Ann Thorac Surg 1999;67:839-841
© 1999 The Society of Thoracic Surgeons
Case Reports
Angiosarcoma of the chest wall
Donna E. Maziak, MDCMa,
Farid M. Shamji, MDa,b,c,
Rebecca Peterson, MDa,b,c,
D. Garth Perkins, MDa,b,c
a Thoracic Surgery, University of Ottawa, Ottawa, Ontario, Canada
b Radiology, University of Ottawa, Ottawa, Ontario, Canada
c Pathology, University of Ottawa, Ottawa, Ontario, Canada
Accepted for publication August 27, 1998.
Address reprint requests to Dr Maziak, Ottawa Civic Hospital, 1053 Carling Ave, C.P.C. Rm. 162, Ottawa, ON K1Y 4E9 Canada
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Abstract
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Angiosarcoma is a rare and highly malignant tumor of vascular origin. The causative factors include trauma, radiation, foreign bodies, thorium dioxide, and viral infections. We report a case of angiosarcoma occurring in a thoracotomy incision 17 years after operation for stage I lung cancer.
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Introduction
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A 68-year-old man, treated for a primary lung cancer 17 years previously, complained of a new pain and swelling of 5 months duration in the previous thoracotomy incision; the patient had noticed a swelling beginning in the incision. There had been no complications after his left pneumonectomy for stage I squamous cell carcinoma, and he had remained well and free of recurrence until now. On physical examination, there was a firm nonpulsatile chest wall mass, 18 x 12 cm, centered on the thoracotomy incision. Subsequent studies included a computed tomographic scan of the chest and abdomen, which showed a large mass involving the left chest wall, filling the pneumonectomy space, with increased vascularity and destruction of the seventh rib (Fig 1). A fine needle aspiration of the mass with a 22-gauge spinal needle resulted in severe bleeding into the surrounding soft tissues of the chest wall, with a corresponding decrease in the patient’s hemoglobin from 140 to 85 g/L necessitating a blood transfusion. The fine needle aspirate was highly suspicious for malignancy.
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Fig 1. Computed tomographic scan of the chest with contrast showing the large chest wall mass occupying the pneumonectomy space, with increased vascularity and the presence of calcification.
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Before proceeding with an incisional biopsy, a primary tumor in the kidney was ruled out and a thoracic aortogram was performed to assess the vascularity of the tumor. Multiple abnormal tortuous blood vessels were seen feeding the tumor mass from the left subclavian, left internal mammary, and intercostal arteries. A metastatic survey, including computed tomographic scan of the head, abdomen, and total body bone scan, revealed no evidence of metastatic disease. An incisional biopsy of the chest wall mass revealed an angiosarcoma, grade 2 to 3, confirmed by light microscopy and positive immunoperoxidase stains for vimentin, factor VIII-related antigen, and Ulex europaeus agglutinin 1.
Three days before undertaking major resection, an arteriogram with embolization of two large chest wall arteries from the left subclavian artery feeding the mass was done to decrease its vascularity. The operation consisted of en bloc resection of the chest wall mass with a 6-cm margin of skin and soft tissue to include the previous biopsy site, latissimus dorsi muscle, inferior angle of the scapula, ribs 2 through 10 inclusive and an 11 x 7-cm part of the diaphragm. Reconstruction was carried out with mobilization of the omentum to fill the pneumonectomy space over which a 2-mm Gor-Tex patch (W.L. Gore and Assoc, Flagstaff, AZ) was sutured to the chest wall margins followed with primary skin closure. The patient had an uneventful postoperative recovery and remains well with no recurrence 54 months later.
The excised specimen weighed 3,730 g and had an overall dimension of 28.0 x 25.0 x 18.0 cm, including an overlying 28.0 x 5.0 cm ellipse of skin. Portions of nine ribs were removed; the middle three had been partially destroyed by the tumor which was a predominantly cystic hemorrhagic 17.5 x 12-cm mass (Fig 2). An incomplete fibrous scar, 0.3 to 0.4 cm in thickness, was present around the medial and lateral borders of the lesion. Histologically, this scar was composed of dense, poorly cellular fibrous tissue and is consistent with old scarring secondary to the previous pneumonectomy.
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Fig 2. Cross-section through the anterior portion of the cystic tumor including skin and chest wall. The cut surface of the tumor is multicystic and very hemorrhagic due to extensive necrosis induced by the preoperative embolization. The scale indicates 1 cm.
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Much of the resected angiosarcoma was necrotic and recognized only by the ghost outlines of the vascular spaces. In other areas, tumor cells showed marked ischemic degenerative changes likely secondary to the preoperative embolization. There were, however, areas of viable tumor (Fig 3). Angiosarcoma was noted at the periphery of the cystic mass, immediately adjacent to the thick fibrous capsule. In none of the sections did the tumor extend through the capsule. All resection margins were free. No embolized material was identified within the vessels.
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Fig 3. Photomicrograph (hematoxylin-phloxine saffron stain; x 480 before 49.5% reduction) of vascular spaces lined by pleomorphic endothelial cells. The arrow indicates a mitotic figure.
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Comment
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Angiosarcoma is a rare soft tissue tumor, accounting for only 1% to 2% of these tumors. The etiologic factors include trauma, chronic lymphedema, radiation, foreign bodies, thorium dioxide, viral infections, and chronic pyothorax [1–8]. In the present patient, an angiosarcoma occurred in the incision 17 years after a left posterolateral thoracotomy for stage I squamous cell carcinoma of the lung. The incision had healed normally without a complication. The pneumonectomy space had not become infected. No foreign material was placed in the pneumonectomy space and he did not receive postoperative radiation or chemotherapy. If the tumor occurred on the basis of the trauma of the incision, one would expect to see a higher incidence of angiosarcomas in thoracotomy incisions.
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References
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Abstract
Introduction
