Post-mastectomy lymphangiosarcoma (Stewart-Treves syndrome): report of two long-term survivals

Canine sarcomas as a surrogate for the human disease

Pet dogs are becoming increasingly recognized as a population with the potential to inform medical research through their treatment for a variety of maladies by veterinary health professionals. This is the basis of the One Health initiative, supporting the idea of collaboration between human and animal health researchers and clinicians to study spontaneous disease processes and treatment in animals to inform human health. Cancer is a major health burden in pet dogs, accounting for approximately 30% of deaths across breeds. As such, pet dogs with cancer are becoming increasingly recognized as a resource for studying the pharmacology and therapeutic potential of anticancer drugs and therapies under development. This was recently highlighted by a National Academy of Medicine Workshop on Comparative Oncology that took place in mid-2015 (http://www.nap.edu/21830). One component of cancer burden in dogs is their significantly higher incidence of sarcomas as compared to humans. This increased incidence led to canine osteosarcoma being an important component in the development of surgical approaches for osteosarcoma in children. Included in this review of sarcomas in dogs is a description of the incidence, pathology, molecular characteristics and previous translational therapeutic studies associated with these tumors. An understanding of the patho-physiological and molecular characteristics of these naturally occurring canine sarcomas holds great promise for effective incorporation into drug development schemas, for evaluation of target modulation or other pharmacodynamic measures associated with therapeutic response. These data could serve to supplement other preclinical data and bolster clinical investigations in tumor types for which there is a paucity of human patients for clinical trials.

Stewart-Treves Syndrome Involving Chronic Lymphedema after Mastectomy of Breast Cancer

Steward-Treves syndrome is a cutaneous angiosarcoma that usually appears after long evolution of a lymphoedema after mastectomy for mammary neoplasia associated with an axillary dissection. This is a rare disease develop most of the time in upper arm and often confounded with cutaneous metastasis. Only the biopsy and immunohistochemical study confirm the diagnosis. The treatment is surgical and consists of large cutaneous excision, an amputation of the limb or even its disarticulation and will be followed by chemotherapy. Despite the treatment, the prognosis remains severe with poor survival. We report the case of a patient who had a Steward-Treves syndrome 20 years after lymphoedema following a left mastectomy with axillary dissection.

Stewart Treves Syndrome: A Case Report

Angiosarcomas are malignant tumors, which originate from the vessel endothelium and resemble the vessel structure. Stewart-Treves syndrome is an angiosarcoma which in general, develops in female patients after mastectomy and axillary lymph node dissection and is associated with chronic lymphedema. The prognosis of this rare complication is very poor. We present the case of a 52-year-old female who had undergone mastectomy due to breast cancer and 13 years later required shoulder disarticulation due to Stewart-Treves syndrome.

Epithelioid Angiosarcoma of the Small Intestine After Occupational Exposure to Radiation and Polyvinyl Chloride: A case Report and Review of Literature

Angiosarcomas represent 1–2% of soft tissue sarcomas and most frequently occur in the subcutis. They may affect internal organs, such as the heart, liver, and spleen, and only rarely do they emerge in the gastrointestinal tract. The association between angiosarcomas and certain toxic chemical substances or previous external-beam radiation therapy is well documented.

Lymphangiosarcoma of the arm presenting with lymphedema in a woman 16 years after mastectomy: a case report

Lymphangiosarcoma following breast cancer is a relatively rare entity, with around 300 cases so far reported worldwide. Affecting the long term survivors of breast cancer, lymphangiosarcoma (Stewart-Traves Syndrome) has a high mortality rate. Since lympedema following radical mastectomy or axillary clearance and radiotherapy seems to be the main predisposing factor, further research regarding modifications in the surgical technique of axillary nodes dissection as well as the development of new chemotherapeutic agents effective in lymphangiosarcoma are required.

Stewart-Treves syndrome: MR imaging of a postmastectomy upper-limb chronic lymphedema with angiosarcoma

The rare occurrence of angiosarcoma in postmastectomy upper-limb lymphedema with magnetic resonance (MR) imaging is discussed. Unfamiliarity with this aggressive vascular tumor and its harmless appearance often leads to delayed diagnosis. Angiosarcoma complicating chronic lymphedema may be low in signal intensity on T2-weighting and short tau inversion recovery (STIR) imaging reflecting the densely cellular, fibrous stroma, and sparsely vascularized tumor histology. Additional administration of intravenous contrast medium revealed significant enhancement of the tumorous lesions. Awareness of angiosarcoma and its MR imaging appearance in patients with chronic lymphedema may be a key to early diagnosis or allow at least inclusion in the differential diagnosis.

Isolated limb perfusion with tumor necrosis factor and melphalan for nonresectable sSewart-Treves lymphangiosarcoma

BACKGROUND

Cutaneous Stewart-Treves lymphangiosarcomas represent a rare group of tumors characterized by a high grade of vascularization and by localization in an extremity with lymphedema. The multifocality and the localization makes these tumors eligible for treatment with isolated limb perfusion (ILP). ILP with tumor necrosis factor (TNF) and melphalan is a safe and highly effective procedure that can achieve limb salvage in >or=80% of all patients with nonresectable extremity soft tissue sarcoma or melanoma.

METHODS

In 10 patients with multifocal Stewart-Treves lymphangiosarcoma of the extremities, 16 ILPs with TNF plus melphalan were performed. All patients would have been candidates for exarticulation of the extremity.

RESULTS

We observed an 87% overall response rate (complete and partial responses); one patient had a mixed response, and one patient did not respond to the therapy. In nine perfusions (56%), a complete response was achieved, and five perfusions (31%) resulted in a partial response. Limb salvage was achieved in eight patients (80%), with a mean follow-up duration of 34.8 months (range, 3 to >or=115 months). Regional toxicity was limited and systemic toxicity minimal to moderate, with no toxic deaths.

CONCLUSIONS

Multifocal Stewart-Treves lymphangiosarcomas in extremities with chronic lymphedema can be successfully treated by ILP with TNF and melphalan.

Long-term survival after radical operations for cancer treatment-induced sarcomas: how two survivors invite reflection on oncologic treatment concepts

Extent and radicality of surgical oncologic treatment has changed in the past 30 years. Two patients with node-positive breast cancer are presented, who underwent (total or radical) mastectomy with lymphadenectomy and postoperative radiation 24 and 40 years ago. A radiation-associated sarcoma of the parascapular soft tissue developed in one patient 9 years after treatment; the other one sought treatment for a lymphedema-associated Stewart-Treves lymphangiosarcoma 16 years after initial therapy. Both patients underwent a forequarter amputation for their treatment-associated high-grade sarcoma. Both are currently alive and cancer-free 15 and 24 years after amputation. These reports remind us that radical locoregional treatment can cure some solid cancers in the absence of systemic therapy; that such extensive treatment may induce significant disability or secondary malignancies long-term; that even advanced treatment-associated sarcomas can be cured with aggressive resection; that today's multimodality therapy approaches and appropriate patient selection have rendered such extensive locoregional treatment for many tumors obsolete or unnecessary; and that if no effective alternative treatment exists and organ or limb preservation is not feasible, an aggressive resection approach for high-grade cancer should not be discounted unless systemic failure is certain or imminent.

Lymphangiosarcoma (Stewart-Treves syndrome) in postmastectomy patients

Stewart-Treves syndrome (STS) is a rare but aggressive upper extremity lymphangiosarcoma in postmastectomy patients. Unfamiliarity with this disease and the innocuous appearance of the tumor often lead to delayed diagnosis. A comprehensive search of the databases at a single tertiary-care academic institution revealed only 3 cases of STS in the last 63 years. The latency time between breast cancer treatment and diagnosis of STS was 11 to 21 years. Survival after diagnosis of STS ranged from 8 to 15 months. One patient underwent radical surgery. The extensive lymphangiosarcoma in the other 2 patients precluded surgical resection and they underwent chemotherapy. All patients had adjuvant radiation therapy at the time of the original breast cancer resection. This report includes a discussion of the epidemiology, etiology, presentation, treatment, and prognosis of STS.

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.

Lymphangiosarcoma in chronic lymphoedema. Stewart-Treves syndrome

A case of post-mastectomy lymphangiosarcoma is reported. Lymphangiosarcoma is an extremely rare but highly lethal complication of chronic lymphoedema. Our patient was treated by amputation and died 6 months later. Treatment of post-mastectomy lymphangiosarcoma is still unsatisfactory. Early recognition and radical ablative surgery seem to provide best chance for survival.

Well-differentiated liposarcoma (atypical lipoma) of the lower extremity in a patient with bilateral leg lipodystrophy and lymphedema

We present a report of a patient with bilateral lower extremity lipodystrophy and lymphedema who underwent excision of a large extremity liposarcoma. Total excision of the tumor was performed with no evidence of recurrence to date. The natural history, characteristics, and management of this tumor are discussed. A high index of suspicion and awareness among surgeons and pathologists should allow accurate diagnosis and treatment of this condition.

Axillary lymph nodes and breast cancer: a review

BACKGROUND

The value of surgical staging and treatment of the axillary lymph nodes with either surgery or radiotherapy in the initial management of patients with Stage I or II invasive breast cancer is controversial.

METHODS

A review of retrospective and prospective clinical studies was performed to assess the risks of axillary lymph node involvement and the effectiveness and morbidity of various treatment options.

RESULTS

The risk of axillary lymph node involvement is substantial for most patients, even those with small tumors. The morbidity resulting from a careful Level I/II axillary dissection or moderate-dose axillary radiotherapy is limited. Such treatment is highly effective in preventing axillary recurrence. The symptoms resulting from axillary failure can be controlled in many, but not all, patients. The available data suggest, but do not prove, that the initial use of effective axillary treatment may result in a small improvement in long term outcome in some patient subgroups.

CONCLUSIONS

Most patients should be treated with either axillary surgery or irradiation. Highly selected subgroups of patients may have such low risks of involvement that specific axillary treatment is of little value. However, such subgroups have not yet been well defined. Treatment approaches that do not involve specific axillary treatment should be considered investigational at present, and the patients should be informed as to their potential risks. Prospective clinical studies of these issues should be pursued.

Lymphedema-induced lymphangiosarcoma

A series of eight patients with chronic lymphedema-related lymphangiosarcoma is presented. All but one case showed a typical rapid progression and fatal outcome, as has been reported in other series. In one patient the lymphangiosarcoma developed on the chest wall, the axilla and the arm where persisting lymphedema and fibrosis occurred after bilateral mastectomy and bilateral postoperative radiotherapy. In this patient an asymptomatic course and slow locoregional progression of lesions was seen. The clinical picture, the etiological considerations and the therapeutic options of the lymphedema-induced lymphangiosarcoma with regard to the literature are discussed.

Cutaneous angiosarcoma as a second malignancy in a lymphedematous leg in a Hodgkin's disease survivor

Angiosarcoma is a rare and highly malignant neoplasm. Cutaneous angiosarcoma not associated with postmastectomy lymphedema is rare. There are only eight reported cases of development of cutaneous angiosarcoma in a lymphedematous extremity in a patient with preexisting malignancy other than breast cancer. This is the first reported case of development of cutaneous angiosarcoma in a lymphedematous extremity in a Hodgkin's disease survivor. A review of cutaneous angiosarcoma associated with lymphedema and a discussion of the pathogenesis of angiosarcoma are included.

Post-treatment sarcoma in breast cancer patients

BACKGROUND

Many patients treated for breast cancer with radiotherapy will survive their disease and be at risk for treatment-related sarcoma for many years.

METHODS

In order to identify patients with post-treatment sarcoma and define this disease, we examined the records of 99 patients treated for sarcoma with a history of antecedent breast carcinoma. Of these patients, 51 were felt to have a sarcoma unrelated to breast cancer treatment and 48 were felt to have a treatment-related sarcoma (secondary to lymphedema and/or radiation).

RESULTS

Lymphangiosarcoma of the extremity was the most common histologic subtype of post-treatment sarcoma, accounting for 22 of 48 cases (46%). Twenty-six patients (54%) developed nonlymphangiosarcoma post-treatment sarcoma; all of these were radiation-associated sarcomas. The median latency interval between the diagnosis of breast cancer and the development of sarcoma was 11 years (range 4-44) and was not different between the two groups. However, patients with nonlymphangiosarcoma were significantly younger when diagnosed with breast cancer than were those with lymphangiosarcoma of the extremity (median 43 vs. 51 years, p < 0.001). The survival of all 48 patients was poor: 5-year survival was 29%. Five-year survival of patients with other types of post-treatment sarcoma was just as poor as those with lymphangiosarcoma of the extremity (30% vs. 28%, p = 0.98).

CONCLUSIONS

Patients who develop sarcoma after treatment for breast cancer have a poor prognosis whether it occurs as Stewart-Treves syndrome or other types of post-treatment sarcoma. Younger patients may be at higher risk than are older patients for the development of nonlymphangiosarcoma post-treatment sarcoma.