Case Report: Metachronous bilateral primary and secondary angiosarcoma of the breast

Figures

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  Figure 1. Flowchart summarizing the patient’s clinical timeline. This figure illustrates the chronological sequence of key diagnostic, therapeutic, and clinical events from the initial presentation (March 2021) to the patient’s death (February 2023). Major milestones include: right breast biopsy and mastectomy (March 2021), adjuvant chemotherapy and radiotherapy (April–June 2021), detection of left breast primary angiosarcoma (October–November 2021), diagnosis of secondary angiosarcoma in the irradiated field (March–April 2022), widespread distant metastases (April 2022), and death from respiratory failure (22 months after initial diagnosis). (Figure created by the authors).

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  Figure 2. (a–f) Preoperative imaging of the right breast primary angiosarcoma. (a, b) B-mode ultrasound and color Doppler showing a diffuse, inhomogeneous, hypoechoic lesion with poorly defined borders and internal vascularity (arrows). (c, d) Mammography [CC view (c) MLO view (d)] revealing focal asymmetric density and skin thickening (arrows). (e, f) Contrast-enhanced CT demonstrating an ill-defined soft-tissue mass with inhomogeneous enhancement and overlying skin thickening (arrows).

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  Figure 3. (a–c) Histopathology of the primary right breast angiosarcoma. (a) Microscopic examination (hematoxylin and eosin [H&E] stain, ×100) showing a well-differentiated angiosarcoma with dermal infiltration. (b) Gross specimens of the right axillary lymph nodes. (c) H&E stain (×10) of the sentinel lymph node confirming no tumor involvement (0/2).

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  Figure 4. (a–g) Imaging of the left breast primary angiosarcoma. (a, b) Mammography (CC view a; MLO view b) showing an irregular nodule with indistinct margin (arrows). (c) Ultrasound demonstrating a partially angular, microlobulated mass with peri-lesional blood flow (arrow). (d–g) MRI: (d) fat-suppressed T1-weighted image – low signal; (e) T2-weighted image – high signal; (f) dynamic contrast-enhanced MRI – heterogeneous enhancement (arrow); (g) diffusion-weighted image – diffusion restriction (arrow).

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  Figure 5. (a–c) Gross and microscopic pathology of the left breast primary angiosarcoma. (a) Gross specimen showing an ill-defined, soft, hemorrhagic tumour. (b) H&E stain (×40) confirming a well-differentiated primary angiosarcoma (Grade 1). (c) Immunohistochemistry (×100): CD31+, ERG+, SMA+, CK–, Ki-67 20%.

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  Figure 6. (a–g) Clinical and pathological findings of the secondary angiosarcoma. (a, b) Physical examination showing erythematous, friable cutaneous nodules on the anterior chest wall and left axilla (arrows). (c, d) Ultrasound revealing hypoechoic nodules with abundant colour Doppler flow within the dermis (arrows). (e–g) H&E sections (e, f from chest wall; g from axilla, ×40) demonstrating an infiltrative vasoformative neoplasm in the dermis and superficial subcutis.

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  Figure 7. (a–d) Post-mortem imaging evidence of widespread haematogenous metastases. Contrast-enhanced CT showing metastatic lesions in (a) the lung, (b) the liver, (c) the spleen, and (d) the bilateral adnexal region (arrows).