Radiotherapy-Induced Scalp Angiosarcoma

Actas Dermosifiliogr. 2007;98:372-6 373 To the Editor: We describe a 57-year-old man with multiple basal cell carcinomas on the scalp, where he had undergone radiation therapy in childhood. He consulted for a pearly mass adjacent to a violaceous mass of 5 cm that was poorly defined, indurated, asymptomatic, and with several peripheral nodules (Figure 1), but no local or regional lymph node enlargement. The biopsy showed a basal cell carcinoma and a highly malignant angiosarcoma, with mixed epithelioid and fusiform cell type, high mitotic index, and considerable vascular invasion (Figure 2). Immunohistochemistry showed strong positivity for CD31 (Figure 3), partial for cytokeratins, and low for CD34 and VIII antigen. The computed tomography scans and magnetic resonance imaging revealed infiltration of the subcutaneous cellular tissue and a lesion in the left frontoparietal lobe, the nature of which could not be determined, as the patient declined angiography. Biopsies of the underlying bone and cerebral parenchyma showed no evidence of infiltration. Surgery and local radiation therapy were performed. However, at 2 months, new nodules appeared on the scalp as well as enlarged retroauricular lymph nodes; these were treated by local radiation therapy. Pulmonary metastases have appeared recently, and the patient is undergoing systemic chemotherapy at the time of writing. Angiosarcoma is a rare malignant tumor. A third of these tumors occur in the skin, with a predisposition for superficial soft tissues.1 The condition is more common in older white men. Lymphedema, chronic radiodermatitis, and immunosuppression are related factors. The pathogenesis is unknown, although it appears to have a multifocal origin in the lymphatic vessels. As occurs with basal cell carcinomas, gene mutations have been found in the gene for p53, which would induce overexpression of vascular endothelial growth factor.2,3 Angiosarcoma can display 4 clinical presentations: idiopathic angiosarcoma of the scalp and face, angiosarcoma associated with chronic lymphedema, angiosarcoma secondary to radiation therapy, and primary angiosarcoma of the breast. Initially, all of these types Radiotherapy-Induced Scalp Angiosarcoma