Radiation-induced angiosarcoma of the breast: a retrospective analysis of 15 years' experience at an oncology center

Abstract

Objective: To characterize a population of patients with radiation-induced angiosarcoma (RIAS) of the breast treated at an oncology center, focusing mainly on the imaging features, although also on the clinical presentation, diagnosis, and management.

Materials and methods: We performed a retrospective review of patients with histologically proven angiosarcoma of the breast or chest wall, all of whom received radiotherapy, after conservative or radical breast surgery, between 2000 and 2015.

Results: Eleven patients met the inclusion criteria. The median age at the time of diagnosis of RIAS of the breast was 71.5 years (range, 58-87 years), and the median latency period was 8.9 years (range, 4-27 years). The rate of local recurrence was 54.4%, RIAS recurring after a median period of 10 months (range, 3-18 months), and distant metastases occurred in three patients (27.3%). All of the tumors were accompanied by skin changes, and a palpable mass was seen in four. Most of the imaging findings were nonspecific. Six patients underwent magnetic resonance imaging, which revealed pronounced skin enhancement in all six. Ultrasound-guided core needle biopsies were negative in three of the eight patients.

Conclusion: RIAS of the breast is a rare but recognized complication of radiotherapy for breast carcinoma, with a poor prognosis and high recurrence rate, which requires a high index of suspicion for a prompt diagnosis.

Keywords: Breast neoplasms; Hemangiosarcoma/diagnosis; Neoplasms, radiation-induced; Radiotherapy; Tertiary care centers.

Figure 1

58-year-old female with high-grade RIAS. Mediolateral oblique and craniocaudal mammograms of the right breast (A and B, respectively) showing an ill-defined asymmetric lesion in the upper-outer quadrant, with skin thickening and course calcifications.

Figure 2

77-year-old female with intermediate-grade RIAS presenting as nodules and ulcers. Mediolateral oblique mammograms of the left breast showing hyperdense areas underlying scar tissue, accompanied by a rounded, well-circumscribed mass that was not visible in the previous examination, together with coarse calcifications and skin thickening.

Figure 3

82-year-old female with high-grade RIAS and extensive papules. Gray-scale and color Doppler ultrasound of the left breast (A and B, respectively), showing a central superficial heterogeneous mass with some cystic areas and increased blood flow.

Figure 4

72-year-old female with high-grade RIAS, presenting with a nodule with signs of inflammation. Ultrasound of the right breast, showing multiple solid, rounded, well circumscribed masses with heterogeneous echogenicity.

Figure 5

58-year-old female with high-grade RIAS who presented with mild skin discoloration. Axial sagittal gadolinium-enhanced fat-suppressed T1-weighted MRI scan showing anomalous skin enhancement on the left breast.

Figure 6

81-year-old female with high-grade RIAS who presented with extensive skin discoloration. Axial T1-weighted, gadolinium-enhanced, fat-saturated MRI sequence after subtraction (A) and axial diffusion-weighted (b = 1000) MRI sequence (B), both depicting retroareolar lesions with early, avid enhancement and restricted diffusion, highly suggestive of recurrence.

Figure 7

59-year-old female with high-grade RIAS who presented with a nodule and ulcers. Axial T2-weighted MRI sequence (A) and axial T1-weighted, gadoliniumenhanced, fat-saturated MRI sequence after subtraction (B), both showing enhancement of the skin and subcutaneous tissue down to the pectoralis fascia, without invasion of the muscle.