1 ) . the lesion had rapidly enlarged . at the anamnesis she previously underwent breast - conservative surgery and axillary dissection for invasive ductal carcinoma of the left breast in 2003 . she received radiotherapy as follows : 50  gy in 25 fractions of 200  cgy / daily with boost of 10  gy in 5 fractions of 200  cgy / daily . she received adjuvant hormone therapy ( tamoxifene 20  mg daily for two years and anastrozole for three years ) . the patient noticed a subcutaneous lesion of about 3  cm in diameter at the left breast . histopathological examination revealed a vascular structure lined by atypical cells with hyperchromatic nuclei and eosinophilic cytoplasm . tumor cells were positive for cd34 and vimentin and negative for sma and ckp , indicating an endothelial origin . the diagnosis of capillary - like grade - ii angiosarcoma of the breast was made . a total left mastectomy was performed , followed by repair of the skin defect using a dorsal skin graft . microscopically , the lesion was composed of intricate vascular channels surrounding and invading the breast lobules . this was consistent with the diagnosis of capillary- and papillary - like grade - ii angiosarcoma of the breast . a total body ct scan was repeated and showed no metastases . the cancer was completely removed , but three months later the patient noticed a mass in her right breast with local relapse with multifocal nodes in her left chest wall . the lesions into the chest wall were not amenable for surgery . the left chest wall was treated with local ect with intravenous bleomicin ( fig . 2 ) . treatment was performed according to the standard operating procedures for ect ( esope  european standard operating procedures of electrochemotherapy )   under general anesthesia . electric pulses were delivered using a square wave electroporator ( igea , carpi , italy ) . the applied voltage was 1.0  kv / cm for needle electrodes , and pulses were applied at 5  khz . six months later the patient developed multiple abdominal skin nodules not suitable for surgical treatment . response rate was evaluated similarly to the response evaluation criteria in solid tumors ( recist version 1.0 ) . overall , 51 lesion were treated at first and second therapeutic session of ect with median ( range ) diameter of 15 ( 1025 ) mm . considering all treated nodules ( n  =  51 ) , 51(100% ) had complete response , as assessed atphysical examination ( fig . adjuvant chemotherapy with doxorubicine(40  mg / m ) was prescribed , repeated every 4 weeks for 6 cycles aiming to prevent distant recurrences . breast angiosarcomas can be either observed as primary neoplasms or , more commonly , in upper limb lymphedema as a result of breast conservative surgery and radiotherapy for breast carcinoma [ 110 ] . radiation - induced angiosarcoma ( ria ) was first reported in the literature in 1929 , and is a common form of angiosarcoma . the diagnostic criteria for ria include : a previous history of radiotherapy , peak incidence between 5 and 10 years , development of sarcoma within a previous irradiated field , histology confirmation .rias are characterized by their aggressive nature and most of them are high - grade tumors . the prognosis is poor and local recurrence rates reaches 70% after mastectomy [ 1113 ] . rias often present as cutaneous or subcutaneous painless , flat or nodular , bluish or purplish lesion / s , similar to benign angiomas , small hematomas , or atypical telangiectasia . due to the rarity of the disease , prospective studies with regard to adjuvant therapy skin metastases from solid tumors behave in a similar fashion , irrespective of the tumor entity . the lesions may be distressing for the patient , due to their visibility or symptoms such as weeping , bleeding , and pain . ect has emerged as an effective local treatment for patients with cutaneous and subcutaneous tumor nodules . it combines the effects of a cytotoxic intravenous drug and electroporation by means of electric fields , which temporarily increase the permeability of cell membrane allowing the direct diffusion of the drug within malignant cells [ 4,1719 ] . ect has recently been proposed as a novel , complementary therapeutic option for the control of superficial disease . this therapeutic approach is a feasible alternative in case of inoperable tumors , located in pre - irradiated areas and in areas resistant to chemotherapy . since recurrence and survival rate of angiosarcomas mainly depend on wide excision margins , safety histological margins of at least 5  cm are recommended , but may require extended excisions , which are not always possible . due to the rarity of the disease , prospective studies concerning adjuvant or neoadjuvant therapy are limited and no evidence - based guidelines exist . however , anthracyclines are effective agents for soft tissue sarcomas and are mainly used as first - line therapy . in this case local treatment was combined with doxorubicine . in our patient , presenting with unresectable and extended angiosarcomas , treatment with ect in addition to systemic chemotherapy was likely to have significantly boosted the efficacy of the intravenous drug at the sites of angiosarcomas , achieving a complete response in all the lesions and improving patient body image perception . neither symptomatic nor asymptomatic recurrences were observed at 18-months follow - up , suggesting that ect is a promising tool in the palliative care of patients presenting with angiosarcomas after breast surgery . our research is based on clinical notes of an individual patient and does not require research ethical approval . written informed consent was obtained from the patient for publication of this case report and accompanying images . a copy of the written consent is available for review by the editor - in - chief of this journal on request . nine authors have contributed to this study : ( 1 ) all authors made substantial contributions to conception and design , acquisition of data , analysis and interpretation of data . ( 2 ) all authors participated in drafting the article or revising it critically for important intellectual content . md antonio santoriello  department of medical , surgical , neurologic , metabolic and ageing sciences , second university of naples , naples , italy .
highlightswe report the case of a 76-year - old woman who developed an exuberant and aggressive post radiation angiosarcoma of the breast and discuss different aspects of therapy for this disease.the lesions into the chest wall , and multiple abdominal skin nodules were treated with local electrochemotherapy ( ect ) with intravenous bleomicin.treatment with ect in addition to systemic chemotherapy achieves a complete response in all the lesions and improving patient body image perception .