Case Reports

Cutaneous Angiosarcoma of the Lower Leg

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Angiosarcoma is a vascular malignancy that can affect various anatomic sites. Although rare, cutaneous angiosarcoma is the most common clinical manifestation, accounting for approximately 50% to 60% of cases. Cutaneous angiosarcoma typically is known to occur in 3 settings: (1) idiopathic, (2) following radiation treatment, and (3) in the setting of chronic lymphedema following mastectomy (known as Stewart-Treves syndrome). The clinical manifestation of angiosarcoma can mimic other processes. We present a case of cutaneous angiosarcoma on the leg in an elderly woman in the setting of a chronic nonhealing wound and lymphedema. We also discuss the differential diagnosis and treatment options.

Practice Points

  • Cutaneous angiosarcoma is a rare malignant vascular neoplasm typically seen in 3 settings: (1) idiopathic (commonly on the face and neck), (2) following radiation treatment, and (3) classically in the setting of chronic lymphedema following mastectomy (Stewart-Treves syndrome).
  • There should be a low threshold for biopsy in patients who present with nonhealing wounds that do not progress in the normal phase of wound healing with suspicion for malignancy.
  • Histologic analysis of angiosarcoma shows positive staining for CD34 and vimentin with poorly differentiated endothelial atypia with mitotic figures.


 

References

Angiosarcoma is a rare and aggressive vascular malignant neoplasm derived from endothelial cells. In general, sarcomas account for approximately 1% of all malignancies, with approximately 2% being angiosarcomas.1 The risk of recurrence at 5 years is estimated to be 84%, and 5-year survival is estimated at 15% to 30%. Poor prognostic factors for angiosarcoma include large tumor size, depth of invasion greater than 3 mm, high mitotic rate, positive surgical margins, and metastasis.2 Approximately 20% to 40% of patients who are diagnosed with angiosarcoma already have distant metastasis, contributing to the aggressive nature of this neoplasm.3

Angiosarcoma can affect various anatomic locations, including the skin, soft tissue, breasts, and liver. Cutaneous angiosarcoma is the most common clinical manifestation, accounting for approximately 50% to 60% of all cases, and typically is known to occur in 3 distinct settings.2 Primary or idiopathic cutaneous angiosarcoma is most commonly seen in elderly individuals, with a peak incidence in the seventh to eighth decades of life, and presents as a bruiselike lesion predominantly on the head and neck. Angiosarcoma also is seen clinically in patients exposed to radiation treatment, with a median onset of symptoms occurring 5 to 10 years posttreatment, and in patients with chronic lymphedema, usually on the arm following radical mastectomy, which also is known as Stewart-Treves syndrome.2

With any sarcoma, treatment typically first involves surgical excision; however, there is no direct approach for treatment of cutaneous angiosarcoma, as an individual plan typically is needed for each patient. Treatment options include surgical excision, radiation, chemotherapy, or a combination of these therapies.2,4

We present a rare case of cutaneous angiosarcoma of the left leg in the setting of chronic venous insufficiency with some degree of lymphedema and a nonhealing ulcer. This case is unique in that it does not fit the classic presentation of cutaneous angiosarcoma previously described.

Case Report

An 83-year-old woman with a medical history of advanced dementia, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, type 2 diabetes mellitus, hypertension, and chronic venous insufficiency with stasis dermatitis presented to the emergency department following a mechanical fall. Most of her medical history was obtained from the patient’s family. She had a history of multiple falls originally thought to be related to a chronic leg ulcer that had been managed with wound care. Recently, however, the lesion was noted to have increasing erythema surrounding the wound margins. An 8×8-cm erythematous plaque on the anterior lateral left leg with a firm central nodule with hemorrhagic crust that measured approximately 4 cm in diameter was noted by the emergency department physicians (Figure 1). In the emergency department, vitals and other laboratory values were within reference range, and a radiograph of the left tibia/fibula was unremarkable. Cellulitis initially was considered in the emergency department and cephalexin was started; however, since the patient was afebrile and had no leukocytosis, plastic surgery also was consulted. Biopsies were obtained from the superior and inferior parts of the lesion. Histologic analysis revealed a poorly differentiated vascular neoplasm of epithelioid endothelial cells with considerable cell atypia that extended through the entirety of the dermis (Figure 2). The tumor cells stained positive with vimentin and CD34. Pathology noted no immunohistochemistry stains to synaptophysin, S-100, human melanoma black 45, MART-1, CK20, CK7, CK8/18, CK5/6, and p63. The pathologic diagnosis was consistent with cutaneous angiosarcoma. Computed tomography of the chest, abdomen, and pelvis revealed no local or distant metastases.

Figure1

Figure 1. Cutaneous angiosarcoma presenting as a large erythematous plaque on the anterior lateral left lower leg with a firm central nodule with overlying hemorrhagic crust.

Figure2

Figure 2. Histologic analysis revealed a poorly differentiated vascular neoplasm extending through the dermis (A) with epithelioid endothelial cells (B)(H&E, original magnifications ×40 and ×100). Considerable cell atypia and mitotic figures were appreciated on higher power (C)(H&E, original magnification ×400).

A wide excision of the cutaneous angiosarcoma was performed. The initial frozen section analysis revealed positive margins. Three additional excisions still showed positive margins, and further excision was held after obtaining family consent due to the extensive nature of the neoplasm and lengthy operating room time. The final defect after excision measured 15×10×2.5 cm (Figure 3A), and subsequent application of a split-thickness graft was performed. Additional treatment options were discussed with the family, including radiation therapy, amputation of the left lower leg, or no treatment. The family opted not to proceed with further treatment. The graft healed without signs of reoccurrence approximately 3 months later (Figure 3B), and the patient received physical therapy, which allowed her to gain strength and some independence.

Figure3

Figure 3. Wide surgical excision of the cutaneous angiosarcoma yielded a final defect measuring 15×10×2.5 cm (A). Approximately 3 months following excision and subsequent split-thickness skin graft, the patient was healing well with no evidence of reoccurrence (B).

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