Via Research Recognition Day Program VCOM-Carolinas 2025

Case Reports

A Case of Stewart-Treves Syndrome Post Radical Mastectomy Jack Golder OMS-II & Lindsay Tijattas-Saleski DO, MBA Edward Via College of Osteopathic Medicine - Carolinas Campus Prisma Health Upstate Introduction Lymphangiosarcoma, or Stewart-Treves Syndrome (STS) is a rare complication observed in breast cancer patients who have undergone axillary lymph node radiation and developed post-mastectomy lymphedema, with an overall incidence of 0.07-0.45%. 1,2 STS typically presents years after surgery as a tender purple skin lesion, often on the neck or upper extremities, which can progress to ulceration, hemorrhage, and necrosis. 3,4 These lesions are often without systemic symptoms, making diagnosis difficult. 5 Due to its rarity and poor prognosis, STS should be considered in patients with new skin changes following mastectomy in breast cancer. A 58-year-old female presents to the emergency room with complaints of an upper extremity wound. Now what? 1 1, 2 1 2 1 2 3,4 5

History

Treatment Plan The patient received treatment for electrolyte abnormalities and pain control. Referrals were made to wound care & surgery , in which further referral was made to outpatient surgical oncology for additional diagnostic procedures. The patient was discharged from the emergency department in stable condition. Outcome Outpatient surgical oncology diagnosed the patient with multifocal angiosarcoma , confirmed by MRI showing a large mass of the upper extremity with metastasis to the chest wall. With the diagnosis of consistent with STS, treatment was initiated involving first a right forequarter amputation followed by adjunctive chemotherapy . Discussion 3 4 The incidence of STS has been significantly decreased with reduced radiation to axillary lymph nodes in post-mastectomy breast cancer treatment, 2 however, still prevalent as seen in this case. While the findings emphasize the importance of timely diagnosis and management, their generalizability is limited. Red-purple papules, often misdiagnosed as bruises, require clinician vigilance, especially if lesions persist, show necrosis, or edema. Early recognition is critical to imitate oncologic therapies, as untreated STS has a poor prognosis. Moreover, the presentation of this case within an emergency department highlights the importance of emergency medicine physician education in the recognition of dermatologic pathologies. References 1. STEWART, F W, and N TREVES. “Lymphangiosarcoma in postmastectomy lymphedema; a report of six cases in elephantiasis chirurgica .” Cancer vol. 1,1 (1948): 64 -81 2. Stewart-Treves syndrome: a rapidly fatal complication of breast cancer treatment. Hsu, Andrew et al.The Lancet Oncology, Volume 21, Issue 10, e495 3. Garimella , Vishal et al. “Lower Extremity Angiosarcoma: A Life - Threatening Complication of Lymphedema.” Advances in skin & wound care vol . 37,5 (2024): 268-270. 4. Sepah , Yasir J et al. “Lymphangiosarcoma of the arm presenting with lymphedema in a woman 16 years after mastectomy: a case report.” 1 Sep. 2009, 5. Chopra, S., Ors, F., & Bergin, D. (2007). MRI of angiosarcoma associated with chronic lymphoedema: Stewart Treves syndrome. The British journal of radiology, 80(960), e310 – e313. https://doi.org/10.1259/bjr/19441948

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Patient History: The patient reported a past medical history of right-sided breast cancer and chronic lymphedema , having undergone a mastectomy and radiation therapy six years ago as part of her treatment. f History of Present Illness : The patient reported pinching her right arm between a coffee table and a chair one month ago , which led to irritation , granuloma formation , and intermittent bleeding . After initial advice to monitor the wound, she returned to the ER due to its worsening size, new areas of concern, and increased pain. Physical Exam Vital Signs: BP 116/75, HR 92 bpm, O2 99%, RR 15, Temp 98.2, & BMI 44.25 General: Negative fever, chills, or fatigue Cardiovascular: Normal rate & rhythm, the patient denied any chest pain Respiratory: Lungs clear & equal bilaterally, the patient denied any shortness of breath HEENT : Moist mucus membranes, negative lymphadenopathy, JVD, or scleral icterus Extremities: Right upper extremity presented with diffuse lymphedema and a large hemorrhagic & granulomatous wound , with small spots continuing to the lower forearm. All other extremities presented warm and well perfused, normal in color, and with no rash. 2

Figures 1, 2, & 3: Cutaneous findings of the patient

2025 Research Recognition Day

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