Pathologic Complete Response Following Frailty-Adjusted Neoadjuvant Paclitaxel in an 88-Year-Old Patient With Radiation-Associated Breast Angiosarcoma

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Radiation-associated breast angiosarcoma is a rare but highly aggressive malignancy with limited evidence to guide optimal management in elderly patients. We present the case of an 88-year-old woman with a history of stage IIIA estrogen receptor-positive invasive ductal carcinoma of the right breast treated with breast-conserving surgery, chemotherapy, radiation therapy, and endocrine therapy in 2014. Approximately 11 years after completing radiation therapy, she developed progressive right breast firmness, violaceous skin discoloration, and persistent ecchymotic changes concerning for vascular malignancy. Imaging demonstrated diffuse skin thickening without a discrete mass, and punch biopsy of skin changes confirmed high-grade angiosarcoma with MYC amplification. Staging studies showed no distant metastatic disease. Given her advanced age, frailty, and comorbidities, she underwent neoadjuvant weekly paclitaxel with initial dose reduction followed by response- and tolerance-guided dose escalation. Despite treatment interruptions related to frailty and fall-related injuries, she completed 12 cycles and subsequently underwent right simple mastectomy. Final pathology demonstrated no residual angiosarcoma, consistent with a pathologic complete response. This case highlights the potential efficacy of frailty-adjusted neoadjuvant paclitaxel in elderly patients with radiation-associated breast angiosarcoma and supports individualized neoadjuvant strategies for patients who are not candidates for standard multi-agent chemotherapy.

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