Atypical vascular lesions of the breast
following breast cancer
Trevor Thompson MD, (1)
Lihue, Hawaii, USA
Ron Yaar MD, PhD, (2)
Boston, MA, USA
October 26, 2010
(1) Dermatologist, Kauai Medical Group, Lihue, Kauai, HI, USA
(2) Assistant Professor, Director of Dermatopathology Training, Boston Medical Centre, Boston, MA, USA
- Mandrell J, Mehta S, McClure S. Atypical vascular lesion of the breast. J Am Acad Dermatol Aug 2010 Aug; 63(2):337-340
Atypical vascular lesions (AVLs) are vascular proliferations that develop after surgery and radiation for breast carcinoma and may represent precursors to angiosarcoma. AVLs are not well-known entities and currently lack official prognostic factors and guidelines for surgical treatment.
We report the case of a patient who developed an AVL, vascular type, 4 years after lumpectomy and radiation therapy for ductal carcinoma in situ of the breast. The patient underwent wide local excision with 1-cm margins with subsequent pathologic examination confirming complete excision of the residual atypical vascular proliferation. This case highlights the importance of close cutaneous surveillance in patients with a history of surgery and radiation for breast carcinoma, and a low threshold for biopsy. More studies are needed to further delineate the risk of AVLs progressing to angiosarcoma and to identify histologic features or immunophenotypic markers, which may be predictive of this risk. Furthermore, formal treatment recommendations for these enigmatic entities would be helpful. Full Text PDF (1MB)
- Gengler C, Coindre JM, Leroux A, Trassard M, Ranchère-Vince D, Valo I, Michels JJ, Guillou L. 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. 2007 Apr 15;109(8):1584-98
Department of Pathology, University Institute of Pathology, Lausanne, Switzerland.
BACKGROUND: Cutaneous vascular proliferations that occur in the field of prior radiotherapy include angiosarcoma and small, cutaneous lesions with a pseudosarcomatous pattern that previously were reported as atypical vascular lesions or benign lymphangiomatous papules.
METHODS: The objective of this study was to investigate the clinicopathologic features and outcomes of 56 radiation-induced vascular proliferations that occurred in 36 patients who received previous treatment for breast carcinoma. Data from all patients were retrieved from the files of the French Sarcoma Group. Immunostaining with D2.40 antibody was performed in 24 lesions.
RESULTS: All patients (median age, 52 years) had received external radiotherapy. Small papules developed within the field of prior radiotherapy (median latency interval, 66 months). Microscopically, the lesions were relatively well circumscribed, and they were located mostly in the superficial/middermis. They were composed of dilated or irregular-jagged vascular channels that were lined by a single layer of bland endothelial cells, and they demonstrated either a predominately lymphangioendothelioma-like or lymphangioma/lymphangioma circumscriptum-like growth pattern. Micropapillary tufts were common findings. Ten lesions showed additional cytologic and/or architectural atypia. Twenty of 24 lesions showed D2.40 positivity. Follow-up information was available for 31 patients (median follow-up, 48 months): Five women developed new cutaneous lesions, and 1 woman had spontaneous regression of her lesions. None of the patients developed cutaneous angiosarcoma. Five patients were lost to follow-up.
CONCLUSIONS: Although vascular proliferations in irradiated skin may mimic angiosarcoma morphologically, the large majority of these lesions showed a benign clinical outcome. Despite relatively limited follow-up, the current results indicate the benign nature of these vascular proliferations. Full Text PDF (2MB)
Lucas D. Angiosarcoma, Radiation-Associated Angiosarcoma, and
Atypical Vascular Lesion Arch Pathol Lab Med. 2009;133:1804–1809
Angiosarcoma, one of the least common sarcomas, has
become increasingly important because of its association
with radiation therapy, especially for breast cancer. Most
are sporadic, presenting as cutaneous tumors in the scalp/
face of elderly patients. However, angiosarcoma has a
wide anatomic distribution including soft tissue, visceral
organ, and osseous locations. Predisposing conditions
include environmental exposures to chemical or radioactive
sources. Radiation-associated angiosarcoma typically
presents as a cutaneous tumor several years posttherapy.
The latency for radiation-associated mammary angiosarcoma
is relatively short, sometimes less than 3 years.
Atypical vascular lesion refers to a small, usually lymphatic-
type vascular proliferation in radiated skin. Although
most atypical vascular lesions pursue a benign course, they
recur and very rarely progress to angiosarcoma. Distinguishing
this lesion from well-differentiated angiosarcoma
in a biopsy can be challenging, especially because areas
indistinguishable from atypical vascular lesion are found
adjacent to angiosarcoma. Recently, vascular-type atypical
vascular lesion, which resembles hemangioma, has been
described, thus expanding the definition of this entity.
(Arch Pathol Lab Med. 2009;133:1804–1809)
Full Text PDF (6MB)
- Luis Requena, Heinz Kutzner, Thomas Mentzel,
Rafael Durán, and José Luis Rodríguez-Peralto. Benign Vascular Proliferations in Irradiated Skin.
Am J Surg Pathol 26(3): 328–337, 2002
Several types of cutaneous vascular proliferations have been
described in areas of irradiated skin, including both benign
lesions, such as benign lymphangiomatous papules, atypical
vascular lesions, or benign lymphangioendothelioma, and malignant
neoplasms such as high-grade angiosarcomas. This report
describes the clinicopathologic features of 15 cases of
different types of benign cutaneous vascular proliferations
arisen within irradiated skin. All patients were female ranging
in age from 33 to 72 years, and they had received postoperative
external radiotherapy for treatment of breast carcinoma (14
cases) or ovarian carcinoma (one case). In those cases in which
the latency interval period between radiotherapy and the development
of the vascular lesion was known from the clinical
records, the latency interval period elapsed between radiotherapy
and diagnosis of the vascular lesion ranged from 3 to
20 years. The most common clinical presentation of the cutaneous
lesions consisted of papules, small vesicles, or erythematous
plaques on the irradiated field. Histopathologically, most
lesions consisted of irregular dilated vascular spaces, with a
branching and anastomosing pattern, thin walls, and lymphatic
appearance involving the superficial dermis. A discontinuous
single layer of endothelial cells with flattened nuclei lined these
vascular channels, and numerous small stromal papillary formations
also lined by endothelial cells projected into the lumina
of the dilated lymphatic vessels. These cases were classified as
benign lymphangiomatous papules or plaques. Two cases
showed different histopathologic findings because they consisted
of poorly circumscribed and focally infiltrating irregular
jagged vascular spaces involving the entire dermis and lined by
inconspicuous endothelial cells. In some areas these irregular
slit-like vascular spaces dissected collagen bundles of the dermis.
These cases were classified as atypical vascular proliferations
mimicking benign lymphangioendothelioma or patchstage
Kaposi’s sarcoma. All cases showed similar immunohistochemical
findings and the endothelial cells lining the vascular
spaces expressed immunoreactivity for CD31, but they stained
only focally positive for CD34 or were negative for this marker.
Immunohistochemical investigations for -smooth muscle actin
failed to demonstrate a complete peripheral ring of actinpositive
pericytes in most of the neoformed vascular structures.
This immunohistochemical profile also supported the lymphatic
nature of these vascular proliferations developed in irradiated
skin. Although some of these lesions may mimic histopathologically
patch-stage Kaposi’s sarcoma or welldifferentiated
angiosarcoma, the follow-up of the patients of
this series demonstrated that the vascular proliferations arisen
in irradiated skin invariably showed a benign biologic behavior.
Am J Surg Pathol 26(3): 328–337, 2002. Full Text PDF (3MB)