Breast Sarcoma Case: ALT and LTP Flaps in the Management of Bilateral Asynchronous Breast Angiosarcoma

Abstract

Greater clarity is needed in the surgical management of breast sarcoma. Breast sarcoma should not be managed according to breast carcinoma algorithms, and should mandate the involvement of a tertiary sarcoma center experienced in the management of such cases. This case centers around the management of a patient with primary breast angiosarcoma, initially treated in a non-sarcoma center with mastectomy and latissimus dorsi (LD) flap reconstruction, but with incomplete surgical margins. The patient’s further management was discussed through the National Scottish Sarcoma Network MDT, and surgical care transferred to the specialist sarcoma unit in Glasgow. A radical extended neo-mastectomy was performed on the right side, and reconstruction with an anterolateral thigh (ALT) flap at 1 week, once definitive pathology confirmed clear margins. Treatment goals are aimed at primary clearance of sarcoma, with angiosarcoma showing a clear survival benefit with a negative margin excision, with positive margins having a 6-month mean survival versus negative margin 42 months. Subsequent metastasis to the contralateral breast was later treated with paclitaxel followed by radical mastectomy and lateral thigh perforator (LTP) flap. The supporting rationale, current evidence, data from the West of Scotland breast sarcoma audit, and recent Scottish Sarcoma Network guidelines on breast sarcoma are discussed in the context of this case.