Molecular Pathogenesis of Vascular Anomalies: Classification into Three Categories Based upon Clinical and Biochemical Characteristics

Role of ultrasound and colored Doppler examination in the diagnosis and the classification of the superficial soft tissue vascular anomalies

Background

Vascular anomalies are congenital lesions of abnormal vascular development, and a primary distinction have to be made between a vascular tumor and a vascular malformation, hemangiomas are considered the commonest vascular tumor, correct diagnosis is imperative for appropriate treatment. In this report, we tried to verify the role of ultrasonography and Doppler examination in the initial diagnosis, the classification of vascular anomalies and in the post-treatment follow-up.

Results (main findings)

This report included cases of vascular anomalies who attended the interventional radiology department as well as the vascular anomaly clinic in Abo El-Rish hospitals during the period 2019 through 2021. Data of all patients attending the clinic were prospectively examined. Files of 60 cases with vascular anomalies were available for review. The diagnosis of vascular anomalies was done according to their history and characteristic findings at clinical examination as well as U/S and color Doppler examinations, MRI and angiographic studies were done as needed. A significant female predominance was noticed. A significant predominance in the head and neck region was noticed (60%). Treatment was individualized according to each case; propranolol was chosen as the first line of treatment in IH. Intra-lesional steroids injections were done in hemangiomas, and intra-lesional bleomycin was done in venous and lymphatic malformations, endovascular embolization was done in high flow vascular malformations.

Conclusion

Ultrasound and color Doppler examination were effective and accurate methods in the diagnosis, the classification of superficial soft tissue vascular anomalies, the detection of early complications and in the follow-up after different treatment methods applied, it was also beneficial in the exclusion of non-vascular lesions.

Orbital Vascular Anomalies: A Nomenclatorial, Etiological, and Nosologic Conundrum

PURPOSE

Vascular anomalies are a heterogeneous group of disorders that frequently present in the periorbital region. They encompass 2 broad entities: vascular tumors, which possess a proliferative endothelium, and vascular malformations, which are basically localized defects of vascular morphogenesis. The primary goal of this review was to address inaccurate or controversial terminology in the oculoplastic literature concerning orbital and periorbital vascular anomalies and to categorize these lesions in an abridged and simplified hierarchical list that adheres as much as possible to the most recent (2018) iteration for the classification of vascular lesions proposed by the International Society for the Study of Vascular Anomalies (ISSVA). The secondary goal of this review was to review and update information regarding the genetic underpinnings of vascular anomalies and the downstream signaling pathways that are subsequently affected as a result of these genetic errors.

METHODS

A literature review was conducted in PubMed, MEDLINE, PubMed Central, National Center for Biotechnology Information Bookshelf, and Embase for several related keywords including "vascular anomalies, vascular malformations, vascular tumors, and cavernous venous malformation," both with and without adding the keywords "eyelid," "orbital," and "periorbital." In addition, a detailed search was conducted for controversial or obsolete keywords like "cavernous hemangioma," "lymphangioma," and "varices," again in their systemic and orbital/periorbital context.

RESULTS

Crucial issues in the 2018 ISSVA classification regarding the proper categorization of orbital vascular anomalies, particularly venous lesions, were critically evaluated and revised, and a regional, simplified, and abridged modification of the ISSVA 2018 classification was proposed.

CONCLUSIONS

Interdisciplinary and intradisciplinary dialogue concerning orbital vascular anomalies is seriously compromised due to the lack of a unanimous agreement on terminology and the absence of a unified classification concept system. The authors recommend that oculoplastic surgeons adopt ISSVA terminology whenever technically possible and scientifically sound. However, they also propose modifying the ISSVA 2018 classification specifically to adapt to the peculiarities of vascular anomalies in the periorbital region. At present, the simplified classification proposed here is a preliminary first step towards managing patients with orbital vascular anomalies with greater diagnostic and therapeutic precision, until such time in the future when the entire genetic makeup of orbital vascular anomalies is more completely elucidated. Optimistically, this could pave the way for a more robust classification and the ultimate therapeutic cure.

A rare case of mediastinal lymphatic venous malformations in children

We report a case of mediastinal lymphatic venous malformations (LVM) in a 11-year-old boy who presented with chest pain after jumping into a swimming pool, with review of the literature. A superior mediastinal mass was incidentally found from the chest x-ray. Chest computed tomography revealed a large heterogenous mass at the left-sided mediastinum containing fat, minimal enhancing solid portion, non-enhancing cystic portion and calcification. Because of the large size of the mass, the patient underwent tumour removal. Operative findings gave a definitive diagnosis of mediastinal LVM. The patient had an uneventful clinical course and was discharged without complication. This report highlights that it is possible to misdiagnose mediastinal LVM especially if its predominant portion is lymphatic tissue with only minimal contrast enhancement. Tissue biopsy must be avoided because it may lead to haemorrhagic complication.

Unusual Gigantiform Angiomatosis of Jawbone

ABSTRACT

The purpose of this paper is to highlight rare highly infiltrative massive Angiomatosis and depict surgical outcome of a rare case series of gigantic lesions in the maxillofacial region. Data were recorded from the medical records of patients. Predictor variables were drawn from demographics, age, gender, site, evaluation of surgical treatment. The outcome variables were the challenges encountered and related complications. Out of 6 patients, the youngest was 10 and the oldest was 26 years old. Soft tissue and jawbone involvement were seen in 3 patients each with a single massive lesion involving both maxilla and mandible. All 6 patients had wide excision of the lesion with one patient having 2 stage procedures. No complications or recurrence was seen at 1-year follow-up. Angiomatosis is a rare and benign lesion in the head and neck region. Its diffuse infiltrating nature may give a false malignant picture. It clinically mimics Hemangioma or Arteriovenous (AV) malformation thus requires thorough evaluation and its surgical intervention is challenging as described in this case series because of its magnitude and infiltrative nature.

Mediastinal venolymphatic malformations mimicking thymic carcinoma

This report was about a 60‐year‐old asymptomatic female patient who presented to our clinic with an anterior mediastinal mass found on routine chest computed tomography (CT). Chest CT revealed an irregular poorly enhanced anterior mediastinal mass which showed signs of infiltration to adjacent structures with sparse calcifications. The preliminary diagnosis was thymic carcinoma. The patient underwent extended thymectomy via median sternotomy and complete excision of the tumor. A small draining vein to the left brachiocephalic vein and phleboliths were identified in the tumor. A definitive diagnosis was made of mediastinal venolymphatic malformation (VLM). The patient had an uneventful clinical course and was discharged without further complication. This report highlights that it is possible to misdiagnose mediastinal VLM as thymic carcinoma and could serve as a useful reminder to physicians in the future.

Effectiveness and Safety of Treatment with Direct Oral Anticoagulant Rivaroxaban in Patients with Slow-Flow Vascular Malformations: A Case Series

BACKGROUND

Slow-flow vascular malformations (VM) can be associated with localized intravascular coagulopathy (LIC) that is characterized by elevated D-Dimer levels and low fibrinogen and platelets. This can lead to bleeding and clotting tendencies, which can give rise to functional limitations such as pain and swelling and even progress to disseminated intravascular coagulopathy.

METHODS AND RESULTS

We conducted a chart review of four patients with evidence of LIC who were started on rivaroxaban. We found an improvement of D-Dimer and/or fibrinogen levels in all four patients. They also had an improvement of pain and functionality.

CONCLUSIONS

We report on four patients in whom anticoagulation with a direct oral anticoagulant, rivaroxaban, was effective in controlling signs and symptoms of consumptive coagulopathy with no evidence of bleeding from the use of rivaroxaban.

Surgical management of vascular anomalies in children at a tertiary care hospital in a resource-limited setting: a Tanzanian experience with 134 patients

BACKGROUND

Vascular anomalies pose major diagnostic and therapeutic challenges among pediatricians and pediatric surgeons practicing in resource limited countries. There is paucity of published data regarding this subject in Tanzania and Bugando Medical Centre in particular. This study describes our experiences on the challenges and outcome of surgical management of childhood vascular anomalies in our environment.

METHODS

Between January 2009 and December 2013, a prospective study on the surgical management of vascular anomalies was undertaken at Bugando Medical Centre.

RESULTS

A total of 134 patients (M; F = 1:2.5) were studied. The median age at presentation was 6 years. Of the 134 patients, 101 (75.4%) were diagnosed as having vascular tumors and 33 (24.6%) had vascular malformations. The head and the neck were the most frequent anatomical site recorded as having a tumor (56.7% of patients). Out of 134 patients, 129 (96.3%) underwent surgical treatment. Failure to respond to non-operative treatment (86.8%), huge disfiguring/obstructing mass (4.7%), infection (3.1%), ulceration (3.1%) and hemorrhage (2.3%) were indications for surgical intervention. Tumor excision and primary wound closure was the most common type of surgical procedure performed in 80.6% of patients. Surgical site infection was the most frequent complications accounting for 33.8% of cases. Mortality rate was 1.5%. Tumor excision and primary wound closure gave better outcome compared with other surgical options (p < 0.001). Outcome of injection sclerotherapy in 3 (3.7%) children, serial ligation of feeder vessels employed in 2 (1.6%), and conservative treatment in 5 (3.7%), were poor and required conversion to surgical excision. Despite low mortality rate recorded in this study, but ugly scar, 14 (20.6%) and limb deformity, 6 (8.8%) were problems. The overall result of surgical treatment at the end of follow up period was excellent in 108 (87.1%) patients.

CONCLUSION

Surgical excision and primary wound closure gave good outcome which could be employed in complicated and vascular anomalies which failed to respond to other treatment in regions with limited resources.

A case of vascular malformation of the neck

Vascular malformations are rare congenital vascular anomalies composed of inappropriately connected vasculature. They are usually present at birth, are progressive, infiltrative and require intervention. Vascular malformations need to be differentiated from haemangiomas which are congenital vascular neoplasms. We present a case of vascular malformation in a 6-year old child who presented with a progressive swelling in the neck and was treated by surgical excision. This case is being presented because of its peculiar clinical presentation.

Aspirin therapy in venous malformation: a retrospective cohort study of benefits, side effects, and patient experiences

Venous malformations (VMs) are often painful and may enlarge over time. Chronic coagulopathy is common in VMs and may contribute to phleboliths and potentially to disease progression. Few studies have examined the effects of anticoagulation on VMs and to our knowledge none have examined the use of aspirin therapy. A survey was administered to patients and parents of patients with VMs who attended the University of California at San Francisco Vascular Anomalies Center over a 4-year period (2008-2012) to whom aspirin had been recommended. They were surveyed regarding whether they were taking aspirin and, if yes, whether aspirin had resulted in any appreciable benefit. Sixty-five letters were sent to potential subjects: 38 participated and 27 declined to participate or could not be contacted. Twenty-eight of the 38 had begun aspirin and 22 reported current use. Seventeen reported some benefit, including less aching (n = 2), less shooting pain (n = 15), less fullness and swelling (n = 13), and shrinking of the VM (n = 1). Discontinuation of aspirin was associated with worsening VM symptoms in five of six patients. Side effects were reported in 6 of 28 patients, including five episodes of minor bleeding or excessive bruising and one of nausea and vomiting. This study suggests that aspirin may be a beneficial treatment for VM, with a reduction in pain and soft tissue swelling and an acceptable side-effect profile, but the retrospective nature of the study and the small size of the cohort limited our conclusions. Larger prospective studies of aspirin for VM using clinical and laboratory outcome measures are needed to confirm these observations.

Dermoscopy, confocal laser microscopy, and hi-tech evaluation of vascular skin lesions: diagnostic and therapeutic perspectives

Vascular skin lesions comprise a wide and heterogeneous group of malformations and tumors that can be correctly diagnosed based on natural history and physical examination. However, considering the high incidence of such lesions, a great number of them can be misdiagnosed. In addition, it is not so rare that an aggressive amelanotic melanoma can be misdiagnosed as a vascular lesion. In this regard, dermoscopy and confocal laser microscopy examination can play a central role in increasing the specificity of the diagnosis of such lesions. In fact, the superiority of these tools over clinical examination has encouraged dermatologists to adopt these devices for routine clinical practice, with a progressive spread of their use. In this review, we will go through the dermoscopic and the confocal laser microscopy of diagnosis of most frequent vascular lesions (i.e., hemangiomas angiokeratoma, pyogenic granuloma, angiosarcoma) taking into particular consideration the differential diagnosis with amelanotic melanoma.

Early Surgical Excision of Giant Congenital Hemangiomas of the Scalp in Newborns: Clinical Indications and Reconstructive Aspects

Background:

Infantile hemangioma is the most common vascular tumor in newborns, with an incidence from 12 to 23% among preterm infants with low weight at birth and a female to male ratio of 3:1. The head and neck is the most frequently affected area (60%), and the scalp is a typical site for such large lesions.

Objective:

We describe some clinical and medical aspects in comparison with the surgical approach to giant infantile hemangioma of the scalp.

Methods:

The indications to treatment are discussed. An outcome basis evaluation, by reviewing some clinical cases, is provided to help readers better understand when and how to undergo surgery safely.

Conclusion:

Early excision of huge infantile hemangioma of the scalp is the treatment of choice if feasible within 5 months of age.

Pathogenesis of infantile hemangiomas

1.Review the key features of the life cycle of infantile hemangiomas.2.Highlight cellular and molecular pathways involved in hemangioma-genesis.3.Discuss theories that may account for hemangioma-genesis.In the past, it was believed that a mother's visual impressions or behavior during pregnancy caused the growth of infantile hemangioma in her unborn child. She might have had an excessive craving for strawberries, witnessed the slaughter of an animal, directly contacted human or animal blood, or mocked a child with a similar birthmark.1 This folklore began to slowly fade once hemangiomas were examined through the light microscope. In 1863, Virchow2 suggested that hemangiomas are composed of proliferating new blood vessels resulting from progressive irritation of tissue. In 1933, Laidlow and Murray3 proposed a phylogenetic origin for hemangiomas and hypothesized that hemangiomas are remnants of vascular tufts functioning as accessory lungs for primitive amphibia. Pack and Miller4 (1950) hypothesized that hemangiomas develop from embryonic islands of angioblastic cells that were isolated from the systemic vasculature during fetal development.

Lymphatic and venous malformation or "lymphangiohemangioma" of the anterior mediastinum: case report and literature review

Lymphatic and venous malformations (LVM) are tumor-like lesions combining dysplastic lymphatic and venous vessel structures. They are rarely found in the mediastinum. We present a case of mediastinal LVM, with review of the literature. An asymptomatic 60-yearold man presented for evaluation of an anterior mediastinal mass. On chest computed tomography (CT), the mass demonstrated contrast enhancement and its 7-mm vein draining directly into the left brachiocephalic vein. The tumor was resected completely using video-assisted thoracoscopic surgery. The surgical specimen revealed combined features of venous and lymphatic dysplasia, and was diagnosed it as LVM, so-called mediastinal lymphangiohemangioma. Management plans based on precise imaging studies using magnetic resonance imaging and multi-detector-row CT phlebography could be helpful in guiding both preoperative diagnosis and subsequent treatment decisions for mediastinal LVM.

Sclerotherapy for vascular malformations in the oral and maxillofacial region: treatment and follow-up of 66 lesions

PURPOSE

The aim of the present study was to relate the use of 5% monoethanolamine oleate in sclerotherapy for vascular malformations and to suggest a protocol for its use.

PATIENTS AND METHODS

A total of 53 patients with 66 vascular malformation lesions were treated with an intralesional injection of 5% monoethanolamine oleate at 0.1 mL/cm of lesion with at least a 15-day interval and as many as 4 applications. A descriptive statistical analysis was performed using SigmaPlot, version 9.0, software.

RESULTS

The treatment with the protocol suggested was effective in 65 cases, and in 1 case, surgical intervention was required.

CONCLUSIONS

Sclerotherapy was effective in the treatment of vascular malformations, and the method chosen was adequate for lesion resolution without complications.

Differentiation of vascular tumors from vascular malformations by expression of Wilms tumor 1 gene: evaluation of 126 cases

BACKGROUND

Vascular tumors and malformations can be challenging to diagnose. Although they may initially appear very similar, they have distinct clinical courses and management. Wilms tumor 1 (WT1) gene expression has been reported in many different tumors including hematologic malignancies and some solid tumors.

OBJECTIVE

We sought to evaluate the expression of WT1 in 126 vascular lesions (64 vascular tumors, one Masson tumor, and 61 vascular malformations).

METHODS

Based on the International Society for the Study of Vascular Anomalies classification of vascular anomalies, we studied the expression of WT1 in vascular tumors composed of infantile hemangioma, congenital hemangiomas (non-involuting, rapidly involuting, and not otherwise specified), pyogenic granuloma, tufted angioma, cherry angioma, Kaposi sarcoma, and angiosarcoma. We also studied WT1 expression in vascular malformations composed of angiokeratoma/verrucous hemangioma, combined vascular malformations, venous malformations, glomuvenous malformations, lymphatic malformations/lymphangioma, telangiectasia, and targetoid hemosiderotic hemangioma.

RESULTS

All vascular tumors and proliferations had positive WT1 cytoplasmic endothelial immunostaining whereas only 3 vascular malformations were WT1 positive. Moreover the positivity of WT1 in these vascular malformations was focal and involved only re-endothelialized neovessels within thrombi.

LIMITATIONS

The low number of malignant vascular tumors is a limitation.

CONCLUSIONS

Immunohistochemical detection of WT1 could be a useful tool to routine evaluation of vascular anomalies allowing the distinction of vascular tumors and proliferations from vascular malformations. Staining for WT1 may guide the clinician in difficult cases, as positive results would suggest a proliferative vascular lesion whereas negative results might point to a vascular malformation.

Recent progress in studies of infantile hemangioma

A hallmark of infantile hemangioma, the most common tumor of infancy, is its dramatic growth after birth, by diffuse proliferation of immature endothelial cells, followed by spontaneous regression. The growth and involution of infantile hemangioma is quite different from other vascular anomalies, which do not regress and can occur at any time during life. Some hemangioma lesions can be extremely disfiguring and destructive to normal tissue and may even be life-threatening. Unfortunately, existing therapeutic approaches have limited success and significant adverse effects of some treatment modalities limit their use. Better understanding of the pathogenesis of hemangioma will enable the development of better therapeutic strategies. Here, we review recent studies and new hypotheses on the pathogenesis of the tumor. Detailed mechanisms of activated vascular endothelial growth factor signaling in tumor cells, identification of their origin and characterization of multipotent stem cells that can give rise to infantile hemangioma are shedding new light on this intriguing vascular tumor.

Clinical course of arteriovenous malformations of the head and neck: A case series

Objective: To demonstrate, in a case series, the relentless growth of arteriovenous malformations (AVMs) of the head and neck and the importance of their vigilant management within the context of a modified staging system.

Study Design: Retrospective review.

Setting: Tertiary care institution, Vascular Anomalies Center.

Subjects and Methods: Subjects were patients with advanced AVMs presenting to our Vascular Anomalies Center. Medical records were examined for age at first diagnosis, disease course, prior treatments, age at presentation, management, therapeutic outcomes, stage of disease, and impact on quality of life. Early patient photographs were evaluated.

Results: Ten patients (ages 13-46 yrs) with extensive cervicofacial AVMs were examined. Progressive growth, worsening symptoms, and graduated disease stage were universally experienced by each patient, as evident by serial photographs, over a course of many years. Each patient presented to our institution with massive lesions, bleeding, pain, and facial destruction. Prior embolization and/or surgery had been performed in all but one patient. Every patient had been previously told that their AVMs were incurable or that treatment options were exhausted. The patients were subsequently treated at our institution with surgical resection with or without preoperative embolization. Disease control, symptom improvement, and enhanced daily functioning were attained in each patient.

Conclusion: The natural course of AVMs is progressive, invasive, and destructive. Vigilant observation, early treatment, and radical therapy are necessary for AVMs of the head and neck.

Presence of a distinct neural component in congenital vascular malformations relates to the histological type and location of the lesion

Congruency of the development of peripheral nerves and blood vessels has been well described, and usually, the nerves and blood vessels follow each other during development. Although little is known about the existence of a substantial neural component in vascular malformations, we investigate the presence of an intralesional component of nerve bundles in congenital vascular malformations of soft tissues. Resection specimens of 130 congenital vascular malformations of soft tissue were retrospectively screened for the presence and extent of intralesional mature nerves bundles. Lesions were histologically categorized in arteriovenous malformations (n = 83), pure venous malformations (n = 33), and lymphatic-venous malformations (n = 14). For identification of nerves, all sections were immunostained with anti-S100. GLUT-1 immunostaining excluded the presence of infantile hemangiomas in these series. Of 130 cases, 96 (74%) showed a substantial increase of intralesional nerves in close apposition to the vessels. The nervous component appeared to be more extensive in the head and neck region and upper extremities than in malformations of other topographic sites. Most cases of arteriovenous malformations showed an increase in nerve elements (87% of all arteriovenous malformations), which was more than in pure venous malformations (55%). In cases of lymphatic-venous malformations, the areas composed of lymphatic vessels showed an almost complete absence of nerves. Prior surgery in the malformation gave no different nerve pattern compared to cases that were surgically treated for the first time. The abundant presence of intralesional mature nerves in most congenital vascular malformations suggests that at least in a large subset of lesions, neural components are an integral part of the developmental disorder. This is particularly evident in the arteriovenous type of malformations and lesions that arise in the head and neck region of the body.

Aortic coarctation complicated with multiple saccular aortic aneurysms

Aortic coarctation is a congenital malformation of the aorta that should be diagnosed and corrected early in life. The natural history of unrepaired coarctation of the aorta includes the development of systemic hypertension and subsequent morbidity and death from cardiovascular disease. Here, we present a case with replacement of the aortic arch and its branches by tortuous multilobulated aneurysms as a result of untreated aortic coarctation.

Update on hemangiomas and vascular malformations of the head and neck

Although the current classification systems of vascular malformations and hemangiomas are increasingly accepted, there are nonetheless several aspects that show us how special and at the same time difficult it is to diagnose, evaluate, and treat some of those diseases. Close interdisciplinary cooperation of all involved disciplines is essential; the discussion of the adequate individual procedure must be performed in angioma boards, as it is already well established in the context of tumor boards. The interface of angioma therapy and tumor therapy seems to be very close, which is certainly true for the aspect of angiogenesis and of course for the inhibited proliferation as promising therapeutic approach of complex vascular malformations. This leads to another obvious necessity of intensifying experimental scientific research on vascular malformations and hemangiomas, which is a precondition for optimizing or elimination of different current problems and deficits in the mentioned field.

Pharmacologic blockade of angiopoietin-2 is efficacious against model hemangiomas in mice

Hemangioma of infancy is the most common neoplasm of childhood. While hemangiomas are classic examples of angiogenesis, the angiogenic factors responsible for hemangiomas are not fully understood. Previously, we demonstrated that malignant endothelial tumors arise in the setting of autocrine loops involving vascular endothelial growth factor (VEGF) and its major mitogenic receptor vascular endothelial growth factor receptor 2. Hemangiomas of infancy differ from malignant endothelial tumors in that they usually regress, or can be induced to regress by pharmacologic means, suggesting that angiogenesis in hemangiomas differs fundamentally from that of malignant endothelial tumors. Here, we demonstrate constitutive activation of the endothelial tie-2 receptor in human hemangioma of infancy and, using a murine model of hemangioma, bEnd.3 cells; we show that bEnd.3 hemangiomas produce both angiopoietin-2 (ang-2) and its receptor, tie-2, in vivo. We also demonstrate that inhibition of tie-2 signaling with a soluble tie-2 receptor decreases bEnd.3 hemangioma growth in vivo. The efficacy of tie-2 blockade suggests that either tie-2 activation or ang-2 may be required for in vivo growth. To address this issue, we used tie-2-deficient bEnd.3 hemangioma cells, which, surprisingly, were fully proficient in in vivo growth. Previous studies from our laboratory and others have implicated reactive oxygen-generating nox enzymes in the angiogenic switch, so we examined the effect of nox inhibitors on ang-2 production in vitro and on bEnd.3 tumor growth in vivo. We then inhibited ang-2 production pharmacologically using novel inhibitors of nox enzymes and found that this treatment nearly abolished bEnd.3 hemangioma growth in vivo. Signal-transduction blockade targeting ang-2 production may be useful in the treatment of human hemangiomas in vivo.

Angiosarcoma after conservation treatment for breast carcinoma: Our experience and a review of the literature

The development of angiosarcoma of the breast is a recognized complication of breast conservation therapy (BCT), but the evolution, prevalence, and outcome have not been accurately established. We sought to evaluate and review the clinicopathologic, prognostic, and treatment attributes of angiosarcoma arising in the irradiated breast after BCT. We conducted a retrospective chart and slide review of 8 patients seen between 1996 and 2004 with a diagnosis of secondary angiosarcoma. All were treated with mastectomy. Clinical and histopathologic findings were studied and previously reported cases were reviewed. Primary surgery-related breast edema and cellulitis was observed in 7 and 5 patients of the 8 patients studied, respectively. Postirradiation breast edema and grade 2/3 fibrosis occurred in 5 and 8 patients, respectively. The mean age of the patients at onset of the breast cancer and angiosarcoma was 65 and 72 years, respectively. The mean latency period between the treatment of the breast cancer and the diagnosis of angiosarcoma was 75 months. The actuarial rate of 2-year survival for patients presented with single (n = 4) compared with multiple (n = 4) skin lesions was 50% and 0%, respectively (P = .0233). The estimated incidence of angiosarcoma after BCT was found to be 0.14 %. BCT-associated angiosarcoma arises after a relatively brief interval, and breast edema-fibrosis can possibly contribute to its development. Special attention should be paid to skin changes occurring after BCT. The extent of skin lesions is predictive of survival. As shown by a review of the literature, angiosarcomas are often resistant to surgery, chemotherapy, and radiotherapy, and targeted therapy against tumor biological properties may be a new approach to angiosarcoma treatment.