Angiosarcoma Treatment & Management

Updated: Aug 18, 2022
  • Author: Maria Belén Carsi, MD, PhD, FRCS; Chief Editor: Edwin Choy, MD, PhD  more...
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Approach Considerations

Treatment of soft-tissue angiosarcoma

For stage I angiosarcomas, the National Comprehensive Cancer Network (NCCN) recommends surgery to obtain adequate oncologic margins. For stage II and stage IIIA and IIIB disease that can be resected with acceptable functional outcomes, the NCCN also recommends preoperative radiation therapy (category 1). For stage IIIA-B disease, category 2B recommendations include preoperative chemoradiation or chemotherapy, and postoperative chemoradiation. [25] The NCCN lists the following as preferred for treatment of angiosarcoma:

  • Paclitaxel
  • Anthracycline-based regimens
  • Gemcitabine-based regimens

Anthracycline-based regimens include the following:

  • Doxorubicin
  • Epirubicin
  • Liposomal doxorubicin
  • AD (doxorubicin, dacarbazine)
  • AIM (doxorubicin, ifosfamide, mesna)
  • Ifosfamide, epirubicin, mesna

Gemcitabine-based regimens include the following:

  • Gemcitabine and docetaxel
  • Gemcitabine and vinorelbine
  • Gemcitabine and dacarbazine

Neoadjuvant chemotherapy can be considered in patients with large localized angiosarcomas, where achieving negative margins may be a challenge. [1]  However, response to preoperative chemotherapy is only 40-50% with the most active regimens, and toxicity is significant. European guidelines list neoadjuvant chemotherapy as an option in selected patients with high-risk local or locoregional disease. [26]

Angiosarcoma is highly sensitive to taxanes, and paclitaxel has proved well tolerated and active even in pretreated patients with locally advanced or metastatic angiosarcoma. [27, 26]  Paclitaxel is used as single-agent therapy and is administered weekly. [28]

Ravi et al report exceptional response to treatment with pazopanib in a patient with angiosarcoma that harbored amplification of vascular endothelial growth factor receptor (VEGFR) and that had not responded to sorafenib. These authors suggest that a subset of patients with angiosarcoma with genomic alterations in vascular signaling genes may respond well to pazopanib. [29]  In a retrospective study of treatment for advanced vascular sarcomas in patients previously treated with standard chemotherapy including anthracyclines, 8 of 40 patients with angiosarcoma responded to pazopanib, with median progression-free survival of 3 months and median overall survival of 9.9 months. [30]  

Pasquier et al reported effective treatment in seven patients with advanced angiosarcoma using the combination of twice-daily propranolol (40 mg) and weekly metronomic vinblastine (6 mg/m2) and methotrexate (35 mg/m2). All patients responded; one patient showed a complete response and three showed very good partial responses. Median progression-free and overall survival was 11 months (range 5–24) and 16 months (range 10–30), respectively. [31] In 2017, propranolol was granted orphan drug status in Europe for the treatment of soft tissue sarcoma. [32]

Similarly, Amaya et al reported increased progression-free and overall survival in patients with metastatic angiosarcoma who received treatment with nonselective beta-blockers. Eight of their patients were treated with propranolol (20 to 100 mg/day) and one patient was treated with carvedilol (6.25 mg/day). [33]

Offer patients with unresponsive tumors different treatment regimens. Response to neoadjuvant chemotherapy can be observed, but it does not always correlate with radiographic response.


With larger higher-grade soft-tissue angiosarcomas, adjuvant radiotherapy is effective in reducing local recurrence.

Radiotherapy can be delivered intraoperatively, by brachytherapy, or by external beam radiotherapy (EBRT). The brachytherapy technique results in rates of tumor control similar to those obtained with EBRT, with a similar rate of wound complications. Moreover, it presents the advantage of requiring only 5 days, rather than the 5-6 weeks needed for EBRT, and reduces radiation scatter. Brachytherapy is often the technique of choice in angiosarcomas near joints or gonads.

The use of irradiation in conjunction with surgery continues to evolve and results in 80% of local control and excellent functional and cosmetic outcome. [16] However, consider that 50% of angiosarcomas have distant metastases, and irradiation does not improve survival. Better definition of the extent of the disease with the use of MRI helps to further delineate the radiotherapy fields and decrease long-term morbidity. Intraoperative radiation, brachytherapy, or more external beam therapy can complement preoperative external beam radiotherapy.

The disadvantage of preoperative radiation is that a higher wound complication rate may delay surgery (1 wk of healing per 10 Gy of radiation delivered). The advantages of preoperative radiation are as follows:

  • Optimization for surgery
  • Smaller volume of external beam fields
  • Less hypoxic tissue
  • Potential to reduce the chance of intraoperative implantation
  • Potential improvement in local control in advanced tumors

A novel treatment of cardiac angiosarcoma with concurrent proton beam therapy and paclitaxel followed by adjuvant chemotherapy with gemcitabine and docetaxel reported prolonged survival and improved quality of life in a 26-year-old patient. [34]

Bone angiosarcoma

In bone angiosarcoma, specialists use combinations of radiation therapy and chemotherapy for adjuvant treatment, but significant data about their effectiveness are lacking. Evidence of tumor multicentricity must be sought before making any decision regarding therapy. Patients have presented with lesions affecting as many as 45 different bones. In such cases, consider neoadjuvant chemotherapy.

A chemotherapeutic regimen common for sarcomatous tumors can be administered (ifosfamide and doxorubicin used together or sequentially). If clinical or radiographic improvement is not observed, consider a second regimen with cyclophosphamide, etoposide, and cisplatin. Gemcitabine may be effective as second-line or third-line therapy.

Cutaneous angiosarcoma

The best outcomes are reported with surgery followed by radiotherapy. Postoperative radiotherapy is warranted in cases with unsatisfactory margins, large tumor size, deep extension, and multicentricity. Radical radiation therapy in the form of high-field electron beam therapy shows promise in prolonging survival of patients with localized lesions.

The role of chemotherapy in cutaneous angiosarcoma has not yet been established, although for patients with metastasis or tumors deemed unresectable, doxorubicin (intraarterial or systemic) is indicated. [35]

Paclitaxel as a single agent has shown substantial activity against cutaneous angiosarcoma, even in patients previously treated with chemotherapy or radiation therapy. [36]  Solid evidence supports first-line use of paclitaxel in advanced cutaneous angiosarcoma. Options for second-line treatment include pazopanib, eribulin, and trabectedin. [37]


Surgical Care

Surgical treatment of angiosarcoma of the soft tissue, retroperitoneum, and abdomen is as follows [13] :

  • Target obtaining wide surgical margins, with at least 2 cm of unaffected tissue surrounding the tumor. The resection should include skin when applicable and the soft tissue around the angiosarcoma. Resect biopsy sites, including the biopsy tract, en bloc with the specimen.

  • Resection of large lesions can be extremely difficult and sometimes requires amputation for local control; however, local control does not prevent distant relapse.

  • Free surgical margins sometimes have anatomic constraints, especially in retroperitoneal tumors.

Surgical treatment of angiosarcoma of bone is as follows:

  • Surgical resection and radiation therapy are the standard treatment for localized disease.

  • Low-grade lesions lead to similar benefits with either technique.

  • Treat high-grade lesions as malignant bone neoplasms, with a combination of radical en bloc excision followed by radiotherapy and/or chemotherapy.

  • The number of lesions in a limb may render limb salvage impossible, and amputation may be indicated.

Surgical treatment of cutaneous angiosarcoma is as follows [6] :

  • Surgical treatment is contraindicated in tumors extending into vital structures, in those of massive size, or in those with multicentricity.

  • The lesion may be solitary or multicentric and frequently extends laterally throughout the dermis, making gross assessment of surgical margins difficult and necessitating multiple biopsies of the surrounding tissues.

  • In the primary treatment of angiosarcomas of the scalp, recognizing the horizontal and vertical extensions of the tumor is essential, which can only be discerned by microscopic examination of all the margins of the resected specimen. The primary excision of the scalp should be full-thickness, including the pericranium and, if indicated, the outer table of the cranial vault; the margins should be wide (at least 5 cm) on all sides.



Complications from radiotherapy include the following:

  • Wound complications
  • Fractures

Complications from chemotherapy include the following:

  • Fever
  • Dose-dependent myelosuppression
  • Nausea and vomiting unresponsive to antiemetics
  • Moderate-to-severe fatigue
  • Alopecia or hemialopecia in intra-arterial chemotherapy

Complications from surgery are as follows:

  • Anesthetic complications
  • Blood loss
  • Infection, sepsis
  • Wound complications
  • Iatrogenic neurovascular injury
  • Deep vein thrombosis, pulmonary embolism
  • Limited limb function


Prevention of angiosarcoma is included in cancer prevention guidelines. The reduction of cancer mortality is achieved via reduction in the incidence of cancer.

Prevention strategies include avoiding carcinogens and adopting lifestyle or dietary factors that modify cancer-causing factors or genetic predispositions, alter carcinogen metabolism, or alter end-organ effects of carcinogens. Prevention also includes the successful treatment of preneoplastic lesions.


Long-Term Monitoring

Soft-tissue and bone angiosarcomas

Recurrent neoplasms typically (80% of cases) develop within 2 years of the resection. Thus, the follow-up should be extremely stringent (ie, every 3 months in the first 2 years).

A chest radiograph every 6 months during this period is mandatory. If the chest radiograph reveals a suspicious nodule, obtain a CT scan of the chest for confirmation.

MRI is the most accurate technique for detecting locally recurrent or residual sarcoma. The baseline postoperative MRI examination serves a vital role in the evaluation.

After the first 2 years, schedule visits every 6 months for the next 3 years. After 5 years, see patients annually.

The differential diagnosis for signal abnormality on a postoperative MRI includes the following:

  • Residual or recurrent neoplasm
  • Postsurgical/postradiation change
  • Scarring
  • Fluid collection

The residual or recurrent neoplasm usually is a discrete, ovoid, or rounded soft tissue mass. Nonspecific signal characteristics are present, with intermediate-to-low signal intensity in T1-weighted images and high signal on T2-weighted images. The lesion enhances with gadolinium. Comparison with prior postoperative examinations is essential.

Postsurgical/postradiation change usually appears as a regional distribution of signal abnormality, with a linear, trabeculated, or latticelike morphology. This has low-to-intermediate signal on T1-weighted images and high signal on T2-weighted images.

Scars show a linear morphology. Scars correspond with skin thickening and the loss of adjacent subcutaneous fat. A scar has low signal on both T1-weighted images and T2-weighted images, although they can present a linear high-signal intensity on T2-weighted images and a variable enhancement with gadolinium.

Fluid collection develops as an abscess, seroma, or hematoma. Seromas are the most common. They represent a signal intensity lower than muscle on T1-weighted images and high signal on T2-weighted images and can be differentiated from recurrence with gadolinium.

Hematomas usually appear in the subacute stage at the time of the first postoperative MRI. Because of the methemoglobin, hematomas show a characteristic high signal on T1-weighted images and T2-weighted images.

Abscesses present as low signal on T1-weighted images and high signal on T2-weighted images and may show some low-signal intensity depending on the presence of a fibrous capsule. Following gadolinium administration, they appear as a nonenhancing fluid collection with a thick, nodular, peripherally enhancing rim.

Cutaneous angiosarcoma

Patients need clinical examination every 3 months to detect possible recurrences. Palpation of the cervical lymph nodes remains a major tool.

Imaging studies include CT scan and MRI of the head and neck and plain chest radiograph and CT chest scans every 3 months for 1 year, every 6 months for 2 more years, and then annually. Distant metastasis can occur late.