Stewart–Treves syndrome—treatment and outcome in six patients from a single centre

Angiosarcoma of the breast: A review

Breast angiosarcoma is a rare and highly aggressive malignancy with a poor prognosis. It can occur spontaneously or be associated with factors such as radiation therapy or chronic lymphedema. The etiology and pathogenesis of this disease are still unclear, the clinical symptoms and imaging findings lack specificity, and the pathological morphology is diverse, which is easy to be confused with other diseases. There is no clear guideline for surgical treatment. Although the optimal surgical approach remains unclear, the ultimate goal is surgical excision with optimal margins, which remains the primary method of treatment. In clinical practice, the choice of the surgical approach should be made by considering the tumor size, pathological type, and patient preferences. In clinical practice, the selection of surgical methods should be carried out with comprehensive consideration of tumor size, pathological types and patients' wishes. There is no clear consensus on whether radiotherapy and chemotherapy should be carried out after surgery, and its optimal program and efficacy are uncertain. This article reviews the etiology, clinical manifestations, pathological features, imaging findings, treatment, prognosis and other aspects of breast angiosarcoma, so as to strengthen clinicians' overall understanding of this disease and avoid missed diagnosis and misdiagnosis.

A retrospective analysis of Stewart-Treves syndrome in the context of chronic lymphedema

BACKGROUND

stewart-treves syndrome (STS) is an angiosarcoma associated with chronic lymphedema.

OBJECTIVES

This article analyses the characteristics of twenty-two patients and proposes active intervention in lymphedema and the early diagnosis of STS.

METHODS

Twenty-two patients with STS were diagnosed at the centre over an 11-year period. Clinical manifestations, a series of conventional analyses, and histopathology were used to study these cases retrospectively.

RESULTS

The age range of 22 patients with STS was 15 to 78 years. The main clinical manifestations included multiple skin and subcutaneous nodules and scattered red or purplish-red rashes in the lymphoedematous limbs. These patients often showed clinical symptoms such as lymphedema, weakness, emaciation, pain, mass, lymphadenopathy and so on. The positive rates of ultrasonography, MRI and radionuclide imaging were 66.7% (6/9), 92.3% (12/13) and 18.2% (2/11), respectively. The main points regarding active intervention in lymphedema and early diagnosis of STS were summarized.

STUDY LIMITATIONS

Since this was a retrospective study, the main points summarized by the author need to be further quantified in clinical work to guide the diagnosis of this kind of disease more conveniently. In addition, further clinical trials are needed to evaluate the role of lymphedema in the occurrence and development of malignant tumors.

CONCLUSIONS

STS can appear in lymphoedematous tissue many years after lymphedema onset. To avoid delays in the diagnosis and therapy of STS, physicians should actively look for signs or symptoms of malignant lymphedema during the follow-up period and promptly manage patients developing problems.

Angiosarcoma of the breast with hypofibrinogenemia: A rare case report and review of the literature

BACKGROUND

Breast angiosarcoma is a rare malignant tumor, accounting for approximately 0.04% of all breast malignancies. Angiosarcoma of the breast with hypofibrinogenemia is even rarer and has not been described in man. Breast angiosarcoma is associated with high metastatic potential and poor prognosis, and there is no specific manifestation in imaging. At present, surgery is considered to be the only effective treatment. There is no unified standard for postoperative adjuvant radiotherapy and chemotherapy.

CASE PRESENTATION

A 30-year-old female patient underwent left breast mass resection under local anesthesia on May 22, 2014. Postoperative pathology showed a vasogenic tumor. On November 10, 2017, she visited us again due to left breast swelling and pain during lactation, and underwent breast mass puncture. She was diagnosed with breast hematoma and fibrinogen reduction. On November 14, 2017, mastectomy was performed under tracheal intubation and general anesthesia, and the fibrinogen gradually returned to normal after surgery. Pathological examination showed a hemangiosarcoma with hematoma formation in the left breast. According to the pathological findings and after comprehensive evaluation, the patient underwent modified radical mastectomy for left breast cancer and right axillary sentinel lymph node biopsy on December 5, 2017. The patient died on January 28, 2018 due to rupture and hemorrhage of liver cancer and hemorrhagic shock.

CONCLUSION

Breast angiosarcoma with hypofibrinogenemia is a rare and highly aggressive malignancy. Clinicians should be familiar with its clinicopathological features and diagnostic criteria. Multidisciplinary approach is recommended to benefit the patients.

Unusual coexistence of Stewart-Treves syndrome and sickle cell anaemia: a case of dual pathology

Chronic lymphoedema can rarely be complicated by an angiosarcoma. This combination called Stewart-Treves syndrome usually observed in upper limb in patients of post-mastectomy with axillary lymph node resection. Here, we report a male patient who had a 10-year history of right leg elephantiasis. Later on, he developed two large ulceronodular masses in the same leg with few satellite nodules in the surrounding skin. With the clinical suspicion of malignancy, a wedge biopsy was performed which revealed histological features of angiosarcoma with sickled red cells. The above knee amputation specimen received further confirmed the histological diagnosis. The investigation for haemoglobinopathy also suggested the presence of sickle cell trait. This report describes a multifocal tumour as a rare manifestation of Stewart-Treves syndrome in a post-filariasis case with sickle cell trait, which is an extremely uncommon combination.

Stewart-Treves syndrome: Case report and literature review

Lymphangiosarcoma, or Stewart-Treves Syndrome (STS), is a very rare skin angiosarcoma with poor prognosis, which usually affects the upper limbs of patients who underwent breast cancer surgery, including axillary dissection followed by radiotherapy (RT). Cutaneous lymphangiosarcomas, which account for approximately 5% of all angiosarcomas, usually originate in the limb with chronic lymphedema. Lymphatic blockade is involved in the onset of STS. RT contributes indirectly to an increased risk of developing STS by causing axillary-node sclerosis and resulting in a lymphatic blockade and lymphedema. Chronic lymphedema causes local immunodeficiency, which indirectly leads to oncogenesis. Currently, axillary nodes are no longer routinely irradiated after axillary dissection, which is associated with a reduction in the incidence of chronic lymphedema from 40% to 4%. The use of sentinel lymph node biopsy technique is also widespread and the associated risk of lymphedema is further reduced. Thus, the incidence of STS decreased significantly with improved surgical and radiation techniques. The overall prognosis of STS patients is very poor. Only early radical surgical removal, including amputation or disarticulation of the affected limb, or wide excision at an early stage offers the greatest chance of long-term survival. Only a few case reports and series with a small number of patients with lymphangiosarcoma can be found in the literature. We present a case report of the first diagnosed STS at our department in an effort to highlight the need of the consideration of developing lymphangiosarcoma in patients with chronic lymphedema.

Primary and secondary breast angiosarcoma: single center report and a meta-analysis

Background

Primary and secondary breast angiosarcoma is a rare and aggressive malignancy with limited published literature. Optimal management is mostly based on expert opinion. Our study aims to describe a single institution experience with breast angiosarcoma and evaluate other publications on this topic to further clarify prognostic outcomes and treatment modalities in this disease.

Methods

Twenty two cases of breast angiosarcoma from Roswell Park Comprehensive Cancer Center were retrospectively analyzed. Additionally, a systemic review and meta-analysis was conducted to study the association between survival outcomes, overall survival (OS), and recurrence-free survival (RFS) in both primary (PAS) and secondary breast angiosarcoma (SAS).

Results

9 PAS patients (41%) and 13 SAS patients (59%) were retrospectively analyzed. No significant differences were noted in tumor characteristics and survival outcomes between PAS and SAS. Treatment modality had no significant effects on survival outcomes although adjuvant chemotherapy demonstrated a trend towards improved RFS in high grade tumors. 380 PAS and 595 SAS patients were included in the outcome meta-analysis. Survival outcomes were significantly worse with high grade tumors and tumor size of > 5 cm. Adjuvant radiation therapy demonstrated significantly better RFS, while adjuvant chemotherapy had no effect on survival outcomes.

Conclusion

Tumor size and grade seem to be reliable predictors of survival in both PAS and SAS. Mastectomy does not seem to be adding any additional benefit to BCS. Adjuvant radiation therapy showed statistically significant RFS benefit, while adjuvant chemotherapy can be beneficial in high grade tumors.

Angiosarcoma complicating lower leg elephantiasis in a male patient: An unusual clinical complication, case report and literature review

Chronic lymphedema is rarely complicated by an angiosarcoma. Angiosarcoma superimposed on chronic lymphedema (Stewart-Treves syndrome) is usually seen post breast cancer surgery accompanied by lymph node resection of the axilla. This is a case report of a 59-year-old male patient with elephantiasis that developed an angiosarcoma of the lower leg. He died a month after the diagnostic biopsy was obtained. This is a rare multifocal tumor in a male with an unusual lower leg location. We reviewed the literature and the need to differentiate this often deadly lesion from a Kaposi's sarcoma.

Sarcomas of the Breast

Sarcoma of the breast is extremely rare and differs from epithelial breast carcinomas in staging and treatment. Diagnostic workup includes breast imaging and core biopsy as in breast epithelial carcinoma. Surgical management is often wide local excision in the form of breast conservation if possible for primary breast sarcoma or total mastectomy. Radiation-associated breast angiosarcomas often require total mastectomy with radical excision of skin. Breast sarcomas have a hematogenous spread so lymph node evaluation is not a part of treatment or staging. Local recurrence rates are high; prognosis remains poor despite on-going advances in the treatment of epithelial breast carcinoma.

Stewart-Treves syndrome following idiopathic leg lymphoedema: remember sarcoma

Patients with skin complaints secondary to oedema are commonly encountered and can be a diagnostic challenge. Here, we present the case of a 78-year-old lady with Stewart-Treves syndrome, a rare cutaneous angiosarcoma. The histology showed angiocutaneous sarcoma with poorly defined margins. The prognosis remains extremely poor. A successful transfemoral amputation reduced the massive tumour burden and cleared a source of sepsis from this fungating tumour. Our aim is to highlight this rare but high-grade sarcoma which results from chronic lymphoedema. The red flag signs of sarcoma are masses greater than 5 cm, tumours which are rapidly growing, deep to fascia or painful, and tumours that recur after previous surgery. Non-healing or progressive ulceration in the background of chronic lymphoedema should raise the possibility of underlying malignancy. We need a low threshold for biopsy and early referral to an appropriate multidisciplinary team for the optimum management of the patient.

The spectrum of rare morphological variants of cutaneous epithelioid angiosarcoma

AIMS

Unusual cytoplasmic alterations have recently been reported in poorly differentiated cutaneous angiosarcoma, making an accurate diagnosis challenging. As these tumours remain poorly documented, we aimed to study their clinicopathological characteristics more comprehensively.

METHODS AND RESULTS

Six cutaneous angiosarcomas with unusual cytoplasmic alterations were identified from referral files. All tumours arose as nodules or plaques (range: 05-195 mm) on sun-damaged skin of the head and neck of elderly males (median age: 76.5 years). Histologically, the tumours were composed of enlarged epithelioid cells showing prominent signet ring (n = 3), foam (n = 2) or granular cell (n = 1) change. Vasoformative elements were only focally noted. By immunohistochemistry, all tumours expressed CD31 and avian v-ets erythroblastosis virus E26 oncogene homologue (ERG). Foam cell change was associated with additional expression of CD68 and CD163. Follow-up (median: 8 months) showed death from disease (n = 1), death from a gastrointestinal bleed (n = 1), and a cutaneous metastasis (n = 1). Only two patients are alive with no evidence of disease.

CONCLUSIONS

Our findings outline the morphological spectrum of cytoplasmic change in cutaneous angiosarcoma. Awareness and a high degree of suspicion in the context of tumours affecting sun-damaged skin of the elderly are necessary to direct appropriate immunohistochemical work-up with inclusion of the endothelial cell markers CD31 and ERG.

[Cutaneous angiosarcoma: new aspects]

Cutaneous angiosarcoma is an aggressive endothelial cell neoplasm with a high associated mortality. Reliable and confident diagnosis is necessary but frequently challenging due to the wide morphological spectrum and broad differential diagnosis of the disease. Furthermore, the final diagnosis often relies on immunohistochemical evidence of endothelial cell differentiation which is further complicated by the lack of sensitivity and specificity of conventional endothelial cell markers. The following article outlines the clinical and histological spectrum of cutaneous angiosarcoma with emphasis on novel findings relating to immunohistochemistry and molecular genetics in the context of the relevant differential diagnosis.

Primary and secondary angiosarcoma of the breast

Angiosarcoma is a rare soft tissue tumor of the breast. It occurs in both a primary form without a known precursor, and a secondary form that has been associated to a history of irradiated breast tissue. These forms differ in many ways including median age, precipitating factors, and presentation. Both forms have a malignant behavior and a poor prognosis. The endeavor of this paper is to review what is known about the presentation, diagnostic and therapeutic modalities to date.

Genomic profiling reveals extensive heterogeneity in somatic DNA copy number aberrations of canine hemangiosarcoma

Canine hemangiosarcoma is a highly aggressive vascular neoplasm associated with extensive clinical and anatomical heterogeneity and a grave prognosis. Comprehensive molecular characterization of hemangiosarcoma may identify novel therapeutic targets and advanced clinical management strategies, but there are no published reports of tumor-associated genome instability and disrupted gene dosage in this cancer. We performed genome-wide microarray-based somatic DNA copy number profiling of 75 primary intra-abdominal hemangiosarcomas from five popular dog breeds that are highly predisposed to this disease. The cohort exhibited limited global genomic instability, compared to other canine sarcomas studied to date, and DNA copy number aberrations (CNAs) were predominantly of low amplitude. Recurrent imbalances of several key cancer-associated genes were evident; however, the global penetrance of any single CNA was low and no distinct hallmark aberrations were evident. Copy number gains of dog chromosomes 13, 24, and 31, and loss of chromosome 16, were the most recurrent CNAs involving large chromosome regions, but their relative distribution within and between cases suggests they most likely represent passenger aberrations. CNAs involving CDKN2A, VEGFA, and the SKI oncogene were identified as potential driver aberrations of hemangiosarcoma development, highlighting potential targets for therapeutic modulation. CNA profiles were broadly conserved between the five breeds, although subregional variation was evident, including a near twofold lower incidence of VEGFA gain in Golden Retrievers versus other breeds (22 versus 40 %). These observations support prior transcriptional studies suggesting that the clinical heterogeneity of this cancer may reflect the existence of multiple, molecularly distinct subtypes of canine hemangiosarcoma.

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.

Use of surgery and mitoxantrone chemotherapy in a dog with disseminated lymphangiosarcoma

CASE DESCRIPTION

A 5-year-old sexually intact male Giant Schnauzer was evaluated because of difficulty breathing and left pelvic limb swelling. Eighteen months previously, the patient had had intermittent left pelvic limb swelling, but the owner declined further testing at that time.

CLINICAL FINDINGS

Physical examination revealed severe pitting edema of the left pelvic limb and prepuce and muffled heart sounds on thoracic auscultation. Results of thoracic radiography and thoracocentesis were consistent with chylothorax, and CT imaging of the thorax and abdomen revealed a mass involving the whole left sublumbar area.

TREATMENT AND OUTCOME

In an attempt to treat the chylothorax, pleural omentalization and pericardectomy were performed. Histologic evaluation of several biopsy specimens harvested in the abdominal and thoracic cavities revealed disseminated lymphangiosarcoma. The patient recovered well from surgery, and mitoxantrone chemotherapy was administered. As of 10 months after surgery, the dog was clinically normal except for mild pelvic limb edema.

CLINICAL RELEVANCE

The combination of clinical signs, multiple imaging features, surgical findings, and histologic examination findings enabled the final diagnosis of lymphangiosarcoma. Clinical management that included medical and surgical treatments and chemotherapy resulted in improved quality of life and extended survival time in a dog with metastatic lymphangiosarcoma.

Pathological steps of cancer-related lymphedema: histological changes in the collecting lymphatic vessels after lymphadenectomy

Introduction

To date, an electron microscopy study of the collecting lymphatic vessels has not been conducted to examine the early stages of lymphedema. However, such histological studies could be useful for elucidating the mechanism of lymphedema onset. The aim of this study was to clarify the changes occurring in collecting lymphatic vessels after lymphadenectomy.

Methods

The study was conducted on 114 specimens from 37 patients who developed lymphedema of the lower limbs after receiving surgical treatment for gynecologic cancers and who consulted the University of Tokyo Hospital and affiliated hospitals from April 2009 to March 2011. Lymphatic vessels that were not needed for lymphatico venous anastomosis surgery were trimmed and subsequently examined using electron microscopy and light microscopy.

Results

Based on macroscopic findings, the histochemical changes in the collecting lymphatic vessels were defined as follows: normal, ectasis, contraction, and sclerosis type (NECST). In the ectasis type, an increase in endolymphatic pressure was accompanied by a flattening of the lymphatic vessel endothelial cells. In the contraction type, smooth muscle cells were transformed into synthetic cells and promoted the growth of collagen fibers. In the sclerosis type, fibrous elements accounted for the majority of the components, the lymphatic vessels lost their transport and concentrating abilities, and the lumen was either narrowed or completely obstructed.

Conclusions

The increase in pressure inside the collecting lymphatic vessels after lymphadenectomy was accompanied by histological changes that began before the onset of lymphedema.

Angiosarcoma of the breast: a difficult surgical challenge

BACKGROUND AND OBJECTIVES

Breast angiosarcoma presents following radiotherapy after breast conserving surgery, in the setting of chronic lymphoedema after axillary dissection or as a primary tumour. The Peter MacCallum Cancer Centre has significant experience due to large breast and sarcoma units and as a primary radiotherapy centre. Our aims were to evaluate the management and locoregional and distant outcomes after breast angiosarcoma.

METHODS

Retrospective study of all patients from the prospective breast and sarcoma databases with a diagnosis of primary or secondary breast angiosarcoma at Peter MacCallum Cancer Centre was performed between January 2000 and December 2010. Mode of presentation, management, loco-regional recurrence and survival rates were reviewed.

RESULTS

Eight women developed angiosarcoma in the setting of breast conservation with a median latency of 7 years post radiotherapy. Six patients had primary breast angiosarcoma. All breast angiosarcomas were managed with total mastectomy with 5 patients requiring autologous tissue transfer. Four patients had adjuvant radiotherapy and three patients had adjuvant paclitaxel. The median follow-up was 2.5 years (6 month-10 years) with 7 episodes of local recurrence in four patients and 7 patients with distal metastases including two deaths from distant disease.

CONCLUSIONS

Primary angiosarcoma occurs de novo, presenting as a breast mass. Secondary angiosarcoma presents predominantly as a skin lesion, in the setting post-operative radiotherapy for breast conserving therapy. Angiosarcoma remains a rare and difficult management problem with poor loco-regional and distal control. Secondary AS is an iatrogenic condition that warrants close follow-up and judicial use of radiotherapy in breast conserving therapy.

Frequency of certain established risk factors in soft tissue sarcomas in adults: a prospective descriptive study of 658 cases

Soft tissue sarcomas are rare tumours with infrequent identified aetiological factors. Several genetic syndromes as well as previous radiation therapy and/or chronic lymphoedema have been suspected to predispose to some soft tissue sarcomas. Between January 1997 and September 2005, we carried out a prospective descriptive study to estimate the frequency of some particular etiological factors among 658 patients with soft tissue sarcomas. Sarcomas associated with a clinically identified genetic disease represent 2.8% out of all cases (95%CI: 1.5–3.8%). Most of these cases (14/19) are related to Recklinghausen neurofibromatosis. Radiation-induced sarcomas represent 3.3% out of all cases (95%CI: 1.7–5.1%). Most of these cases (9/22) are related to prior breast cancer treatment. We had observed only 1 case of Stewart-Treves syndrome. Liposarcoma, the most frequent histological subtype observed, is not associated with any particular aetiological entity. Finally, most of the adult soft tissue sarcomas are not related to any classical clinically identified genetic disease or previous radiation therapy and/or chronic lymphoedema risk factors. Frequency of underlying genetic syndrome which may predispose to soft tissue sarcomas could be higher than previously reported.

Forequarter amputation for malignancy

Background

Forequarter amputation (FQA) is an important treatment for malignant disease of the shoulder girdle. The aim of this study was to elucidate its role in surgical oncology.

Methods

This retrospective study analysed 40 patients who had an FQA. In nine, the chest wall was resected. The most frequent diagnoses were soft-tissue sarcoma (28 patients) and recurrent breast cancer (five).

Results

Median follow-up was 16 (range 1–184) months. The 1-year, 2-year and 5-year overall survival for patients with malignant disease was 71, 59 and 38 per cent respectively. The median time to local recurrence (eight patients) was 4 (range 1–19) months. Thirty-two patients had curative FQA with a 1-year, 2-year and 5-year overall survival of 90, 75 and 48 per cent respectively, and a median overall survival of 51 months. The 5-year overall and disease-free survival for soft-tissue sarcoma was 41 and 26 per cent respectively. Eight patients had a palliative FQA with a median survival of 5 (range 1–12) months.

Conclusion

In locoregional disease such as sarcoma, FQA may offer the only possibility of cure. However, in patients with axillary metastasis, FQA has no impact on survival, although local control may improve the patient's quality of life.

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.

Malignant tumors of blood vessels: angiosarcomas, hemangioendotheliomas, and hemangioperictyomas

Sarcomas that arise from or resemble the components of blood vessels are uncommon and include angiosarcomas, hemangioendotheliomas, and hemangiopericytomas. This article reviews the management of these three types of sarcomas. Diagnosis can sometimes be difficult, with the diagnosis of hemangiopericytoma versus solitary fibrous tumor currently in debate. Each of these sarcomas subtypes has certain unique clinical traits. The mainstay of treatment is surgical resection, sometimes combined with radiation therapy. Adjuvant chemotherapy is unproven but can be considered. For patients with advanced disease, various chemotherapeutic regimens may result in meaningful responses in a minority of patients.

Detection and characterization of vascular endothelial growth factors and their receptors in a series of angiosarcomas

BACKGROUND

Angiosarcomas are malignant mesenchymal neoplasms, including sarcomas of presumptive vascular endothelial origin and sarcomas of probable lymphatic origin. It is, however, often difficult to determine whether they are from blood vascular or lymphatic endothelium. The majority of angiosarcomas are thought to originate from vascular endothelia and spread via bloodstream to lung, but lymphatic metastases can occur.

METHODS

We investigated immunohistochemical expression of vascular endothelial growth factors (VEGF-A, VEGF-C) and their receptors (VEGFR-1, VEGFR-2, VEGFR-3) in a series of 34 angiosarcomas.

RESULTS

VEGF-A was expressed by 32/34 (94%), VEGF-C by 4/34 (12%), VEGFR-1 by 32/34 (94%), VEGFR-2 by 22/34 (65%), and VEGFR-3 by 27/34 (79%). Patients who expressed low or no VEGFR-2 showed a significantly unfavorable prognosis by log-rank test (P = 0.010) and multivariate analysis (hazard ratio, 5.16; 95% CI, 1.40-19.04; P = 0.014). VEGFR-1 and VEGFR-3 were not significantly associated with patients' prognosis.

CONCLUSIONS

VEGF-A and VEGFR-1 were detected in diverse subtypes of angiosarcomas. In cooperation, VEGF-A and VEGF-C are likely to be involved in the development of angiosarcoma associated with lymphedema. VEGF-C expression may cause susceptibility to lymphatic metastasis through tumor lymphangiogenesis. Angiosarcoma of the scalp, which is traditionally considered as a true hemangiosarcoma, may include some cases of lymphatic origin.

Treatment and outcome of 82 patients with angiosarcoma

BACKGROUND

Angiosarcomas are an uncommon type of malignancy that are generally thought to behave usually in a locally aggressive fashion; they often metastasize to distant sites.

METHODS

Patients with a diagnosis of angiosarcoma treated at our institution between 1980 and 2006 were analyzed for patient demographics, tumor characteristics, multimodality treatment, and outcomes.

RESULTS

A total of 82 patients were divided into those with primary and advanced disease. Overall, the median age was 65 (range, 22-91) years, and 44% of patients were women. Median size of tumors was 3.8 cm, and 76% of tumors were intermediate or high grade. Tumors were located throughout the body: 32 cutaneous, 22 deep soft tissues or organs, 10 radiation or lymphedema field, 8 bone, and 7 nonirradiated breast. Of 46 patients with primary disease, all patients underwent surgical resection, 67% received radiotherapy, and 27% received chemotherapy. Five-year disease-specific survival was 60%, and negative prognostic factors included intermediate or high grade, and tumors arising in a radiated or lymphedema field. Of 36 patients with advanced disease, 36% underwent a palliative operation, 78% received radiation, and 58% received chemotherapy. Median survival was just 7.3 months, and cutaneous tumors predicted a better prognosis compared with other sites.

CONCLUSIONS

Primary angiosarcomas treated with aggressive surgical resection and the addition of radiation for close margins or worrisome pathologic features can result in long-term survival in most patients. The role of adjuvant chemotherapy is unclear. Patients with advanced disease have a poor prognosis, but there can be dramatic responses to chemotherapy in a minority of patients.

Primary Angiosarcoma of the Breast: Do Enlarged Axillary Nodes Matter?

Primary angiosarcoma of the breast is a rare and aggressive malignancy that is typically seen in premenopausal patients. The tumor's spread occurs predominantly through the bloodstream; involvement of the lymphatics is unusual. We present a case of breast angiosarcoma presenting with enlarged axillary lymph nodes treated with a modified mastectomy and axillary lymph node dissection. Pathology found no tumor in the lymph nodes. Based on this experience and data from the literature, we suggest evaluation of the sentinel nodes prior to potentially morbid standard level 1 and 2 axillary lymph node clearance.

Postradiation vascular proliferations: an increasing problem

The occurrence of cutaneous vascular lesions is a rare but well-documented complication of radiation treatment and may be associated with significant morbidity as well as mortality. The overall incidence is low but appears to be rising due to a change in the prevailing treatment of breast carcinoma with increased use of radiation in the setting of breast-conserving therapy for stage 1 and 2 disease. The spectrum of postradiation vascular lesions is wide and ranges from atypical vascular lesions with reportedly benign clinical behaviour to frank cutaneous angiosarcoma. There is, however, significant clinical as well as histological overlap. It is frequently difficult to classify these postradiation vascular lesions accurately and they create an emerging diagnostic and therapeutic challenge to both pathologists and clinicians. Experience with these vascular lesions is very limited, and this article aims to provide an overview of our current understanding and concept of radiation-associated vascular lesions with focus on their clinical and histological presentation as well as behaviour and treatment.