In a patient with solitary metastasis skin/subcutaneous wrist, resected with graft, from a primary breast angiosarcoma, what would be your preferred fields and dose?

Agree, odd presentation. Hopefully, the patient was fully staged with PET and MRI brain after this was diagnosed to confirm solitary metastasis. If so, agree with chemo first; angiosarcoma in general, has formidable DM risk (though hard to know how much that applies to this presentation) so makes sense to reduce that, and timing of adjuvant RT in sarcoma has never been shown to be critical. Once chemo is done, agree with consolidating this site with RT, but 1) carefully, because an STSG is not very robust, and 2) with particular attention to spare the wrist joint as much as possible and to avoid 20 Gy circumferential dose. This is tough in a narrow upper extremity and may be best achieved with electrons or IMRT rather than VMAT. I personall...

This is an uncommon patter of distant metastatic spread with long natural history from the original diagnosis. I would consider standard postop (60/30) given single site and 6 years; alternatively, given distant metastatic disease one could consider a hypofractionated regimen, I have used 32-40/8-10 fx twice weekly with hyperthermia considered based on breast (non-angiosarcoma patients) literature but no data in angiosarcoma with this approach to my knowledge.