CASE REPORT Radiation-Induced Angiosarcoma After Mastectomy and TRAM Flap Breast Reconstruction Matthew M. Hanasono, MD,* Michael P. Osborne, MD,† Elodi J. Dielubanza,* Sara B. Peters, MD,‡ and Lloyd B. Gayle, MD* Abstract: Radiation-induced angiosarcoma of the breast is being reported with increasing frequency as a result of the increased use of radiation therapy in conjunction with breast conservation surgery. However, this entity has not been well documented in patients undergoing mastectomy. The authors present a case of angiosarcoma occurring in a patient 6 years after undergoing mastectomy for invasive duct carcinoma with immediate transverse rectus abdomi- nis musculocutaneous flap reconstruction followed by postoperative radiation therapy. The diagnosis of angiosarcoma was made by skin biopsy performed by the patient’s reconstructive surgeon on routine follow-up examination. This is the first reported case of postradia- tion angiosarcoma occurring in a postmastectomy breast recon- structed with autogenous tissue and it is unusual in that the cancer invaded the musculocutaneous flap. Diagnosis and management recommendations for radiation-induced angiosarcoma are discussed. (Ann Plast Surg 2005;54: 211–214) R adiation-induced angiosarcoma of the breast, although not well documented in the plastic surgery literature, is being reported with increasing frequency. Most cases occur in the setting of breast conservation therapy using lumpec- tomy with postoperative radiation therapy. We present a patient who underwent a modified radical mastectomy for invasive duct carcinoma with immediate breast reconstruc- tion using a free transverse rectus abdominis musculocutane- ous (TRAM) flap followed by postoperative radiation ther- apy. The patient developed a purplish skin lesion on the native mastectomy flap 6 years later, which was sampled by her reconstructive surgeon (L.B.G.) and revealed angiosar- coma. The malignancy, which arose secondary to treatment with radiation therapy, is the first to be reported in a patient with autologous breast reconstruction and is unusual in that it involved a portion of the TRAM flap. CASE REPORT The patient is a 37-year-old woman with a history of moderately differentiated invasive duct carcinoma of the left breast. She had undergone a modified radical mastectomy with immediate breast reconstruction using a free TRAM flap in March 1996. Seventeen of 21 axillary lymph nodes were positive for cancer, and focal extracapsular extension was observed. She received postoperative chemotherapy consist- ing of Adriamycin and cyclophosphamide, which was in turn followed by high-dose cyclophosphamide with thiotepa sup- ported by peripheral blood stem cell support. Subsequently, she received radiation therapy to the left chest wall and supraclavicular area. Her tumor was estrogen receptor and progesterone receptor positive, and did not express HER2/ neu. She was maintained on long-term anastrozole, an aro- matase inhibitor that decreases the production of estrogen used in the treatment of estrogen receptor-positive breast cancer. There was no family history of breast cancer and her past medical history was otherwise unremarkable. She presented to her reconstructive surgeon (L.B.G.) for routine follow-up in November 2002 with 3 adjacent purplish skin lesions with surrounding erythema on the infe- rior mastectomy flap, inferior and medial to the skin paddle of the TRAM flap (Fig. 1). A biopsy was performed that demonstrated atypical spindle cells and more dilated vascular channels extending into the subcutaneous soft tissue with a chronic inflammatory infiltrate within the dermis (Fig. 2A). At higher magnification, solid areas demonstrated pleomor- phic spindle cells with numerous mitotic figures and “blood lake” formation (Fig. 2B). The diagnosis of angiosarcoma was made after immunoperoxidase staining for the antigens CD31 and Ki-67. Staining for CD31 was positive in the majority of the spindles cells in the dermis, as was Ki-67—a Received January 31, 2004 and accepted for publication, after revision, May 13, 2004. From the *Division of Plastic Surgery, Department of Surgery; the †Breast Service, Department of Surgery; and the ‡Division of Dermatopathology, Department of Pathology, New York Presbyterian Hospital–Weill Cor- nell Medical Center, New York, New York. Reprints: Lloyd B. Gayle, MD, Division of Plastic Surgery, New York Presbyterian Hospital–Weill Cornell Medical Center, 525 East 68th Street, Box 115, New York, NY 10021. Tel: 212 746 5593; fax: 212 746 8666; E-mail: lloydbgayle@msn.com Copyright © 2005 by Lippincott Williams & Wilkins ISSN: 0148-7043/05/5402-0211 DOI: 10.1097/01.sap.0000134751.73260.3a Annals of Plastic Surgery • Volume 54, Number 2, February 2005 211