A 54-year-old woman comes to the physician because of multiple firm violaceous nodules on her right upper arm. She was diagnosed with right-sided breast carcinoma twelve years ago and was treated with radical mastectomy. Extensive axillary lymph node dissection performed at that time revealed no lymph node metastases. Post-operatively, the patient developed chronic lymphedema involving her right arm. Which of the following is the most likely etiology of her current skin lesions?

Question

A 54-year-old woman comes to the physician because of multiple firm violaceous nodules on her right upper arm.  She was diagnosed with right-sided breast carcinoma twelve years ago and was treated with radical mastectomy.  Extensive axillary lymph node dissection performed at that time revealed no lymph node metastases.  Post-operatively, the patient developed chronic lymphedema involving her right arm.  Which of the following is the most likely etiology of her current skin lesions?

Quizplus · Accepted Answer

Chronic lymphedema is a risk factor for the development of cutaneous angiosarcoma, also known as Stewart-Treves syndrome. Radical mastectomy with axillary lymph node dissection is a classic predisposing procedure, although any form of chronic lymphedema can be implicated. Histopathologically, angiosarcoma will show infiltration of the dermis with slit-like abnormal vascular spaces. The prognosis for patients with angiosarcoma is poor because the tumor is usually widespread by the time of diagnosis. There is controversy regarding use of the term angiosarcoma versus lymphangiosarcoma, as it appears that this entity arises from blood vessels rather than from lymphatic vessels. (Choice A) Thrombosis of the subclavian or axillary vein most frequently occurs as a complication of a chronic indwelling catheter. (Choice C) Metastatic breast cancer is most likely to travel to bone, liver, and lung tissue. While it can have cutaneous metastases (usually affecting the anterior chest wall), the absence of lymphatic metastases on initial lymph node dissection makes this diagnosis less likely in this patient. (Choice D) Neurofibromas are soft, rubbery, asymptomatic cutaneous nodules that commonly appear during the second and third decades of life. (Choice E) Hemangiomas are benign congenital vascular neoplasms that affect infants. Hemangiomas often enlarge in the months following birth before spontaneously involuting. A cavernous hemangioma is a deep hemangioma. Educational objective: Axillary lymph node dissection is a risk factor for the development of chronic lymphedema involving the ipsilateral arm. Chronic lymphedema predisposes to the development of angiosarcoma (Stewart-Treves syndrome). __________ References: MRI of angiosarcoma associated with chronic lymphoedema: Stewart Treves syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/18065640) Images in clinical medicine. The Stewart-Treves syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/18753651)

A 54-Year-Old Woman Comes to the Physician Because of Multiple