Solitary Subcutaneous Tissue Metastasis as Recurrence in a Case of Primary Angiosarcoma of Breast: Findings on ¹⁸F-Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography

A 20-year-old female underwent radical mastectomy with axillary lymph node dissection for a lump in the right breast. Histopathology of the surgical specimen revealed primary angiosarcoma of the breast. She developed a swelling in the right posterior arm after 1 year of surgery. Follow-up was done with ¹⁸F-fluorodeoxyglucose positron emission tomography-computed tomography ⁽¹⁸F FDG PET-CT) in view of high suspicion of metastasis and to locate any other distant site of metastasis. “PETCT scan findings revealed a mass lesion with variegated contour in the subcutaneous tissue of the right posterior arm, infiltrating the underlying triceps muscle and showing increased FDG uptake [Figure 1a–g]. No other FDG avid focal lesion was seen elsewhere in the body to suggest any distant visceral or skeletal metastasis. Biopsy from the mass revealed metastasis from the primary angiosarcoma of the breast, which showed perineural invasion and was positive for CD31 and CD34 on immunohistochemistry.

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Figure 1

(a) Maximum intensity projection image of positron emission tomography- computed tomography scan showing a large photopenic area with a rim of radiotracer uptake in the chest region on the right side corresponding to an operated right breast on computed tomography (b) and fused positron emission tomography-computed tomography (c) images with the hot rim denoting increased tracer uptake around the surgical margins. Also noted in (a) is an enlarged area of tracer uptake in the right distal arm (d). Coronal computed tomography showing mass lesion in the posterior right arm showing increased fluorodeoxyglucose uptake on fused positron emission tomography-computed tomography image (e and f). Sagittal computed tomography showing mass lesion in the posterior right arm showing increased fluorodeoxyglucose uptake on fused positron emission tomography-computed tomography image (g)

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Primary angiosarcoma of the breast is a rare, but aggressive malignancy of endovascular origin, comprising only 0.04% of all the malignancies involving breast, and affects the parenchyma of nonirradiated breast fields.[123] In contrast, secondary angiosarcoma arises in the dermal and subcutaneous layers of the skin of radiated fields after a period of 7–10 years after radiotherapy and may not necessarily involve the parenchyma.[4] Breast angiosarcoma showed a propensity for hematogenous metastasis, and the reported sites involved include lung, skin, liver, bone, central nervous system, spleen, ovary, and heart.[56] It frequently affects young women aged 20–50 years without any previous history of a malignancy.[7] Breast angiosarcomas are highly FDG avid tumors, and standardized uptake volume (SUV_max) is an important prognostic parameter in ¹⁸F FDG PET-CT studies and higher SUV_maxvalues correlates directly with a poorer prognosis. Furthermore, there is a significant difference in the values of SUVmax of primary and secondary angiosarcomas.[8] The authors through this case want to highlight the role of ¹⁸F FDG PET-CT in restaging of such rare tumors, while demonstrating a rare site of metastasis without any other distant visceral and skeletal metastasis.