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Benign Vascular Proliferations in Irradiated Skin

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Benign Vascular Proliferations in Irradiated Skin The American Journal of Surgical Pathology 26(3): 328–337, 2002 © 2002 Lippincott Williams & Wilkins, Inc., Philadelphia Benign Vascular Proliferations in Irradiated Skin Luis Requena, M.D., Heinz Kutzner, M.D., Thomas Mentzel, M.D., Rafael Durán, M.D., and José Luis Rodríguez-Peralto, M.D. Several types of cutaneous vascular proliferations have been This immunohistochemical profile also supported the lym- described in areas of irradiated skin, including both benign phatic nature of these vascular proliferations developed in ir- lesions, such as benign lymphangiomatous papules, atypical radiated skin. Although some of these lesions may mimic his- vascular lesions, or benign lymphangioendothelioma, and ma- topathologically patch-stage Kaposi’s sarcoma or well- lignant neoplasms such as high-grade angiosarcomas. This re- differentiated angiosarcoma, the follow-up of the patients of port describes the clinicopathologic features of 15 cases of this series demonstrated that the vascular proliferations arisen different types of benign cutaneous vascular proliferations in irradiated skin invariably showed a benign biologic behavior. arisen within irradiated skin. All patients were female ranging Key Words: Benign lymphangiomatous papules—Atypical in age from 33 to 72 years, and they had received postoperative vascular proliferations—Benign lymphangioendothelioma— external radiotherapy for treatment of breast carcinoma (14 Kaposi’s sarcoma—Angiosarcoma—Radiotherapy. cases) or ovarian carcinoma (one case). In those cases in which the latency interval period between radiotherapy and the devel- Am J Surg Pathol 26(3): 328–337, 2002. opment of the vascular lesion was known from the clinical records, the latency interval period elapsed between radio- therapy and diagnosis of the vascular lesion ranged from 3 to 20 years. The most common clinical presentation of the cuta- The occurrence of vascular proliferations arisen in neous lesions consisted of papules, small vesicles, or erythem- previously irradiated areas of the skin is well known. atous plaques on the irradiated field. Histopathologically, most These cutaneous vascular proliferations after radio- lesions consisted of irregular dilated vascular spaces, with a branching and anastomosing pattern, thin walls, and lymphatic therapy include both benign lesions, such as benign 1,10,13,15,21,22,25,27,28,30,38,40,55 appearance involving the superficial dermis. A discontinuous lymphangiomatous papules, single layer of endothelial cells with flattened nuclei lined these atypical vascular lesions,12 or benign lymphangioendo- vascular channels, and numerous small stromal papillary for- thelioma (also named acquired progressive lymphangio- mations also lined by endothelial cells projected into the lumina ma),44 and malignant neoplasms such as high-grade an- of the dilated lymphatic vessels. These cases were classified as 2,3,5,7,9,11,12,16,17,20,31,34–37,39,45–47,49 benign lymphangiomatous papules or plaques. Two cases giosarcomas. These showed different histopathologic findings because they con- vascular lesions appear within the field of radiation sisted of poorly circumscribed and focally infiltrating irregular therapy, and the latency interval time elapsed between jagged vascular spaces involving the entire dermis and lined by radiotherapy and the onset of the cutaneous lesions is inconspicuous endothelial cells. In some areas these irregular usually of several years. Some of the benign lesions, slit-like vascular spaces dissected collagen bundles of the der- 12 mis. These cases were classified as atypical vascular prolifera- such as atypical vascular proliferations and benign 44 tions mimicking benign lymphangioendothelioma or patch- lymphangioendothelioma, may mimic histopathologi- stage Kaposi’s sarcoma. All cases showed similar immunohis- cally patch-stage Kaposi’s sarcoma or well-differentiated tochemical findings and the endothelial cells lining the vascular angiosarcoma and thus may cause problems in the his- spaces expressed immunoreactivity for CD31, but they stained topathologic differential diagnosis. only focally positive for CD34 or were negative for this marker. Immunohistochemical investigations for ␣-smooth muscle ac- In this study 15 patients with several types of benign tin failed to demonstrate a complete peripheral ring of actin- vascular proliferations arisen within the area of irradiated positive pericytes in most of the neoformed vascular structures. skin were investigated from clinical, histopathologic, and immunohistochemical standpoints. Benign lymphangi- From the Department of Dermatology (L.R.), Fundación Jiménez Díaz, omatous papules and plaques were the most common Universidad Autónoma, Madrid, Spain; Dermatohistopathologisches lesions. Prominent intravascular papillary projections Gemeinschaftslabor (H.K., T.M.), Friedrichshafen, Germany; the Department of Pathology (R.D.), Hospital de Elda, Alicante, and lined by endothelial cells were seen in some of the di- the Department of Pathology (J.L.R.-P.), Hospital 12 de Octubre, lated lymphatic vessels. Other patients showed more Universidad Complutense, Madrid, Spain. atypical vascular proliferations mimicking benign lym- Address correspondence and reprint requests to Luis Requena, MD, Department of Dermatology, Fundación Jiménez Díaz, Avda. Reyes phangioendothelioma, patch-stage Kaposi’s sarcoma, or Católicos 2, 28040-Madrid, Spain; e-mail: [email protected] Dabska’s tumor in miniature. This report expands the 328 BENIGN VASCULAR PROLIFERATIONS 329 TABLE 1. Clinical data of the patients with benign vascular proliferations within irradiated skin Case Age (y)/ Primary Latency Clinical Histopathologic no. sex disease interval (y)* presentation Site Treatment findings Follow-up (mo) 1 72/F Breast 20 Two papules Axillary Local BLAPa NERM 6 mo carcinoma fold excision after diagnosis 2 — Breast 10 Two papules Chest BLAPa, nodular NERM 13 y carcinoma wall lymphocytic after diagnosis infiltrates 3 64/F Breast – Single papule Chest Local BLAPa, nodular NERM 5 y carcinoma wall excision lymphocytic after diagnosis infiltrates 4 44/F Breast – Erythematous Chest Local BLAPl NERM 4 y carcinoma plaque wall excision after diagnosis 5 49/F Breast – Several papules Chest Local BLAPl NERM 3 y carcinoma wall excision after diagnosis 6 62/F Breast 11 Several papules Chest Local BLAPa in upper NERM 3 y carcinoma wall excision areas, atypical after diagnosis vascular proliferation in deeper areas 7 62/F Breast 6 Several papules Chest Local BLAPa NERM 2 y carcinoma wall excision after diagnosis 8 61/F Ovarian – Erythematous Inguinal Local BLAPa NERM1yafter carcinoma plaque with area excision diagnosis overlying papular lesions 9 33/F Breast 3 Single papule Chest Local BLAPl NERM 6 mo carcinoma wall excision after diagnosis 10 44/F Breast – Single papule Chest Local BLAPl NERM 6 y carcinoma wall excision after diagnosis 11 70/F Breast 4 Single papule Chest Local Atypical vascular NERM 5 y carcinoma wall excision proliferation with after diagnosis endothelial tufts 12 54/F Breast 12 Single papule with Chest Local Atypical vascular NERM 2 y carcinoma appearance of wall excision proliferation after diagnosis dermatofibroma 13 68/F Breast 10 Single papule Chest Local BLAPa NERM 4 y carcinoma wall excision after diagnosis 14 67/F Breast 6 Erythematous Chest Biopsy BLAPl NERM1yafter carcinoma plaque wall diagnosis 15 58/F Breast 14 Single Chest Local BLAPa in upper NERM1yafter carcinoma pedunculated wall excision areas, atypical diagnosis lesion vascular proliferation in deeper areas * Latency interval refers to the time elapsed between radiotherapy and diagnosis of the vascular lesion. BLAPa, benign lymphangiomatous papule; BLAPl, benign lymphangiomatous plaque; NERM, no evidence of recurrence or metastatic disease. histopathologic spectrum of vascular proliferations able, for each patient: age, sex, primary disease, time arisen within previously irradiated skin. latency interval elapsed between radiotherapy and diag- nosis of the vascular lesion, clinical appearance, and lo- MATERIALS AND METHODS cation of the lesions. Where possible, follow-up infor- mation was obtained from the laboratory request forms Fifteen cases of cutaneous vascular proliferations and referring dermatologists or pathologists. arisen in areas of previously irradiated skin were re- For conventional light microscopy, tissue was fixed in trieved from the files of Dermatohistopathologisches 4% formalin, embedded in paraffin wax, and cut and Gemeinschaftslabor, Friedrichshafen, Germany (10 stained with hematoxylin and eosin. For immunohisto- cases), the Department of Dermatology, Fundación chemical studies representative sections of 10 cases Jiménez Díaz, Universidad Autónoma, Madrid, Spain were examined by the alkaline phosphatase anti-alkaline (three cases), the Department of Pathology, Hospital 12 phosphatase technique using appropriate positive and de Octubre, Universidad Complutense, Madrid, Spain negative controls throughout. Automated immunostain- (one case), and the Department of Pathology, Hospital de ing was performed on a BioTek Solutions Tech Mate Elda, Alicante, Spain (one case). Clinical information (TechMate 500, Biotech Solutions, Dako, Glostrup, Den- was obtained from the hospital records or laboratory re- mark). The following antibodies were used: CD31 quest forms. The following data were recorded, if avail- (JC/70A, 1:30, Dako, Hamburg, Germany), CD34 Am J Surg Pathol, Vol. 26, No. 3, 2002 330 L. REQUENA ET AL. (HPCA-1, 1:100, Becton-Dickinson, San Jose,
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