Breast-nonmalignant - Atypical or benign vascular lesion, post-radiation

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Breast-nonmalignant

Benign tumors / changes

Atypical or benign vascular lesion, post-radiation

Reviewer: Hind Nassar, M.D., Johns Hopkins Medical Institutions (see Reviewers page)
Revised: 5 October 2012, last major update October 2011
Copyright: (c) 2001-2011, PathologyOutlines.com, Inc.

Definition
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● Vascular proliferations that develop after external radiotherapy for breast carcinoma, within field of radiation (Am J Clin Path 1994;102:757)

Terminology
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● Atypical vascular lesion
● Note: atypical vascular pattern refers to a dermoscopic pattern that helps differentiate benign cutaneous lesions from melanoma

Epidemiology
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● Mean age 61 years
● Develops 1-12 years (mean 6 years) after therapy in radiation field

Sites
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● Breast exposed to previous radiation, usually in the skin area

Etiology
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● May have lymphatic origin (Histopathology 1999;35:319)

Clinical features
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● May recur within radiation field (Cancer 2007;109:1584)

Prognostic features
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● May progress to angiosarcoma, particularly vascular type (Am J Surg Pathol 2008;32:943, Am J Surg Pathol 2005;29:983)

Treatment
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● Complete excision with careful follow up for recurrence

Clinical images
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Left breast is erythematous with sclerotic tissue changes

Gross description
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● One or more circumscribed papules, small vesicles or erythematous plaques, usually in irradiated field, median 0.5 cm
● Frequently multiple synchronous lesions with discoloration

Micro description
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● Relatively well circumscribed, anastomosing growth pattern of irregular slit-like vascular spaces dissecting dermal collagen but not extending into subcutis
● Lined by single layer of endothelial cells without atypia
● Often micropapillary tufts
● Resembles benign lymphangioendothelioma or patch-stage Kaposi's sarcoma (Am J Surg Pathol 2002;26:328)

Lymphatic type:
● Predominantly thin walled, variably anastomosing lymphatics primarily in superficial dermis

Vascular type:
● Predominantly small, irregularly dispersed, capillary type vessels, invested by pericytes, often blood filled, in superficial or deep dermis
● Associated with extravasated red blood cells or hemosiderin, minor lymphatic type component (Arch Pathol Lab Med 2009;133:1804)
● Higher risk for angiosarcoma (Am J Dermatopathol 2005;27:301)

Micro images
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Figures 9-11

H&E, CD31 and FLI-1

Positive stains
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● CD31, D2-40
● Variable CD34

Molecular
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● No MYC amplification (Mod Pathol 2011 Sep 9 [Epub ahead of print])

Differential diagnosis
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● Angiosarcoma, well differentiated: atypical endothelial cells, infiltrative margins, usually high grade; may be part of morphologic continuum with atypical vascular lesions (J Am Acad Dermatol 2007;57:126); may need additional biopsies to distinguish these entities
● Hobnail hemangioma: smaller, more superficial and more localized
● Lymphangioendothelioma: also has intravascular papillary stromal projections that resemble papillary endothelial hyperplasia

End of Breast-nonmalignant > Benign tumors / changes > Atypical or benign vascular lesion, post-radiation

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