If breast skin hematomas occur spontaneously after radiotherapy for breast cancer, close follow-up examinations and, if they persist, further dermatological clarification is also necessary. This is underlined by the interdisciplinary team of authors led by Antonio Ruiu (Bolzano). The recommendation is based on the history of an 80-year-old patient.
The patient and her story
The patient underwent surgery in 2012 for breast cancer in the area of the upper outer quadrant of the right breast.
Tumor staging was pt1C N0 R0 V0 L0.The patient underwent radiotherapy in the same year (total dose 56 Gy with dose 2 Gy per fraction). Subsequently, the woman underwent annual check-ups. In 2020, during the mammography check-up, the patient reported that a year earlier, shortly after a minor trauma, a breast hematoma (right) had occurred.
The data
According to the authors, a bluish skin area was found in the area of the traumatized site on clinical examination. The mammogram had not revealed any major changes after surgery and radiotherapy.
Even the ultrasound examination did not reveal any abnormal findings. At observation, subcutaneous fluid was present in the area of the bluish area, located in the right outer lower quadrant. This condition was classified as «following the slow regression of a traumatic hematoma during antiplatelet therapy.» The skin area was easily mobilized but poorly compressed. No elastography had been performed.
Course, diagnosis and therapy
Clinical examination and mammography remained unchanged after one year.On ultrasound, however, «a morphologically similar dermal area was observed, but increasing in volume» on the right breast; The corresponding bluish skin area above it was still present. Also in this check-up the findings had been interpreted as «a condition following a hematoma with trauma».
A few months later, however, a second bluish skin spot appeared spontaneously in the lower inner quadrant, without any trauma: a biopsy of the area was then performed. Histological examination revealed epithelioid angiosarcoma (cell proliferation index Ki67: 80%). The therapy consisted of a mastectomy. The patient refused chemotherapy.
Discussion
According to Antonio Ruiu and his colleagues, angiosarcomas occur four to ten years after radiotherapy, especially after postoperative radiation therapy of the breast. The cumulative incidence is 0.9 per thousand women treated. The prognostic benefit of adjuvant breast radiotherapy therefore outweighs the risk of sarcoma for most patients by many times.
Additional risk factors for developing sarcoma/angiosarcoma following radiotherapy could be lymphedema and possibly predisposing genetic defects, e.g. mutations in the BRCA1 and BRCA2 genes.
According to the authors, diagnosing radiation-induced angiosarcoma is difficult.Angiosarcoma metastases are almost exclusively hematogenous and affect the lungs, pleura, liver, bones, adrenal glands, brain and chest wall.
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