Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 18-1993. A 57-year-old man with chronic lymphedema and enlarging purple cutaneous nodules of the leg

Clinical update on cutaneous and subcutaneous sarcomas

BACKGROUND

Cutaneous sarcomas are uncommon cancers that can have a wide range of clinical symptoms and lead to considerable cutaneous as well as systemic morbidity.

AIM

The objective of this review article is to discuss epidemiology, clinical features, diagnosis, and therapy of different types of cutaneous sarcomas.

MATERIAL AND METHODS

Literature was screened to retrieve articles from PubMed/Medline and Google Scholar and related websites. Cross-references from the relevant articles were also considered for review. Review articles, clinical studies, systematic reviews, meta-analyses, and relevant information from selected websites were included.

RESULTS AND DISCUSSION

Cutaneous sarcomas have a negative effect on the quality of life. In their diagnosis, clinical presentation and histological evaluation are crucial. Complete surgical removal is the solution for more or less all cutaneous and subcutaneous sarcomas. The prognosis for cutaneous sarcomas is generally favorable since they tend to recur locally with distant metastases only on rare occasions. Patients having advanced disease should be treated in the setting of clinical trials if possible; choices include radiation therapy and systemic medicines. The value of innovative immunotherapy cannot be determined decisively at this time due to a paucity of relevant trials.

CONCLUSION

As cutaneous sarcomas are rarely diagnosed based on clinical findings, histology plays an important role in the diagnosis. They have a relatively favorable prognosis if treated properly. Patients should be treated at specialized centres.

Angiosarcoma after excisional surgery for chronic lymphedema

Angiosarcoma is a rare soft tissue sarcoma of endothelial cell origin. It can arise from the endothelium of lymphatics (lymphangiosarcoma) or blood vessels (hemangiosarcoma). Chronic lymphedema of any origin is associated with its development. Few cases have been reported after surgical procedures for lymphedema. Here, we report one case of angiosarcoma that developed 15 months after excisional surgery for lymphedema. In spite of radical surgery and adjuvant chemoradiotherapy, the patient died of multiple lung metastases and pleural effusion 13 months later.

Lymphangiosarcoma: Is Stewart-Treves Syndrome a Preventable Condition?

BACKGROUND

Stewart-Treves syndrome is a rare complication of breast cancer treatment, representing a lymphangiosarcoma commonly associated with lymphedema and severely impacting patient's outcome. The tumor typically develops in the atrophic, pachydermatous, hyperkeratotic skin of limbs affected by long-standing lymphedema. Clinical data associated with Stewart-Treves syndrome and lymphedema management have rarely been published.

METHODS AND RESULTS

In the period between 1980 and 2009, ten patients with Stewart-Treves syndrome were diagnosed and treated at the Foeldiklinik, Hinterzarten, Germany. Nine of the ten patients were female. Five patients had previously suffered from breast cancer (and were treated with mastectomy); two from other malignancies; two patients had primary lymphedema, and one had undergone lower extremity lymphadenectomy. All cancer patients had undergone radiation treatment. In all cases, the sarcoma developed in non-irradiated areas 6-48 years (average 16.3 years) after the onset of lymphedema. None of the patients had received complex decongestive physical therapy (CDT). Two patients had above-elbow amputation, one had shoulder exarticulation, two patients had wide excision and skin grafting, two patients had above-knee amputation procedure, two patients had a below-knee amputation procedure, and one patient had no surgical treatment at all. The time to recurrence after surgery, time to metastasis, patient survival and CDT were recorded.

CONCLUSIONS

Patients with lymphedema should be closely examined starting 5 years from the time of lymphedema onset, paying special attention to those with associated malignancies. Only early diagnosis and treatment by radical ablative surgery confers a reasonable prognosis with this rare but aggressive disease. A potential effect of CDT on lymphangiosarcoma has to be studied in a greater patient cohort.

Cutaneous lymphangiosarcoma following chronic lymphedema of filarial origin

We are reporting a case of 36 yr old female with chronic filarial lymphedema of both legs. Subsequently she developed lymphangiosarcoma of her left leg which was confirmed histologically and on immunohistochemistry. Only three more cases of lymphagiosarcoma occurring in patients with filarial lymphedema are reviewed from available literature.

Angiosarcoma in an area of lipodermatosclerosis

We present an unusual case in a post phlebitic lower limb that had previously developed an area of lipodermatosclerosis. An area within this broke down as a result of an angiosarcoma rather than the more probable: formation of a venous ulcer.

Role of surgery in the management of postmastectomy extremity angiosarcoma (Stewart-Treves syndrome)

Stewart-Treves syndrome (STS) is the rare occurrence of angiosarcoma in a setting of postmastectomy upper extremity lymphedema. A collective comparison of outcomes following various initial treatment options in STS has not previously been reported. We reviewed 160 cases of STS reported in the literature since 1966. We analyzed the relationship between initial treatment and survival in all 92 of these patients for whom detailed treatment and outcome data had been reported. There was no significant difference in survival comparing those initially treated with wide excision (n = 16) and those treated with amputation (n = 45) (P = 0.40). Even in the setting of initial surgical treatment, overall long-term survival was poor (<40%). There have been even fewer long-term survivors among those treated initially with regional chemotherapy (n = 7) or radiation therapy (n = 24). An update on STS and a discussion of recent advances in the understanding of its molecular pathogenesis that may result in future treatment improvements are presented.

Lymphangiosarcomata--experience in a lymphoedema clinic

Two cases of patients attending a lymphoedema clinic and developing lymphangiosarcomata are described. The epidemiology, natural history and management of this uncommon malignancy are discussed and the pertinent features that should be sought by professionals involved in routine follow-up of patients prone to lymphoedema outlined.