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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 7  |  Issue : 3  |  Page : 119-121

Cytokeratin positivity in secondary angiosarcoma of breast: A diagnostic pitfall


1 Department of Pathology, Sir Ganga Ram Hospital, New Delhi, India
2 Department of Histopathology, Sir Ganga Ram Hospital, New Delhi, India

Date of Web Publication6-Dec-2018

Correspondence Address:
Dr. Prakriti Gupta
Department of Pathology, Sir Ganga Ram Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ccij.ccij_16_18

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  Abstract 


Reappearing breast lump in a known case of breast carcinoma often turns out to be a recurrence of the carcinoma. However, in patients receiving radiotherapy for the disease, possibility of secondary angiosarcoma should also be suspected. Secondary angiosarcoma can pose a challenge in pathological diagnosis especially in small trucut biopsies. Aberrant expression of epithelial marker can also add to the difficulty. In this article, we report a case wherein similar difficulties were faced during the diagnosis.

Keywords: Angiosarcoma, breast, carcinoma, cytokeratin positivity, secondary


How to cite this article:
Gupta P, Rao S, Bhalla S. Cytokeratin positivity in secondary angiosarcoma of breast: A diagnostic pitfall. Clin Cancer Investig J 2018;7:119-21

How to cite this URL:
Gupta P, Rao S, Bhalla S. Cytokeratin positivity in secondary angiosarcoma of breast: A diagnostic pitfall. Clin Cancer Investig J [serial online] 2018 [cited 2019 Mar 18];7:119-21. Available from: http://www.ccij-online.org/text.asp?2018/7/3/119/247011




  Introduction Top


Angiosarcoma of the breast is rare, accounting for 0.04% of all soft-tissue breast tumors.[1] It can be primary or present as a secondary tumor often the following radiotherapy. Primary angiosarcoma arises in younger women with no known risk factor while secondary angiosarcoma of the breast is more prevalent in older patients with a history of radiation exposure or lymphedema. The relative risk for developing angiosarcoma of the chest and/or breast among women with a history of invasive breast cancer has been estimated to be 11.6%.[2]

Over 200 cases of radiation-induced angiosarcoma of the breast are currently known in literature.[3] Secondary angiosarcoma commonly presents with predominant cutaneous involvement. Only a minority of cases (~7%) present as a palpable mass in the breast.[4]

Angiosarcoma has distinct morphological features with a vasoformative pattern. However, small biopsies may pose a problem due to paucity of diagnostic material combined with a strong differential of carcinoma recurrence, thus making preoperative diagnosis difficult. Aberrant immunoexpression of epithelial markers in angiosarcoma can also mislead toward a diagnosis of breast carcinoma. Both these problems were faced in our case. We hereby report an unusual case of secondary angiosarcoma arising in an irradiated breast as a palpable mass and with aberrant cytokeratin (CK) expression.


  Case Report Top


A 55-year-old female was diagnosed of invasive carcinoma of the right breast in 2010 and managed with breast conservation surgery and local radiotherapy. She presented 6 years later with a lump at surgery site. A trucut biopsy was done which showed fibro-fatty tissue with scattered tumor cells in one corner of the biopsy. The tumor cells were infiltrating the adipose tissue diffusely with vague acini formation [Figure 1]a. Suspecting a recurrence of infiltrating carcinoma, immunohistochemistry (IHC) for CK was done which showed strong positivity in tumor cells [Figure 1]b. A diagnosis suggestive of recurrence of breast carcinoma was rendered following which the patient underwent right-sided mastectomy.
Figure 1: Trucut biopsy of the right breast lump showed scattered tumor cells in fibroadipose tissue, (a, ×200); Inset showing cellularity in the corner of the biopsy, (H and E, ×100). Tumor cells with strong cytokeratin expression, (b, ×400), immunohistochemistry

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Resected specimen showed an infiltrating lesion in the right breast parenchyma with gray-white and firm cut surface [Figure 2]. Overlying skin was largely normal.
Figure 2: Right mastectomy specimen

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Microscopic examination showed similar malignant tumor cells as seen in biopsy, but with a distinct sinusoidal pattern suggesting it to be of vascular origin. Intersecting vascular channels lined by pleomorphic cells were observed. The cells had varied amount of cytoplasm with distinct hyperchromatic nuclei and anisonucleosis [Figure 3]a and [Figure 3]b.
Figure 3: Microscopic examination of resection specimen showed tumor cells arranged in anastomosing vascular channels containing red blood cells, (a, H and E, ×200). Tumor cells are epithelioid to elongated with hyperchromatic nuclei and moderate to abundant eosinophilic cytoplasm, (b, H and E, ×400)

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IHC for CD34, CD31, and CK showed strong positivity in tumor cells [Figure 4]. Therefore, a diagnosis of secondary postradiation epithelioid angiosarcoma was rendered.
Figure 4: Tumor cells expressed CD34, CD31 and cytokeratin, ×200, immunohistochemistry

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  Discussion Top


Reappearing mass in a known case of breast carcinoma is a worrisome sign implying poor prognosis. It proves to be a recurring invasive carcinoma most of the time; however, differential of a secondary malignancy should also be kept in mind. An attempted biopsy or aspirate from a recurring lump in a treated case of breast carcinoma may sometimes be diagnostically challenging due to poor overall yield, especially in cases with diffuse necrosis and fibrosis of the tumor. Scattered malignant looking cells without any specific pattern may render multiple differential diagnoses with relapse of the breast carcinoma being most probable. However, in the setting of previous irradiation, similar to our case, caution must be exercised. It should be kept in mind that irradiated breast is prone to secondary sarcomas with angiosarcoma being the most prevalent.[5] In cases of doubtful morphology, immunostaining with epithelial markers must be done to confirm the suspicion of relapse. A diagnosis of relapse of breast carcinoma can be confidently made on the basis of strong CK expression by tumor cells. However, angiosarcomas, especially of epithelioid type, pose a challenge. They occasionally show positivity for CK and focally for EMA.[6],[7]

Adding to the difficulty, positivity for estrogen and progesterone receptors have also been reported in secondary angiosarcomas of the breast.[8] Endothelial markers such as factor VIII, CD 34, and CD31 come to rescue in such cases. Angiosarcomas almost always express these markers of vascular differentiation with the exception of rare cases of high grade and poor differentiation. Tumor cells in breast carcinoma do not express endothelial markers. Immunophenotyping of such tumors with conflicting morphology should thus be done with a comprehensive panel including both vascular and epithelial markers. Secondary angiosarcomas are treated with radical surgery with negative resection margins followed by chemotherapy. However, recurrent breast carcinoma is treated by mastectomy followed by neoadjuvant chemotherapy and/or hormonal therapy. The difference in management and evidence of better faring of patients treated for recurrent breast carcinoma as compared to secondary angiosarcoma mandate their distinction by histology and immunophenotyping.


  Conclusion Top


We, therefore, stress that despite rarity, secondary angiosarcoma should be considered as a possibility in cases of suspected recurrence of breast lump. High index of suspicion should be maintained in postradiotherapy cases. When trucut biopsy of the recurrent lump is done, a panel of IHC markers should be applied. It is desirable to include epithelial as well as endothelial markers in such cases to avoid misdiagnosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yang WT, Hennessy BT, Dryden MJ, Valero V, Hunt KK, Krishnamurthy S, et al. Mammary angiosarcomas: Imaging findings in 24 patients. Radiology 2007;242:725-34.  Back to cited text no. 1
    
2.
Cozen W, Bernstein L, Wang F, Press MF, Mack TM. The risk of angiosarcoma following primary breast cancer. Br J Cancer 1999;81:532-6.  Back to cited text no. 2
    
3.
Fraga-Guedes C, Gobbi H, Mastropasqua MG, Botteri E, Luini A, Viale G, et al. Primary and secondary angiosarcomas of the breast: A single institution experience. Breast Cancer Res Treat 2012;132:1081-8.  Back to cited text no. 3
    
4.
Scow JS, Reynolds CA, Degnim AC, Petersen IA, Jakub JW, Boughey JC, et al. Primary and secondary angiosarcoma of the breast: The mayo clinic experience. J Surg Oncol 2010;101:401-7.  Back to cited text no. 4
    
5.
Yap J, Chuba PJ, Thomas R, Aref A, Lucas D, Severson RK, et al. Sarcoma as a second malignancy after treatment for breast cancer. Int J Radiat Oncol Biol Phys 2002;52:1231-7.  Back to cited text no. 5
    
6.
Ohsawa M, Naka N, Tomita Y, Kawamori D, Kanno H, Aozasa K, et al. Use of immunohistochemical procedures in diagnosing angiosarcoma. Evaluation of 98 cases. Cancer 1995;75:2867-74.  Back to cited text no. 6
    
7.
Seo IS, Min KW. Postirradiation epithelioid angiosarcoma of the breast: A case report with immunohistochemical and electron microscopic study. Ultrastruct Pathol 2003;27:197-203.  Back to cited text no. 7
    
8.
Singh Y, Inoue K, Kawanishi H, Hioki K, Horio T, Shikata N, et al. Angiosarcoma of the breast: Immunohistochemical demonstration of steroid receptors and literature review. Breast Cancer 1996;3:125-9.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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