Radiation-associated angiosarcoma after autologous breast reconstruction: report of two cases in a plastic surgery unit
Radiation-associated breast angiosarcoma is a rare diagnosis but is commonly reported. Angiosarcoma occurring in non-breast tissue in breasts that have been reconstructed with autologous tissue following mastectomy is extremely rare. In our unit, we have managed two patients with angiosarcoma arising in non-breast tissue autologous reconstructions. Our report emphasises that any tissue treated with radiotherapy—that is, the residual mastectomy skin flaps or non-breast tissue autologous reconstructions—are at a risk of secondary angiosarcoma. We also discuss recommended surgical management, surveillance and genetic testing.
Level of Evidence is V, risk study.
KeywordsRadiation Angiosarcoma Breast reconstruction
Radiation-associated breast angiosarcoma is a rare diagnosis but is commonly reported. Angiosarcoma occurring in non-breast tissue in breasts that have been reconstructed with autologous tissue following mastectomy is extremely rare. Thus far only one case has been reported in the literature . In our unit, we have managed two patients with angiosarcoma arising in non-breast tissue autologous reconstructions. Our report emphasises that angiosarcoma can arise in breasts that have been treated with mastectomy—in residual skin flaps and in the tissue from the reconstructions themselves. We also discuss recommended surgical management, surveillance and genetic testing.
A 61-year-old patient was diagnosed with bilateral screen-detected breast cancer and required bilateral mastectomy, axillary node sampling and immediate latissimus dorsi reconstruction in 2003. Her pathology report suggested a more advanced tumour on the right (grade 1, oestrogen positive, invasive ductal carcinoma of 22 mm), with one out of seven right axillary lymph nodes involved; she therefore required adjuvant radiotherapy (50 Gy in 25 fractions) to her right reconstructed breast and right supraclavicular fossa.
Secondary angiosarcoma of the breast, as a result of previous radiotherapy following breast conservation surgery or mastectomy, is very rare, with a reported incidence of 0.1–0.2% per year . Although radiation to the breast was used therapeutically, it can also lead to DNA damage, resulting in genome instability, which in selected cases may lead to the formation of sarcoma . It may have a latency period of several years prior to presentation and the initial clinical signs can be very subtle, as demonstrated in our cases. Radiotherapy contributes to a ‘field effect’ in all previously irradiated tissue; hence, clinical signs of angiosarcoma can appear on the mastectomy skin flap or on the skin paddle of the abdominal flap. It is vital to have a high index of suspicion, close monitoring of the changes in clinical signs and repeat biopsies as necessary, in order to diagnose secondary angiosarcoma.
Feinberg et al. recently reviewed the impact of early specialist management on survival from angiosarcoma and suggested that patients managed initially by the sarcoma team have fewer local recurrences and significant improved disease-specific survival . Higher rates of positive margins have been seen with wide local excision, and specialist sarcoma units such as the Royal Marsden suggest radical excision . Excision of the field change associated with previously irradiated tissue may lead to better local control, reducing the incidence of future local recurrence . Our surgical approach to radiation-associated angiosarcoma is similar to Feinberg et al.: we advocate radical neo-mastectomy rather than wide local excision, frozen section for margin analysis and chest wall reconstruction. Follow-up is in keeping with the Scottish Sarcoma National Follow-Up guidelines with 4 monthly clinical assessment, chest X-ray and annual regional imaging . Genetic testing should be considered in this group of patients, as pre-existing genetic abnormalities such as BRCA and p53 mutations may potentiate the carcinogenic effects of irradiation, leading to secondary angiosarcoma [6, 7, 8].
The cases we describe here indicate that angiosarcoma can occur in breasts that have been treated with mastectomy, and that breast tissue itself is not a pre-requisite for angiosarcoma formation. Any tissue treated with radiotherapy—that is, the residual mastectomy skin flaps or non-breast tissue autologous reconstructions—are at a risk of secondary angiosarcoma. It is essential that the treating breast clinician is aware of this rare but critical possibility.
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- 5.Scottish Sarcoma Network Guidelines (2004): https://www.ssn.scot.nhs.uk/guidelines/. Accessed 05 Feb 2019
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