CRCM  Vol.4 No.6 , June 2015
Early Onset Post-Radiation Cutaneous Angiosarcoma of the Breast with Features of Atypical-Vascular Lesion: A Diagnostic Pitfall and Its Biologic Significance
Abstract: Vascular proliferations may arise in the breast following radiation treatment for a primary breast adenocarcinoma. A post-radiation vascular proliferation can usually be classified as angiosarcoma or as an atypical vascular lesion (AVL). Angiosarcomas with a “low-grade” morphology, behave aggressively but exhibit substantial histomorphologic overlap with AVLs, which have a generally benign clinical course. We present a case of a post-radiation angiosarcoma of the breast with histologic features that mimic an atypical vascular lesion and discuss this challenging differential diagnosis. In addition to histologic mimicry, the lesion exhibited only patchy amplification of the avian myelocytomatosis viral oncogene homolog (MYC) gene by present fluorescence in-situ hybridization (FISH), and patchy MYC overexpression by immunohistochemistry. These features further complicate the distinction between AVL and angiosarcoma, and would be particularly problematic on a small biopsy. We believe that the morphologic and immunohistochemical overlap between these entities is suggestive of a biologic spectrum, and thus that, at least in some instances, angiosarcoma may arise from a pre-existing AVL or AVL-like lesion.
Cite this paper: Wojcik, J. , Czerniecki, B. , Zhang, P. (2015) Early Onset Post-Radiation Cutaneous Angiosarcoma of the Breast with Features of Atypical-Vascular Lesion: A Diagnostic Pitfall and Its Biologic Significance. Case Reports in Clinical Medicine, 4, 203-208. doi: 10.4236/crcm.2015.46041.

[1]   Stewart, F.W. and Treves, N. (1948) Lymphangiosarcoma in Postmastectomy Lymphedema; a Report of Six Cases in Elephantiasis Chirurgica. Cancer, 1, 64-81.<64::AID-CNCR2820010105>3.0.CO;2-W

[2]   Billings, S.D., McKenney, J.K., Folpe, A.L., Hardacre, M.C. and Weiss, S.W. (2004) Cutaneous Angiosarcoma Following Breast-Conserving Surgery and Radiation: An Analysis of 27 Cases. American Journal of Surgical Pathology, 28, 781-788.

[3]   Mentzel, T., Schildhaus, H.U., Palmedo, G., Buttner, R. and Kutzner, H. (2012) Postradiation Cutaneous Angiosarcoma after Treatment of Breast Carcinoma Is Characterized by MYC Amplification in Contrast to Atypical Vascular Lesions after Radiotherapy and Control Cases: Clinicopathological, Immunohistochemical and Molecular Analysis of 66 Cases. Modern Pathology, 25, 75-85.

[4]   Fineberg, S. and Rosen, P.P. (1994) Cutaneous Angiosarcoma and Atypical Vascular Lesions of the Skin and Breast after Radiation Therapy for Breast Carcinoma. American Journal of Clinical Pathology, 102, 757-763.

[5]   Brenn, T. and Fletcher, C.D. (2006) Postradiation Vascular Proliferations: An Increasing Problem. Histopathology, 48, 106-114.

[6]   Lucas, D.R. (2009) Angiosarcoma, Radiation-Associated Angiosarcoma, and Atypical Vascular Lesion. Archives of Pathology and Laboratory Medicine, 133, 1804-1809.

[7]   Patton, K.T., Deyrup, A.T. and Weiss, S.W. (2008) Atypical Vascular Lesions after Surgery and Radiation of the Breast: A Clinicopathologic Study of 32 Cases Analyzing Histologic Heterogeneity and Association with Angiosarcoma. American Journal of Surgical Pathology, 32, 943-950.

[8]   Brenn, T. and Fletcher, C.D. (2005) Radiation-Associated Cutaneous Atypical Vascular Lesions and Angiosarcoma: Clinicopathologic Analysis of 42 Cases. American Journal of Surgical Pathology, 29, 983-996.

[9]   Fraga-Guedes, C., Gobbi, H., Mastropasqua, M.G., Rocha, R.M., Botteri, E., Toesca, A. and Viale, G. (2014) Clinicopathological and Immunohistochemical Study of 30 Cases of Post-Radiation Atypical Vascular Lesion of the Breast. Breast Cancer Research and Treatment, 146, 347-354.

[10]   Gengler, C., Coindre, J.M., Leroux, A., Trassard, M., Ranchere-Vince, D., Valo, I., Michels, J.J. and Guillou, L. (2007) Vascular Proliferations of the Skin after Radiation Therapy for Breast Cancer: Clinicopathologic Analysis of a Series in Favor of a Benign Process: A Study from the French Sarcoma Group. Cancer, 109, 1584-1598.

[11]   Manner, J., Radlwimmer, B., Hohenberger, P., Mossinger, K., Kuffer, S., Sauer, C., Belharazem, D., Zettl, A., Coindre, J.M., Hallermann, C., Hartmann, J.T., Katenkamp, D., Katenkamp, K., Schoffski, P., Sciot, R., Wozniak, A., Lichter, P., Marx, A. and Strobel, P. (2010) MYC High Level Gene Amplification Is a Distinctive Feature of Angiosarcomas after Irradiation or Chronic Lymphedema. American Journal of Pathology, 176, 34-39.

[12]   Shon, W., Sukov, W.R., Jenkins, S.M. and Folpe, A.L. (2014) MYC Amplification and Overexpression in Primary Cutaneous Angiosarcoma: A Fluorescence In-Situ Hybridization and Immunohistochemical Study. Modern Pathology, 27, 509-515.

[13]   Ginter, P.S., Mosquera, J.M., MacDonald, T.Y., D’Alfonso, T.M., Rubin, M.A. and Shin, S.J. (2014) Diagnostic Utility of MYC Amplification and Anti-MYC Immunohistochemistry in Atypical Vascular Lesions, Primary or Radiation-Induced Mammary Angiosarcomas, and Primary Angiosarcomas of Other Sites. Human Pathology, 45, 709-716.

[14]   Hafner, C. (2013) MYC Amplification Distinguishes between Atypical Vascular Lesion and Radiation-Induced Angiosarcoma of the Breast. Der Hautarzt, 64, 533-534.

[15]   Kahn, H.J., Bailey, D. and Marks, A. (2002) Monoclonal Antibody d2-40, a New Marker of Lymphatic Endothelium, Reacts with Kaposi’s Sarcoma and a Subset of Angiosarcomas. Modern Pathology, 15, 434-440.