- Email: [email protected]
Three cases of breast angiosarcomas after breast-conserving treatment for carcinoma
250
Letter to the Editors/Radiotherapy
The set-upsin the accelerator and CT rooms did not detect any magnetic disturbances (no data presented). The magnetic-sensorsystem can be used as a positioning tool. The resolution of the translation errors are proportional to the distance between two units in the sensor, the voltage supply and to the size and strength of the magnetic field. To detect rotational errors more than one magnet is needed. The discrimination capacity of the sensor and the position calculation are dependent on a detectablemagnetic field in the unit with the strongest signal and in the surrounding units. In Table 1 it can be seen that the small magnet cannot detect a displacement of 0.5 mm if the units are separatedby 7.2 mm, although the signal from the centre-unit is strong enough (not shown). However, if the units are more compact the distance between two units is less than the radius of the magnetic field and it is possible to calculate a displacement of 0.5 mm. The optimal position is approximately half the radius of the detectable field. This position is not critical and it is also dependent on the signal-to-noise ratio and the approximations in the interpolation algorithm. A higher voltage supply increasesthe sensitivity of the units and the radius of the detectable magnetic field increases.The result is that a displacement of 0.5 mm can be detected with the smaller magnets at larger distances from the sensor. There are other parts of the system that needs further investigations before it can be used in a clinical situation. The sensorneedsto be positioned with a high level of accuracy in relation to the gantry, and a systemto achieve this needsto be developed.A conceivable solution is a gantry arm as described by Troccax et al. [7], or arms mounted on the treatment table or the gantry. The accuracy of implant position determination during CT investigations, in the treatment planning system, and on the simulator, need to be evaluated. Whether this system can fare better in a clinical situation and display possible advantages with ftxed reference points using implanted markersat CT and on the simulator needsfurther studies. Other systemsfor positioning using implanted non-magnetic markers have been presented,as well as systems using non-implanted magnetic fields for positioning [ 1,2,4]. These systemshave a resolution of 0.5-l mm. General disadvantagesof the method are that surgical intervention is required and that MRT cannot be used when the magnets have been implanted. This MRT incompatibility is temporarily, since the magnets can be removed after radiotherapy. MRT is seldom performed during a radiotherapy course, but this may alter in the future. One solution is to implant a catheter in which the magnets are temporarily inserted when the positioning system is used. The discomfort causedby the implantation is at present unknown. Magnets have been successfully implanted for different purposes [2,6]. Magnets are used in prosthodontics but the magnet is usually situated in the denture [5]. There are severalpossible combinations of alloys and magnetic coatings, as well as different implantation methods. This is currently subject for further studies.
References (11 Feustel, H. and Hennig, G. Kontinente Kolostomi durch Magnetverschluss.Dtsch. Med. Wschr. 100: 1063-1064, 1975. [2] Gall, K.P. and Verhey, L.J. Computer-assisted positioning of
and Oncology 37 (1995) 249-252
radiotherapy patients using implanted radiopaque Bduciab. Med. Phys. 20: 1153-1159, 1993. [31 Hendrickson, F.R. Precision in radiation oncology. Int. J. Radiat. Oncol. Biol. Phys. 8: 311-312, 1982. i41 Houdek, P.V., Schwade, J.G., Serago, C.F., Landy, H.J., Pisciotta, V., Wu, X., Markoe, A.M., Lewin, A.A., Abitbol, A.A., Bujnoski, J.L., Marienberg, ES., Fiedler, J.A. and Ginsberg, MS. Computer controlled stereotaxic radiotherapy system. Int. J. Radiat. Oncol. Biol. Phys. 22: 175-180, 1991. ]51 Jackson, T.R. and Healey, K.W. Rare earth magnetic attachments: the state of art in removable prosthodontics. Quintess. Int. 18(l): 41-51, 1987. 161 Von Schulz+, F. Beitrag zur Implantation von Permanentmagneten beu Faxialisparesen. Folia Ophthalmol. 4: 228-236, 1979. I71 Troccax, J., Menguy, Y., Bolla, M., Cinquin, Ph., Vassal P., Laieb, N., Desbat, L., Dusserre, A. and Dal Soglio, S. Conforma1external radiotherapy of prostatic carcinoma: requirements and experimental results. Radiother. Oncol. 29: 176-183, 1993.
Sincerely, Bo Lennemas, Sten Nilsson (Received 7 March 1995; revision receivedII July 1995; accepted14 September1995) Department of Oncology, Akademiska sjukhuset, University Hospital, S-751 85 Uppsala, Sweden
THREE CASES OF BREAST ANGIOSARCOMAS AFTER BREAST-CONSERVING TREATMENT FOR CARCINOMA To the Editors, We report here three casesof breast angiosarcoma (of skin and parenchyma)developing after breast conserving treatment for inoperable (one case)and operable (two cases)breast carcinomas. All of them were irradiated and two received chemotherapy (one in neoadjuvant setting, one in adjuvant setting). Case no. 1. A 4%year-old patient developed a breast angiosarcoma5 years after primary chemotherapy and radiation therapy (50 Gy to the breast and to the regional lymph nodes in 25 fractions over 5 weeks, and a boost of 20 Gy in 10 fractions to the tumor) for a breast inflammatory carcinoma. The angiosarcoma arose in the skin and parenchyma of the breast presenting with chronic edema and remaining carcinoma. Then she experienced contralateral breast chest wall and pleura metastases.The recurrences responded temporarily to the combination of radiotherapy, hyperthermia and 5-fluorouracil and to anthracyclin-containing regimens. Caseno. 2. A 43-year-old woman with Tl; grade 3, steroid receptor-negativeand node-positive was treated by conserving surgery followed by radiotherapy (50 Gy to the breast in 25 fractions over 35 days, 46 Gy to axillary and supraclavicular chains in 23 fractions over 34 days, 50 Gy to internal mammary chain in 25 fractions over 35 days) and adjuvant chemotherapy. Six years later, a red nodule of 3 mm in diameter developed on the skin overlying the lower internal quadrant (with no residual edema)inside the previously irradiated fields. Pathological examination of the skin resection showed
Letter
to the Editors
/Radiotherapy
and Oncology
37 (1995)
251
249-2S2
Table I Angiosarcoma after breast-conserving treatment
Author
Year of
Surgery
publication
Benda [3]
BUY [41 Shaikh [14] Givens [9] Stotter [17] Rubin 1121 Roukema [11] Roukema [I l] Badwe [1] Turner [19] Edeiken [S] Moshaluk [ 101 Session[13] Stokkel [la] Stokkel [ 161 Stokkel [ 161 Taat [18] Wijmaalen [20] Wijmaalen [20] Wijmaalen [20] Del Mastro [7] Slotman [15] slotman [15] Zucali [21] Zucali (211 Buatti [5]
1987 1987 1988 1989 1989 1990 1991 1991 1991 1991 1992 1992 1992 1992 1992 1992 1992 1993 1993 1993 1994 1994 1994 1994 1994 1994
R-I-(GY)
Site of AS
Latency (months)
cs cs cs cs cs cs cs cs cs cs cs cs cs cs cs cs No cs cs cs cs cs cs cs cs No
noRT 50 NS 50+ 15 50 46 50 + 20 50 + 25 46+20 40 56 + 20 48.6 + 18.6 50 + 20 50 + 25 50+ 15 50+25 45 + 25 45 + 25 45 + 25 45 + 20 50, 6 + 10 50 + 14 50 + 13 (30 ax) 45+ 15 50+ 10 50 (60 ax)
skin skin parench parench skin skin + par skin skin skin + par skin skin skin parench skin + par skin + par skin skin skin + par parench skin skin subcut skin + par skin skin (?)
48 72 48 150 144 84 84 60 78 108 52 88 54 69 29 83 66 66 77 84 42 56 52 59 41 72
Recurrence Survival of AS (months) (delay, months) 4 No 6 NS NS NS No NS No 4 8 NS NS No 6 No 5 16 No No 2 No 2 11 13 6
12 (NED) 24 (NED) 10 (D) NS NS NS 12 (NED) NS 6 (NED) 50 20 (NED) NS NS 24 (NED) 6 03 24 (NED) 8 (Db) 34 (W 33 (NED) 7 (NED) 16 (NED) 24 (NED) 9 (EVOL) 15 UV 25 (NED) 42 (NED)
CS, conservative surgery; AS, angiosarcoma; NS, Not stated; RT, Radiotherapy (Grays); Parench-Par, Parenchyma; NED, non-evolutive disease; D, Dead. aPostoperative. bHeart failure.
angiosarcoma. She is doing well 36 months after conservative surgical treatment of a cutaneous angiosarcoma of the breast. Case no. 3. A M-year-old postmenopausal woman underwent radiotherapy (50 Gy to the breast in 24 fractions over 35 days, 50 Gy to the mammary chain in 24 fractions over 35 days, 46 Gy to the subclavian chain in 22 fractions over 33 days) after conserving surgery for a Tl breast carcinoma, grade 2, steroid receptor positive, node negative. Five years later, she presented with a l-cm nodule, with skin discoloration in the fold under the breast. Skin resection revealed an angiosarcoma.She is disease-free24 months after conservative surgical treatment of cutaneous breast angiosarcoma. To our knowledge (in February 1995) twenty-six casesof angiosarcomas developing in breasts treated for carcinoma have been published (Table 1). Local treatment for operable breast cancer consisted of lumpectomy followed by radiation therapy in all casesbut one [3]. Radiation dosesto the tumor bed were over 50 Gy in all casesbut two 112,191.A boost of 15-25 Gy was generally administered by electron beam or iridium implant (no information in one case [14]). One inoperable breast cancer was treated by radiotherapy alone (45 + 25 Gy). One patient received adjuvant chemotherapy.
The latency interval (time elapsed between locoregional treatment for carcinoma and diagnosis of angiosarcoma) ranges from 29 to 150 months with a median value of 67 months, In conclusion, even if the pathogenesis is unknown, it is necessaryto select the indications of boost dose to tumor site and pay attention to skin changes after breast irradiation. References
111Badwe, R.A., Hanby, A.M., Fentiman, IS. and Chaudary,
M.A. Angiosarcoma of the skin overlying an irradiated breast. Br. CancerRes.Treat. 19:69-72, 1991. I21 Baum, J.K., Levine, A.J. and Ingold, J.A. Angiosarcoma of the breast with report of unusual site of first metastasis. J. Surg. Oncol. 43: 125-130, 1990. ]31 Benda, J.A., Al Jurf, A.S. and Benson, A.B. III. Angiosarcoma of the breast following segmental mastectomy complicated by lymphoedema. Am. J. Clin. Pathol. 87: 651-655, 1987. ]4l Body, G., Sauvenet,E., Calais, G., Fignon, A., Fetissof, F. and Lansac, J. Angiosarcome cutane du sein apres adenocarcinome mammaire op& et irradie. J. Gynecol. Obstet. Biol. Reprod. lti: 479-483, 1987. I51 Buatti, J.M., Harari, P.M., Leigh, B.R. and Cassady, J.R.
252
Letter to the Editors/ Radiotherapyand Oncology37 (1995)249-252
Radiation-induced angiosarcoma of the breast. Am. J. Clin. Oncol. 17(5):444-447, 1994 161Davies, J.D., Rees, G.J. and Mera, S.L. Angiosarcoma in irradiated post-mastectomy chest wall. Histopathology 7: 947-956, 1983. r71 Del Ma&o, L., Garrone, O., Guenxi, M., Catiero, F., Nicolo, G., Rosso, R. and Venturini, M. Angiosarcoma of the residual breast alter conservative surgery and radiotherapy for primary carcinoma. Ann. Oncol. 5: 163-165, 1994. PI Edeiken, S., Russo, D.P., Knecht, J., Parry, L.A. and Thompson, R.M. Angiosarcoma after tylectomy and radiation therapy for carcinoma of the breast. Cancer (Philad.) 70: 644-647,1992. 191 Givens, S.S., Ellerbroek, N.A., Butler, J.J., Libishtiz, HI., Hortobagyi, G.N. and McNeese, M.D. Angiosarcoma arising in an irradiated breast - A case report and review of the litterature. Cancer (Philad.) 64: 2214-2216, 1989. WI Mot&ah&, C.A., Merino, M.J., Danforth, D.N. and Medeiros, L.J. Low grade angiosarcoma of the skin of the breast: a complication of lumpectomy and radiation therapy for breast carcinoma. Hum. Pathol. 23: 710-714, 1992. IIll Roukema, J.A., Leenen, L.P.H., Kuixinga, M.C. and Maat, B. Angiosamoma of the irradiated breast: A new problem after breast conserving therapy? Neth. J. Surg. 43: 114-l 16, 1991. w1 Rubin, E., Maddox, W.A. and Maxur, M.T. Cutaneous angiosarcomaof the breast 7 years after lumpectomy and radiation therapy. Radiology 174: 258-260, 1990. 1131 Session,S.C. and Smink, R.D. Cutaneous angiosarcoma of the breast after segmentalmastectomy and radiation therapy. Arch. Surg. 127: 1362-1364, 1992. 1141 Shaikh, N.A., Beaconsfield, T., Walker, M. and Ghilchikh, M.W. Post-irradiation angiosarcoma of breast - a casereport. Eur. J. Surg. Oncol. 14: 449-451, 1988. I151 Slotman, B.J., Van Hattum, A.H., Meyer, S., Njo, K.H. and Karim, A.B.M.F. Angiosarcoma of the breast following conser-
[16]
[17]
[18]
[19] [20]
[21]
ving treatment for breast cancer. Eur. J. Cancer 30: 416-417, 1994. Stokkel, M. and Peterse,H.L. Angiosarcoma of the breast after lumpectomy and radiation therapy for adenocarcinoma. Cancer (Philad.) 69: 2965-2968, 1992. Stotter, A.T., McNeese, M., Ames, F.C., Oswald, M.J. and Ellerbroek, N.A. Predicting the rate and extent of locoregional failure after breast conservation therapy for early breast cancer. Cancer (Philad) 64: 2217-2225, 1989. Taat, C.W., Van Toor, B.S.J., Slots, J.F.M., Bras, J., Blank, L.E.C.M. and Van Coevorden, F. Dermal angiosarcoma of the breast: a complication of primary radiotherapy? Eur. J. Surg. Oncol. 18: 391-395, 1992. Turner, W.H. and Greenall, M.J. Sarcoma induced by radiotherapy after breast conservative surgery. Br. J. Surg. 78: 1317-1318, 1991. Wijmnaalen, A., Van Ooijen, B., Van Geel, B.N., HenxenLogman S. and Treumiet-Donker A. Angiosarcoma of the breast following lumpectomy, axillary lymph node dissection and radiotherapy for primary breast cancer: three case reports and a review of the literature. Int. J. Radiat. Oncol. Biol. Phys. 26: 135-139, 1993. Zucali, R., Menon, M., Placucci, M., Di Palma, S. and Veronesi, U. Soft tissue sarcoma of the breast after conservative surgery and irrradiation for early mammary cancer. Radiother. Oncol. 30: 271-273, 1994.
Sincerely,
EikatriceWeber, Christian Marchal (Received 26 April 1995; accepted14 September1995) Centre Alexis Vautrin, Avenue de Bourgogne 54511. Vanabeuvre-l&Nancy, France
Letter to the Editors/Radiotherapy
The set-upsin the accelerator and CT rooms did not detect any magnetic disturbances (no data presented). The magnetic-sensorsystem can be used as a positioning tool. The resolution of the translation errors are proportional to the distance between two units in the sensor, the voltage supply and to the size and strength of the magnetic field. To detect rotational errors more than one magnet is needed. The discrimination capacity of the sensor and the position calculation are dependent on a detectablemagnetic field in the unit with the strongest signal and in the surrounding units. In Table 1 it can be seen that the small magnet cannot detect a displacement of 0.5 mm if the units are separatedby 7.2 mm, although the signal from the centre-unit is strong enough (not shown). However, if the units are more compact the distance between two units is less than the radius of the magnetic field and it is possible to calculate a displacement of 0.5 mm. The optimal position is approximately half the radius of the detectable field. This position is not critical and it is also dependent on the signal-to-noise ratio and the approximations in the interpolation algorithm. A higher voltage supply increasesthe sensitivity of the units and the radius of the detectable magnetic field increases.The result is that a displacement of 0.5 mm can be detected with the smaller magnets at larger distances from the sensor. There are other parts of the system that needs further investigations before it can be used in a clinical situation. The sensorneedsto be positioned with a high level of accuracy in relation to the gantry, and a systemto achieve this needsto be developed.A conceivable solution is a gantry arm as described by Troccax et al. [7], or arms mounted on the treatment table or the gantry. The accuracy of implant position determination during CT investigations, in the treatment planning system, and on the simulator, need to be evaluated. Whether this system can fare better in a clinical situation and display possible advantages with ftxed reference points using implanted markersat CT and on the simulator needsfurther studies. Other systemsfor positioning using implanted non-magnetic markers have been presented,as well as systems using non-implanted magnetic fields for positioning [ 1,2,4]. These systemshave a resolution of 0.5-l mm. General disadvantagesof the method are that surgical intervention is required and that MRT cannot be used when the magnets have been implanted. This MRT incompatibility is temporarily, since the magnets can be removed after radiotherapy. MRT is seldom performed during a radiotherapy course, but this may alter in the future. One solution is to implant a catheter in which the magnets are temporarily inserted when the positioning system is used. The discomfort causedby the implantation is at present unknown. Magnets have been successfully implanted for different purposes [2,6]. Magnets are used in prosthodontics but the magnet is usually situated in the denture [5]. There are severalpossible combinations of alloys and magnetic coatings, as well as different implantation methods. This is currently subject for further studies.
References (11 Feustel, H. and Hennig, G. Kontinente Kolostomi durch Magnetverschluss.Dtsch. Med. Wschr. 100: 1063-1064, 1975. [2] Gall, K.P. and Verhey, L.J. Computer-assisted positioning of
and Oncology 37 (1995) 249-252
radiotherapy patients using implanted radiopaque Bduciab. Med. Phys. 20: 1153-1159, 1993. [31 Hendrickson, F.R. Precision in radiation oncology. Int. J. Radiat. Oncol. Biol. Phys. 8: 311-312, 1982. i41 Houdek, P.V., Schwade, J.G., Serago, C.F., Landy, H.J., Pisciotta, V., Wu, X., Markoe, A.M., Lewin, A.A., Abitbol, A.A., Bujnoski, J.L., Marienberg, ES., Fiedler, J.A. and Ginsberg, MS. Computer controlled stereotaxic radiotherapy system. Int. J. Radiat. Oncol. Biol. Phys. 22: 175-180, 1991. ]51 Jackson, T.R. and Healey, K.W. Rare earth magnetic attachments: the state of art in removable prosthodontics. Quintess. Int. 18(l): 41-51, 1987. 161 Von Schulz+, F. Beitrag zur Implantation von Permanentmagneten beu Faxialisparesen. Folia Ophthalmol. 4: 228-236, 1979. I71 Troccax, J., Menguy, Y., Bolla, M., Cinquin, Ph., Vassal P., Laieb, N., Desbat, L., Dusserre, A. and Dal Soglio, S. Conforma1external radiotherapy of prostatic carcinoma: requirements and experimental results. Radiother. Oncol. 29: 176-183, 1993.
Sincerely, Bo Lennemas, Sten Nilsson (Received 7 March 1995; revision receivedII July 1995; accepted14 September1995) Department of Oncology, Akademiska sjukhuset, University Hospital, S-751 85 Uppsala, Sweden
THREE CASES OF BREAST ANGIOSARCOMAS AFTER BREAST-CONSERVING TREATMENT FOR CARCINOMA To the Editors, We report here three casesof breast angiosarcoma (of skin and parenchyma)developing after breast conserving treatment for inoperable (one case)and operable (two cases)breast carcinomas. All of them were irradiated and two received chemotherapy (one in neoadjuvant setting, one in adjuvant setting). Case no. 1. A 4%year-old patient developed a breast angiosarcoma5 years after primary chemotherapy and radiation therapy (50 Gy to the breast and to the regional lymph nodes in 25 fractions over 5 weeks, and a boost of 20 Gy in 10 fractions to the tumor) for a breast inflammatory carcinoma. The angiosarcoma arose in the skin and parenchyma of the breast presenting with chronic edema and remaining carcinoma. Then she experienced contralateral breast chest wall and pleura metastases.The recurrences responded temporarily to the combination of radiotherapy, hyperthermia and 5-fluorouracil and to anthracyclin-containing regimens. Caseno. 2. A 43-year-old woman with Tl; grade 3, steroid receptor-negativeand node-positive was treated by conserving surgery followed by radiotherapy (50 Gy to the breast in 25 fractions over 35 days, 46 Gy to axillary and supraclavicular chains in 23 fractions over 34 days, 50 Gy to internal mammary chain in 25 fractions over 35 days) and adjuvant chemotherapy. Six years later, a red nodule of 3 mm in diameter developed on the skin overlying the lower internal quadrant (with no residual edema)inside the previously irradiated fields. Pathological examination of the skin resection showed
Letter
to the Editors
/Radiotherapy
and Oncology
37 (1995)
251
249-2S2
Table I Angiosarcoma after breast-conserving treatment
Author
Year of
Surgery
publication
Benda [3]
BUY [41 Shaikh [14] Givens [9] Stotter [17] Rubin 1121 Roukema [11] Roukema [I l] Badwe [1] Turner [19] Edeiken [S] Moshaluk [ 101 Session[13] Stokkel [la] Stokkel [ 161 Stokkel [ 161 Taat [18] Wijmaalen [20] Wijmaalen [20] Wijmaalen [20] Del Mastro [7] Slotman [15] slotman [15] Zucali [21] Zucali (211 Buatti [5]
1987 1987 1988 1989 1989 1990 1991 1991 1991 1991 1992 1992 1992 1992 1992 1992 1992 1993 1993 1993 1994 1994 1994 1994 1994 1994
R-I-(GY)
Site of AS
Latency (months)
cs cs cs cs cs cs cs cs cs cs cs cs cs cs cs cs No cs cs cs cs cs cs cs cs No
noRT 50 NS 50+ 15 50 46 50 + 20 50 + 25 46+20 40 56 + 20 48.6 + 18.6 50 + 20 50 + 25 50+ 15 50+25 45 + 25 45 + 25 45 + 25 45 + 20 50, 6 + 10 50 + 14 50 + 13 (30 ax) 45+ 15 50+ 10 50 (60 ax)
skin skin parench parench skin skin + par skin skin skin + par skin skin skin parench skin + par skin + par skin skin skin + par parench skin skin subcut skin + par skin skin (?)
48 72 48 150 144 84 84 60 78 108 52 88 54 69 29 83 66 66 77 84 42 56 52 59 41 72
Recurrence Survival of AS (months) (delay, months) 4 No 6 NS NS NS No NS No 4 8 NS NS No 6 No 5 16 No No 2 No 2 11 13 6
12 (NED) 24 (NED) 10 (D) NS NS NS 12 (NED) NS 6 (NED) 50 20 (NED) NS NS 24 (NED) 6 03 24 (NED) 8 (Db) 34 (W 33 (NED) 7 (NED) 16 (NED) 24 (NED) 9 (EVOL) 15 UV 25 (NED) 42 (NED)
CS, conservative surgery; AS, angiosarcoma; NS, Not stated; RT, Radiotherapy (Grays); Parench-Par, Parenchyma; NED, non-evolutive disease; D, Dead. aPostoperative. bHeart failure.
angiosarcoma. She is doing well 36 months after conservative surgical treatment of a cutaneous angiosarcoma of the breast. Case no. 3. A M-year-old postmenopausal woman underwent radiotherapy (50 Gy to the breast in 24 fractions over 35 days, 50 Gy to the mammary chain in 24 fractions over 35 days, 46 Gy to the subclavian chain in 22 fractions over 33 days) after conserving surgery for a Tl breast carcinoma, grade 2, steroid receptor positive, node negative. Five years later, she presented with a l-cm nodule, with skin discoloration in the fold under the breast. Skin resection revealed an angiosarcoma.She is disease-free24 months after conservative surgical treatment of cutaneous breast angiosarcoma. To our knowledge (in February 1995) twenty-six casesof angiosarcomas developing in breasts treated for carcinoma have been published (Table 1). Local treatment for operable breast cancer consisted of lumpectomy followed by radiation therapy in all casesbut one [3]. Radiation dosesto the tumor bed were over 50 Gy in all casesbut two 112,191.A boost of 15-25 Gy was generally administered by electron beam or iridium implant (no information in one case [14]). One inoperable breast cancer was treated by radiotherapy alone (45 + 25 Gy). One patient received adjuvant chemotherapy.
The latency interval (time elapsed between locoregional treatment for carcinoma and diagnosis of angiosarcoma) ranges from 29 to 150 months with a median value of 67 months, In conclusion, even if the pathogenesis is unknown, it is necessaryto select the indications of boost dose to tumor site and pay attention to skin changes after breast irradiation. References
111Badwe, R.A., Hanby, A.M., Fentiman, IS. and Chaudary,
M.A. Angiosarcoma of the skin overlying an irradiated breast. Br. CancerRes.Treat. 19:69-72, 1991. I21 Baum, J.K., Levine, A.J. and Ingold, J.A. Angiosarcoma of the breast with report of unusual site of first metastasis. J. Surg. Oncol. 43: 125-130, 1990. ]31 Benda, J.A., Al Jurf, A.S. and Benson, A.B. III. Angiosarcoma of the breast following segmental mastectomy complicated by lymphoedema. Am. J. Clin. Pathol. 87: 651-655, 1987. ]4l Body, G., Sauvenet,E., Calais, G., Fignon, A., Fetissof, F. and Lansac, J. Angiosarcome cutane du sein apres adenocarcinome mammaire op& et irradie. J. Gynecol. Obstet. Biol. Reprod. lti: 479-483, 1987. I51 Buatti, J.M., Harari, P.M., Leigh, B.R. and Cassady, J.R.
252
Letter to the Editors/ Radiotherapyand Oncology37 (1995)249-252
Radiation-induced angiosarcoma of the breast. Am. J. Clin. Oncol. 17(5):444-447, 1994 161Davies, J.D., Rees, G.J. and Mera, S.L. Angiosarcoma in irradiated post-mastectomy chest wall. Histopathology 7: 947-956, 1983. r71 Del Ma&o, L., Garrone, O., Guenxi, M., Catiero, F., Nicolo, G., Rosso, R. and Venturini, M. Angiosarcoma of the residual breast alter conservative surgery and radiotherapy for primary carcinoma. Ann. Oncol. 5: 163-165, 1994. PI Edeiken, S., Russo, D.P., Knecht, J., Parry, L.A. and Thompson, R.M. Angiosarcoma after tylectomy and radiation therapy for carcinoma of the breast. Cancer (Philad.) 70: 644-647,1992. 191 Givens, S.S., Ellerbroek, N.A., Butler, J.J., Libishtiz, HI., Hortobagyi, G.N. and McNeese, M.D. Angiosarcoma arising in an irradiated breast - A case report and review of the litterature. Cancer (Philad.) 64: 2214-2216, 1989. WI Mot&ah&, C.A., Merino, M.J., Danforth, D.N. and Medeiros, L.J. Low grade angiosarcoma of the skin of the breast: a complication of lumpectomy and radiation therapy for breast carcinoma. Hum. Pathol. 23: 710-714, 1992. IIll Roukema, J.A., Leenen, L.P.H., Kuixinga, M.C. and Maat, B. Angiosamoma of the irradiated breast: A new problem after breast conserving therapy? Neth. J. Surg. 43: 114-l 16, 1991. w1 Rubin, E., Maddox, W.A. and Maxur, M.T. Cutaneous angiosarcomaof the breast 7 years after lumpectomy and radiation therapy. Radiology 174: 258-260, 1990. 1131 Session,S.C. and Smink, R.D. Cutaneous angiosarcoma of the breast after segmentalmastectomy and radiation therapy. Arch. Surg. 127: 1362-1364, 1992. 1141 Shaikh, N.A., Beaconsfield, T., Walker, M. and Ghilchikh, M.W. Post-irradiation angiosarcoma of breast - a casereport. Eur. J. Surg. Oncol. 14: 449-451, 1988. I151 Slotman, B.J., Van Hattum, A.H., Meyer, S., Njo, K.H. and Karim, A.B.M.F. Angiosarcoma of the breast following conser-
[16]
[17]
[18]
[19] [20]
[21]
ving treatment for breast cancer. Eur. J. Cancer 30: 416-417, 1994. Stokkel, M. and Peterse,H.L. Angiosarcoma of the breast after lumpectomy and radiation therapy for adenocarcinoma. Cancer (Philad.) 69: 2965-2968, 1992. Stotter, A.T., McNeese, M., Ames, F.C., Oswald, M.J. and Ellerbroek, N.A. Predicting the rate and extent of locoregional failure after breast conservation therapy for early breast cancer. Cancer (Philad) 64: 2217-2225, 1989. Taat, C.W., Van Toor, B.S.J., Slots, J.F.M., Bras, J., Blank, L.E.C.M. and Van Coevorden, F. Dermal angiosarcoma of the breast: a complication of primary radiotherapy? Eur. J. Surg. Oncol. 18: 391-395, 1992. Turner, W.H. and Greenall, M.J. Sarcoma induced by radiotherapy after breast conservative surgery. Br. J. Surg. 78: 1317-1318, 1991. Wijmnaalen, A., Van Ooijen, B., Van Geel, B.N., HenxenLogman S. and Treumiet-Donker A. Angiosarcoma of the breast following lumpectomy, axillary lymph node dissection and radiotherapy for primary breast cancer: three case reports and a review of the literature. Int. J. Radiat. Oncol. Biol. Phys. 26: 135-139, 1993. Zucali, R., Menon, M., Placucci, M., Di Palma, S. and Veronesi, U. Soft tissue sarcoma of the breast after conservative surgery and irrradiation for early mammary cancer. Radiother. Oncol. 30: 271-273, 1994.
Sincerely,
EikatriceWeber, Christian Marchal (Received 26 April 1995; accepted14 September1995) Centre Alexis Vautrin, Avenue de Bourgogne 54511. Vanabeuvre-l&Nancy, France