DOI:10.2214/AJR.05.1940
AJR 2006; 187:W143-W146
© American Roentgen Ray Society
Cutaneous Angiosarcoma of the Breast on MRI
Linda M. Sanders1,
Arthur C. Groves1 and
Sara Schaefer2
1 The Breast Center at The Ambulatory Care Center, Saint Barnabas Health Care
System, 200 S Orange Ave., Livingston, NJ 07039.
2 The Breast Care and Treatment Center, Livingston, NJ 07039.
Received November 2, 2005;
accepted after revision January 19, 2006.
Address correspondence to L. M. Sanders
(lsanders{at}sbhcs.com).
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Keywords: angiosarcoma • breast • cancer • MRI
Introduction
Angiosarcoma of the breast is a rare malignant tumor. First described as a
large intraparenchymal tumor of the breast, a subtype has emerged in the
irradiated breast termed "cutaneous postirradiation angiosarcoma of the
breast." The angiosarcomas described in the radiology literature are of
the large intraparenchymal variety. We report the clinical history and MRI
findings in two patients with this cutaneous subtype.
Case Reports
Both patients were scanned on a 1.5-T Intera scanner (Philips Medical
Systems, The Netherlands), and images were viewed on a View Forum workstation
(Philips Medical Systems).
Case 1
A 51-year-old woman was treated for a stage I cancer with lumpectomy of the
left breast and irradiation 5 years previously (2000). MRI performed because
of the patient's high-risk status showed a 7.4-mm rapidly enhancing smooth,
well-circumscribed homogeneous nodule in the skin of the left breast
immediately adjacent to the lumpectomy scar. Review of enhancement kinetics
revealed a plateau curve. Her breast surgeon performed a clinical examination
after the MRI examination, and a purplish papule was seen. No lymphedema was
noted. The patient was referred to a dermatologist, who diagnosed a cutaneous
angiosarcoma (Figs. 1A and
1B).
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Fig. 1A —51-year-old woman with 5-year history of lumpectomy and
irradiation in left breast. Axial and sagittal MR images from dynamic sequence
with fat subtraction show enhanced cutaneous angiosarcoma
(arrowheads) in postoperative site. Note that lesion is located in
thickened, irradiated skin.
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Fig. 1B —51-year-old woman with 5-year history of lumpectomy and
irradiation in left breast. Enhancement kinetics of cutaneous lesion shows
rapid wash-in and leveling off of enhancement (plateau type enhancement, type
2 curve).
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Case 2
A 71-year-old woman was treated with lumpectomy and irradiation for cancer
in the left breast 11 years previously (1994) for a stage I lesion. Axillary
nodes were negative. In 2005, the patient developed a palpable right breast
mass that underwent core biopsy and was diagnosed as invasive ductal
carcinoma. Her breast surgeon noticed a small periincisional discoloration in
the left breast. No lymphedema was noted. The patient was referred to a
dermatologist, who diagnosed cutaneous angiosarcoma at biopsy. MRI performed
to determine the extent of disease in the right breast showed the known right
breast cancer and a 7.2-mm heterogeneous area of nonmass, focal cutaneous
enhancement in the left breast at the scar site. Enhancement kinetics showed
significant rapid wash-in and wash-out (Figs.
2A,
2B,
2C, and
2D).
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Fig. 2A —71-year-old woman with 11-year history of lumpectomy and
irradiation in left breast and with new cancer in right breast. Axial and
sagittal MR images from dynamic sequence with fat subtraction show cutaneous
angiosarcoma (arrowheads), also seen in postoperative site in this
patient, in thickened irradiated skin.
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Fig. 2B —71-year-old woman with 11-year history of lumpectomy and
irradiation in left breast and with new cancer in right breast. Enhancement
kinetics of cutaneous lesion shows rapid wash-in and wash-out (type 3
curve).
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Fig. 2D —71-year-old woman with 11-year history of lumpectomy and
irradiation in left breast and with new cancer in right breast. Enhancement
kinetics of new breast cancer shows type 2 (plateau) curve.
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Discussion
Vascular tumors of the breast are rare. Subcutaneous vascular masses are
generally benign, whereas most intraparenchymal lesions are malignant
angiosarcomas [1,
2]. These angiosarcomas account
for fewer than 1% of all malignant breast tumors. In the radiology literature,
angiosarcoma of the breast was described by Liberman et al. in 1992
[3]. Twenty-nine women were
described, all of whom presented with a palpable mass. MRI findings were
submitted for only one patient, in whom the lesion was described as having a
low signal on T1-weighted and a higher signal on T2-weighted images. In 1997,
bilateral intraparenchymal angiosarcomas of the breast in a 28-year-old woman
were described on MRI as markedly enhancing large masses
[4].
Iatrogenic angiosarcoma attributed to chronic lymphedema after treatment of
breast cancer was first described by Stewart and Treves
[5] and thereafter was referred
to as a syndrome. A different subtype of postirradiation angiosarcoma of the
breast has been recognized that involves the skin, which is termed
"cutaneous postirradiation angiosarcoma of the breast." This
lesion differs from the original description by Stewart and Treves in its
shorter latency and its lack of association with lymphedema. Cutaneous
angiosarcoma has been described as developing 7 years after treatment
[6] in a woman who had primary
breast carcinoma treated with lumpectomy and irradiation. The imaging
description did not include MRI. A recent review in the surgical pathology
literature by Brenn and Fletcher
[7] presented a series of 42
patients with radiation-associated atypical cutaneous vascular lesions or
angiosarcoma, but did not present imaging findings; 35 of the 42 cases were in
irradiated breasts. The lesions ranged in size from 0.1 to 20 cm. The median
time since irradiation to the development of the cutaneous lesion was 6 years
in that series. In one patient, the atypical vascular lesion progressed to
angiosarcoma. A pictorial review of vascular breast lesions
[8] included an MR image of a
large intraparenchymal angiosarcoma showing blood lakes and large draining
veins, not the more recently described cutaneous postirradiation angiosarcoma
of the breast.
To our knowledge, the two cases reported here constitute the first MRI
report of this cutaneous entity. In both patients, the lesions are small (<
1 cm) and obviously vascular on MR dynamic enhanced images. In our practice,
the assessment of all breast lesions depends on both morphologic and kinetic
criteria [9]. We applied this
rule to these cutaneous lesions, although there is no precedent in the
literature for doing so. In the first patient, enhancement reached a steady
state after rapid initial enhancement (type 2, plateau kinetics) was shown. In
this case, the MR finding preceded the patient's clinical evaluation and was
the first documentation of the abnormality. In the second case, the cutaneous
lesion showed rapid wash-in and rapid decrease in enhancement early in the
kinetics curve (type 3, washout kinetics). However, because locally increased
vascularity is not specific for malignancy, kinetics are less helpful than the
visualization of a focus of skin enhancement on a dynamic breast MRI study in
an area of irradiated, thickened skin.
We present these cases as a reminder that if an enhancing skin lesion is
identified on a contrast-enhanced MR image of a breast in the postoperative
and irradiated site, the possibility of cutaneous angiosarcoma of the breast
should be considered. Because these lesions may be quite small, making
morphologic assessment difficult, it is important to notice any enhancing
cutaneous foci, which may be as small as 1 mm, in the irradiated territory. As
enhanced MRI becomes a more widespread tool in the evaluation of the conserved
breast, we might expect these lesions to become more widely observed. It
should be emphasized that the radiologist may be the first to diagnose these
cutaneous lesions on contrast-enhanced MRI.
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Introduction
Case Reports
