Biomed Imaging Interv J 2006; 2(3):e30
© 2006 Biomedical Imaging and
Haemorrhaging lesion in the breast: is there a role for embolisation?
NA Taib1,*, MBBS, MS, MRCS,
CH Yip1, MBBS, FRCS,
S Ranganathan2, MBBS, MRad,
F Moosa2, MBBS, FRCR,
KS Mun3, MBBS, MPath,
1 Department of Surgery, Faculty of Medicine,
University of Malaya, Kuala Lumpur, Malaysia
2 Department of Radiology, Faculty of Medicine, University of
Malaya, Kuala Lumpur, Malaysia
3 Department of Pathology, Faculty of Medicine, University of
Malaya, Kuala Lumpur, Malaysia
Angiosarcoma of the breast is an extremely rare condition.
This case illustrates the use of embolisation as a modality of treatment for
primary breast angiosarcoma. No other case has been reported on the use of embolisation
for this disorder. � 2006 Biomedical Imaging and Intervention Journal. All
Angiosarcoma is the most malignant amongst all vascular tumours.
This entity is also known as haemangiosarcoma, haemangioblastoma, and metastasizing
haemangioma. Diagnosis of this lesion usually translates to a lethal disease.
Common sites that have been reported are skin, soft tissue, breast, liver, and
spleen. Angiosarcoma of the breast is a very rare condition. At our centre,
this was the only case seen over a period of 10 years. Compared with primary angiosarcoma,
secondary angiosarcoma from a previously irradiated breast is more commonly
The patient was a thirty-year old clerk. She complained of
an abnormal warm sensation in her left breast. She consulted her doctors
regarding this problem, but was reassured that it was normal. Sixteen months
later she noted a definite lump in her left breast, and an excision biopsy was
done. The lump recurred two months later, and a similar procedure was
performed. Both biopsies were reported as benign haemangiomas. The lesion
recurred during the next two months and, this time, she approached our clinic.
Physical examination revealed a mass which measured approximately 6 cm. She was
advised mastectomy with immediate breast reconstruction. She refused, but one
month later, returned to our hospital with a haemorrhaging lesion in the left
breast (Figure 1). She was found to be pale, but was haemodynamically stable.
She underwent radiological embolisation of the lesion. The angiogram showed a tumour
blush that had feeding arteries from branches of the left internal mammary
artery and lateral thoracic artery. Embolisation of the feeding vessels was
done using polyvinyl alcohol (PVA). Post-embolisation images showed complete
occlusion of these feeding vessels (Figures 2a, 2b). She later consented for mastectomy.
The tumour was completely excised�and
was reported as a grade 2 angiosarcoma. Radiotherapy of the chest wall was
given, and investigations showed multiple lung metastases and bone metastases.
She, however, refused palliative chemotherapy. Five months after mastectomy,
she returned with right hypochondrium pain and abdominal distension. On
clinical examination, she was pale. Her haemoglobin was 6 g/dl with a platelet
count of 83 x 109/L. The low platelet count could be attributed to
continuing platelet consumption due to formation of thrombi in the vascular metastatic
lesions. Her abdomen was found to be grossly distended, tense, and tender. The
fluid thrill test was positive. CT scan of the abdomen revealed multiple liver
metastases with free fluid in the peritoneal cavity. The main hepatic artery
was successfully embolised. Palliation of symptoms was achieved with
analgesics, repeated peritoneal tapping, and blood transfusions. The patient
also developed minor local recurrence on the chest wall, which fortunately did
not bleed. Seven months after treatment and 28 months after initial excision
biopsy, she deteriorated rapidly and passed away.
Figure 1 Haemorrhaging lesion of the
Figure 2 (a) Pre-embolisation
angiogram of the left breast; (b) Post-embolisation angiogram
of the left breast.
The peak incidence of angiosarcoma of the breast is usually
in the fourth decade of life. The overall survival is poor; five�year survival
is only 33% . Many studies show that prognosis is closely correlated with
the histological grade of the tumour . Misdiagnosis appears to be a common
problem with angiosarcoma , illustrated perfectly by this case. Histological
misdiagnosis has been reported to be as high as 39% in cases involving the
first biopsy . Angiosarcoma must be ruled out in all vascular lesions of the
breast. Angiosarcoma can be divided into three histological grades . The tumour
may exhibit features of more than one histological grade, i.e., one area may
show a lower grade or even benign features, while other areas in the tumour may
show malignant features. Adequate sampling is essential to ensure accurate
diagnosis. In this case, previous histopathological slides were not available
for review. It may have been that the areas sampled in the two lesions excised
first showed a grade 1 tumour, which could be easily mistaken for a benign
lesion. Clinical presentation of angiosarcoma may range from a lump to an
overtly bleeding lesion. It may also present as a painless mass or general
enlargement of the breast without a definite mass. Many cases show involvement
of both breasts . Our patient reported a �warm� sensation in the breast
before any lump could be detected. In this case, diagnosis of angiosarcoma at
an earlier stage may not have altered the unfortunate end result as she was not
compliant to treatment. The radiographic features of breast angiosarcoma are
not specific. Mammogram was not done for this patient as the mass bled easily
even with the lightest compression. To arrest the bleeding, embolisation was
performed, but this was only a temporary measure. Eventually she agreed to
mastectomy, which was the definitive treatment. No other case has been reported
so far on a Medline search for embolisation of angiosarcoma of the breast as a
form of treatment for primary angiosarcoma of the breast. There are, however,
three reports of embolisation treatment for primary hepatic angiosarcoma [4-6].
Invasive procedures are usually not carried out in patients with metastatic
disease, but in this patient, embolisation of the main hepatic artery was
indicated as she continued to bleed intraperitoneally. The role of adjuvant
therapy (chemotherapy and/or radiotherapy) for breast angiosarcoma is still
unclear, due to the small number of cases seen .
Angiosarcoma is a rare, but highly aggressive tumour. As
shown by this case, all vascular lesions in the breast warrant a careful workup
to rule out angiosarcoma. Embolisation may have a limited role in the
management of primary breast angiosarcoma and metastases in the liver.
Therefore, a multidisciplinary approach is crucial to the management of this condition.
Chen KT, Kirkegaard DD, Bocian JJ. Angiosarcoma of the breast. Cancer 1980;46(2):368-71.
Donnell RM, Rosen PP, Lieberman PH, et al. Angiosarcoma and other vascular tumors of the breast. Am J Surg Pathol 1981;5(7):629-42.
Britt LD, Lambert P, Sharma R, et al. Angiosarcoma of the breast. Initial misdiagnosis is still common. Arch Surg 1995;130(2):221-3.
Ozden I, Bilge O, Erkan M, et al. Five years and 4 months of recurrence-free survival in hepatic angiosarcoma. J Hepatobiliary Pancreat Surg 2003;10(3):250-2.
Horger MS. [Spontaneously ruptured hemangiosarcoma of the liver]. Rofo 2003;175(3):307-8.
Hoppe H, Dinkel HP, Triller J. [Interventional-radiologic emergency therapy in bleeding hemangiosarcoma of the liver]. Rofo 2001;173(8):763-5.
| Received 22 January 2006; received in revised form 19 April 2006; accepted 6 June 2006
Correspondence: Department of Surgery, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia. E-mail: firstname.lastname@example.org (Nur Aishah Mohd. Taib).
Please cite as: Taib NA, Yip CH, Ranganathan S, Moosa F, Mun KS,
Haemorrhaging lesion in the breast: is there a role for embolisation?, Biomed Imaging Interv J 2006; 2(3):e30
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