Pathlet 013
Josh Hubbard '15
with the pathology team

These pathlets are edutainment. This site collects no information about visitors, and cannot substitute for your own doctor's care. There are many questions without clear right-or-wrong answers.

Frederick Childe Hassam
"Lady in Flower Garden"
Concentrate all your thoughts upon the work at hand. The sun's rays do not burn until brought to a focus.

        -- Alexander Graham Bell
A 40-year-old female Ms. Sun Shine, an avid gardener, presents to your office after she noticed a blue-red mass under her right breast (lower outer quadrant). She describes the mass as painless, non-tender, firm but does not itch. She denies any nipple discharge. She says she first noticed the mass two days ago but does not know how long it has been present since it is in a difficult location to see and she lives alone. She does not report any other symptoms.

She is not currently taking any medications, but is allergic to sulfa drugs. Past surgical history includes tonsillectomy as child, breast biopsy, followed by lumpectomy for Ductal Carcinoma in Situ, diagnosed 8 years prior to this office visit. She received post lumpectomy radiation. Has never had lymph edema in her arm or the local area around the lumpectomy scar.

Vitals: T 98.6 R 13 P 67 BP 129/85. On physical exam her heart has a RRR without murmurs. Her lungs are CTAB (clear to auscultation bilaterally) without wheezes, crackles or rales and no areas dullness on percussion. The mass is a moderately well demarcated plaque lesion and measures approximately 5.0 x 3.0 cm on the skin surface.

What's next?
Order a mammogram
Order a CT of the chest
Order a MRI of the chest
Do a bone marrow biopsy
Order routine labs
Place a centeral line
Recommend last vacation / hospice
Radiation oncology consult
     (Dr. Glowing)
Pathology consult for fine-needle
     (Dr. Pathguy)
Oncology consult for chemotherapy
     (Dr. RightDrug)
Surgery consult for excisional biopsy
     (Dr. SharpKnife)
Do nothing.


Dr. Path-Guy receives a 3.0 X 1.5 X 1.5 cm piece of skin and subcutaneous tissue and fat. The skin surface is partially colored blue black to red; the color extends into the subcutaneous fatty tissue of the specimen also. The remaining skin is tan, but the specimen is friable with focal areas of hemorrhage. The specimen is sectioned and representative portions are submitted for processing. The next day Dr. PathGuy is sitting at his microscope, examining the slide, a representative picture is provided for your viewing pleasure. You see inter-anastomosing vascular channels, some filled with red blood cells; intermingled with solid spindled and plump cuboidal cells. You consider a variety of tumors. You are welcome to order some immunostains. When you are done, make your diagnosis.

Order your stains:

Factor VIII
   (blood vessel endothelium)
   (endothelium, primitive cells)
   (endothelium, many WBC's)
   (some lymphoid)
   (most white cells)
   (negative in lobular CA)
Estrogen receptor
   (many breast cancers)
   (angioma architecture)
   (many breast cancers)
   (basal cells)
   (basal cells)
What is your diagnosis?

Infiltrating ductal carcinoma
Infiltrating lobular carcinoma


A few points about angiosarcomas....

  • There are about 2500 primary breast carcinomas for every bresat angiosarcoma.
  • If they appear on the skin, they look red-blue.
  • In the breast, they may be primary, or secondary to previous radiation.
  • The endothelial cells may be plump and cuboidal, as they are here, or or more falt as in benign endothelium.
  • The tumor often shows different grades of cancer in the same mass. Pathologists are warned never, ever to trust any "benign hemangioma" of the breast!
  • Even with a rather bland histology, these tumors often metastasize. Common sites are skin, soft tissue, lung, lymph nodes, liver and bone.
  • Grade I angiosarcomas appear to be normal-type vessels growing exuberantly or into the fat. They are easily mistaken for "tubular carcinoma" or "benign hemangioma."
  • Grade II angiosarcomas have solid neoplastic vascular formations, usually with some papillary endothelial growth.
  • Grade III angiosarcomas have hemorrhage and/or necrosis.
  • Five-year survival decreases inversely with the grade of the lesion. A grade II / intermediate grade mass has a 68% chance of a five-year survival.

Josh Hubbard KCUMB '15

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