Radiation-Associated Breast Angiosarcoma

Abstract

Radiation-associated breast angiosarcomas are rare following breast-conserving surgery. These angiosarcomas are considered adverse events associated with radiation therapy and are characterized by a high risk of both local and distant recurrence, even after complete resection. Despite this, there is currently no established standard treatment for them. The patient was a 70-year-old woman who had breast-conserving surgery for right breast cancer 10 years before presentation. She was followed up for 10 years after receiving 50 Gy of residual breast irradiation and an aromatase inhibitor for 5 years. During follow-up, a painless purplish area with induration, measuring 10 cm by 5.4 cm, was noted on the right nipple. A skin biopsy confirmed hemangiosarcoma. Treatment included surgery with a 2.0 cm margin from the area, followed by skin excision and total mastectomy. A final diagnosis of radiation-associated breast angiosarcoma was made. Radiation-associated breast angiosarcoma is a rare disease with a poor prognosis that lacks standard treatment. An aggressive skin biopsy should be considered when skin findings such as purpura are seen after breast cancer radiotherapy, as in this case.

Keywords: breast-conserving surgery; purpura; radiation therapy; radiation-associated breast angiosarcoma; skin biopsy.

Figure 1. Physical examination

A 10 cm × 5.4 cm area of painless purpura around the right nipple with some induration was observed.

Figure 2. Chest computed tomography (CT) findings

The section showed thickening of the skin in the right breast, but no evident mass lesion was found in the mammary gland.

Figure 3. Contrast-enhanced magnetic resonance imaging (MRI) of the breast findings

A: Right breast skin thickening with high signal along the thickened area (STIR/DWI). B: In the dynamic study, there was a strong enhancement effect in the subcutaneous area in the form of dots and an enhancement effect predominantly at the limbus on the skin surface (early phase). C: Prolonged enhancing effect (late phase).

Figure 4. Histopathological findings

A: Atypical cells with irregularly shaped enlarged nuclei stained with chromatin were observed from the dermis to the adipose tissue using hematoxylin-eosin (HE) staining. Scale bar: 50 μm. B: Aberrant cells positive for CD31. C: Aberrant cells positive for CD34. D: Aberrant cells positive for D2-40 E: Diffusely positive c-Myc. F: partial loss of H3K27me3 expression.

Figure 5. Physical examination

Skin after a partial mastectomy. No additional skin grafting was performed.