Postmastectomy lymphangiosarcoma: ultrastructural observations

Postmastectomy Angiosarcoma: Ultrastructural Study of a Case

The ultrastructural findings of a case of Stewart-Treves syndrome are reported. The authors believe that some features, never described before, confirm the truly vascular nature of this neoplasm.

Cutaneous vascular proliferations. Part III. Malignant neoplasms, other cutaneous neoplasms with significant vascular component, and disorders erroneously considered as vascular neoplasms

In this third and last part of our review of cutaneous vascular proliferations we include malignant vascular neoplasms and a group of heterogeneous cutaneous neoplasms characterized by a significant vascular component. We also review some disorders that, in our opinion, have been erroneously considered as vascular neoplasms. We review the epidemiologic, histogenetic, clinical, and histopathologic aspects of Kaposi's sarcoma in its four distinctive variants (classic, African-endemic, immunosuppressive drug-associated, and AIDS-associated Kaposi's sarcoma). There is still controversy about whether Kaposi's sarcoma represents a reactive vascular proliferation or a true neoplastic proliferation. In any event, most authors believe that Kaposi's sarcoma does not produce metastatic disease, but rather develops in multifocal fashion. However, Kaposi's sarcoma may cause death, especially in immunosuppressed patients. Epithelioid hemangioendothelioma, Dabska's tumor, and retiform hemangioendothelioma are examples of low-grade angiosarcoma. In contrast, cutaneous angiosarcomas, including the clinical variants of angiosarcoma of face and scalp in elderly patients, angiosarcoma associated with lymphedema, and radiation-induced angiosarcoma are highly aggressive neoplasms with poor prognosis and most patients die within a short period after presentation. A group of benign and relatively frequent cutaneous neoplasms, including multinucleate cell angiohistiocytoma, angiofibroma, angioleiomyoma, angiolipoma, cutaneous angiolipoleiomyoma, and cutaneous angiomyxoma are here covered because of their significant vascular component. Finally, we review briefly a series of cutaneous disorders that have been erroneously considered as vascular neoplasms. Kimura's disease is an inflammatory reactive condition of unknown origin, "benign" angioendotheliomatosis is a reactive intravascular proliferation of endothelial cells that occurs in the skin as a response to a variety of stimuli, "malignant" angioendotheliomatosis is an intravascular lymphoma, and acral pseudolymphomatous angiokeratoma of children (APACHE) is better interpreted as a pseudolymphoma.

Lymphangiosarcoma and haemangiosarcoma in a cat

Ultrastructural findings in a feline ventral abdominal vascular tumour showed lack of basal lamina, few micropinocytotic vesicles and intercellular junctions and a discontinuous endothelial cell layer. A splenic cyst had a continuous basal lamina, numerous micropinocytotic vesicles and intercellular junctions and a continuous endothelial cell layer. These findings were compatible with diagnosis of lymphangiosarcoma (ventral abdomen and metastases) and haemangiosarcoma (splenic cyst).

Lymphangiosarcoma in postmastectomy lymphedema (Stewart-Treves syndrome): ultrastructural and immunohistologic characteristics

Two cases of lymphangiosarcoma arising in a chronic lymphedematous extremity following mastectomy (Stewart-Treves syndrome) were reported with not only standard histology, but also special study on the ultrastructure and immunohistology. These cancers developed as a result of chronic lymphedema of the involved limb following mastectomy 15 and 16 years ago, respectively, for breast carcinoma. Immunohistologic and electron microscopic examinations proved that this tumor originates in the vascular endotheliocytes, even though they are clinically chronic lesions apparently derived from the lymphatic vessels. This sarcoma develops multicentrically in an edematous arm and spreads out rapidly, so prognosis is quite discouraging in those patients. They need to be radically surgically treated without hesitation; hence, amputation, not limb-saving surgery, should be indicated.

Lymph nodes as sites of metastases from sarcomas of soft tissue

Records of 323 patients with TNM Stage M0 sarcoma of soft tissue treated by the Radiation Medicine Service of the Massachusetts General Hospital over a 14-year period were reviewed to study the incidence and the implication of regional lymph node involvement. Nineteen patients (5.9%) had evidence of sarcoma metastatic to draining lymph nodes, zero of 63 (0%) were Grade 1 sarcomas, two of 118 (2%) were Grade 2, and 17 of 142 (12%) were Grade 3 sarcomas. Among patients with Grade 3 sarcomas, rhabdomyosarcoma (five of 14), vascular sarcoma (two of five), and epithelioid sarcoma (four of five) were associated with a higher incidence of lymph node involvement than synovial sarcomas (zero of four), fibrosarcomas (zero of 16), malignant fibrohistiocytomas (one of 29), neurofibrosarcomas (one of eight), liposarcomas (one of 14), and leiomyosarcomas (one of ten). From the 19 patients who had evidence of metastatic nodes, six (32%) were alive more than 58 months after the treatment of the nodes; four of six patients were without further tumor. The data of this study are compared with those cited in a review of the literature.

Stewart-Treves syndrome: an histogenetic (ultrastructural and immunohistological) study

One case of the so-called "Stewart-Treves syndrome" (STS), appearing on a lymphoedematous arm complicating radical mastectomy for breast cancer, was characterized electronmicroscopically and immunohistologically, in order to elucidate its disputed (epithelial vs endothelial) histogenesis. Epithelial and endothelial differentiation markers used comprised: antibodies against keratin, vimentin, factor VIII-related antigen (F VIII-RA), HLA-DR antigens and the lectin Ulex europeaus agglutinin I (UEA I). At the ultrastructural level, neoplastic cells were found to contain typical Weibel-Palade bodies, whereas by immunohistological techniques they proved to be keratin-negative/vimentin+, F VIII-RA+, UEAI+, HLA-DR+. These results rule out a possible epithelial differentiation and strongly favour an endothelial one for STS.

Histogenesis of post-mastectomy angiosarcoma--an ultrastructural study

An example of post-mastectomy angiosarcoma was studied by electron microscopy to determine its histogenesis. Unequivocal evidence of endothelial differentiation was found in well and poorly differentiated areas. Positive staining for factor VIII related antigen and negative staining for epithelial membrane antigen further confirmed that the tumour was a true angiosarcoma rather than a peculiar form of carcinomatous metastasis.

Lymphangiosarcoma of the edematous thigh after radiation therapy for carcinoma of the vulva

A 66-year-old patient was treated with external radiation therapy for an advanced carcinoma of the vulva. Seven years later, a lymphangiosarcoma developed in her edematous lower extremity. Lymphangiosarcomas have been reported to occur in postmastectomy patients; however, this is only the third case in a patient with a gynecologic primary malignancy. In anticipation of possible increased use of radiation therapy in vulvar carcinoma, gynecologists should be aware of this rare, highly aggressive neoplasm.

Angiosarcomas arising in edematous extremities: immunostaining for factor VIII-related antigen and ultrastructural features

Immunostaining for Factor VIII-related antigen was seen in deparaffinized sections from 19 of 20 postmastectomy angiosarcomas and from four of four sarcomas that arose in chronically edematous tissue unrelated to breast carcinoma. Staining was also seen in sections from two malignant hemangioendotheliomas, four capillary hemangiomas, and one granulation tissue specimen. Sections from two lymphangiomas were immunonegative for Factor VIII-related antigen in the endothelium of lymphatic channels, whereas staining was observed in the surrounding normal blood vessels. Electron microscopic study of four postmastectomy angiosarcomas disclosed ultrastructural features (fenestrae, intense pinocytotic activity, cell junctions, and Weibel-Palade bodies) supporting the blood vascular endothelial nature of the neoplastic cells. It is concluded that a neoplastic blood vessel component is present in sarcomas that arise in chronically edematous tissues. It is questionable whether a lymphatic component is also present. These tumors, therefore, should be regarded as angiosarcomas rather than lymphangiosarcomas.

Electron microscopic observations of lymphangiosarcoma arising from chronic lymphedema

Lymphangiosarcoma, so-called Stewart-Treves syndrome, originating from the edematous left leg after hysterectomy in a 53-year-old woman has been studied by light and electron microscopy. Histologically the tumor was composed of either vascular channels or solid nests of the neoplastic cells having a large hyperchromatic nucleus with a single or multiple prominent nucleoli. The inner surface of the vascular channels was lined by either single or several layers of identical cells. Erythrocytes were occasionally observed in the lumina of the vascular channels. By electron microscopy the maturation of the neoplastic cells differed considerably from one area to another even in the same section. The immature cells were clustered in groups and consisted of scanty cytoplasm and a large nucleus with prominent nucleoli, whereas some of the mature cells lining the lumina had rod-shaped tubulated bodies (Weibel-Palade bodies). Desmosomes were frequently observed between the neoplastic cells. Basal lamina was generally not continuous or not present although some vascular structures were completely surrounded by a basal lamina. An autopsy was performed but revealed no metastatic lesions in any organs or lymph nodes.

Vascular tumors of the mammary gland. A histochemical and ultrastructural study

A total of five haemangiosarcomata and two benign haemangiomas arising in the mammary gland have been studied electron microscopically and by histochemical techniques. Malignant tumors were mainly composed of endothelial cells reactive to alkaline phosphatase and adenosine triphosphatase, and of pericytes and undifferentiated mesenchymal elements. A juvenile haemangioma showed a more structured wall with an increase of endoplasmic reticulum and filaments, and a diminution of membrane modulations and rod-like tubular bodies. A cavernous haemangioma showed an ultrastructure very similar to normal vessels. The ultrastructural and histochemical data suggest a blood vessel origin of mammary angiosarcomas and show that vascular neoplasms of the breast, benign or malignant, are composed of a combined proliferation of the different cell types present in the vessel wall, as described in other organs.

Vascular tumors in the region of the breast

Three vascular tumors in the breast region with different degrees of differentiation are presented. The first neoplasm is a haemangiosarcoma (of the vascular neoplasms, these tumors are the type which occur most frequently in the breast). Haemangiosarcomas show an infiltrative growth of atypical blood capillaries, frequently with formation of highly cellular and solid capillary sprouts. Ultrastructurally, the tumor cells are characterized as endothelial, also in the region of the capillary sprouts. The second tumor (an angiosarcoma in Stewart-Treves-syndrome, STS) is characterized by an intensive endothelial proliferation. Solid spindle-celled regions are also found in which the tumor cells correspond to undifferentiated mesenchymal cells, but other cells possessing properties of smooth muscle cells and pericytes may be found. The third tumor corresponds light and electron microscopically to a haemangiopericytoma of the soft tissue. The pericytic character of the tumor cells is most clearly seen in the immediate vicinity of the vessels. With increasing distance from the capillaries, the tumor cells take on the characteristics of fibroblasts. The tumors reflect the diversity of the angioplastic differentiation potential of the mesenchyme.

Cellular angiomas of infancy: an ultrastructural study of two cases

Vascular tumors in infants may be clinically disfiguring, requiring surgical intervention. Some of these lesions are histopathologically worrisome, due to increased cellularity and mitotic activity. The interpretation of these lesions is hampered by a surfeit of terminology, although, regardless of the diagnostic name, they are clinically benign. Two such cellular angiomas are reported, one typical and one unusual case. Electron microscopy of both cases demonstrated a heterogeneous cellular composition, primarily endothelial cells and pericytes. In those light microscopic areas of diffuse growth, primitive vascular structures were resolved. Electron microscopy may be diagnostically useful in supporting the light microscopic impression of a vascular tumor.

Malignant hemangioendothelioma (angiosarcoma) of the salivary gland: an ultrastructural study

A case of malignant hemangioendothelioma (angiosarcoma) of the submaxillary salivary gland is reported and its microscopic and ultrastructural features are described and compared to previous reports of angiosarcoma arising in other locations. These tumors may often contain areas of solid sheets of cells without vascular characteristics and may be confused with poorly differentiated carcinoma or other sarcomas. The ultrastructural features of angiosarcoma are compared to other poorly differentiated tumors. It is concluded that the ultrastructural features of angiosarcoma are distinctive and aid in the diagnosis of this neoplasm.

Postmastectomy lymphangiosarcoma: a reappraisal of the concept--a critical review and report of an illustrative case

The syndrome of postmastectomy lymphangiosarcoma (LAS) has been universally accepted since it was first outlined by Stewart & Treves (1948), except for a small number of authors who concluded that the neoplasms arising in the chronic lymphoedematous arms were in fact due to retrograde spread from the original breast carcinoma (Laffargue, Pinet & le Go 1960, Giannardi, Pelù & Zampi 1960, Giannardi & Pelù 1961, Delarue 1962, Salm 1963, Laugier, Olmos, Hunziker & Orusco 1973), but their views have been largely ignored. A case is reported in whom neoplastic arm lesions appeared 27 years after mastectomy and were due, in our opinion, to recent metastases from a new primary Carcinoma of the lung. The validity of the entire concept of LAS is re-examined.

Neoplastic angioendotheliosis: ultrastructural study and review of the literature

Neoplastic angioendotheliosis is a rare disorder characterized by progressive multifocal neurological deficit and dementia. The principal pathological findings are multiple infarcts in the brain and spinal cord and the microscopical demonstration of proliferated neoplastic cells, primarily within the lumens of arteries, arterioles, and capillaries. Vessels of the central nervous system are the most severely affected and appear to be the primary site of neoplastic proliferation. Systemic intravascular and focal extravascular proliferation can also be identified. The endothelial origin of the neoplastic cell with a gradation of changes from normal to neoplastic is demonstrated by the electron microscopical study of involved meningeal vessels. Our patient and those reported in the literature all demonstrate involvement of the central nervous system. In addition, an elevated cerebrospinal fluid protein level is present in all patients for whom that information is available, and fever and renal involvement are frequently present. Steroid therapy is generally ineffective. If the disease is suspected clinically, our studies suggest that meningeal biopsy is the diagnostic procedure of choice to help determine whether chemotherapy should be instituted.

Stewart-Treves syndrome: the histopathological evolution of epithelial metastases

Clinical, histopathologic, and ultrastructural observations in a patient who developed all the characteristics of the Stewart-Treves syndrome 25 years after mastectomy has convinced the authors that the neoplasm arises as a glandular metastasis after an initial phase of sclerosis and that the neoplastic cells are of myoepithelial type.

Angiosarcoma of the skin. A clinicopathologic and fine structural study

A study of ten cutaneous angiosarcomas is presented. These tumors characteristically involve the scalp or face of elderly individuals, where they present as bluish or violaceous plaques and nodules. They have a marked tendency for local spread in surface and depth, and a third of them eventually give rise to distant metastases, particularly to cervical lymph nodes and lung. Microscopically, angiomatous areas of freely anastomosing channels lined by atypical endothelial cells are seen alternating with Kaposi-like spindle cell areas and undifferentiated foci. By electron microscopy, the tumor cells are seen to have all the features of endothelial cells, including pinocytotic vesicles, tubulated bodies, and in one case closed fenestrations. They also exhibit a cytoplasmic specialization here interpreted as the intracellular formation of a vascular lumen. Pericytes and cells resembling smooth muscle cells are also present. In the differential diagnosis this entity has to be distinguished from other clinical types of angiosarcoma of the skin and from a number of benign and malignant conditions. It is suggested that surgery be used for solitary, well circumscribed tumors and radiation therapy for tumors that either are multicentric or have ill defined margins.