Treatment and prognosis of angiosarcoma of the scalp and face: a retrospective analysis of 48 patients

Mesenchymal Tumors of the Skin: A Review

Mesenchymal tumors of the skin are rare and clinically heterogeneous, and can represent diagnostic challenge for pathologists. Most of these lesions have overlapping clinical and histological features, thus the understanding of architectural patterns, cytoplasmic and stromal features can facilitate proper diagnosis. Anatomic site may be an important factor in the differential diagnosis, as are patient's age and sex. Ancillary tests are often required and can be useful to rule out other entities. Molecular diagnostics is playing an increasingly important role in the diagnosis of soft tissue neoplasms. Here, we review clinical, histological, and molecular features of some of the most common of these uncommon entities including benign and malignant lesions.

Sustained activation of the FGF1-MEK-ERK pathway inhibits proliferation, invasion and migration and enhances radiosensitivity in mouse angiosarcoma cells

Angiosarcoma is a rare refractory soft-tissue tumor with a poor prognosis and is treated by radiotherapy. The fibroblast growth factor 1 (FGF1) mutant, with enhanced thermostability due to several substituted amino acids, inhibits angiosarcoma cell metastasis, yet the mechanism of action is unclear. This study aims to clarify the FGF1 mutant mechanism of action using ISOS-1 mouse angiosarcoma cells. The wild-type FGF1 or FGF1 mutant was added to ISOS-1 cells and cultured, evaluating cell numbers over time. The invasive and migratory capacity of ISOS-1 cells was assessed by transwell analysis. ISOS-1 cell radiosensitivity was assessed by colony formation assay after X-ray irradiation. To examine whether mitogen-activated protein kinase (MEK) inhibitor counteracts the FGF1 mutant effects, a combination of MEK inhibitor and FGF1 mutant was added to ISOS-1 cells and cultured. The FGF1 mutant was observed to inhibit ISOS-1 cell proliferation, invasion and migration by sustained FGF1 signaling activation. A MEK inhibitor suppressed the FGF1 mutant-induced inhibition of proliferation, invasion and migration of ISOS-1 cells. Furthermore, the FGF1 mutant enhanced radiosensitivity of ISOS-1 cells, but MEK inhibition suppressed the increased radiosensitivity. In addition, we found that the FGF1 mutant strongly inhibits actin polymerization, suggesting that actin cytoskeletal dynamics are closely related to ISOS-1 cell radiosensitivity. Overall, this study demonstrated that in ISOS-1 cells, the FGF1 mutant inhibits proliferation, invasion and migration while enhancing radiosensitivity through sustained activation of the MEK-mediated signaling pathway.

Global frequency and distribution of head and neck sarcomas in adulthood: a systematic review

PURPOSE

Head and neck sarcomas (HNS) constitute a rare and heterogeneous cancer entity. Management remains a challenge due their rarity and different biological behaviour among tens of subtypes. This systematic review aimed to describe HNS global frequency and distribution in adulthood.

METHODS

A systematic review was performed using PICOTS search strategies for qualitative question and it was written in accordance with PRISMA 2020 Statement. 70,653 publications were identified, and 15 variables were evaluated for a total of 2428 patients.

RESULTS

We identified 47 studies from 21 different countries from 5 different continents. Most of studies (83.3%) were performed in single institutions and America and Asia overruled for number of papers included (21 and 10, respectivelly). Osteosarcoma was more frequent, followed by chondrosarcoma, angiosarcoma and malignant fibrous histiocytoma. Early stage accounted for almost 80% of cases; advanced stage prevailed in developing countries. 1783 patients (90.1%) underwent surgery and 780 (39.4%) had adjuvant therapy. 50.8% of patients experienced tumour recurrence and the lowest mortality rate was reported in Europe (29.9%).

CONCLUSIONS

HNS holds a relative poor prognosis possibly explained by the heterogeneity of the disease. Treatment of HNS has shown to be highly diverse among different countries, underlining the importance of uniformed treatment guidelines to achieve better patient management and to improve survival outcomes.

High-dose planned adaptive helical tomotherapy for cutaneous angiosarcoma of the scalp

PURPOSE

The purpose of this study was to investigate the feasibility and effectiveness of high-dose planned adaptive intensity-modulated radiation therapy (IMRT) with helical tomotherapy (HT) for cutaneous angiosarcoma (cAS) of the scalp.

METHODS

This retrospective cross-sectional included a total of 12 consecutive patients with cAS of the scalp who underwent high-dose planned adaptive IMRT with HT. Prescribed doses were 72.5-74 Gy in 35-37 fractions for the gross tumor volume plus a 1-2 mm margin (PTV1), 58-60 Gy in 29-30 fractions for the clinical target volume plus a 2-3 mm margin (PTV2), and 46 Gy in 23 fractions for the clinical target volume plus a 5-15 mm margin (PTV3) over periods of 7.5, 6 and 4.5 weeks, respectively.

RESULTS

The estimated 1‑year and 2‑year overall survival rate were 65.6% and 27.3%, respectively, and the local progression-free survival at 2 years was 74.1%. All local recurrences were either in or marginal to the PTV2 or PTV3. No local recurrence was observed in the PTV1. All patients tolerated the treatment without grade 3 or higher adverse events during the radiotherapy period. No late adverse events were observed during the follow-up period.

CONCLUSION

Planned adaptive high-dose IMRT with HT has the potential to improve local control rate without increasing adverse events.

Clinical outcomes of scalp or face angiosarcoma treatment with intensity-modulated radiotherapy: a multicenter study

Combined modality therapy, including radiotherapy (RT), is a common treatment for scalp or face angiosarcoma. Although intensity-modulated radiotherapy (IMRT) can deliver homogeneous doses to the scalp or face, clinical data are limited. This multicenter study aimed to evaluate scalp or face angiosarcoma treated with definitive or post-operative IMRT. We retrospectively analyzed data from patients who received IMRT for scalp or face angiosarcoma at three institutions between January 2015 and March 2020. Local control (LC) rate, overall survival (OS), progression-free survival (PFS), recurrence patterns and toxicity were evaluated. Fifteen patients underwent IMRT during the study period. Definitive RT was performed on 10 patients and post-operative RT was performed on 5 patients. The 1-year LC rate was 85.7% (95% confidence interval [CI], 53.9-96.2%). The 1-year OS and PFS rates were 66.7% (95% CI, 37.5-84.6%) and 53.3% (95% CI, 26.3%-74.4%), respectively. Univariate analysis revealed that a clinical target volume over 500 cm3 was associated with poor LC. Distant metastasis was the most common recurrence pattern. All patients experienced Grade 2 or 3 radiation dermatitis, and five patients experienced grade ≥ 3 skin ulceration. One patient who underwent maintenance therapy with pazopanib developed Grade 5 skin ulceration. Fisher's exact test showed that post-operative RT was significantly associated with an increased risk of skin ulceration of grade ≥ 3. These results demonstrate that IMRT is a feasible and effective treatment for scalp or face angiosarcoma, although skin ulceration of grade ≥ 3 is a common adverse event in patients who receive post-operative RT.

John M. Cutaneous head and neck angiosarcoma: The 30-year UCLA experience

Background

Cutaneous angiosarcoma is an aggressive tumor commonly found in the head and neck region. There is no consensus regarding the definitive treatment for angiosarcoma.

Methods

This was a retrospective chart review that evaluated 64 patients from 1983 to 2019. Demographic and clinical variables were examined for impact on recurrence using the time to recurrence and the overall survival in Kaplan-Meier curves.

Results

Average age at diagnosis was 71 (32-95) years, with a 2.8 male: female ratio. Surgery was utilized in 62% of patients, with mean defect size of 11.4 ± 8.1 cm. Recurrence was found in 70% of patients, and mean time to recurrence was 15.3 ± 12.3 months. Decreased recurrence was associated with use of intraoperative frozen section analysis (p = .036) and negative margins (p = .086). Two-year overall survival was 80%, and recurrence free survival was 30%.

Conclusions

Negative margins are associated with decreased recurrence, and intraoperative frozen section analysis may be considered to obtain preliminary surgical margins.Level of Evidence: 4.

Intensified Adjuvant Treatment for High-Risk Resected Cutaneous Angiosarcoma of the Head and Neck

OBJECTIVE

Previous studies have highlighted the poor survival of patients with cutaneous angiosarcoma of the head and neck. Therapeutic options are limited, and effective treatment strategies are yet to be discovered. The objective of this study is to evaluate overall survival following intensified adjuvant treatment for high-risk resected angiosarcoma of the head and neck.

STUDY DESIGN

Retrospective observational.

SETTING

National Cancer Database (NCDB).

METHODS

Patients diagnosed with nonmetastatic cutaneous angiosarcoma of the head and neck from 2004 to 2016 were identified by NCDB. We retrospectively compared demographics and overall survival between patients who received surgery and radiation therapy (SR) and patients who received surgery and chemoradiation (SRC). The χ2 test, Kaplan-Meier method, and Cox regression models were used to analyze data.

RESULTS

A total of 249 patients were identified, of which 79.5% were treated with surgery and radiation alone and 20.5% were treated with surgery and chemoradiation. The addition of chemotherapy, regardless of the sequence of administration, was not associated with significantly higher overall survival. Factors associated with worse survival in both groups included positive nodal status and positive margins. Patients with positive nodes had higher overall survival with radiation doses >50.4 Gy compared to ≤50.4 Gy (hazard ratio: 2.93, confidence interval: 1.60-5.36, p < 0.001).

CONCLUSION

Adjuvant chemotherapy was not significantly associated with higher overall survival for resected nonmetastatic angiosarcoma of the head and neck. Higher radiation doses appear to be prognostic for high-risk diseases.

The Utility of Bone Burring for the Clearance of Locally Advanced Scalp Malignancies: A Scoping Review

The scalp harbors a range of neoplasms occurring at inordinate rates and associated with poorer outcomes. Its unique anatomy poses surgical challenges, including clear deep margins when resecting these lesions. For malignancies extending to the pericranium, removal of outer cortical cranial bone is ideal and routinely achieved with a burr. This review aims to investigate the literature to ascertain the utility and safety of this technique while highlighting evidence gaps.

Methods

A literature search was conducted systematically using MEDLINE, Embase, and PubMed. Articles were reviewed for inclusion, and eligible studies were analyzed for study design, patient and intervention details, and outcome measures. A formal statistical analysis was not conducted.

Results

The original search yielded 1506 unique results, and eight studies met the inclusion criteria: four case series, two retrospective analysis of records, two case reports. A number of tumor types were identified, but the burring method used was consistent in all studies. Despite reassuring primary outcome measure results, specifically in terms of local control rates, the overall evidence quality is limited by the nature of the included studies. Few adverse events were reported.

Conclusions

Evidence for the oncological efficacy of scalp bone burring remains limited. Although the technique seems relatively safe, further investigation is required into its utility and drawbacks. Future studies should aim to report more technical details and more information about outcomes. It may also be worth comparing burring to alternatives such as outer cortical splitting, curettage, and high-dose curative radiotherapy.

Outcomes after definitive treatment for cutaneous angiosarcomas of the face and scalp: Reevaluating the role of surgery and radiation therapy

INTRODUCTION

We investigated outcomes and prognostic factors for patients treated for cutaneous angiosarcoma (CA).

METHODS

We conducted a retrospective review of patients treated for CA of the face and scalp from 1962 to 2019. All received definitive treatment with surgery, radiation (RT), or a combination (S-XRT). The Kaplan-Meier method was used to estimate outcomes. Multivariable analyses were conducted using the Cox proportional hazards model.

RESULTS

For the 143 patients evaluated median follow-up was 33 months. Five-year LC was 51% and worse in patients with tumors >5 cm, multifocal tumors, those treated pre-2000, and with single modality therapy (SMT). These remained associated with worse LC on multivariable analysis. The 5-year disease-specific survival (DSS) for the cohort was 56%. Tumor size >5 cm, non-scalp primary site, treatment pre-2000, and SMT were associated with worse DSS.

CONCLUSION

Large or multifocal tumors are negative prognostic factors in patients with head and neck CA. S-XRT improved outcomes.

Clinical Outcomes of Radiation Therapy for Angiosarcoma of the Scalp and Face: A Multi-Institutional Observational Study

Angiosarcoma of the scalp and face (ASF) is a rare, aggressive tumor often treated with multimodal therapy, including radiation therapy (RT). This study assessed RT outcomes for ASF and identified prognostic factors. Data from 68 non-metastatic ASF patients undergoing RT with or without other therapies were analyzed. Median radiation dose was 66 Gy in 33 fractions (interquartile range (IQR) 60-70 Gy in 28-35 fractions). Local control (LC), progression-free survival (PFS), and overall survival (OS) rates were calculated using Kaplan-Meier analysis. Multivariate analyses and adverse event evaluation were conducted. Median patient age was 75 years (IQR 71-80 years), with a median follow-up of 17 months (IQR 11-42 months). One-/three-year LC rates were 57/37%, PFS rates were 44/22%, and OS rates were 81/44%. Multivariate analyses showed that an equivalent dose in a 2 Gy fraction (EQD₂) >66 Gy correlated with improved LC (HR 2.35, 95% CI 1.03-5.32, p = 0.041). Combining chemotherapy (HR 2.43, 95% CI 1.08-5.46, p = 0.032) or surgery (HR 2.41, 95% CI 1.03-5.59, p = 0.041) improved PFS. No factors influenced OS. Late grade 3+ toxicities occurred in 1%, with one patient developing a grade 4 skin ulcer. These findings suggest that EQD₂ > 66 Gy and combining chemotherapy or surgery can enhance LC or PFS in ASF. Further prospective studies are needed to determine the optimal treatment strategy for this rare malignancy, particularly in elderly patients.

Bilateral pneumothorax in a patient with angiosarcoma of the scalp: a case report

BACKGROUND

Angiosarcoma is a rare, vascular malignancy that arises from endothelial cells of blood vessels. This case report aims to create the awareness of its existence in the region and its mode of presentation.

CASE PRESENTATION

A 63-year-old Pakistani man presented to the emergency department with sudden bilateral chest pain and shortness of breath for 2 days. On examination, a scalp lesion was seen which had been increasing in size over the last 6 weeks. The lesion was 8 × 10 cm in size with an irregular border, non-tender, violet and dome-shaped in elevation on the right occipito-parietal lobe of the skull. Chest computed tomography (CT) showed multiple cystic lesions on both lungs, patchy areas of ground-glass opacities, nodules of variable sizes and bilateral pneumothorax. Bilateral tube thoracostomy was performed which provided symptomatic relief for shortness of breath. His bronchoalveolar lavage (BAL) was negative for infection. He underwent biopsy of scalp lesion which was positive for aggressive angiosarcoma.

CONCLUSION

Bilateral spontaneous pneumothorax can be the initial manifestation of aggressive cutaneous angiosarcoma and frequently leads to respiratory failure. Early recognition is essential to prevent delay in diagnosis and management.

Utility of Multimodal Treatment Protocols in the Management of Scalp Cutaneous Angiosarcoma

Cutaneous angiosarcomas are rare, aggressive tumors with high recurrence and poor prognosis. We share our experiences with the challenging surgical management of these lesions, focusing on both ablative and reconstructive outcomes.

Methods

Retrospective cross-sectional chart review was conducted of patients diagnosed with scalp cutaneous angiosarcoma between 2005 and 2021. Resectability, defect reconstruction, and survival outcomes were analyzed.

Results

Thirty patients were included, 27 (90%) men and three (10%) women, with a mean age at diagnosis of 71.77 ± 7.3 years, and mean follow-up of 429.43 ± 305.6 days. Only 12 patients completed their regular follow-up, while the remaining patients died. There was a median survival of 443.50 days (range, 42-1283) and median time to recurrence of 21 days (range, 30-1690). Multimodal therapy compared with surgery alone had a significantly better overall median survival (468 days versus 71 days; P = 0.021). Defect coverage was obtained in 24 cases (75%) through an anterolateral thigh flap, two patients (6%) with a local transposition flap, and one patient (3%) with a transverse rectus abdominis myocutaneous flap. The remaining three patients received a skin graft. All of the flaps survived, with one requiring a vein graft for venous congestion.

Conclusions

Timely multimodal therapy with a histologically safe margin, combined with adjuvant therapy, improves survival and delays recurrence and metastasis, in cutaneous angiosarcoma patients. An anterolateral thigh flap facilitates the coverage of wide defects. Further investigations of advanced treatment modalities such as immunotherapy and/or gene therapy are required to deal with this highly aggressive tumor.

[Face to a bilateral pneumothorax, just scratch your head!]

Head and neck skin angiosarcoma is a rare and aggressive tumor (1 % of head and neck tumors). Prognosis remains poor, with a 5-year survival rate ranging from 10 to 54%, depending on the initial stage. Metastatic disease markedly worsens the prognosis. Metastatic lung involvement is classic and can take on several forms. The cystic form is responsible for numerous complications, particularly pneumothorax. In this case, an 83-year-old patient was diagnosed with bilateral pneumothorax complicating cystic interstitial lung disease, which was revealed by hemoptoic sputum. Skin examination revealed two large necrotic lesions of the calvaria. Anatomo-pathological examination confirmed cutaneous angiosarcoma on both skin biopsy and lung resection. At a metastatic stage, only systemic treatment with paclitaxel can be proposed. The clinical course was unfavorable, leading to death before any specific treatment. This observation highlights the importance of a complete clinical skin examination in the assessment of pulmonary cystic lesions.

Exploring the landscape of immunotherapy approaches in sarcomas

Sarcomas comprise a heterogenous group of malignancies, of more than 100 different entities, arising from mesenchymal tissue, and accounting for 1% of adult malignancies. Surgery, radiotherapy and systemic therapy constitute the therapeutic armamentarium against sarcomas, with surgical excision and conventional chemotherapy, remaining the mainstay of treatment for local and advanced disease, respectively. The prognosis for patients with metastatic disease is dismal and novel therapeutic approaches are urgently required to improve survival outcomes. Immunotherapy, is a rapidly evolving field in oncology, which has been successfully applied in multiple cancers to date. Immunomodulating antibodies, adoptive cellular therapy, cancer vaccines, and cytokines have been tested in patients with different types of sarcomas through clinical trials, pilot studies, retrospective and prospective studies. The results of these studies regarding the efficacy of different types of immunotherapies in sarcomas are conflicting, and the application of immunotherapy in daily clinical practice remains limited. Additional clinical studies are ongoing in an effort to delineate the role of immunotherapy in patients with specific sarcoma subtypes.

Clinical significance of local control of primary tumour in definitive radiotherapy for scalp angiosarcomas

INTRODUCTION

Scalp angiosarcoma is a rare and aggressive cancer. Definitive radiotherapy is a treatment option for localised scalp angiosarcoma patients. Although definitive surgical resection reportedly prolongs overall survival (OS), whether initial local treatment effect affects OS when definitive radiotherapy is administered is unclear. Therefore, this study analysed whether local recurrence within 6 months of irradiation correlates with OS and cancer-specific survival (CSS). Furthermore, how local control affects patients' quality of life was investigated.

MATERIALS AND METHODS

Thirty-one localised scalp angiosarcoma patients who had received definitive radiotherapy at our institution between October 2010 and July 2021 were analysed retrospectively. The most commonly used dose fractionation was 70 Gy in 35 fractions (83.9%). Local recurrence within 6 months of radiotherapy and other clinical factors were examined in univariate and subsequent multivariate analyses for correlation with OS and CSS.

RESULTS

The median follow-up period was 16 months (range, 6-45 months). Local recurrence was detected in 16 patients (51.6%), 12 of whom had recurrence within 6 months. In multivariate analyses, the presence of local recurrence within 6 months of radiotherapy was significantly associated with OS and CSS (p = 0.003, 0.0001, respectively). Ten of the 16 patients with local recurrence had severe symptoms such as bleeding, pain, difficulty opening the eye and malodour.

CONCLUSIONS

The initial local treatment effect was significantly associated with OS and CSS after definitive radiotherapy. Furthermore, local recurrence after radiotherapy resulted in a variety of symptoms, including bleeding and pain, which reduced the patient's quality of life.

Outcomes after definitive treatment for head and neck angiosarcoma

INTRODUCTION

Head and neck angiosarcoma (HN-AS) is a rare and aggressive, representing <1% of all head and neck malignancies. It is characterized by a high rate of local recurrence and poor 5-year survival (10-54%). Australian data in this rare disease is lacking. We aim review the clinical outcomes of HN-AS from two high volume head and neck cancer units in Australia.

METHODS

Retrospective chart review.

RESULTS

A total 26 patients were identified, consist of predominantly male patients (81%) with a mean age of 77 year old. Most of the HN-AS arises from the scalp (62%). The 5-year overall survival (OS) and disease free survival (DFS) were 41% and 15%, respectively. Patients treated with upfront surgery with adjuvant therapy has better OS and DFS compared with patients receiving upfront chemoradiotherapy (median OS 3.63 vs. 0.53 years, P = 0.011 and median DFS 1.19 vs. 0.33 years, P = 0.001). There is no difference in OS or DFS for the sites of HN-AS or age of patients. Recurrences were noted in 15 patients (57.7%). For those with metastatic disease, the most common site was the lung (80%) with a median time to development of distant disease of 2.7 years (range 1.8-3.6 years). In patients who underwent salvage treatment, the median survival (post-salvage) was 1.3 years (0-2.8 years).

CONCLUSION

This is the first Australian report of treatment patterns and outcomes of patients with HN-AS. Our cohort confirms that HN-AS is a slowly progressive disease with poor survival. Patients treated with surgery and adjuvant radiotherapy in this series had better outcomes compared with those treated with chemoradiotherapy alone. The role of neoadjuvant chemotherapy is an area of ongoing research.

Prognostic factor analysis of definitive radiotherapy using intensity-modulated radiation therapy and volumetric modulated arc therapy with boluses for scalp angiosarcomas

Cutaneous angiosarcomas is a rare cancer with poor prognoses. The common radiotherapy techniques that have been reported so far are two pairs of lateral X-ray and electron fields. However, it is quite difficult to irradiate scalp angiosarcomas (SAs) homogeneously with this technique. In this study, safety, effectiveness, and risk factors were assessed for localized SAs ≥ 5 cm treated with intensity-modulated radiotherapy (IMRT) or volumetric modulated arc therapy (VMAT) with boluses. Sixty-eight angiosarcoma patients who had received radiotherapy in our institution between January 2007 and November 2020 were retrieved from our radiotherapy database. Of these patients, 27 localized SA patients were included in the retrospective analysis. The 2-year overall survival, local progression-free rate, and distant metastases-free survival were 41.8%, 48.4%, and 33.1%. All the patients experienced acute radiation dermatitis ≥ grade 2, with18 (66.7%) ≥ grade 3. No nodule lesion was a significant unfavorable predictive factor of acute radiation dermatitis ≥ grade 3. Tumor bleeding at the initiation of radiotherapy and tumor invasion to the face were significant predictive factors of overall survival, and tumor bleeding at the initiation of radiotherapy was also a significant predictive factor of local progression-free rate.

Management of Cutaneous Angiosarcoma: an Update Review

OPINION STATEMENT

Cutaneous angiosarcoma is a rare and invasive malignant tumor. For localized cAS patients, wide-margin excision was recommended. Due to the latent local invasion characteristic of cAS, we suggest preoperative and postoperative radiotherapy to nearly all patients. Recently, there is growing interest in using neoadjuvant chemotherapy and/or radiotherapy as part of a combination therapy regimen, which may allow some patients to undergo potentially less disabling surgery. For metastatic cAS patients with unresectable tumors and who refuse surgery, radical radiotherapy or chemoradiotherapy may be an option. Paclitaxel was recognized as the first-line treatment. For tumors resistant to taxanes, emerging medications such as targeted agents and immunotherapy are also under investigation.

Two Cases of Angiosarcoma with Persistent Unilateral Eyelid Swelling

Angiosarcoma is a widely known neoplasm with one of the poorest prognoses; however, such cases are rarely observed by the ophthalmologists in clinical practice. The tumor commonly develops on the face and scalp and may cause eyelid swelling. We present 2 such cases. Case 1 was an 82-year-old woman who presented with indulated swelling of the right eyelid that extended to the upper forehead. Biopsy revealed a poorly circumscribed tumor infiltrated throughout the dermis and fat tissue, exhibiting both angiomatous and solid patterns. Immunohistochemistry showed CD31(-) and D2-40/podoplanin(+), suggesting angiosarcoma. The patient had multiple lung metastases and died 14 months later. Case 2 was a 77-year-old man who presented with swelling of the left eyelid, and erythema on the left temporal skin developed ulcerated nodules. Biopsy showed proliferated tumor cells in a sheet form, extensively throughout the dermis. Angiosarcoma was preferred based on immunohistochemistry: CD31(+), CD34(+), and D2-40(-). The patient was treated with electron beam therapy and chemotherapy and died after 13 months. It would be difficult for an ophthalmologist to suspect such a rare neoplasm only from swelling of the eyelids. However, angiosarcoma should be considered if the swelling spreads steadily from a head rash with a nodule or ulcer nearby.

A successful approach for angiosarcoma of the scalp using helical tomotherapy and customized surface mold brachytherapy: A case report

RATIONALE

Angiosarcoma of the scalp (ASS) is a rare solid tumor with a high risk of local recurrence. Effective treatment strategies are not currently available for angiosarcoma of the scalp (ASS). The aim of this study was to report the utility of high-dose-rate brachytherapy (HDRBT) as a boost treatment for ASS following total scalp irradiation using helical tomotherapy (HT). This is the first report of successful treatment of ASS using HT and HDRBT.

PATIENT CONCERNS

An 81-year-old woman presented with hemorrhagic nodular skin tumors of the scalp. The patient first noticed the scalp mass 3 months before consultation, which became significantly enlarged within a short period. The tumor was positioned mostly in the parietal area, although the skin color change was widely spread to the surrounding scalp.

DIAGNOSIS

The patient underwent biopsy of the skin lesion at the right parietal region, which revealed the presence of angiosarcoma on pathological examination. There was neither regional lymphadenopathy nor distant metastases on PET/CT.

INTERVENTIONS

Considering the patient's old age and poor performance status because of a history of cerebral infarction, we considered that she was eligible for definitive chemoradiotherapy of the scalp. We adopted an individual surface mold HDRBT boost of 18 Gy in three fractions following total scalp irradiation with 50 Gy in 25 fractions delivered using HT. Docetaxel (40 mg/m2) was administered every 4 weeks, concurrently with radiotherapy.

OUTCOMES

Treatment tolerance was good, and severe toxicity has not been observed to date. At 18 months after radiotherapy, the patient does not have any evidence of recurrence.

CONCLUSION

Customized surface mold HDRBT following total scalp irradiation using HT resulted in excellent disease control and minimal toxicity; thus, it may be a promising therapeutic option for ASS.

Malignant Vascular Tumors of the Head and Neck-Which Type of Therapy Works Best?

Simple Summary

Malignant vascular tumors are extremely rare tumors with variable clinical courses, and few data on their clinical management are available. Diagnosis is difficult due to their wide morphologic appearance. The intent of the present review is to demonstrate the current knowledge and management on malignant vascular tumors of the head and neck area. The mainstay of treatment for malignant vascular tumors is surgery, but radiotherapy and chemotherapy are also parts of the treatment concept especially in angiosarcomas. Targeted therapy, antiangiogenetic drugs and immunotherapy have been studied as new treatment options.

Abstract

Malignant vascular tumors of the head and neck are rare neoplasms with variable clinical presentation, wide age distribution, and variable clinical courses. The heterogeneous presentation of angiosarcomas and epithelioid hemangioendothelioma often leads to misdiagnosis and unsuitable treatment. While risk factors for angiosarcomas are previous radiation, chronic lymphedema, and exposure to arsenic, thorium oxide, or vinyl chloride, there are only limited and retrospective data available on prognostic factors in EHE. In both angiosarcomas and EHE, surgery is the mainstay of treatment. There is limited evidence regarding the role of radiotherapy in EHE, although EHE is considered relatively radiosensitive. In angiosarcomas, adjuvant radiotherapy is recommended according to retrospective case series. A standard medical therapy for metastasized malignant vascular tumors is lacking. Chemotherapy, which is effective in angiosarcoma, is mostly ineffective in EHE. Targeted therapy, antiangiogenetic drugs and immunotherapy have been studied as new treatment options. The goal of this review is to summarize the current data regarding malignant vascular tumors along with their diagnosis and management.

Development and validation of a prognostic nomogram model in primary cutaneous and subcutaneous soft tissue angiosarcoma

OBJECTIVE

The current study aimed to investigate the prognosis and treatment of primary cutaneous angiosarcoma (PCA) and primary subcutaneous angiosarcoma (PSCA), and tried to develop a prognostic nomogram model of them.

METHODS

A total of 1763 cases retrieved from the Surveillance, Epidemiology, and End Results (SEER) database were retrospectively analyzed. Survival analyses were performed to explore the prognosis of patients and the effects of different treatment methods. All data were randomly allocated into a training set and a testing set to develop and validate the nomogram model.

RESULTS

The findings showed that age, sex, grade, tumor size, multiple primary malignant tumors, stage, primary site surgery (PSS), radiotherapy (RT), and chemotherapy (CT) were correlated with prognosis (p < .05). The nomogram achieved good accuracy in predicting the prognosis. PSS + RT + CT showed the best prognosis for patients in stages I, II, and III (p < .05).

CONCLUSION

PCA and PSCA are rare with poor prognoses. Patients undergoing PSS may not gain survival benefits from combining with RT or (and) CT, whereas PSS + RT + CT should be actively performed in earlier stages to improve the prognosis of patients. The nomogram model can be used to predict the overall survival rate and guide better treatment.

Metastatic angiosarcoma of the scalp presented as posttraumatic subgaleal hematoma: The many faces of a diagnostic challenge

Angiosarcomas represent highly-aggressive malignant lesions of the endothelial cells of blood vessels, affecting mostly the elderly population, and usually located in the scalp or face. As cutaneous angiosarcomas often metastasize to the lung, they can manifest in various forms. We report a case of a 77-year-old male who presented after a posttraumatic blunt scalp lump that was initially diagnosed as infected subgaleal hematoma. This was later found to be an angiosarcoma. Further workup revealed that the tumor was invading the dura, with a rare pattern of mixed concomitant cystic and solid lung metastasis with ground-glass infiltrates. The patient underwent soft tissue reconstruction with split-thickness skin graft for the scalp lesion and palliative chemotherapy. We are discussing the common manifestations of scalp angiosarcomas and their potential pulmonary metastatic patterns. Also, a review of the differential diagnoses that may mimic cutaneous scalp angiosarcoma will be demonstrated.

Radical radiotherapy for localized cutaneous angiosarcoma of the scalp

Angiosarcoma is a rare but highly aggressive sarcoma of mesenchymal origin with a high mortality rate. Due to its rarity, there are very limited reports on the clinical outcomes of angiosarcoma treated with radical radiotherapy. The aim of the present study was to evaluate the efficacy and feasibility of treating patients with radiotherapy for cutaneous angiosarcoma localized to the scalp at The University of Tokyo Hospital (Tokyo, Japan). The present study analyzed 15 consecutive patients treated for cutaneous angiosarcoma of the scalp with radiotherapy between June 2008 and January 2020. All patients were treated with 70 Gy of irradiation split into 35 fractions, focused on the lesion, including 9 patients who received total scalp radiotherapy. The median follow-up period in all patients was 9.7 months. The median overall survival (OS) time was 20.7 months, and the 1-, 2- and 5-year OS rates were 56.2, 28.1 and 9.4%, respectively. At the time of analysis, 13 patients (86.7%) developed recurrence. Among these 13 patients, the first site of recurrence was the scalp as local recurrence in 7 patients (46.7%), parotid recurrence in 2 patients (13%) and distant metastasis in 4 patients (26.7%). No patient exhibited grade 3-5 radiation-induced late toxicity. Therefore, the present study revealed the clinical outcomes of radical radiotherapy for cutaneous angiosarcoma of the scalp.

Angiosarcoma of the Face: A Case Study and Literature Review of Local and Metastatic Angiosarcoma

Angiosarcomas are vascular malignancies with a tendency to spread extensively both locally and systemically. We report a case of cutaneous angiosarcoma of the face in a 53-year-old man that was originally misdiagnosed as an abscess. Initially small, the lesion enlarged over a four-to-six-month period and began to bleed. Two shave biopsies were performed that returned a diagnosis of angiosarcoma. The patient underwent radical resection and lymph node dissection, which revealed positive margins and ten of forty-six positive lymph nodes. The patient was treated with paclitaxel and concurrent radiation therapy (RT). Restaging scans showed a new sclerotic lesion of the T10 vertebra, three hepatic lesions, and an adrenal lesion, all concerning for metastasis. Biopsy of one of the hepatic lesions was consistent with metastatic angiosarcoma. In this review, we discuss the presentation of cutaneous angiosarcoma, the importance of early diagnosis, and the treatment options available for metastatic disease that has failed first-line chemotherapy.

Efficacy of Anlotinib for the Treatment of Angiosarcoma of the Face and Neck: A Case Report

Angiosarcoma of the face and neck is a rare soft tissue sarcoma with a high degree of malignancy. The current treatment methods mainly rely on a combination of surgery and radiotherapy and/or chemotherapy. However, the options for drug treatment are very limited and surgery can be difficult to carry out due to the location of the tumor, so the efficacy of first-line drugs needs to be constantly explored. A case of angiosarcoma of the head and face diagnosed by biopsy is reported here. The patient received an oral anlotinib hydrochloride capsule once a day (12 mg on days 1 - 14/1 week off for a 21-day cycle) due to the difficulty of surgery. Until now (April, 2020), after 10 months of treatment, the patient's scalp and facial lesions have gradually reduced and the partial response and progression-free survival of this patient were good, with moderate or tolerable adverse events. This approach provides a new approach for the clinical treatment of malignant angiosarcoma of the face and neck with anlotinib as first-line therapy.

Retrospective Analysis of the Clinical Presentation, Treatment and Outcome of Angiosarcoma in a Sarcoma Referral Center

INTRODUCTION

Angiosarcoma (AS) is a rare subtype of soft tissue sarcoma. We performed a retrospective analysis of patient characteristics, treatments and prognostic factors in patients treated in a single sarcoma center.

METHODS

We reviewed records of patients treated between 1987 and 2018, categorized in 7 different subtypes according to tissue of origin and underlying risk factors. The Kaplan-Meier method was used to estimate overall survival (OS); the Cox proportional hazards model was used to study prognostic variables.

RESULTS

Among 134 patients, 30% had radiation-induced, 31% primary soft tissue, 24% cutaneous, 5% breast, 4% bone, 2% lymphedema-associated and 4% unknown primary AS. Key patient/disease characteristics varied between subgroups. The median OS was 22.0 months for the entire cohort, with 28.9% with a 5-year survival. Metastasis at diagnosis was seen in 23% of patients; 38% developed metachronous metastasis. Sixty-six (49%) patients received systemic therapy; common first-line treatments were doxorubicin (48%) and paclitaxel (39%), without a significant difference in OS between agents. Younger age, breast/radiation-induced AS, primary surgery and palliative chemotherapy were associated with better OS. Synchronous metastasis, soft tissue/unknown primary location correlated with poor survival.

CONCLUSION

AS is a very heterogeneous sarcoma subtype, with substantial variability in clinical presentation and survival among patient subsets. Prognosis is poor, and there is no difference in outcome comparing the 2 most frequently used chemotherapy agents in the first line, paclitaxel and doxorubicin.

Benefits of the Multidisciplinary Approach After Curative Surgery for the Treatment of Scalp Angiosarcoma

BACKGROUND

Patients with scalp angiosarcoma still present with a dismal prognosis, indicating the need for a multidisciplinary approach. The present study aimed to investigate the treatment outcomes of scalp angiosarcoma with a focus on the effect of radiotherapy and chemotherapy, performed in either an adjuvant or palliative setting, after curative surgical treatment.

METHODS

Patients with scalp angiosarcoma without evidence of systemic metastasis who were treated with curative ablative surgery between 2008 and 2018 were assessed. Oncologic outcomes, including recurrence-free survival (RFS) and overall survival (OS), were evaluated.

RESULTS

A total of 23 patients were analyzed. All patients underwent radical resection, most of whom (82.6%) achieved R0 resection. Adjuvant radiotherapy and chemotherapy (all taxane-based) were delivered for 11 and 3 patients, respectively. Recurrence developed in 17 (73.9%) of 23 patients during a mean follow-up period of 18.4 months. The overall 2-year RFS and OS were 15.5% and 44.4%, respectively. Multivariate analysis showed that adjuvant radiotherapy and chemotherapy were associated with a significantly low risk of recurrence. In 17 patients with recurrence, those receiving palliative radiotherapy or chemotherapy had significantly higher OS than those not receiving any treatments. Compared with patients treated during the first half of the study period, those treated during the latter part, who received adjuvant and palliative radiotherapy or chemotherapy more frequently, had significantly favorable OS, with a 2-year OS of 77.8%.

CONCLUSIONS

A multidisciplinary approach using radiotherapy and/or chemotherapy combined with curative resection might be associated with better oncologic outcomes in patients with scalp angiosarcoma.

The Management and Prognosis of Facial and Scalp Angiosarcoma: A Retrospective Analysis of 15 Patients

BACKGROUND

Angiosarcomas are extremely aggressive malignant tumors that arise from vascular endothelial cells. The risk factors, etiology, prognostic factors, and optimal management strategies for angiosarcomas are as yet unknown.

METHODS

We retrospectively analyzed data from 15 patients who were treated in Asan Medical Center, Seoul, Republic of Korea, in the past 12 years, to assess the effect of different treatment modalities and reconstructive methods on the locoregional recurrence, metastasis, and overall survival.

RESULTS

A total of 15 patients were identified (median age at diagnosis, 72 years; range, 61-82 years). Median tumor size was 6 cm. Median follow-up was 287 days. The median overall survival was 14.96 months; a total of 13 (87%) patients had died by the end of the study.The median locoregional recurrence, metastasis, and overall survival were 7.3, 6.5, and 16.7 months, respectively. On univariate analysis, the use of adjuvant therapy after surgery (vs surgery without adjuvant therapy) was associated with delayed median time to detection of recurrence (7.9 months vs 3.1 months, respectively; P = 0.825), delayed median time to metastasis (8.7 months vs 3.1 months, respectively; P = 0.191), and better median overall survival (7.3 months vs 3.1 months, respectively; P = 0.078).The use of flap versus skin graft as a reconstructive method was associated with delayed median recurrence (8.75 vs 7.32 months, respectively; P = 0.274) and earlier median metastasis (3.75 vs 6.53 months, respectively; P = 0.365), but the same median overall survival of 16.7 months (P value: 0.945) and tumor smaller or bigger than 5 cm show earlier median time to detection of recurrence (4.17-7.32 months; P = 0.41), earlier median time to metastasis (3.75-6.53 months; P = 0.651), but better median overall survival of 18.21 versus 16.7 months, respectively (P = 0.111).

CONCLUSIONS

Multimodal treatment that combines surgery with adjuvant therapy is the best management strategy that influences survival positively in patients with angiosarcoma. The study shows that the reconstructive method does not affect the prognosis in these patients. So it is better to choose the simplest suitable resection and reconstructive method with the least complications and to avoid unnecessary procedures.

Survival predictors of metastatic angiosarcomas: a surveillance, epidemiology, and end results program population-based retrospective study

Background

Angiosarcomas (AS) have poor prognosis and often metastasize to distant sites. The potential predictors of metastatic angiosarcomas (MAS) have not been extensively investigated. The main objective of this study was to identify survival predictors of MAS.

Methods

Surveillance, Epidemiology, and End Results (SEER) datasets were used to identify patients with MAS from 2010 to 2016. Risk predictors were determined with the aid of Kaplan-Meier and Cox regression model analyses.

Results

A total of 284 MAS patients met the study entry criteria. Among these, 121 patients (42.6%) were diagnosed with metastasis in bone, 26 in brain (9.2%), 86 in liver (30.3%) and 171 in lung (60.2%). Overall, 96 patients (33.8%) had two or more metastatic sites. The 1- and 3-year overall survival (OS) rates were 20.8 and 3.8% while 1- and 3-year cancer-specific survival (CSS) rates were 22.0 and 5.2%, respectively. Cox regression analysis revealed chemotherapy, radiation treatment (RT) and tumor size ≤10 cm as independent favorable predictors of OS. In terms of CSS, tumor grade IV, tumor size > 10 cm and absence of chemotherapy were independent adverse predictors. Surgery did not prolong survival outcomes (both OS and CSS) in the current cohort.

Conclusion

MAS is associated with extremely poor survival. Chemotherapy, RT, and tumor size are independent predictors of OS. Chemotherapy and tumor size are independent prognostic factors of CSS. Chemotherapy is therefore recommended as the preferred treatment option for MAS patients.

Prognostic significance of positive surgical margins for scalp angiosarcoma

BACKGROUND

Scalp angiosarcomas (AS) are aggressive soft tissue sarcomas that present with outcomes different from other AS of the head and neck region. Due to the rarity of the disease, limited data on the clinical outcome of scalp AS are available. In particular, the prognostic significance of surgical margins remains controversial and the impact of margin status on survival has not been documented.

METHODS

We retrospectively reviewed 41 scalp AS patients, including 30 patients with localized disease and 11 patients with initial distant metastasis, treated in our institution between 1997 and 2017. Survival was determined by Kaplan-Meier analysis. In the 30 patients without distant metastasis (localized disease), univariate and multivariate analysis using the Cox proportional hazards model were used to determine clinicopathologic characteristics associated with recurrence free survival (RFS), locoregional control (LRC), and overall survival (OS).

RESULTS

Totally 41 patients diagnosed with scalp AS were identified, including 30 patients with localized disease and 11 patients with initial distant metastasis on diagnosis. Overall, the median follow-up period was 19.3 (range 0.3-128.5) months. The median survival time was 16.6 (range 0.3-144.3) months and the 5-year OS (95% Confidence Interval (CI)) rate was 22% (12%-42%). In the 30 patients with localized disease, univariate analysis showed that positive margins, either lateral-side or deep-side, were significant prognostic factors for RFS, LRC, and OS (p < 0.05). On multivariate analysis, positive margins emerged as adverse prognostic factors for RFS (Hazard Ratio (HR) 4.29, 95% CI, 1.71-10.75, p = 0.002), LRC (HR 6.35, 95% CI, 2.19-18.37, p = 0.001), and OS (HR 4.73, 95% CI, 1.71-13.07, p = 0.003).

CONCLUSION

Scalp AS is associated with high local recurrence rates and poor survival outcomes. Positive surgical margins are adverse prognostic factors for survival.

Epidemiology, tumor characteristics and survival in patients with angiosarcoma in the United States: a population-based study of 4537 cases

OBJECTIVE

Limited by sample size, angiosarcoma was rarely studied. We aimed to investigate the characteristics and prognosis of angiosarcoma in the National Cancer Institute's Surveillance, Epidemiology and End Results database.

METHODS

Patients who were diagnosed with primary angiosarcoma from 1973 to 2014 were extracted from the Surveillance, Epidemiology and End Results database. Kaplan-Meier analysis was used to estimate the overall survival, and the difference between groups was tested by the log-rank test. Multivariate Cox regression analyses were employed to identify prognostic factors for primary angiosarcoma.

RESULTS

A total of 4537 patients with angiosarcoma were included with the median age of 69 years. The median overall survival was 82.1 (95% confidence interval: 76.5-87.7) months. Overall 1-, 2- and 5-year survival rates were 55.2 ± 0.7, 41.0 ± 0.7 and 26.3 ± 0.7%, respectively. In the univariate analysis, age, gender, marital status, race, primary site, tumor grade, tumor size, Surveillance, Epidemiology and End Results historic stage and the surgery of primary site were significantly associated with overall survival. Multivariate Cox regression showed that factors including the patients older than 69 years, male, unmarried status, other primary sites, grades (III and IV), tumor size ≥ 5 cm, regional and distant stage and non-surgery were independently associated with poor survival. The results were consistent after excluding the patients in IV stages.

CONCLUSIONS

This large population-based study comprehensively described the survival rate and prognostic factors for angiosarcoma in the United States. Age, gender, marital status, primary sites, tumor grade and size and historic stage were determinants of survival, and surgery can improve the prognosis of patients with angiosarcoma.

Patterns of Care and Survival of Cutaneous Angiosarcoma of the Head and Neck

OBJECTIVE

To analyze the patterns of care and survival of cutaneous angiosarcomas of the head and neck.

STUDY DESIGN

Retrospective cohort study.

SETTING

National Cancer Database.

METHODS

The National Cancer Database was queried to select patients with cutaneous angiosarcoma of the head and neck between 2004 and 2015. For survival analysis, patients were included only if they received definitive treatment and complete data. Prognostic factors were analyzed by univariate and multivariable Cox regression.

RESULTS

We identified 693 patients diagnosed with head and neck angiosarcomas during the study period. The majority were male (n = 489, 70.6%) and elderly (median, 77 years). A total of 421 patients (60.8%) met the criteria for survival analyses. These patients were treated with surgery and radiation (n = 178, 42.3%), surgery alone (n = 138, 32.8%), triple-modality therapy (n = 48, 11.4%), surgery and chemotherapy (n = 29, 6.9%), and chemoradiation (n = 28, 6.7%). With a median follow-up of 29 months, the 3-year survival was 50.1%. Patients undergoing surgery had better median survival than those who did not (38.1 vs 21.0 months, P = .04). Age, comorbidity, tumor size, and surgical margins were significant factors in univariate analyses. On multivariable analysis, age ≥75 years (hazard ratio, 2.65; 95% CI, 1.80-3.88; P < .001) and positive margins (hazard ratio, 1.91; 95% CI, 1.44-2.51; P < .001) predicted worse overall survival.

CONCLUSION

Angiosarcoma of head and neck is a rare malignancy that affects the elderly. Surgical treatment with negative margins is associated with improved survival. Even with curative-intent multimodality treatment, the survival of patients aged ≥75 years is limited.

Successful treatment of primary cutaneous angiosarcoma of the nose with sequential chemo- and radiotherapy

•

The optimal treatment of primary cutaneous angiosarcoma is considered to be surgical exision.

•

Concurrent chemo-radiotherapy is efficient in the treatment of primary cutaneous angiosarcoma.

•

The toxicity profile of this association is acceptable.

Clinical outcomes in primary scalp angiosarcoma

Scalp angiosarcoma is a rare, extremely aggressive cutaneous malignancy with poor patient prognosis. The present study reviewed the cases of 42 patients who presented scalp angiosarcoma and were treated at the Zhongshan Hospital of Fudan University between January 2002 and December 2013. The clinical characteristics, demographics, treatment regimens and outcomes of patients were analyzed, and the overall survival (OS) and recurrence-free survival (RFS) rates were calculated. A total of 42 patients were examined in this study. Surgery was the most common therapeutic measure, and was performed in 39 patients, alone (12 patients), in combination with chemotherapy (14 patients), radiotherapy (6 patients) or 3-modality-therapy (7 patients). The median follow-up time of patients was 28.5 months. The 5-year OS rate was 19%, and the 5-year RFS rate was 10%. Taken together, the results of the present study suggested that patients whose tumor presented a nodular localized lesion had a significantly improved OS rate (P=0.0078). Patients aged ≥70 years were associated with a lower 5-year OS (P=0.0071) and RFS rates (P=0.0095) vs. patients aged <70 years. Different treatments were not identified to be significantly associated with an improved OS or RFS. The present results also indicated that if the tumor presented nodular localized lesions, the patients exhibited a better prognosis than those with a diffuse lesion. Although younger patients had better clinical outcomes, the likelihood of recurrence and mortality remained high for all patients.

Single institutional experience of radiation therapy for angiosarcoma of the scalp without cervical lymph node metastases: Impact of concurrent chemoradiation with maintenance chemotherapy using taxanes on patient prognosis

Cutaneous angiosarcoma is a rare aggressive malignant tumor. Concurrent chemoradiation (CCRT) with maintenance chemotherapy using taxanes is one of the primary treatments. The aim of the present study was to retrospectively analyze the efficacy of CCRT with maintenance chemotherapy using taxanes in localized angiosarcoma of the scalp without cervical lymph node metastases. A total of 19 patients treated with radiation therapy for localized angiosarcomas of the scalp without cervical lymph node metastases were enrolled. The overall survival (OS), progression-free survival (PFS), and local control (LC) rates were calculated using Kaplan-Meier analysis. Univariate analyses were performed for various potential prognostic factors for OS, PFS, and LC. The median radiation dose was 70 Gy (range, 60-70 Gy), and the fractional dose was 2 Gy. Radiation therapy alone, radiation therapy + interleukin-2, surgery + CCRT with maintenance chemotherapy, CCRT with maintenance chemotherapy, and CCRT without maintenance chemotherapy were administered to 2, 4, 2, 9 and 2 patients, respectively. The 1- and 3-year OS, PFS, and LC rates were 88 and 52%, 47 and 33%, and 74 and 56%, respectively. CCRT with maintenance chemotherapy and surgery were significant prognostic factors for PFS (P=0.036 and 0.025, respectively). Therefore, CCRT with maintenance chemotherapy using taxanes might be effective in treating localized angiosarcomas of the scalp without cervical lymph node metastases.

Cutaneous Angiosarcoma of Head and Neck - A Single-Centre Analysis

BACKGROUND:

Cutaneous angiosarcoma of the head and neck region is a subtype of cutaneous angiosarcoma with an unfavourable prognosis. Diagnosis is often delayed.

PATENTS AND METHODS:

The setting is an Academic Teaching Hospital Skin Cancer Center. Eight Caucasian patients could be identified, 5 men and 3 women. Delay to diagnosis was between 12 to 4 months (mean 7.8 ± 2.9 months). The diagnosis was confirmed in all cases by histopathology and immunohistochemistry. Hematoxylin-eosin, Giemsa, PAS, iron and reticulin stains were performed. Endothelial markers such as CD31, CD34, and Ki67 for proliferation assessment were used in all tumours. Other markers used included pan-cytokeratin (CK), CK7, CK20, ERG, CD 40 and c-MYC. Tumours were classified as localised versus multifocal or diffuse form. Tumour staging was performed according to the 8th edition of the AJCC. The mean age of patients was 79 years ± 26.4 years. The male to female ratio was 1.7. Tumour classification was diffuse in 2 patients, multilocular in one and localised in 5 patients. In 5 of 8 patients, a multimodal treatment was performed, one had radiotherapy alone, in another patient surgery was performed, and radiotherapy is planned. The mean OS was 26.4 months ± 24.5 months.

CONCLUSION:

Cutaneous angiosarcoma of the head and neck is an aggressive tumour with a poor prognosis. Although surgery remains a cornerstone of treatment, the tumour size at first presentation may be too large, and the elderly patients maybe not suitable for extensive surgery. Therefore, multimodal treatment with adjuvant radiotherapy and/ or chemotherapy is necessary. Multimodal treatment offers a better outcome than radiotherapy or chemotherapy alone. Stealth liposomal encapsulated doxorubicin is a therapeutic option for elderly patients with improved safety compared to conventional doxorubicin.

Individual multi-catheter mould technique in high-dose-rate brachytherapy - personalized approach in treating multifocal angiosarcoma of the face

Purpose

The aim of this study was to report individual surface mould multi-catheter high-dose-rate (IMM HDR) application as a salvage treatment for a head and neck angiosarcoma patient, previously treated with surgery followed by external beam radiotherapy.

Material and methods

A 74-year-old male reported to our center with an uncommon malignant neoplasm of blood vessels. The patient was qualified for a wide local excision (WLE) of tumor with simultaneous reconstruction using a free-flap collected from the patient's thigh. After surgery, the patient was qualified for adjuvant external-beam radiotherapy (EBRT). Volumetric arc therapy (VMAT; RapidArc^®, Varian Medical Systems) was used to deliver 52.8 Gy/1.6 Gy in 33 fractions. Overall treatment time was 51 days. Six months after radiotherapy, an incisional biopsy of non-healing ulcer of the nasal bridge revealed angiosarcoma. Wide local excision with skin graft reconstruction was planned. Due to multifocal disease and lack of possibility for further margin, the resection surgery was completed after skin graft reconstruction from the right thigh. Surface IMM HDR was considered as an alternative option for further treatment. Total dose of 48 Gy (12 fractions) was planned.

Results

One month after surface IMM HDR, healing process of the skin was observed in the treated regions and six months later, the irradiated areas recovered. General condition of the patient deteriorated two years after diagnosis and one year after HDR. He was hospitalized to receive palliative care.

Conclusions

HDR brachytherapy may be a valuable option for angiosarcoma treatment. Difficult lesion location may yield non-radical surgery. Surface IMM HDR provides highly conformal plan and allow adjusting the dose to individual clinical situation.

Patterns of infiltration and local recurrences of various types of cutaneous sarcomas following three-dimensional histology

BACKGROUND

Cutaneous sarcomas are rare and characterized by pathogenetic heterogeneity. Knowledge about local infiltration patterns and recurrence rates may be useful in improving patient care and outcomes. The objective of the present study was to compare these two characteristics in sarcomas that had been treated using the identical surgical procedure.

PATIENTS AND METHODS

Between 2006-2010, 84 patients with various types of sarcoma underwent surgery followed by three-dimensional histology. Tumor entities included dermatofibrosarcoma protuberans (DFSP, 54 patients), leiomyosarcoma (ten patients), rhabdomyosarcoma (one patient), angiosarcoma (seven patients) as well as atypical fibroxanthoma (AFX, three patients) and cutaneous undifferentiated pleomorphic sarcoma (UPS, nine patients). Median follow-up was four years (range: 2-6 years).

RESULTS

Local recurrence rates among patients with primary DFSP were 2.2 %. All patients undergoing re-excision were subsequently tumor free. Patients with leiomyosarcoma, rhabdomyosarcoma, AFX, and cutaneous UPS experienced no local recurrence; however, one individual developed in-transit metastasis (UPS) (8.3 %). Three patients with angiosarcoma developed local recurrence (43 %), two of whom remained tumor free following re-excision. Two angiosarcoma patients died from distant metastases (29 %). Both DFSP and especially angiosarcoma lesions exhibited extensive subclinical growth.

CONCLUSIONS

Recurrence rates of cutaneous sarcomas following three-dimensional histology are low. Local recurrences are readily manageable by re-excision. Angiosarcoma is characterized by extensive superficial growth, aggressive biological behavior, and predominantly hematogenous spread.

Anterolateral thigh free flaps for the reconstruction of scalp angiosarcoma - 18-year experience in Chang Gung memorial hospital

BACKGROUND

Scalp angiosarcoma is a rare and highly aggressive cutaneous malignancy with poor prognosis and high recurrence rate. Multimodality approach is currently the treatment protocol for resectable angiosarcoma, including wide local excision and postoperative radiation. This single-institution study reviews the 18-year experience of the surgical treatment of scalp angiosarcomas.

METHODS

A retrospective chart review was performed on patients with scalp angiosarcoma who received wide local excision and free flap reconstruction from 2001 to 2018. The type of free flap, safety margin, outer cortex burring, and dose for radiation were recorded. Kaplan-Meier plots were computed.

RESULTS

Eight male patients (mean age of 74.4 years old) were enrolled in the series. Tumor sizes ranged from 3 × 3 to 8 × 13 cm. All patients underwent wide local excision and outer cortex burring (cortical curettage). Seven (87.5%) scalp defects were reconstructed with anterolateral thigh free flap. All patients received adjuvant radiation therapy for tumor bed and margins. Chemotherapy was adopted for the management of local recurrence (37.5%) or distant metastasis (37.5%). The 2-year and 5-year survival rates are 72.9% and 38.9%, respectively, and 1-year and 2-year disease-free rates are 37.5% each.

CONCLUSION

Scalp angiosarcoma is a rare and highly aggressive cutaneous malignancy with poor prognosis. Anterolateral thigh free flap is a good reconstructive option due to its ability to cover large cutaneous defects with minimal need for skin grafting. Multimodal treatment protocol, including wide local excision with cortical curettage, and adjuvant radiation (regular basis) and chemotherapy (local recurrence or distant metastasis) may offer improved 1-year survival rate (100%).

Clinical Outcomes and Prognostic Features of Angiosarcoma: Significance of Prior Radiation Therapy

AIMS

Angiosarcoma is a rare and aggressive malignancy with a poor prognosis. There is limited literature describing prognostic factors and guidelines for treatment. We aim to describe outcomes in angiosarcoma, including the impact of patient-, tumour- and treatment-related factors on prognosis.

MATERIALS AND METHODS

Patients with non-metastatic angiosarcoma diagnosed between 2008 and 2017 were retrospectively reviewed. Univariable and multivariable Cox proportional hazards methods were used to evaluate factors associated with locoregional recurrence, distant failure and overall survival. The Kaplan-Meier method and log-rank statistics were used to compare outcomes among patients with and without a history of prior radiation therapy.

RESULTS

The cohort included 65 patients. The median age at diagnosis was 68 years (35-93). Nineteen patients had a history of receiving prior radiation therapy at the anatomic location of their angiosarcoma. Treatment modalities included surgery (n = 19), surgery + radiation therapy (n = 12), surgery + chemotherapy (n = 8), chemotherapy + radiation therapy (n = 7) and all three modalities (n = 14). The median follow-up was 18 (2-192) months. The 2-year locoregional control, distant control and overall survival were 61.8, 63.6 and 58.9%, respectively. On multivariable analysis, a history of previous radiation therapy was associated with inferior outcomes with respect to locoregional recurrence (hazard ratio 89.67, 95% confidence interval 8.45-951.07, P < 0.001), distant failure (hazard failure 3.74, 95% confidence interval 1.57-8.91, P = 0.003) and overall survival (hazard ratio 3.89, 95% confidence interval 1.56-9.60, P = 0.003). In patients with primary angiosarcoma, the rates of locoregional control, distant control and overall survival were 72.4, 73.4 and 65.1%, respectively, compared with 31.9, 41.1 and 45.1% in patients with radiation therapy-induced angiosarcoma (P = 0.001).

CONCLUSION

Angiosarcomas that arise as a result of previous radiation therapy have worse outcomes compared with primary angiosarcomas. Although selection bias and compromise of clinical care in radiation therapy-induced angiosarcoma are partially to blame, differences in genomic profiles of the tumours need to be characterised to evaluate the underlying biological differences, as this may guide future treatment management. This study adds to the existing body of literature on angiosarcoma. Results from the current study are presented alongside previously published data to further characterise outcomes and prognostic factors on this rare and aggressive malignancy.

Metastatic Angiosarcoma of the Scalp Presenting with Cystic Lung Lesions: A Case Report and Review of Cystic Lung Diseases

INTRODUCTION

Angiosarcomas are rare, malignant vascular tumors that affect endothelial cells of blood vessels. Angiosarcomas most commonly occur on the scalp or face of elderly individuals and are highly aggressive, with a 5-year survival rate below 15%. Cutaneous angiosarcomas often metastasize to the lung, where they can present with cystic lesions, solid lesions, pneumothorax, and/or hemothorax.

CASE PRESENTATION

We report the case of an 83-year-old woman who presented with a scalp lesion, which was initially thought to be caused by scalp trauma but was later found to be an angiosarcoma. She initially refused any therapy for the tumor. She returned several months later with a cough and shortness of breath and was found to have multiple pulmonary cysts. She was treated with paclitaxel, but her tumor did not respond to the therapy and she died 2 months later.

DISCUSSION

We discuss the common presentation of cutaneous angiosarcomas and their tendency to metastasize to the lung and present as cystic lesions. We also review the common conditions that can cause cystic changes in the lungs.

Characteristics and Prognosis of Primary Head and Neck Angiosarcomas: A Surveillance, Epidemiology, and End Results Program (SEER) Analysis of 1250 Cases

Head and neck angiosarcomas (HN-AS) are rare malignancies with a poor prognosis relative to other soft tissue sarcomas. To date, the HN-AS literature has been limited to short reports and single-institution experiences. This study evaluated patients registered with the Surveillance, Epidemiology, and End Results (SEER) program who had been diagnosed with a primary HN-AS. Predictors were drawn from demographic and baseline tumor characteristics. Outcomes were survival months and cause of death. Kaplan-Meier analyses were used to estimate overall (OS) and disease-specific survival (DSS) rates. Cox proportional hazards regression models were used for multivariate analyses. A total of 1250 patients (mean age 73.3 years) were identified, and nearly all lesions (93.5%) were cutaneous. Two- and 5-year OS rates were 47.3% (95% CI 44.3-50.3) and 26.5% (95% CI 23.7-29.3), while 2- and 5-year DSS rates were 66.6% (95% CI 63.6-69.6) and 48.3% (95% CI 44.5-52.1). In the univariate analyses, age, race, tumor grade, tumor size, AJCC stage, SEER historic stage, and surgery were significant predictors of both OS and DSS. Multivariate regression revealed that independent predictors of poor OS and DSS were older age [OS: HR 1.04 (95% CI 1.02-1.05), p < 0.01; DSS: HR 1.03 (95% CI 1.01-1.05), p < 0.01], increased tumor size [OS: HR 1.01 (95% CI 1.01-1.01), p < 0.01; DSS: HR 1.01 (95% CI 1.01-1.02), p < 0.01], and distant disease [OS: HR 2.97 (95% CI 1.65-5.34), p < 0.01; DSS: HR 4.99 (95% CI 2.50-9.98), p < 0.01]. Age, tumor size, and disease extent were determinants of HN-AS survival. When all other factors were controlled, lower histologic grade and surgery did not improve the risk of death.

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).

Current and Future Directions for Angiosarcoma Therapy

OPINION STATEMENT

Angiosarcomas are rare vascular neoplasms that are among the most aggressive subtypes of soft tissue sarcomas. Surgical resection is often challenging even in localized disease, as the infiltrative nature of these cancers leads to frequent local and metastatic recurrences. Cytotoxic chemotherapy, including anthracycline-based regimens and taxanes can produce significant responses in a subset of patients but durability is limited with most patients ultimately succumbing to metastatic disease. Targeted therapy with tyrosine kinase inhibitors is usually well-tolerated but prone to development of resistance. Few head-to-head trials have addressed the optimal sequence of therapies, or demonstrated conclusive benefits of one therapy over another based on clinical and etiologic factors. Novel therapies in clinical trials, including antibodies to endoglin and checkpoint inhibitors have demonstrated exciting early activity in patients with angiosarcoma. Improved understanding of the genetic heterogeneity within various angiosarcoma subtypes may identify predictive biomarkers to match patients to effective existing and future therapies. Overall, angiosarcoma patients with optimal performance status are best served in clinical trials that incorporate novel combinations of cytotoxic chemotherapy, targeted therapies, and immunotherapies.