Angiosarcoma of the Breast

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Angiosarcoma of the Breast
Dhafir Alazawi
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Case 1

• HS 37 yr GP referral 2 day history of Left
  breast lump.
• No relevant past medical history
• OPD - Palpable lump in the central part of left
  breast just below the areola (S4)
• Right breast axillae NAD.
• Risk factor OCP x 4 years.

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• Mammogram no mass/calcifications.
• US - 9 oclock position 35mm hyperechoic mass,
  ?haematoma but no Hx of trauma. Axillary LN NAD.

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• Core Bx extensive infiltration of atypical
  endothelial cells
• Low Grade Angiosarcoma (B5)

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Breast parenchyma
Fat
Angiosarcoma
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Breast parenchyma
Vasoformative pattern (well formed vascular
channels, lined by a single layer of endothelial
cells). Tumour infiltrates the breast
parenchyma Sieve-like pattern. (Vascular
channels are lined by a Predominantly single
layer of plump, hyperchromatic endothelial
cells.) The endothelial cells are bland. No
significant mitoses.
Breast lobule
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Case 1

• MRI Left Breast bulk of mass in lower inner
  quadrant extending deep to nipple.
• Axillary LN NAD.

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• Grade I Primary Angiosarcoma resected tumour with
  clear margins.

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Gross description

• Tumour Retro-areolar. Size 6.9 x 3.4 x 2.8cm.
• Moderately poorly circumscribed, firm, white,
  dense cut surface with focal areas of
  haemorrhage, adjacent to breast tissue.

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Case 1

• Prof. Chris Fletcher Centre for Sarcoma Bone
  Oncology Bringham Womens Hosp Boston USA
• American Journal of Pathology (Dec 2008)
• Primary angiosarcoma of the breast
  clinicopathologic analysis of 49 cases,
  suggesting that grade is not prognostic.

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American Journal of Surgical Pathology

• 49 female patients with Primary Angiosarcoma.
• Graded using Rosens 3 tier system into Low (I)
  Intermediate (II) and High (III) grades.
• 3 patients Hx of Breast Ca
• Of these, 2 had prior RTX
• 8 lost to follow up
• Conclusion Lack of correlation between
  histologic grade and outcome.

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Outcome

• Local Recurrence (10)

• Metastasis (24)

• Low Grade 3 (median 36mnths post Dx)
• Intermediate Grade 5 (42.5mnths)
• High Grade 2 (23mnths)

• Low Grade 6 (21 months)
• Intermediate Grade 11 (43 months)
• High Grade 6 (17.5mnths)
• Unkown 1

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Case 2

• HS 68 yr old female
• Previous Hx of Left Breast Ca WLE RTX in 2002
• Presented with increasing change to a Haemangioma
  on surface of left breast despite previous biopsy
  of the lesion in 2007 was benign.

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M.
Angiosarcoma, high grade Large vascular
cisterns (blood lakes) Areas of necrosis (pink
areas)
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• MRI Left Breast mass in medial part of Left
  breast.

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• Mastectomy revealed a high grade Angiosarcoma .
• The majority of the tumour is in the dermis and
  subcutaneous tissue, with extension into adjacent
  breast parenchyma.
• Margins are clear by at least 10mm.

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Vascular lesion, 2.5 x 2cm 1.5cm from the
nipple between 7 9 oclock. Tumour, 4 x 4.5 x
4.4cm in the medial breast, the tumour is
haemorrhagic and sclerotic, poorly
circumscribed, firm and invading epidermis.
Focal necrosis is present.
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Breast Angiosarcoma

• lt0.05 of all malignant neoplasms of breast.
• Divided into 2 main catagories
• Primary mammary angiosarcoma
• Cutaneous angiosarcoma assoc with prior radiation
  to breast or persistent lymphoedema.

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• Primary is defined as malignant vascular
  neoplasm arising within breast parenchyma with or
  without minor extension into overlying skin.
• Usually diagnosed in young females.
• Aggressive tumour - 5 year disease free survival
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Diagnosis

• Definitive Dx can be difficult.
• Mammography non specific mass can be confused
  with a benign lesion as uncalcified.
• MRI best imaging modality gadolinium enhanced
  images.
• FNA Punch Bx generally not diagnostic.
• Full thickness incisional or excisional Bx should
  be conclusive.

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Treatment

• Simple mastectomy.
• Accompanied by hyperfractionated radiation
  therapy
• Increasing role for adjuvant neo-adjuvant
  therapy.
• Data suggest that multidisciplinary therapeutic
  approach should be employed in high-risk patients
  with large primary tumours.

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Thank you....
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