Breast Angiosarcoma Case Report
by Aditya Gaddipati, Raquel Gonzalez Heredia, Diane Drugas
Corresponding author: Raquel Gonzalez-Heredia, University of Illinois at Chicago College of Medicine, Illinois, Chicago, United States
Received Date: 24 January, 2024
Accepted Date: 30 January, 2024
Published Date: 2 February, 2024
Citation: Gaddipati A, Gonzalez Heredia R, Drugas D (2024) Angiosarcoma Case Report. J Oncol Res Ther 9: 10196. https://doi.org/10.29011/2574-710X.10196
Abstract
We present a case of a 77-year-old female who was diagnosed with right breast invasive carcinoma treated with breastconserving surgery and adjuvant radiation therapy in 2015. In 2023, she was diagnosed with radiation-induced angiosarcoma (RIAS), and a right breast mastectomy was recommended. RIAS is difficult to diagnose due to its rarity and non-specific symptoms. This paper examines various factors causing RIAS and strategies to manage this disease. Even though achieving clear margins is challenging due to its multifocal nature, surgical resection remains the primary treatment for RIAS. The role of chemotherapy remains unclear, although targeted therapies may offer alternative options. The prognosis for RIAS is influenced by factors including the size of the tumor and stage at diagnosis. Adjuvant chemotherapy’s role is still evolving, and developments within radiotherapy approaches have allowed for enhanced local control. Further research is required to develop optimal treatment protocols and preventive strategies.
Keywords: Angiosarcoma; Breast Cancer; Radiation therapy
Introduction
Breast angiosarcoma is a type of rare cancer that can manifest as either a primary tumor (PBA) or a secondary malignancy (SBA). Due to their varying clinical features, PBA and SBA present with their own clinical challenges. SBA develops primarily as a result of previous breast radiation therapy. The SBA cases are rising due to the increased use of breast-conserving surgery and radiation therapy. Angiosarcoma of the breast accounts for 0.04% of all breast cancers and 8% of breast sarcomas [1]. Secondary angiosarcomas, predominantly observed in women with a history of breast cancer treatment, include lymphedema-associated cutaneous angiosarcoma and post-irradiation angiosarcoma. This malignancy exhibits high local recurrence rates, distant metastases, and poor survival. This study underscores the imperative to comprehend the clinico pathological features, survival, and prognostic factors of breast angiosarcoma.
Clinical Case Presentation
Patient is a 77-year-old female diagnosed with a right breast invasive ductal carcinoma of 1.8 cm in April 2015. There was no family history of breast, ovarian, colon, prostate, or pancreatic cancer. The patient’s medical history indicated osteoporosis, diabetes, and hypertension. Biopsy of the breast mass showed an invasive ductal carcinoma ER/PR positive and HER2 negative, and DCIS grade 3 with cribriform and comedo types. In May of 2015, she underwent a right lumpectomy with x-ray needle localization and sentinel node biopsy that staged her at T1N0M0 with positive inferior and medial margins for DCIS. She underwent a re-excision of the right breast tumor cavity in July 2015. The patient underwent radiation therapy for 21 days but refused adjuvant chemotherapy at that time. She completed radiation therapy in August 2015 and was started on hormonal treatment with Anastrazole, which she continued for 5 years. The patient noted slight discoloration but no pain around the areola in November 2015 to radiation oncology but was reassured that it was secondary to treatment. She also followed oncological and radiation therapy follow up which consisted of clinical examinations every 4-6 months, bilateral mammography, physician breast exams, and monthly selfbreast exams. In March 2016, she was concerned about an area of mobile mass near the posterior end by the healed scar tissue. She underwent an ultrasound and mammogram which revealed it to be a cystic lesion. In May 2016, a significant mass effect was noted along the lateral aspect of the right breast in the area of the lumpectomy, and a repeat mammography indicated post-surgical changes. In November 2016, the patient transitioned to yearly mammograms compared to 6-month visits.
In December 2021, she noticed some bruising around her right breast. The bruising had been present for 2-3 weeks and didn’t cause any pain or drainage. She couldn’t recall any trauma that might have caused the bruising. During the physical examination, it was observed that there was a widespread area of ecchymosis, including the lower half of the breast. The skin had a mix of dark bluish to light pink discoloration, but there was no palpable mass, induration, nipple discharge, or pain. The radiology findings from December 2021 reported scattered areas of fibroglandular density but no suspicious masses, architectural distortion, or micro calcifications. The patient was advised to use empirically over-thecounter antifungal medication, which she did for a few days.
Abnormal skin thickening and discoloration involving a large portion of the right breast with incidentally noted ill-defined hypoechoic skin lesion seen on ultrasound in February 2023. Bilateral diagnostic mammography at the time showed BI-RADS: 4. In February 2023, an MRI bilateral breast revealed diffuse skin thickening and an abnormally enhancing 3.3 cm lesion within the right breast dermis, inferior and lateral to the nipple and extending into the subcutaneous tissue. Differential considerations included skin cancer, dermatitis/abscess, and less likely breast cancer recurrence. Needle core biopsy reviewed grade 2 post-radiation angiosarcoma and metastatic workup was recommended. Further metastatic workup including, CT chest, abdomen, and pelvis with contrast in April 2023 showed no evidence of metastatic disease. Due to the extent of the local disease, plastic surgery service was consulted to help with wound closure, if needed. Patient was scheduled for a right breast mastectomy with a possible skin graft. Mastectomy incision was made, and superior and inferior skin margins were sent intraoperatively for frozen analysis. Pathology exam showed negative results for malignancy. Mastectomy was completed and the wound was successfully closed primarily. Patient recovered well. Final pathology of the right breast mastectomy showed angiosarcoma (secondary/treatment-related), measuring at least ~ 11.5 cm, with features favoring multiple foci of tumor (predominantly involving central and lower quadrants), predominantly involving skin (papillary and reticular dermis), with involvement of likely nipple/areolar related tissue and underlying subcutaneous tissue, with foci of focal mammary parenchymal involvement, prior biopsy/procedural site change and mild to moderate chronic inflammation with germinal center formation. Margins/tissue edges of resection appear uninvolved by tumor, closest clearance ~ 6 mm from anterior-inferior peripheral skin and soft tissue edges. Features compatible with separate appearing prior procedural site change associated with a nodular cyst-like area with dense peripheral fibrosis, hyalinization, dystrophic calcifications, pseudocystic change, mild chronic inflammation, pigment-laden macrophages, cholesterol clefts, fat necrosis and features of remote organizing hematoma. Stromal fibrosis with hyalinization, atrophic change, focal foci of cystic glandular dilatation, focal apocrine metaplasia, and focal intraglandular microcalcification. Skin with scar and features compatible with focal seborrheic keratosis. Skin and subcutaneous tissue for the right breast, superior skin flap, inferior skin flap, posterior margin, and medial margin were all negative for definitive morphologic evidence of tumor. Patient was scheduled for a follow-up visit in the following week but missed the scheduled follow-up visit at the hospital.
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