Advertisement

Post-radiotherapy vascular proliferations in mammary skin: A clinicopathologic study of 11 cases

      Background

      Post-radiotherapy atypical vascular lesions (AVL) in mammary skin show significant clinical and histopathologic overlap with well-differentiated angiosarcoma (AS) and pose a considerable diagnostic and managerial challenge when encountered.

      Objective

      We review Stanford's experience with diagnosing AVL and formulate a clinicopathologic approach to these lesions.

      Methods

      We performed a clinicopathologic study on 11 cases that were initially diagnosed as AVL and examined whether there are specific clinical or histopathologic features that delineate AVLs from well-differentiated AS.

      Results

      Clinically, all patients were women with a mean age of 68.1 years, had a history of infiltrating breast carcinoma, and were treated by excision with postoperative radiation therapy. All lesions were located in mammary skin within the prior radiation field. The clinical presentation included erythema, telangiectasias, papules, plaques, and nodules. All patients were diagnosed with AVL on initial biopsy. Six patients showed no recurrence or progression of disease following incomplete excision with no further therapy (3/6) or re-excision with negative margins (3/6). The remaining 5 patients were shown to have AS in the re-excision specimen. The patients diagnosed with AS were older and had a shorter interval from radiation as compared to those who did not experience an adverse outcome. Histologically, all initial biopsy specimens were transected and were characterized by complex, anastomosing vascular proliferations with dilated spaces. Each case was morphologically evaluated according to the AVL criteria of Fineberg and Rosen. Three cases met all of the criteria for AVL, and these patients showed no progression of disease. The remaining cases met most but not all diagnostic criteria for AVL and showed some features of AS, but fell short of a definitive diagnosis of AS, including the 5 cases that were subsequently diagnosed as angiosarcoma.

      Limitations

      This retrospective study utilized a small number of cases from a single consultation service; therefore, some inherent selection bias may exist.

      Conclusion

      We could not identify unequivocal clinical or histologic criteria that allows for a sharp separation between AVL and AS. Dermatologists and pathologists need to be aware of the overlap between AVL and well-differentiated AS and all patients who receive a diagnosis of AVL should undergo complete excision with close clinical follow-up and biopsy of any new lesions.

      Abbreviations used:

      AS (angiosarcoma), AVL (atypical vascular lesion), BCTAR (breast-conservation therapy with adjuvant radiation therapy), BLAP (benign lymphangiomatous papules), HHV (human herpes virus)
      To read this article in full you will need to make a payment
      AAD Member Login
      AAD Members, full access to the journal is a member benefit. Use your society credentials to access all journal content and features
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Benson J.R.
        • Osborne M.P.
        Breast conservation therapy over the past 15-20 years.
        Breast Cancer Res Treat. 1999; 55: 293
        • Fisher B.
        • Anderson S.
        • Bryant J.
        • Margolese R.G.
        • Deutsch M.
        • Fisher E.R.
        • et al.
        Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer.
        N Engl J Med. 2002; 347: 1233-1241
        • Pass H.
        • Vicini F.A.
        • Kestin L.L.
        • Goldstein N.S.
        • Decker D.
        • Pettinga J.
        • et al.
        Changes in management techniques and patterns of disease recurrence over time in patients with breast carcinoma treated with breast-conserving therapy at a single institution.
        Cancer. 2004; 101: 713-720
        • Veronesi U.
        • Cascinelli N.
        • Mariani L.
        • Greco M.
        • Saccozzi R.
        • Luini A.
        • et al.
        Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer.
        N Engl J Med. 2002; 347: 1227-1232
        • Billings S.D.
        • McKenney J.K.
        • Folpe A.L.
        • Hardacre M.C.
        • Weiss S.W.
        Cutaneous angiosarcoma following breast-conserving surgery and radiation: an analysis of 27 cases.
        Am J Surg Pathol. 2004; 28: 781-788
        • Brenn T.
        • Fletcher C.D.
        Radiation-associated cutaneous atypical vascular lesions and angiosarcoma: clinicopathologic analysis of 42 cases.
        Am J Surg Pathol. 2005; 29: 983-996
        • Brenn T.
        • Fletcher C.D.
        Postradiation vascular proliferations: an increasing problem.
        Histopathology. 2006; 48: 106-114
        • Strobbe L.J.
        • Peterse H.L.
        • van Tinteren H.
        • Wijnmaalen A.
        • Rutgers E.J.
        Angiosarcoma of the breast after conservation therapy for invasive cancer, the incidence and outcome. An unforseen sequela.
        Breast Cancer Res Treat. 1998; 47: 101-109
        • Ambrojo P.
        • Cogolludo E.F.
        • Aguilar A.
        • Sanchez Yus E.
        • Sanchez de Paz F.
        Cutaneous lymphangiectases after therapy for carcinoma of the cervix—a case with unusual clinical and histological features.
        Clin Exp Dermatol. 1990; 15: 57-59
        • Celis A.V.
        • Gaughf C.N.
        • Sangueza O.P.
        • Gourdin F.W.
        Acquired lymphangiectasis.
        South Med J. 1999; 92: 69-72
        • Diaz-Cascajo C.
        • Borghi S.
        • Weyers W.
        • Retzlaff H.
        • Requena L.
        • Metze D.
        Benign lymphangiomatous papules of the skin following radiotherapy: a report of five new cases and review of the literature.
        Histopathology. 1999; 35: 319-327
        • Gottfarstein-Maruani A.
        • Michenet P.
        • Kerdraon R.
        • Esteve E.
        Benign vascular proliferations in previously irradiated skin.
        Am J Surg Pathol. 2002; 26: 1372-1373
        • Guillou L.
        • Fletcher C.D.
        Benign lymphangioendothelioma (acquired progressive lymphangioma): a lesion not to be confused with well-differentiated angiosarcoma and patch stage Kaposi's sarcoma: clinicopathologic analysis of a series.
        Am J Surg Pathol. 2000; 24: 1047-1057
        • Jappe U.
        • Zimmermann T.
        • Kahle B.
        • Petzoldt D.
        Lymphangioma circumscriptum of the vulva following surgical and radiological therapy of cervical cancer.
        Sex Transm Dis. 2002; 29: 533-535
        • Leshin B.
        • Whitaker D.C.
        • Foucar E.
        Lymphangioma circumscriptum following mastectomy and radiation therapy.
        J Am Acad Dermatol. 1986; 15: 1117-1119
        • Prioleau P.G.
        • Santa Cruz D.J.
        Lymphangioma circumscriptum following radical mastectomy and radiation therapy.
        Cancer. 1978; 42: 1989-1991
        • Requena L.
        • Kutzner H.
        • Mentzel T.
        • Duran R.
        • Rodriguez-Peralto J.L.
        Benign vascular proliferations in irradiated skin.
        Am J Surg Pathol. 2002; 26: 328-337
        • Rosso R.
        • Gianelli U.
        • Carnevali L.
        Acquired progressive lymphangioma of the skin following radiotherapy for breast carcinoma.
        J Cutan Pathol. 1995; 22: 164-167
        • Schwab R.A.
        • McCollough M.L.
        Acquired vulvar lymphangiomas: a sequela of radiation therapy.
        Cutis. 2001; 67: 239-240
        • Sener S.F.
        • Milos S.
        • Feldman J.L.
        • Martz C.H.
        • Winchester D.J.
        • Dieterich M.
        • et al.
        The spectrum of vascular lesions in the mammary skin, including angiosarcoma, after breast conservation treatment for breast cancer.
        J Am Coll Surg. 2001; 193: 22-28
        • Weyers W.
        • Nilles M.
        • Konig M.
        [Lymphangioma circumscriptum cysticum following surgical and radiologic therapy].
        Hautarzt. 1990; 41: 102-104
        • Fineberg S.
        • Rosen P.P.
        Cutaneous angiosarcoma and atypical vascular lesions of the skin and breast after radiation therapy for breast carcinoma.
        Am J Clin Pathol. 1994; 102: 757-763
        • West J.G.
        • Qureshi A.
        • West J.E.
        • Chacon M.
        • Sutherland M.L.
        • Haghighi B.
        • et al.
        Risk of angiosarcoma following breast conservation: a clinical alert.
        Breast J. 2005; 11: 115-123
        • Adhikari D.
        • Hajdu S.I.
        • Levine D.
        Post-radiation angiosarcoma and bilateral mastectomy.
        Ann Clin Lab Sci. 2002; 32: 428-433
        • Badwe R.A.
        • Hanby A.M.
        • Fentiman I.S.
        • Chaudary M.A.
        Angiosarcoma of the skin overlying an irradiated breast.
        Breast Cancer Res Treat. 1991; 19: 69-72
        • Catena F.
        • Santini D.
        • Di Saverio S.
        • Laneve A.
        • Ansaloni L.
        • Fogacci T.
        • et al.
        Skin angiosarcoma arising in an irradiated breast: case-report and literature review.
        Dermatol Surg. 2006; 32: 447-455
        • Deutsch M.
        • Rosenstein M.M.
        Angiosarcoma of the breast mimicking radiation dermatitis arising after lumpectomy and breast irradiation: a case report.
        Am J Clin Oncol. 1998; 21: 608-609
        • Di Tommaso L.
        • Fabbri A.
        [Cutaneous angiosarcoma arising after radiotherapy treatment of a breast carcinoma. Description of a case and review of the literature].
        Pathologica. 2003; 95: 196-202
        • Fisher I.
        • Orkin M.
        Acquired lymphangioma (lymphangiectasis). Report of a case.
        Arch Dermatol. 1970; 101: 230-234
        • Fodor J.
        • Orosz Z.
        • Szabo E.
        • Sulyok Z.
        • Polgar C.
        • Zaka Z.
        • et al.
        Angiosarcoma after conservation treatment for breast carcinoma: our experience and a review of the literature.
        J Am Acad Dermatol. 2006; 54: 499-504
        • Hogewind B.F.
        • Boutkan H.B.
        • de Jager-Nowak H.K.
        • Merkus J.W.
        [Angiosarcoma following breast-conserving therapy].
        Ned Tijdschr Geneeskd. 2004; 148: 995-997
        • Lamblin G.
        • Oteifa M.
        • Zinzindohoue C.
        • Isaac S.
        • Termine L.
        • Bobin J.Y.
        Angiosarcoma after conservative treatment and radiation therapy for adenocarcinoma of the breast.
        Eur J Surg Oncol. 2001; 27: 146-151
        • Majeski J.
        • Austin R.M.
        • Fitzgerald R.H.
        Cutaneous angiosarcoma in an irradiated breast after breast conservation therapy for cancer: association with chronic breast lymphedema.
        J Surg Oncol. 2000; 74: 208-212
        • Marchal C.
        • Weber B.
        • de Lafontan B.
        • Resbeut M.
        • Mignotte H.
        • du Chatelard P.P.
        • et al.
        Nine breast angiosarcomas after conservative treatment for breast carcinoma: a survey from French comprehensive Cancer Centers.
        Int J Radiat Oncol Biol Phys. 1999; 44: 113-119
        • Monroe A.T.
        • Feigenberg S.J.
        • Mendenhall N.P.
        Angiosarcoma after breast-conserving therapy.
        Cancer. 2003; 97: 1832-1840
        • Parham D.M.
        • Fisher C.
        Angiosarcomas of the breast developing post radiotherapy.
        Histopathology. 1997; 31: 189-195
        • Polgar C.
        • Orosz Z.
        • Fodor J.
        Is postirradiation angiosarcoma of the breast so rare and does breast lymphedema contribute to its development?.
        J Surg Oncol. 2001; 76: 239-241
        • Polgar C.
        • Orosz Z.
        • Szerdahelyi A.
        • Fodor J.
        • Major T.
        • Magori A.
        • et al.
        Postirradiation angiosarcoma of the chest wall and breast: issues of radiogenic origin, diagnosis and treatment in two cases.
        Oncology. 2001; 60: 31-34
        • Rao J.
        • Dekoven J.G.
        • Beatty J.D.
        • Jones G.
        Cutaneous angiosarcoma as a delayed complication of radiation therapy for carcinoma of the breast.
        J Am Acad Dermatol. 2003; 49: 532-538
        • Rubin E.
        • Maddox W.A.
        • Mazur M.T.
        Cutaneous angiosarcoma of the breast 7 years after lumpectomy and radiation therapy.
        Radiology. 1990; 174: 258-260
        • Slotman B.J.
        • van Hattum A.H.
        • Meyer S.
        • Njo K.H.
        • Karim A.B.
        Angiosarcoma of the breast following conserving treatment for breast cancer.
        Eur J Cancer. 1994; 30A: 416-417
        • Tomasini C.
        • Grassi M.
        • Pippione M.
        Cutaneous angiosarcoma arising in an irradiated breast. Case report and review of the literature.
        Dermatology. 2004; 209: 208-214
        • Weber B.
        • Marchal C.
        Three cases of breast angiosarcomas after breast-conserving treatment for carcinoma.
        Radiother Oncol. 1995; 37: 250-252
        • O'Hara C.D.
        • Nascimento A.G.
        Endothelial lesions of soft tissues: a review of reactive and neoplastic entities with emphasis on low-grade malignant (“borderline”) vascular tumors.
        Adv Anat Pathol. 2003; 10: 69-87