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CASE REPORT Table of Contents   
Year : 2008  |  Volume : 51  |  Issue : 3  |  Page : 421-423
Bilateral angiosarcoma breast diagnosed by fine needle aspiration cytology


1 Department of Pathology, Kasturba Medical College, Mangalore, Karnataka, India
2 Department of Pathology,Yenepoya Medical College, Mangalore, Karnataka, India

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   Abstract 

Concurrent or synchronous angiosarcoma (AS) of breast is a rarity. Specific recognition of this neoplasm in cytological specimens is difficult and conclusive diagnosis in the absence of ancillary methods is achieved only uncommonly. Herein, we present a case of bilateral AS of breasts in a 32-year-old lady diagnosed by fine needle aspiration (FNA) cytology, thus enabling a definitive surgical approach. This case report emphasizes that when aspiration smears show vasoformative features consisting of microacini, arborizing microtissue fragments and intracytoplasmic lumen against a bloody background, diagnosis can be made conclusively by FNA with immunohistochemical confirmation.

Keywords: Angiosarcoma, breast, fine needle aspiration

How to cite this article:
Pai MR, Upadhyaya K, Naik R, Malhotra S. Bilateral angiosarcoma breast diagnosed by fine needle aspiration cytology. Indian J Pathol Microbiol 2008;51:421-3

How to cite this URL:
Pai MR, Upadhyaya K, Naik R, Malhotra S. Bilateral angiosarcoma breast diagnosed by fine needle aspiration cytology. Indian J Pathol Microbiol [serial online] 2008 [cited 2019 Dec 11];51:421-3. Available from: http://www.ijpmonline.org/text.asp?2008/51/3/421/42549



   Introduction Top


Primary angiosarcoma (AS) of the breast is a rare lesion accounting for 0.04% of all malignant breast tumors and 8% of mammary sarcomas. [1] This lesion occurs sporadically in young women between second to fourth decades. Bilateral primary ASs are uncommon and is usually associated with pregnancy. [2] Contralateral breast involvement may be due to either development of a secondary primary tumor or metastatic spread. [2] Secondary ASs may arise following radiation therapy to the breast.

The cytological diagnosis can be made conclusively by fine needle aspiration (FNA) with immunocyto-chemical confirmation of endothelial differentiation.


   Case history Top


A 32-year-old unmarried lady presented with bilateral breast lumps of 3-month duration. The left breast was diffusely enlarged with reddish-brown fungating growth in the lower outer quadrant. The breast mass measured 30 25 18 cm. The right breast had a smaller lump covered by stretched skin measuring 18 15 10 cm. It was located in the inner lower quadrant. FNA was performed from the lesions in both the breasts. Eight smears were studied and as they were all air-dried smears received from peripheral laboratory, they were stained with May Grunwald-Giemsa.

Cytomorphologic features

All the eight smears from both breast masses showed similar morphology. They were very cellular composing of spindle to ovoid cells disposed in loose cohesive clusters, elongated cords and sheets and as numerous single cells having scanty pale blue cytoplasm [Figure 1]. There was no discernible nuclear atypia. Nuclei were round-, oval- or spindle-shaped. Nuclear membranes were smooth and inconspicuous nucleoli were seen. Mitoses were not seen. Some of the cell nests showed prominent intracytoplasmic eosinophilic inclusions [Figure 2]. Intracytoplasmic lumina, microacinar lumen formation and vascular channels prompted us to suggest the diagnosis of bilateral AS of the breast.

Histological findings

Bilateral mastectomy was performed [Figure 3]. The left breast parenchyma was totally replaced by a reddish-brown spongy hemorrhagic tumor measuring 25 20 15 cm. [Figure 4]. Right breast showed an irregular mass measuring 15 10 8 cm with spongy, grey-white cut surface.

Sections from tumor tissue revealed proliferating vascular spaces lined by moderately pleomorphic endothelial cells, endothelial tufting, papillary formations, blood lakes and necrosis [Figure 5A].

Immunohistochemical (IHC) staining was performed for endothelial marker - CD34 showed strong positivity in the tumor cells lining the spaces and those disposed in sheets [Figure 5B].


   Discussion Top


Angiosarcoma of the breast is an uncommon extremely hostile malignant neoplasm of vascular origin. But they are the most common of the pure sarcomas occurring in breast. About 217 cases have been described since the first case reported by Schmidt in 1887 [2] in the world literature. Although AS is the most common of the pure sarcomas occurring in the breast, cytological descriptions in FNA specimens exist predominantly as case reports. [3] Bilateral ASs of the breast are a rarity. Concurrent bilateral ASs are extremely uncommon [4] and documentation of the same is available only in association with pregnancy. In the present case, this lady was unmarried and she was mentally retarded too. The cause of retardation could not be ascertained.

The tumor cells aspirated showed numerous anastomosing vascular structures. The prominent endothelial lining was visualized in them. The tumor cells aggregated as loose sheets, clusters revealed numerous oval to spindle cells with eosinophilic cytoplasmic inclusions [Figure 2] possibly representing erythrocytes within intracytoplasmic lumina. [5] Boucher et al. , [5] in their large study, including 15 cases of AS from various sites studied two cases of AS of breast and noticed vasoformative features consisting of microacinar structures, arborizing microtissue fragments, intracytoplasmic lumina, signet ring like cells and rare erythrophagocytosis. In the present study, except signet ring cells, other features were observed in the smears. Several cytological findings in the present study were compared and contrasted with study by Liu and Layfield. [6] Features common to both studies were oval to spindle cellular morphology, single atypical cells and bloody background.

In contrast to 11 cases reported by Liu and Layfield [6] where smears showed hypocellularity, smears were highly cellular in the present case. Apparently, FNAC of AS was first reported by Nguyen et al . [7] Since then many reports have been encountered on this subject in the literature. [8],[9],[10] The tendency of AS cells in forming vasoformative or acinar arrangement was again noted by Nguyen et al . [7] To date, reported cases of bilateral AS cases were associated with pregnancy [11] and most of the documented cases of primary breast AS were unilateral.

Malignant spindle cells may be seen in the needle aspirates from spindle cell sarcoma such as fibrosarcoma and monophasic spindle-cell synovial sarcoma. However, these neoplasms are uncommon in the breast. Other common breast neoplasms exhibiting both epithelial and stromal components are fibroadenomas with or without hypercellular stroma, phyllodes tumor, and metaplastic carcinoma with sarcomatous elements. In conclusion, vasoformative arrangement is seen only in AS. In the absence of this pattern, ASs are diagnosed as poorly differentiated carcinomas.

 
   References Top

1.Agarwal PK, Mchrora R. Haemangiosarcoma of the breast. Indian J Cancer 1977;14:182-5.  Back to cited text no. 1    
2.Chen TT, Kirkegaard DD, Hocian JJ. Angiosacoma of the breast. Cancer 1980;46:368-71.  Back to cited text no. 2    
3.Gupta RK, Naran S, Dowle C. Needle aspiration cytology and immunocytochemical study in a case of angiosarcoma of the breast. Diagn Cytopathol 1991;7:363-5.  Back to cited text no. 3    
4.Donnell RM, Rosen PP, Lieberman PH, Kaufman RJ, Kay S, Braun DW Jr, et al . Angiosarcoma and other vascular tumors of the breast. Am J Surg Pathol 1981;5:629-42.  Back to cited text no. 4    
5.Boucher LD, Swanson PE, Stanly MW, Silverman JF, Raab SS, Giesinger KR. Cytology of angiosarcoma: Findings in 14 fine needle aspiration biopsy specimens and one pleural fluid specimen. Am J Clin Pathol 2000;114:210-9.  Back to cited text no. 5    
6.Liu K, Layfield LJ. Cytomorphologic features of angiosarcoma on fine needle aspiration biopsy. Acta Cytol 1999;43:407-15.  Back to cited text no. 6    
7.Nguyen Gk, Hussain M. Fine needle aspiration biopsy cytology of angiosarcoma. Diagn Cytopathol 2000;23:143-5.  Back to cited text no. 7    
8.Stanley MW, Tani EM, Horwitz CA, Tulman S, Skog L. Primary spindle cell sarcoma of the breast: Diagnosis by fine needle aspiration. Diagn Cytopathol 1988;4:244-9.  Back to cited text no. 8    
9.Merino MJ, Carter D, Herman M. Angiosarcoma of the breast. Am J Surg Pathol 1983;7:53-60  Back to cited text no. 9    
10.Masin M, Masin F. Cytology of angiosarcoma of the breast: A case report. Acta cytol 1978;22:162-4.  Back to cited text no. 10    
11.Kiyozuka Y, Koyama H, Nakata M, Matsuyama T, Nikaido Y, Shimono N. Diagnostic cytopathology in type II angiosarcoma of the breast: A case report. Acta Cytol 2005;49:560-6.  Back to cited text no. 11    

Top
Correspondence Address:
Muktha R Pai
Department of Pathology, Kasturba Medical College, Light House Hill Road, Mangalore - 575 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.42549

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5A], [Figure 5B]

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