Angiosarcoma arising in a chronically lymphoedematous leg

The Unresolved Pathophysiology of Lymphedema

Lymphedema is the clinical manifestation of impaired lymphatic transport. It remains an under-recognized and under-documented clinical condition that still lacks a cure. Despite the substantial advances in the understanding of lymphatic vessel biology and function in the past two decades, there are still unsolved questions regarding the pathophysiology of lymphedema, especially in humans. As a consequence of impaired lymphatic drainage, proteins and lipids accumulate in the interstitial space, causing the regional tissue to undergo extensive and progressive architectural changes, including adipose tissue deposition and fibrosis. These changes are also associated with inflammation. However, the temporal sequence of these events, the relationship between these events, and their interplay during the progression are not clearly understood. Here, we review our current knowledge on the pathophysiology of lymphedema derived from human and animal studies. We also discuss the possible cellular and molecular mechanisms involved in adipose tissue and collagen accumulation during lymphedema. We suggest that more studies should be dedicated to enhancing our understanding of the human pathophysiology of lymphedema to pave the way for new diagnostic and therapeutic avenues for this condition.

Metastatic Angiosarcoma of Lower Extremity

Angiosarcoma (AS) is an uncommon malignant neoplasm characterized by rapidly proliferating, extensively infiltrating anaplastic cells derived from blood vessels. These are aggressive tumors and tend to recur locally, spread widely with high rate of lymph node and systemic metastases. They are more frequent in skin and soft tissue, head and neck being the most common sites. Here we report a case of metastatic AS affecting lower extremity in an elderly patient on a background of chronic lymphedema due to filariasis (Stewart–Treves syndrome).

Pathological changes of adipose tissue in secondary lymphoedema

BACKGROUND

The pathophysiology of lymphoedema is poorly understood. Current treatment options include compression therapy, resection, liposuction and lymphatic microsurgery, but determining the optimal treatment approach for each patient remains challenging.

OBJECTIVES

We characterized skin and adipose tissue alterations in the setting of secondary lymphoedema.

METHODS

Morphological and histopathological evaluations were conducted for 70 specimens collected from 26 female patients with lower-extremity secondary lymphoedema following surgical intervention for gynaecological cancers. Indocyanine green lymphography was performed for each patient to assess lymphoedema severity.

RESULTS

Macroscopic and ultrasound findings revealed that lymphoedema adipose tissue had larger lobules of adipose tissue, with these lobules surrounded by thick collagen fibres and interstitial lymphatic fluid. In lymphoedema specimens, adipocytes displayed hypertrophic changes and more collagen fibre deposits when examined using electron microscopy, whole-mount staining and immunohistochemistry. The number of capillary lymphatic channels was also found to be increased in the dermis of lymphoedema limbs. Crown-like structures (dead adipocytes surrounded by M1 macrophages) were less frequently seen in lymphoedema samples. Flow cytometry revealed that, among the cellular components of adipose tissue, adipose-derived stem/stromal cells and M2 macrophages were decreased in number in lymphoedema adipose tissue compared with normal controls.

CONCLUSIONS

These findings suggest that long-term lymphatic volume overload can induce chronic tissue inflammation, progressive fibrosis, impaired homeostasis, altered remodelling of adipose tissue, impaired regenerative capacity and immunological dysfunction. Further elucidation of the pathophysiological mechanisms underlying lymphoedema will lead to more reliable therapeutic strategies.

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.

Complex karyotype in a case of cutaneous lymphangiosarcoma associated with chronic lymphedema of the lower limb

Lymphangiosarcoma is a rare malignant neoplasm of endothelial cells. The term is used to describe an angiosarcoma associated with chronic lymphedema. The skin of the head and neck region is the most common site of origin. Rather few cytogenetic studies on lymphangiosarcoma are reported in the literature. We here describe a case of an 87-year-old woman, with a history of recurring lymphangitis and with an ulcerated nodular lesion of the leg. The histological diagnosis was a malignant neoplasm of vascular origin, with the morphological and immunohistochemical features of a lymphangiosarcoma. A series of antibodies (CD31, CD34, vimentin, podoplanin and HHV-8), conventional and molecular cytogenetic and Spectral Karyotyping (SKY-FISH) analyses were used to study this case. The immunohistochemical evaluation revealed that the neoplasm was positive for vimentin, CD31, CD34 and podoplanin and negative for HHV-8. The proliferation rate (Ki-67) was about 70%. Karyotype was defined using conventional cytogenetic and SKY-FISH. In addition, high-level of amplification was observed with MYC split signal probe. The morphological and immunohistochemical evaluations supported the diagnosis of lymphangiosarcoma. Moreover, the cytogenetic and molecular findings contributed towards accurately defining the karyotypic aberrations of this rare sarcoma.

Cutaneous angiosarcoma in chronic lymphedema: secondary to filariasis

Cutaneous angiosarcoma is a very aggressive tumor with poor prognosis. We report a case of cutaneous angiosarcoma in a patient with elephantiasis. To the best of our knowledge, there are very few cases reported in the literature. As there is no ideal treatment for cutaneous angiosarcoma, early detection can lower the morbidity and mortality from this malignancy.

Lymphedema: a comprehensive review

BACKGROUND

Lymphedema is a chronic, debilitating condition that has traditionally been seen as refractory or incurable. Recent years have brought new advances in the study of lymphedema pathophysiology, as well as diagnostic and therapeutic tools that are changing this perspective.

OBJECTIVE

To provide a systematic approach to evaluating and managing patients with lymphedema.

METHODS

We performed MEDLINE searches of the English-language literature (1966 to March 2006) using the terms lymphedema, breast cancer-associated lymphedema, lymphatic complications, lymphatic imaging, decongestive therapy, and surgical treatment of lymphedema. Relevant bibliographies and International Society of Lymphology guidelines were also reviewed.

RESULTS

In the United States, the populations primarily affected by lymphedema are patients undergoing treatment of malignancy, particularly women treated for breast cancer. A thorough evaluation of patients presenting with extremity swelling should include identification of prior surgical or radiation therapy for malignancy, as well as documentation of other risk factors for lymphedema, such as prior trauma to or infection of the affected limb. Physical examination should focus on differentiating signs of lymphedema from other causes of systemic or localized swelling. Lymphatic dysfunction can be visualized through lymphoscintigraphy; the diagnosis of lymphedema can also be confirmed through other imaging modalities, including CT or MRI. The mainstay of therapy in diagnosed cases of lymphedema involves compression garment use, as well as intensive bandaging and lymphatic massage. For patients who are unresponsive to conservative therapy, several surgical options with varied proven efficacies have been used in appropriate candidates, including excisional approaches, microsurgical lymphatic anastomoses, and circumferential suction-assisted lipectomy, an approach that has shown promise for long-term relief of symptoms.

CONCLUSIONS

The diagnosis of lymphedema requires careful attention to patient risk factors and specific findings on physical examination. Noninvasive diagnostic tools and lymphatic imaging can be helpful to confirm the diagnosis of lymphedema or to address a challenging clinical presentation. Initial treatment with decongestive lymphatic therapy can provide significant improvement in patient symptoms and volume reduction of edematous extremities. Selected patients who are unresponsive to conservative therapy can achieve similar outcomes with surgical intervention, most promisingly suction-assisted lipectomy.

Angiosarcoma in a Chronically Lymphedematous Leg: An Unusual Presentation of Stewart-Treves Syndrome

Angiosarcoma arising from chronic lymphedema is referred to as Stewart-Treves syndrome. It typically occurs as a complication of long-lasting lymphedema of the arm after mastectomy and/or radiotherapy for breast cancer. Angiosarcoma associated with idiopathic lymphedema of the lower extremity is extremely rare. We report a case of diffuse angiosarcoma of the leg in a patient with a 25-year history of idiopathic lymphedema. Despite rapid aggressive surgical treatment, the patient died 6 weeks after diagnosis.

Lymphedema: an immunologically vulnerable site for development of neoplasms

Lymphedema is the result of accumulation of protein-rich interstitial fluid (lymph stasis) caused by a failure of lymph drainage in the face of a normal capillary filtration. Whether the origin is congenital or acquired from infection, radiation, trauma, or surgery, chronic lymph stasis impairs local immune surveillance by disrupting trafficking of the immunocompetent cells in the lymphedematous district and stimulates vicarious angiogenesis by promoting development of a collateral lymphatic and hematic network in the lymphedematous district. When the local mechanisms of immune surveillance begin to fail, the lymphedematous region becomes an immunologically vulnerable area, predisposed to malignancy, chiefly vascular tumors such as Stewart-Treves syndrome and Kaposi's sarcoma, because of the continual angiogenic stimulus.

Stewart-Treves syndrome in a patient with elephantiasis

Angiosarcoma that develops in areas of chronic lymphedema is also called Stewart-Treves syndrome. It usually appears in areas of lymphedema several years after mastectomy for breast carcinoma. Only 10% of these angiosarcomas occur in areas of chronic lymphedema as a result of another cause. We present a patient with epithelioid angiosarcoma as a rare complication of elephantiasis.

Chronic lymphoedema and angiosarcoma

Angiosarcoma has frequently been described arising within chronic lymphoedema of the upper limb following mastectomy and radiotherapy for carcinoma of the breast. We report a case of angiosarcoma arising in a lymphoedematous leg that had been subjected to radiotherapy 20 years previously for Hodgkin's disease. The diagnosis was expedited once the patient noticed the development of bleeding nodules. Prognosis of angiosarcoma is poor with treatment options being wide-excision surgery, palliative radiotherapy or chemotherapy. Unusual bruised areas or bleeding nodules developing within chronic lymphoedematous limbs should be biopsied to exclude the diagnosis.