold HDR brachytherapy treatment using an individual applicator was an appropriate tool for the presented patient.

Successful Treatment of Pulmonary Metastasis and Local Recurrence of Angiosarcoma with Docetaxel

Angiosarcoma of the face and scalp of the elderly frequently recurs locally, metastasizes early despite various treatments, and has a poor prognosis. We describe a patient who had angiosarcoma of the scalp with pulmonary metastasis. Local recurrence occurred after excision and local and arterial administration of IL-2. A weekly administration method of docetaxel was therefore selected, resulting in complete remission of the pulmonary metastasis and a partial response of the local recurrence. This favorable clinical outcome in our case suggests that docetaxel therapy may be an option for the treatment of angiosarcoma of the scalp with pulmonary metastasis.

Vascular soft-tissue sarcomas: a prognostic model from a retrospective single-center study

BACKGROUND

Vascular soft-tissue sarcomas are a rare form of sarcoma. Malignant subtypes exhibit a variety of biological behaviors. We describe the clinicopathological characteristics and patient survival outcomes of malignant vascular soft-tissue sarcomas.

METHODS

We conducted a retrospective study on a cohort of 84 patients diagnosed with vascular tumors by histological examination at the Yonsei University College of Medicine between April 1987 and August 2011. The primary end point was overall survival (OS).

RESULTS

The angiosarcoma patients had a significantly shorter OS than the patients with other subtypes of sarcomas (59.0 and 142.7 months, respectively; p < 0.001). Upon multivariate analysis of survival in patients who underwent surgical resection, the following independent prognostic factors were identified: primary site (trunk, p = 0.001), age (older than 65 years, p < 0.001), pathology (angiosarcoma, p = 0.006) and R2 resection (p = 0.002).

CONCLUSION

The independent prognostic factors for shorter survival are the trunk as the primary site, malignant angiosarcoma and age (>65 years). Complete excision should be attempted for providing a survival advantage in the patients with localized disease. In addition, bleeding episodes are much more frequent in patients with a poor survival outcome.

Angiosarcoma of the oral cavity: a clinicopathological study and a review of the literature

Soft tissue sarcomas are uncommon in the head and neck. Primary angiosarcomas of the oral cavity area are extremely rare, and have mostly been presented as case reports. This paper presents the clinical and histological features of three such cases. All patients were diagnosed based on the presence of rapidly extending masses involving the tongue, maxillary gingiva, or mandibular gingiva; bone destruction was present in two cases. The resected specimens revealed clustered large, pleomorphic, and spindle-shaped cells with a markedly haemorrhagic background. Tumour cells showed expression of vascular endothelial markers, such a CD31, CD34, and factor VIII-related antigen. Despite undergoing radical surgery, distant metastases developed in all three cases. We also studied the clinicopathological features of a series of oral angiosarcomas. This article therefore reports the clinicopathological features of the three new cases and provides a review of the cases of primary oral angiosarcoma reported during the past 20 years.

Multiple cutaneous angiosarcomas after breast conserving surgery and bilateral adjuvant radiotherapy: an unusual case and review of the literature

Breast angiosarcomas (BAs) are rare but serious events that may arise after radiation exposure. Disease outcome is poor, with high risk of local and distant failure. Recurrences are frequent also after resection with negative margins. The spectrum of vascular proliferations associated with radiotherapy in the setting of breast cancer has expanded, including radiation-associated atypical vascular lesions (AVLs) of the breast skin as a rare, but well-recognized, entity. Although pursuing a benign behavior, AVLs have been regarded as possible precursors of postradiation BAs. We report an unusual case of a 71-year-old woman affected by well-differentiated bilateral cutaneous BA, diagnosed 1.9 years after adjuvant RT for synchronous bilateral breast cancer. Whole-life clinical followup is of crucial importance in breast cancer patients.

Angiosarcoma of the seminal vesicle: a case report of long-term survival following multimodality therapy

Angiosarcoma of the seminal vesicle is an extremely rare malignancy, with few published case reports in the literature. We present a case of primary angiosarcoma of the seminal vesicle in a 45-year-old male who was treated with multimodality therapy, consisting of neoadjuvant chemotherapy and chemoradiation followed by surgical resection and intraoperative radiation therapy. He has been free of cancer recurrence for more than six years after completion of therapy. To our knowledge, this represents the longest reported survival of a patient with this rare tumor, and one of the few cases reported using a multimodality therapy approach.

Angiosarcoma of the Breast with Solitary Metastasis to the Ovary during Pregnancy: An Uncommon Pattern of Metastatic Disease

Primary de novo angiosarcoma of the breast is an uncommon, aggressive neoplasm. Here, we present a case of a young woman who initially developed primary angiosarcoma of the breast, and subsequently angiosarcoma of the ovary during pregnancy two years later. Only two confirmed primary angiosarcomas of the breast metastasizing specifically to the ovary have been described in the literature. However, all previous cases had ovarian metastases at presentation or shortly after initial diagnosis. This case is unusual as it occurred after a relatively long interval, and apparently developed during pregnancy. We discuss this rare phenomenon, as well as the possible factors contributing to the recurrence.

Clinical management of secondary angiosarcoma after breast conservation therapy

AIM

The aim of this paper is to summarize the treatment outputs of secondary angiosarcoma after breast conservation therapy at St. Eizabeth Cancer Centre, Slovakia.

BACKGROUND

Angiosarcoma of the breast is a rare but very aggressive malignant tumor of the vascular endothelium, characterized by rapidly proliferating and extensively infiltrating growth. 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. Radiotherapy in the treatment of breast cancer is associated with an increased risk of subsequent sarcoma.

MATERIALS AND METHODS

Retrospective study of medical records from the cancer databases was done in order to analyze the secondary breast angiosarcoma. This disease is an iatrogenic condition that warrants close follow-up and judicial use of radiotherapy in breast conserving therapy. Therefore, it is more prevalent in cases treated with radiotherapy, occurring especially in or adjacent to the radiation field. Clinical histories and follow-up data of identified patients after breast conservation therapy of invasive breast cancer were reviewed. In addition, a comprehensive literature review on diagnosis and treatment procedures was done in order to summarize state-of-the-art clinical approach.

RESULTS AND DISCUSSIONS

Three cases of secondary angiosarcoma after breast conservation therapy (BCT) were identified among 4600 patients treated at St. Elizabeth Cancer Institute during previous 16 years (1995-2011). Secondary breast angiosarcoma was diagnosed in a median period of 11 years following primary radiotherapy, median age at the time of diagnosis was 75 years. Surgical treatment consisted of radical mastectomy. The first patient, a 56-year-old woman received neoadjuvant chemotherapy (docetaxel + gemcitabin), second one (75 year) was treated by radiotherapy (TD 26 Gy, 2 Gy per fraction), since chemotherapy was not indicated. The last patient (80 year) got adjuvant chemotherapy (paclitaxel). Average follow up of the patients was 31 months. As of 31 July 2012, our patients were doing well without evidence of recurrent disease after treatment.

CONCLUSIONS

Angiosarcoma remains a difficult management problem with poor loco-regional and distal control. In our study, an overall incidence rate of secondary breast angiosarcoma is 0.065%. Although the prognosis for this disease is poor (typical survival period is 14.5-34 months with a 5-year survival rate of approximately 15%), all the three patients treated at our institute are alive and disease-free at the end of reported period. Finally, it is assumed that the use of breast conserving therapy will increase the incidence of post-irradiation angiosarcoma but the small difference in risk of subsequent sarcoma of the breast cancer patients receiving radiotherapy does not suppress its benefit.

CD8⁺ tumor-infiltrating lymphocytes at primary sites as a possible prognostic factor of cutaneous angiosarcoma

Tumor-infiltrating lymphocytes (TILs) have been reported as a prognostic factor in various cancers and are a promising target for immunotherapy. To investigate whether TILs have any impact on the prognosis of angiosarcoma patients, 55 non-treated patients (40 patients at stage 1 with cutaneous localized tumors, 4 patients at stage 2 with lymph node metastases and 11 patients at stage 3 with distant metastases) with angiosarcoma were evaluated retrospectively by immunohistochemistry stained CD4, CD8, FOXP3 and Ki67. The Kaplan-Meier method was used to estimate overall survival with patients at stage 1. Survival differences were analyzed by the log-rank test. Patients with higher numbers of CD8(+) TILs in their primary tumors survived significantly longer compared with patients with lower values. Moreover, the number of CD8 in TILs was positively correlated with a distant metastasis-free period. The total number of primary TILs (CD4 plus CD8) and CD8(+) primary TILs of stage 3 patients with distant metastases was positively correlated with their overall survival. To evaluate whether CD8(+) effector T cells are activated or differentiated, flow cytometric analysis of peripheral blood mononuclear cells (PBMC) was performed. The percentages of CD8(+) T cells producing IFN-γ in PBMC were significantly higher in patients with angiosarcoma (n = 10) compared not only with that of healthy controls (n = 20) but also patients with advanced melanoma (n = 11). These results suggest that anti-tumor immunity is clinically relevant in angiosarcoma.

Soft tissue sarcomas--new approaches to diagnosis and classification

The study of sarcoma pathology is a rapidly evolving field. The continued refinement of classic diagnostic techniques in conjunction with the molecular diagnostics has resulted in an abundance of data regarding this diverse and rare group of tumors. We anticipate that cutting edge technology including next generation sequencing will continue to further our understanding of saromagenesis and enable more precise classification and diagnosis of sarcomas in the future.

Single institutional experience of the treatment of angiosarcoma of the face and scalp

OBJECTIVE

Angiosarcoma is a rare malignant neoplasm with a poor prognosis. A retrospective study was performed to accumulate radiotherapy (RT) data.

METHODS

Data from 17 patients with angiosarcoma of the face and scalp (AFS) who were treated with definitive RT between January 1999 and July 2011 were retrospectively analysed. The total radiation dose was 70 Gy, and the fractional doses were 2.0-2.5 Gy. Combined with RT, chemotherapy using docetaxel alone, recombinant interleukin-2 immunotherapy alone and both of these was performed in 10, 4 and 2 patients, respectively. Three patients underwent limited surgery before RT.

RESULTS

The response rate was 82%, and the median overall survival (OS) rate was 26 months. Locoregional relapse alone, distant metastasis alone and both of these were confirmed in 4, 5 and 4 patients, respectively. Patients treated with docetaxel showed a better prognosis (p=0.0477), a distant metastasis-free rate (p=0.0063) and a better in-field control rate, although the last was not statistically significant (p=0.1645).

CONCLUSION

Definitive RT combined with docetaxel chemotherapy provided an effective approach for treating AFS.

ADVANCES IN KNOWLEDGE

Since patients treated with chemoradiotherpy using docetaxel showed better OS and distant metastasis-free rates than those who did not receive docetaxel, it was warranted to continue use of docetaxel. In chemoradiotherapy at a dose of 70 Gy using docetaxel, 2-year in-field control rate was 67%.

High-risk features in radiation-associated breast angiosarcomas

BACKGROUND

Radiation-associated breast angiosarcoma (RT-AS) is an uncommon malignancy with an incidence of less than 1 % of all soft tissue sarcomas. The overall prognosis is quite dismal with high rates of recurrences and poor overall survival. There is an obvious paucity of data regarding clinical outcomes of patients with breast RT-AS.

METHODS

We identified all patients with RT-AS treated at the Memorial Sloan-Kettering Cancer Center between 1982-2011 and collected their correlative clinical information.

RESULTS

We identified 79 women with RT-AS with a median age of 68 (range 36-87). The median interval between radiation and development of RT-AS was 7 years (range 3-19). The median time to local and distant recurrence was 1.29 years (95 % CI 0.72-NA) and 2.48 years (95 % CI 1.29-NA), respectively. The median disease-specific survival was 2.97 years (95 % CI 2.21-NA). Independent predictors of worse disease-specific survival included age 68 years (HR 3.11, 95 % CI 1.20-8.08, P=0.020) and deep tumors (HR 3.23, 95 % CI 1.02-10.21, P=0.046.)

CONCLUSION

RT-AS has high local/distant recurrence rates, limited duration on standard chemotherapy and poor disease-specific survival.

Cutaneous angiosarcoma: a single-institution experience

BACKGROUND

Cutaneous angiosarcoma (CAS) is a rare, aggressive vascular sarcoma with a poor prognosis, historically associated with 5-year overall survival (OS) rates between 10 and 30 %.

METHODS

This is a single-institution retrospective review of patients treated for CAS from 1999-2011. Demographics, primary tumor characteristics, treatment, and outcomes were analyzed.

RESULTS

A total of 88 patients were identified (median age 70 years and 57 % female). Median tumor size was 3 cm. Median follow-up was 22 months. The 5-year OS and recurrence-free survival (RFS) were 35.2 and 32.3 %, respectively; median was 22.1 months. Also, 36 patients (41 %) received surgery alone, 7 (8 %) received XRT alone, and 41 (47 %) received surgery and XRT. Of the 67 of 88 patients who were disease-free after treatment, 33 (50 %) recurred (median of 12.3 months). Surgery alone had the highest 5-year OS (46.9 %) and RFS (39.9 %) (p = ns). Four presentation groups were identified: (1) XRT-induced, n = 30 (34 %), 26 of 30 occurred in females with a prior breast cancer, (2) sporadic CAS on head and neck (H/N), n = 38, (3) sporadic CAS on trunk/extremities, n = 13, and (4) Stewart-Treves n = 7. Those with trunk/extremity CAS had the highest 5-year OS (64.8 %), with H/N CAS having the worst 5-year OS (21.5 %). On MV analysis, only tumor size <5 cm correlated with improved OS (p = 0.014).

DISCUSSION

In this large series, there appears to be a better overall prognosis than historically reported, especially in Stewart-Treves and CAS on trunk or extremities. While surgery alone was associated with better OS and RFS compared with other treatment modalities, this was not statistically significant. Tumor size was a significant prognostic factor for OS.

Combination therapy for scalp angiosarcoma using bevacizumab and chemotherapy: a case report and review of literature

Bevacizumab, an angiogenesis inhibitor, is a recombined humanized monoclonal antibody against vascular endothelial growth factor and a promising therapeutic option for angiosarcoma management. This is a case report and review of the literature using bevacizumab and combination chemotherapy for angiosarcoma. The understanding of the effectiveness of combined therapy of bevacizumab and chemotherapy agents is still limited. The benefits of bevacizumab treatment for angiosarcoma will need to be weighed against the risks of venous thromboembolism in this population.

Angiosarcoma: a tissue microarray study with diagnostic implications

BACKGROUND

Angiosarcoma (AS) is a rare soft tissue sarcoma showing endothelial differentiation as indicated by morphology and expression of CD31 (blood), D2-40 (lymphatic), factor VIII, and CD34 (both). We sought to examine the pattern of immunohistochemical markers of differentiation in AS and correlate these with outcome.

DESIGN

An AS tissue microarray (n = 70 specimens) was constructed for immunohistochemical analysis of CD31, CD34, factor VIII, D2-40, and pan-cytokeratin. Samples on this array were linked to clinicopathologic and outcome data for these patients. Univariate analyses were used to explore disease-specific survival (DSS) factors.

RESULTS

Nine metastatic, 23 localized, and 4 recurrent cases were included. Information about the tissue status (ie, primary or metastasis) was unavailable in 4 patients. Primary sites for the tumor included bone (n = 1), breast parenchyma (n = 11), breast skin (n = 4), heart (n = 5), skin (n = 8), soft tissue (n = 7), and unknown (n = 3). Three patients presented with multifocal disease (primary sites in these patients included breast, skin, and soft tissue). Metastatic sites included lung, bone, lymph nodes, brain, liver, and parotid. Of the 40 cases, 8 (20%) showed a pure or predominant epithelioid histology. Of the biomarkers evaluated by tissue microarray, 92% of tumors expressed at least one endothelial marker (factor VIII = 83%, CD31 = 80%, CD34 = 63%, and D2-40 = 43%) with 88% expressing 2 or more markers. Eighty-eight percent of tumors expressing D2-40 coexpressed CD31, an unusual combination in normal vessels. No endothelial marker clearly associated with disease-specific survival. Fifty percent (4/8) of epithelioid cases and 9% (3/32) of nonepithelioid cases showed keratin expression.

CONCLUSIONS

Unusual patterns and loss of endothelial markers are common in AS, suggesting use of multiple markers in challenging cases and perhaps indicating important biologic characteristics.

Chemoembolisation combined with percutaneous radiofrequency ablation in the treatment of primary angiosarcoma of the liver

Angiosarcoma of the liver is a rare disease; however, it ranks as the third most common primary liver malignancy. Diagnosis is difficult and prognosis is very poor. After the onset of clinical symptoms, the disease often progresses rapidly, decreasing the chances of curative treatment. We report the case of an 83-year-old male patient who presented with postprandial fullness. Upper abdominal ultrasound showed a hypervascular mass in segment 6 of the liver. The results of anatomopathological examination and immunohistochemistry were compatible with the diagnosis of primary angiosarcoma of the liver. Patient refused surgery (haepatectomy), and treatment was then initiated with transarterial chemoembolisation, followed by percutaneous radiofrequency ablation. The patient is currently cured based on clinical and radiological evidence. This case report is the first in the literature to describe the combined use of transarterial chemoembolisation with percutaneous radiofrequency ablation in the treatment of primary angiosarcoma of the liver.

Radiation therapy for angiosarcoma: the 35-year University of Florida experience

BACKGROUND AND PURPOSE

We sought to identify prognostic factors and successful therapeutic approaches when treating angiosarcoma with radiotherapy.

MATERIALS AND METHODS

From 1974 to 2009, 41 patients with angiosarcoma were treated with radiotherapy. The median patient age was 67 years. Sixteen angiosarcomas were radiation induced. Tumor sites included the head and the neck in 22 patients, breast in 14, and other sites in five. Thirty-one patients were treated with both surgery and radiotherapy (12 preoperatively and 19 postoperatively) and 10 patients were treated with radiotherapy alone. The median radiotherapy dose was 60 Gy (range, 37.5 to 76 Gy).

RESULTS

The 5-year local control and overall survival rates were 64% and 54%, respectively. Median follow-up was 3.7 years. Of the 23 patients who relapsed, 15 had a local failure. Predictors of 5-year local control were nonscalp primary location, tumor size of ≤5 cm, radiation-induced tumors, and combined-modality local therapy. Predictors of 5-year overall survival were nonscalp location and a tumor size of ≤5 cm. The patients with the best outcomes were treated with surgery and radiotherapy 3 times daily for angiosarcoma that developed after breast-conserving therapy.

CONCLUSIONS

For angiosarcomas treated with radiotherapy, outcome varies widely and is impacted by tumor site, size, and resectability. In amenable sites, aggressive treatment with resection and hyperfractionated radiotherapy may offer the best prognosis.

Cutaneous angiosarcoma of the scalp masquerading as a squamous cell carcinoma: case report and literature review

BACKGROUND

Cutaneous angiosarcoma is a rare tumor of the elderly male, most commonly affecting the head and neck region. It is difficult to differentiate this tumor from hemangiomas, hemangioblastomas, Kaposi sarcoma, squamous cell carcinoma and anaplastic melanomas.

METHODS

Case report and review of pertinent English medical literature.

CASE SUMMARY

We report a case of a 60-year-old male presenting with multiple nodules over the scalp where a preoperative histopathologic diagnosis of squamous cell carcinoma was made by wedge biopsy from the tumor. Postoperative histopathology and immuno histochemistry of the wide local excision specimen proved the tumor to be cutaneous angiosarcoma and the patient completed adjuvant radiotherapy. He is now on regular follow-up for 1 year without recurrence.

CONCLUSIONS

Cutaneous angiosarcoma must be kept in mind in view of its rarity especially in extensive involvement of the scalp by malignancy. The primary treatment is wide local excision with adequate skin cover and adjuvant chemotherapy and radiotherapy in positive margins and lymph node metastasis.

Advances in the systemic treatment of cutaneous sarcomas

Cutaneous sarcomas are a rare subset of soft tissue sarcomas. These tumors are primarily managed with definitive surgical resection; however, upon unresectable recurrence or metastatic spread, systemic therapy is warranted. As with other sarcomas, these treatments have classically included cytotoxic chemotherapy programs that were associated with variable response rates and poor overall survival. Recently, major advances have been made in the understanding of the molecular biology of these tumors, and treatment paradigms are changing. Multiple pathways have been documented to be important in the growth of cutaneous sarcomas, including receptor tyrosine kinases such as platelet-derived growth factor receptor, insulin-like growth factor receptor and KIT. Dysregulated angiogenesis, through vascular endothelial growth factor (VEGF) and other pathways, is also associated with the growth of these tumors. In this review, we discuss the current standard therapies of cutaneous sarcoma and the recent advances and ongoing investigations into cutaneous sarcoma biology.

INK4a/ARF [corrected] inactivation with activation of the NF-κB/IL-6 pathway is sufficient to drive the development and growth of angiosarcoma

Although human angiosarcoma has been associated frequently with mutational inactivation of the tumor suppressor gene Ink4a/Arf, the underlying mechanisms have not been delineated. Here we report that malignant angiosarcoma is associated with high levels of RelA/NF-κB and IL-6 in contrast to normal vessels or benign hemagiomas. Studies of Ink4a/Arf deficient mice not only recapitulate genetic traits observed in human angiosarcoma, but also unveil a possible therapeutic link comprised of the NF-kB/IL-6/Stat3 signaling axis. In Ink4a/Arf(-/-) cells, NF-κB controlled Stat3 signaling by transcriptionally controlling the expression of IL-6, gp130, and Jak2. Further, IL-6 mediated Stat3 signaling through the sIL-6R. Inhibition of Ikkβ solely in myeloid cells was insufficient to block angiosarcoma development; in contrast, systemic inhibition of Ikkβ, IL-6, or Stat3 markedly inhibited angiosarcoma growth. Our findings offer clinical implications for targeting the NF-kB/IL-6/STAT3 pathway as a rational strategy to treat angiosarcoma.

Primary angiosarcoma of the larynx: a rare entity

Angiosarcomas are extremely rare malignant tumours of the larynx. We present a case of laryngeal angiosarcoma in a 58-year-old man who presented with hoarseness of voice, dysphagia and neck swelling. The patient underwent a total laryngectomy with a pre-operative and frozen section diagnosis of a poorly differentiated carcinoma of the larynx. Histopathological and immunohistochemical evaluation revealed features of a laryngeal angiosarcoma. The case is presented for its rarity and diagnostic difficulty.

Liver angiosarcoma, a rare liver malignancy, presented with intraabdominal bleeding due to rupture--a case report

Liver angiosarcoma is a rare disease, however it still ranks as the third of most common primary liver maligancies. The prognosis of liver angiosarcoma is very poor with almost all patients with this kind of disease die within 2 years after diagnosis. No specific symptoms and signs are closely associated with this disease. Here, we report a case presenting shock status at first due to rupture of liver angiosarcoma- induced internal bleeding. After emergent transarterial embolization (TAE), she received partial hepatectomy two weeks later. 4 months after operation, she is still with a good performance status without obvious recurrence or metastasis identified.

[A case of primary pleural angiosarcoma metastasing to the bladder]

The patient was a 79-year-old man who underwent right extrapleural lucite ball plombage for pulmonary tuberculosis at aged 19. He was followed BPH with medication from May 2008 at our hospital. He presented with macrohematuria in January 2010, but cystoscopy and CT scan showed no significant abnormalities. He was admitted to complaining of general fatigue and anemia in February 2010. TURBT was performed 10 days after admission, and showed the bleeding sites with oozing in mucosa at the bilateral and posterior wall of the bladder. Neither CT nor cytological examinations were helpful in diagnosing this disease, although histological observation implied a possibility of malignant vasoformative tumor. He died one month after admission. Autopsy revealed a huge bloody mass at the right upper thoracic wall and same metastatic tumors of both adrenals, the bone, the stomach and the urinary bladder. Microscopic examination revealed that atypical cells had proliferated and formed vascular structures, which were stained positively with CD31, and vimentin. Finally, the diagnosis was made of pleural angiosarcoma and multiple metastasis. Metastatic angiosarcoma of the bladder is very rare and difficult to make definite diagnosis, however we have to keep in mind the presence of this disease.

Confirmed angiosarcoma: prognostic factors and outcome in 50 prospectively followed patients

Purpose. Angiosarcoma is a rare tumor with endothelial cell differentiation that may arise in any anatomic location.The purpose of this report was to identify prognostic factors on outcome in a group of prospectively followed patients with confirmed angiosarcoma.Subjects. Adult patients (>16 years old) with angiosarcoma treated between July 1982 and February 1998 were identified from a prospective database.Methods. Pathologic confirmation of all cases was performed prior to inclusion in this analysis. Various prognostic factors were evaluated for disease-specific survival. Survival was determined by the Kaplan- Meier method. Statistical significance was evaluated by log-rank test for univariate analysis and Cox stepwise regression for multivariate analysis (p<0.05).Results. Fifty patients were identified; at the initial evaluation, this group included 32 patients with a primary tumor, three with local recurrence and 15 with metastatic disease. Tumor sites included 16 head and neck and skin of head, eight extremity, seven trunk, six breast, five pelvis, four viscera and four thoracic. Median follow-up among survivors was 71 months (range, 38-191 months).Two- and 5-year disease-specific survival was 50 and 30%, respectively, with a median of 24 months. The factor predictive of tumor-related mortality was presentation status (p=0.001; relative risk, 5). Two-year disease-specific survival for patients presenting with recurrent or metastatic disease was 13%, compared with 70% for those with primary disease.

Cutaneous angiosarcoma of the scalp: a case report of sustained complete response following liposomal Doxorubicin and radiation therapy

Cutaneous angiosarcomas of the head and neck are aggressive cancers with a mean overall survival of 30 months. We add to the literature a case report of a 65-year-old man with a large, >10 cm, unresectable, angiosarcoma of the scalp who was treated with two cycles of liposomal doxorubicin (Caelyx(R)) followed by electron beam radiation therapy (30 Gy in 10 fractions over 2 weeks) who has sustained a complete response with a 4-year follow-up. The dose and fractionation of the radiation therapy in this case was palliative and was not expected to give lasting local control of this lesion. It is therefore possible that either the genetic profile of the tumour conferred radiosensitivity or that the radiation therapy induced a recall phenomenon of the liposomal doxorubicin.

Angiosarcoma of the scalp

Angiosarcoma is a relatively rare soft tissue tumour. It usually occurs in the head and neck, and especially in the scalp, in elderly people. Its presentation varies from a small plaque to multifocal nodules. The treatment depends on the extent of the disease. Most cases are treated with wide excision with reconstruction. Radiotherapy and chemotherapy are advocated in the recurrent or extensive lesions with regional or distant metastasis. Other modalities such as immunomodulation have been tried. A case of a 55-year-old female patient with a bleeding scalp lesion is presented. Initially thought to be a pyogenic granuloma, on excisional biopsy it was diagnosed as angiosarcoma with microscopic involvement of the margins. Wide excision with reconstruction using a local rotation flap was done at a second stage. The patient was not given postoperative radiotherapy or chemotherapy. There has been no recurrence for two years.

Metastatic angiosarcomas: doxorubicin-based regimens, weekly paclitaxel and metastasectomy significantly improve the outcome

BACKGROUND

Angiosarcomas are a rare but aggressive form of soft tissue sarcoma. At metastatic stage, the clinical benefit of therapeutic intervention remains debatable.

PATIENTS AND METHODS

We have carried a retrospective analysis of 149 cases treated between 1996 and 2009 in the French Sarcoma Group.

RESULTS

The median age was 60; the sex ratio was 0.80. Sixty-two percentage of cases presented with metastasis at the diagnosis. About 20% arose in irradiated fields. The median overall survival was 11 months. Treatment consisted in metastasectomy (5.4%), doxorubicin-based regimen (46.9%), weekly paclitaxel (Taxol) (31.5%), other chemotherapy regimens (10.7%) or exclusive palliative care (10.9%). Clinical prognostic factors identified by univariate analysis were presence of bone metastasis (P = 0.0107), presence of other metastasis (P = 0.0327) and performance status (P < 0.0001). The Cox model retained a performance status of two or more as the sole independent prognostic factor (HR [hazard ratio] = 2.49, P < 0.0001). After adjustment to the performance status and compared with exclusive palliative care, the following treatments significantly improve the outcome: doxorubicin-based regimen as first-line chemotherapy (HR = 0.38, P = 0.0165), weekly paclitaxel as first-line regimen (HR = 0.36, P = 0.0146) and metastasectomy (HR = 0.09, P = 0.0221).

CONCLUSIONS

This retrospective analysis indicates that some therapeutic interventions may significantly improve the outcome of this aggressive disease. Doxorubicin-based regimens and weekly paclitaxel seem to provide the same range of efficacy.

Scalp Angiosarcoma Remission with Bevacizumab and Radiotherapy without Surgery: A Case Report and Review of the Literature

Angiosarcoma (AS) is a rare and aggressive vascular neoplasm with very poor prognosis. Patients with extensive cutaneous AS who are not surgical candidates have very limited options since there is no standard treatment. Treatment options include radiation, chemotherapy, and angiogenesis inhibitor with varying success rates. Here, we report a case an 88 year old patient with extensive scalp angiosarcoma having biopsy proven remission with bevacizumab and radiotherapy without undergoing surgery.

Two cases of periocular cutaneous angiosarcoma

Angiosarcoma is a rare malignancy with only 8 previous reports of eyelid involvement. The authors report 2 further cases, one as a primary lesion and the other as a recurrence from a contiguous area. In both cases, the lesions appeared relatively inconspicuous, and their extent during micrographic excision was considerably larger than anticipated. Although wide surgical margins were obtained and adjuvant radiotherapy and chemotherapy was undertaken, one patient had died from distant metastasis, while the second had distant cutaneous recurrences within 1 year.

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.