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Angiosarcoma following treatment of basal cell
carcinoma: a report of two cases
Cutaneous angiosarcoma (CAS) is an uncommon malignant
neoplasm of vascular or lymphatic origin accounting for less
than 1% of all sarcomas.
The neoplasm typically manifests
as a diffuse bruise-like lesion or an elevated nodule, with
occasional ulceration and bleeding.
Lesions commonly favor
the head and neck in elderly men. On rare occasions, CAS
may also occur around foreign objects, neoplasms, and surgi-
cally created sites.
Herein, we describe two unique presenta-
tions of CAS arising within previous basal cell carcinoma
(BCC) surgical sites.
The ﬁrst patient is an 81-year-old Caucasian man who pre-
sented 9 months after having Mohs micrographic surgery
(MMS) for a BCC on the left lateral eyebrow (Fig. 1a) with a
purpuric plaque extending from his left forehead onto his left
face with an erythematous indurated leading margin and multi-
ple raised, tender tumors on his temporal scalp (Fig. 1b). Punch
biopsy revealed an atypical vascular proliferation of dilated and
slit-like spaces lined by hyperchromatic and pleomorphic
endothelial cells with surrounding red blood cell extravasation
(Fig. 1c). A CD31 immunostain highlighted the vessel lumens
and conﬁrmed an inﬁltrative growth pattern in the superﬁcial
dermis (Fig. 1d). These ﬁndings were consistent with a diagno-
sis of well-differentiated angiosarcoma, extending to peripheral
The second patient is an 88-year-old Caucasian man with
a history of nodular BCC of the right superior posterior helix
who presented 8 months after having MMS with a violaceous
nodule at the site of surgery (Fig. 2a). One week prior to pre-
sentation, the patient noticed the nodule, which he described
as progressively enlarging, bleeding, and painful (Fig 2b). He
denied constitutional symptoms such as weight loss, fatigue,
fever, or chills. A shave biopsy of the right superior posterior
helix revealed mild to focally moderately atypical squamous
cells present in the lower epidermis and dilated vascular
channels with extravasated red blood cells present in the
superﬁcial dermis (Fig 2c). Immunostaining of the endothelial
cells of vascular channels in the dermis were positive for
CD31 (Fig 2d). Also, it was recognized that there were
increased numbers of vascular channels present. In the dee-
per dermis, keloidal collagen was seen. The diagnosis of
well-differentiated angiosarcoma with associated keloid was
There are four proposed variants of cutaneous angiosar-
coma: idiopathic, chronic lymphedema associated, post-radia-
tion, and miscellaneous. The miscellaneous subtype includes
CAS developing around foreign bodies or within varicose ulcers,
surgical sites, port-wine stains, lymphangioma circumscriptum,
and epidermolysis bullosa dystrophica.
To date, few reports of CAS developing within or near sur-
gical scars exist in the literature. Moboni described one
patient who developed CAS very close to the surgical scar from
a previous radical mastectomy.
Similarly, Fessa et al. described
a case of CAS that developed in a peristomal site.
suggested a combined oncogenic effect of the surgically created
site and chronic inﬂammation at the site.
The two patients pre-
sented in this report are unique in that they developed CAS within
the Mohs site for previous BCC, an entity not yet described in the
Although coincidence could certainly explain these ﬁndings,
a more profound answer may be at hand. Wounds are known
to provide favorable environments for tumor development.
This is accomplished by disruption of normal parenchymal
architecture in addition to the normal wound healing
International Journal of Dermatology 2018, 57, 490–501 ª 2018 The International Society of Dermatology