Dhafir Alazawi

Case 1HS 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.

Mammogram no mass/calcifications.

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

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

AngiosarcomaBreast parenchymaFat

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 parenchymaBreast lobule

Case 1

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

Grade I Primary Angiosarcoma resected tumour with clear margins.

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.

Case 1Prof. 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.

American Journal of Surgical Pathology49 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 CaOf these, 2 had prior RTX8 lost to follow upConclusion; Lack of correlation between histologic grade and outcome.

OutcomeLocal 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

Case 2

HS 68 yr old femalePrevious 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.

M. Angiosarcoma, high grade:

Large vascular cisterns (blood lakes)

Areas of necrosis (pink areas)

MRI Left Breast ; mass in medial part of Left breast.

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.

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.

Breast Angiosarcoma

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 33%

DiagnosisDefinitive 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.

TreatmentSimple mastectomy.Accompanied by hyperfractionated radiation therapyIncreasing 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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