Primary Breast Angiosarcoma: A case report and literature review
Stathaki Martha1, Metaxas Georgios1, Christodoulidou Ioulia1, Gogkou Haralambos1, Skarpidi Evangelia2, Mantzouki Christina1, Dimou Evelina1 and Armakolas Athanasios3*
1Third Surgical Clinic, Elena Venizelos Hospital, Athens, Greece
2MICROMEDICALABS Diagnostic Laboratory, Athens, Greece
3Physiology Laboratory, Medical School, National and Kapodestrian University of Athens, Greece
*Corresponding author
*Athanasios Armakolas, Physiology Laboratory, Medical School, National and Kapodestrian University
of Athens, Greece
DOI: 10.55920/JCRMHS.2023.03.001137
Figure 1: Mammogram, ultrasound and breast MRI: A. Spot compression mammogram with non-specific findings. B. Determination of a diffuse area of increased echo texture by ultrasonographic imaging. C. MRI indicates the presence of a large lesion of the superior inner quadrant of the left breast exhibiting persisting and plateau enhancement kinetics.
A second look US scan with multiple guided core needle biopsies was performed (fig. 1c). Pathology described a highly vascular tissue sample, vascular endothelial cells with mild cellular atypia, presence of hob nail like cells, and a Ki-67 of 20-30%. Immunostaining assay for vascular endothelial marker CD31 and markers FLI1 and ERG was markedly positive. A diagnosis of a low to intermediate grade angiosarcoma was concluded. Due to the discordance of the radiology and pathology reports, the sample was referred to a second pathologist who confirmed the diagnosis of well differentiated PBAS. Staging with abdominal, chest and head CT scans did not reveal distant metastases (fig. 2a and b).
Figure 2: Surgical procedure: A. Surgical planning and mastectomy with partial excision of the pectoralis major muscle. B. Cross section of the resected breast showing a poorly circumscribed tumour that extends to the overlying skin.
Following a detailed discussion, the patient was submitted to a right mastectomy and sentinel lymph node biopsy. A superficial layer of pectoralis major fibers underlying the area of concern was removed en block with the breast. Gross examination of the specimen confirmed the presence of a 5,8cm tumor with irregular margins within the breast parenchyma. On cut section the mass had a dark brown to pink color and soft consistency. Microscopically, the tumor was composed of an intricate anastomotic network of vascular channels, with papillary formations, mild to moderate cellular atypia and a mitotic index of 8/mm². Necrosis was absent. The closest radial margin was > 15mm, while the posterior margin though close was negative and there was no infiltration towards the muscle fibers. The 2 sentinel lymph nodes were also negative. The final diagnosis was low/intermediate grade breast angiosarcoma (T3 N0M0) (fig. 3a, b).
Figure 3: Immunohistochemical analysis of the tunour: A. H& E staining. The tumour consisted of anastomosing vascular spaces, lined by cells with mild to moderate atypia. In the absence of high grade features elsewhere, this growth patern may mimic a benign vascular lesion. B. Neoplastic vascular spaces infiltrating a breast lobule.
The oncology board suggested adjuvant radiotherapy only which the patient received in 30 cycles. At 15 months postoperatively the patient remains disease free.
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