Cutaneous Angiosarcoma After Breast-Conserving Surgery and Radiotherapy

Abstract: Angiosarcoma developing after mastectomy with or without postoperative radiotherapy for breast carcinoma has been well described. All tumors were associated with chronic lymphedema, and in those receiving radictherapy, most arose outside the field of radiation. Angiosarcoma arising within the field of irradiation after lumpectomy and radiotherapy is rare. Only 21 cases have been reported. A cutaneous angiosarcoma developed in the breast of an 82-yearold woman, 3 years and 5 months after breast-conserving surgery and radiation for ductal carcinoma. The tumor presented as multiple skin nodules which histologically showed a poorly differentiated neoplasm with prominent epithelioid features. An initial diagnosis of recurrent ductal carcinoma was given. However, review of the neoplasm exhibited features of vascular differentiation with positivity for the endothelial markers factor VII and CD34, diagnostic of high-grade angiosarcoma. This complication raises the question of routine radiotherapy following lumpectomy and whether elderly patients should be soared postoperative radiation.     

Juvenile secretory carcinoma of the breast

Juvenile secretory carcinoma of the breast, a rare tumor in infants and children, has an unusual histological appearance and clinical behavior. Isolated case reports and small series have appeared since this lesion was first described by McDivitt and Stewart in 1966. Our case of a 3-year-old boy with axillary metastasis and 17 cases in children, from the literature, provide the basis of this review. Of the 18 patients, there were three boys and 15 girls. Their ages ranged from 3 to 17 years (mean 9.8 years). All patients presented with an asymptomatic mass in the breast. None had nodes which were clinically involved. Eight patients had excisional biopsy only. Two patients had quadrantectomy. Four had simple mastectomy; one of whom received postoperative axillary irradiation, and one of whom had axillary nodal sampling (our patient). One patient had a modified radical mastectomy and three had radical mastectomy. Two of eight children who had excisional biopsy alone developed local recurrences. In the first patient, the recurrences occurred at 2 and 8 years following initial therapy. In the second, they occurred at 4 and 21 years. Axillary nodal metastases were found in three of the six patients in whom nodal biopsies were performed. In only one patient were estrogen receptors measured and they were negative. No deaths have been reported in children during a follow-up period ranging from 0 to 22 years (mean 6.5 years). Secretory carcinoma of the breast in this group of patients appears to be a slow growing, locally recurring malignancy. Adults with histologically similar tumors also have a good prognosis. Excisional biopsy is probably inadequate therapy.(ABSTRACT TRUNCATED AT 250 WORDS)     

The Development of New, Primary, Noninvasive Carcinoma of the Breast 29 Years after Bilateral Radical Mastectomy

Abstract: We present the case of a patient with a new, primary noninvasive breast carcinoma arising in residual breast tissue 29 years after radical mastectomy. The patient, a 75-year-old black woman with no family history of breast or ovarian cancer, had undergone left radical mastectomy in 1956 (age 35) and right radical mastectomy in 1965 (age 44). Examination revealed a 3-mm nodule in the right anterior axillary line. On excision, the lesion was a 1.5-mm intracystic papillary ductal carcinoma in situ arising in a background of atypical ductal hyperplasia (representing residual breast tissue). The patient has not agreed to testing for BRCA1 or BRCA2 mutations. The theoretical risk of new primary breast cancers arising in residual breast tissue has been suggested as a reason why prophylactic mastectomy may not be completely effective. This case suggests that even after what appeared to be aggressive radical mastectomy, enough breast tissue remained so that the patient was at risk for recurrent breast cancer.     

Adenoid cystic carcinoma of the breast. Data from the Connecticut Tumor Registry and a review of the literature.

The case records of the Connecticut Tumor Registry were reviewed from 1952-1982. There were 37 cases of adenoid cystic carcinoma of the breast (ACC) from a total of 40,350 invasive breast tumors. Patient survival, complications, and pathologic sections were reviewed. Only 14 of 27 surgical pathology slides available for review could be confirmed histologically as ACC. All patients were white females with a mean age of 64 years. The tumor remained localized to the breast in all cases. Nine patients had either radical or modified radical mastectomy, four patients had either simple mastectomy or lumpectomy, and one patient refused treatment. There was no evidence of axillary node involvement, metastases, or local recurrence after excision. At the time of follow-up, nine patients were alive and disease free and four died of disease unrelated to their breast cancer. The one patient who died of breast cancer had a radical mastectomy and survived 11.7 years after diagnosis. It is concluded that ACC has a favorable biologic behavior characterized by a prolonged clinical course and good prognosis. Simple mastectomy is all that is required as initial treatment, and a chest x-ray and thorough physical examination looking for local recurrence is all that is needed for follow-up.     

Inflammatory carcinoma of the breast. A therapeutic approach followed by improved survival.

Disappointing results of radical mastectomy for treatment of inflammatory breast carcinoma led to its abandonment and the use of alternative therapeutic methods without improvement of survival rates. Results of radical mastectomy combined with other therapeutic modalities have not been fully evaluated so far. In a series of nine patients with proven inflammatory breast carcinoma and no distant metastases, two underwent radiotherapy, oophorectomy, and adrenalectomy (group A) and seven underwent preoperative irradiation, radical mastectomy, postoperative irradiation, and chemotherapy (group B). There were no local recurrences in either group. Group A patients survived five and eight months (mean, 6.6+/-2.1) and patients of group B survived 45.5+/-26.2 months (p less than 0.05). Results show no rational basis for withholding radical mastectomy, but suggest that improved survival may be obtained when radical mastectomy is an integral part of a rational sequential therapeutic schedule.     

Incidental lobular carcinoma scar recurrence at delayed breast reconstruction 6 years after mastectomy

A 48-year-old woman was found to have histological recurrence of lobular breast carcinoma in a mastectomy scar excised routinely during delayed breast reconstruction 6 years after a mastectomy. Prior to the subsequent wide excision of the scar, she requested prophylactic contralateral mastectomy and immediate reconstruction. The scar excision revealed positive resection margins prompting further surgery while the contralateral mastectomy showed previously undetected widely infiltrative lobular carcinoma. It is extremely rare to detect lobular carcinoma in incidental histological specimens and even rarer to encounter it in asymptomatic contralateral breasts following prophylactic mastectomy. This unusual presentation and the implications for mastectomy scar management during delayed reconstruction are discussed.     

乳腺乳头状癌17例的诊断与治疗

目的 探讨乳腺乳头状癌的临床特征、病理和诊治.方法 回顾性分析温州医学院附属第一医院收治的17例乳腺乳头状癌的临床资料.结果 乳腺乳头状癌发病率占同期收治所有乳腺癌的0.64％.患者均可触及肿块.12例患者行乳腺癌改良根治术,2例行单纯乳房切除术,2例行保乳手术,1例行乳房单纯切除+前哨淋巴结活检术.术后15例行辅助化疗,其中5例另行放射治疗.术后随访时间1个月～8年,中位随访时间为32.5个月.1例发生骨转移于术后2年死亡,1例发生多器官转移于术后7年死亡.结论 乳腺乳头状癌患者的治疗及预后与其病理类型密切相关.对导管内乳头状癌的治疗宜选择低创伤的手段,对浸润性乳头状癌及浸润性微乳头状癌须按浸润性导管癌治疗原则处理.     

Cutaneous angiosarcoma of the breast after segmental mastectomy and radiation therapy.

Angiosarcoma of the breast is an uncommon entity, and the development of cutaneous angiosarcoma of the breast after segmental mastectomy and irradiation therapy is even less common. We report a case of cutaneous angiosarcoma that developed 4 1/2 years after segmental mastectomy (lumpectomy) with axillary dissection and irradiation therapy for infiltrating ductal carcinoma of the breast.     

Ductal eccrine carcinoma presenting as a Paget's disease-like lesion of the breast

Some types of skin appendage tumors, particularly ductal eccrine carcinomas (DEC), imitate breast carcinomas histologically, thus causing great diagnostic challenges. We describe a case of DEC presenting as an eczematous, crusted skin lesion on the right nipple-areolar complex in a 67-year-old woman. A skin biopsy done under the clinical impression of Paget's disease of the nipple was initially misinterpreted as infiltrating ductal carcinoma, and a subsequent modified radical mastectomy revealed DEC exclusively confined to the nipple with perinodal tumor metastasis in one of the axillary lymph nodes. This case highlights the diagnostic difficulty caused by the histologic homology between breast carcinomas and skin appendage tumors with ductal differentiation.     

Breast Reconstruction after Radical Mastectomy1

In younger women particularly, who have undergone radical mastectomy for carcinoma, the psychological sequel? can be profound. These can be avoided by breast reconstruction in the immediate postoperative period. The technique of this procedure, and the details of the indications for its performance, are discussed. The reconstruction can also be carried out years after the mastectomy, if the psychological impact of this has been such as to render the procedure indicated.     

Dermatosis as the Initial Manifestation of Malignant Breast Tumors: Retrospective Analysis of 4 Cases

BACKGROUND: The aim of this study was to explore the clinical characteristics, diagnosis, treatment, and prognostic factors of dermatosis associated with malignant breast tumors. CASE REPORTS: The clinical data of 4 breast cancer patients, 3 with dermatomyositis and 1 with acquired ichthyosis, were analyzed retrospectively. The 4 patients were >50 years of age, and the malignant breast tumors appeared within 5 years of the diagnosis of dermatosis. Two of the 3 breast cancer patients with dermatomyositis received a modified radical mastectomy, and because they could not afford systemic chemotherapy after surgery, only received endocrine therapy. The third patient received a simple mastectomy and axillary lymph node dissection but died of respiratory failure 2 months after the operation. The patient with acquired ichthyosis and malignant breast tumor received modified radical mastectomy, chemotherapy, radiotherapy, and endocrine therapy; no complications were observed in the postoperative period. During the 9-15 months of follow-up after the surgery, the 3 patients remained in good condition with improvement of the dermatosis symptoms and no cancer relapse. CONCLUSIONS: Malignant breast tumor screening is indicated in women with dermatomyositis or acquired ichthyosis, especially in those aged >50 years.     

Clinical and morphological results after breast augmentation

Summary In 85 patients, breast augmentation mammaplasty (often bilateral) was performed in the course of 5 1/2 years when the breast was too small or after subcutaneous mastectomy. In two women, a very painful deformation and pronounced hardening of the breast clinically simulating cancer and a foreign body reaction of irregular density appeared histologically in association with severe capsular fibrosis. In two further women, enlarged lymph nodes simulating metastases were observed in the axilla with a similar foreign body reaction. Prior performance of lymphography could be excluded with certainty in each case. In one of these cases, a scirrhous carcinoma on the implant capsule occurred in the residual parenchyma after subcutaneous mastectomy.     

Mastectomy as an adjunct to combination chemotherapy.

Three patients with metastatic breast carcinoma who had untreated locally advanced primary tumors were treated initially with combination chemotherapy followed by hygienic mastectomy. There was marked regression of the primary tumor in each case after chemotherapy, allowing for a technically simpler mastectomy without skin grafts. There were no serious postoperative complications, or delay in the resumption of systemic chemotherapy in any of them. The postoperative chemotherapy produced complete disappearance of the distant metastases and the patients remain clinically free of disease without local recurrence for 21, 10, and 7 months, respectively. One of these patients had inflammatory carcinoma and did well with this combined approach. These findings suggest a rationale for such an approach in patients with inflammatory carcinoma and may be applicable to patients with stage III breast cancer in whom the primary tumors are locally advanced and technically difficult to resect.     

Improvement of upper extremity lymphedema after delayed breast reconstruction with an extended latissimus dorsi myocutaneous flap

Lymphedema is a common complication after mastectomy in breast cancer patients. Many treatment options are available, but no treatment results in a complete cure. We report a case of lymphedema that occurred after modified radical mastectomy in a breast cancer patient who showed objective improvement after delayed breast reconstruction with an latissimus dorsi myocutaneous flap. A 41-year-old female patient with left breast cancer had undergone modified radical mastectomy with axillary lymph node dissection and postoperative radiotherapy 12 years previously. Four years after surgery, lymphedema developed and increased in aggravation despite conservative treatment. Eight years after the first operation, the patient underwent delayed breast reconstruction using the extended latissimus dorsi myocutaneous flap method. After reconstruction, the patient's lymphedema symptoms showed dramatic improvement by subjective measures including tissue softness and feeling of lightness, and by objective measures of about 7 mL per a week, resulting in near normal ranges of volume. At a postoperative follow-up after 3 years, no recurrence was observed. Delayed breast reconstruction with extended latissimus dorsi myocutaneous flaps may be helpful to patients with lymphedema after mastectomy. This may be a good option for patients who are worried about the possibility of the occurrence or aggravation of secondary lymphedema.     

Carcinoma arising in fibroadenoma of the breast--a case report and review of the literature

A 47 year old woman with two isolated lumps in her right breast underwent an excisional biopsy and the histological findings of both lesions revealed fibroadenoma with an in situ lobular carcinoma. Patey's modified radical mastectomy was performed after which careful follow-up was continued. To date, a total 161 cases of carcinoma arising in a fibroadenoma have been reported in the world literature and a review of these literature is given following the case report.     

Secretory carcinoma of the male breast

Background Secretory carcinoma is a distinctive and rare variant of breast carcinoma with a favorable prognosis because these tumors usually behave in an indolent manner. The occurrence of this type of breast cancer in males was studied. Methods An extensive literature survey concerning secretory breast cancer in males was performed. Data of one case treated in our institute were added. Results A total of 14 cases were identified, and our case was added to this series. The median age was 17 years. The duration of symptoms varied from 1 month to 21 years, and the tumor size was 1.2 to 4 cm. Surgical treatment varied from local excision only to modified radical mastectomy. Three patients received adjuvant treatment. Lymph nodes were involved in 3 of the 10 cases undergoing axillary lymph node dissection. The primary tumor was only 1.5 cm in diameter in two of those cases. None of the patients presented with systemic metastases. Only one male was reported to develop recurrence and consequently died of systemic disease. Conclusions Secretory breast cancer is very rare in males and seems to occur at a younger age in males than in females. A sufficient number of female cases have been reported with recurrence after local excision. Although in females lymph node metastases are rarely observed in secretory breast carcinoma smaller than 2 cm, in male patients nodal metastases might occur more frequently in smaller tumors. Therefore, mastectomy with sentinel lymph node biopsy or axillary lymph node dissection is recommended in any male case. Biological behavior seems to be similarly favorable in either sex.     

Simple mastectomy for early and advanced mammary carcinoma

Simple mastectomy was used to treat 111 women with invasive mammary carcinoma. In none of eighteen patients with cancer clinically confined to the breast did local recurrence develop after simple mastectomy, but metastases developed in the axilla in three. Adjuvant irradiation, castration, or drug therapy did not improve the survival or ultimate local control achieved by simple mastectomy.No significant difference was demonstrated in survival after simple and radical mastectomy for comparable clinical stages of disease.     

A rare case of aggressive squamous-cell carcinoma of the breast skin: Marjolin's ulcer. A case report

Marjolin's ulcer is an epidermoid carcinoma arising in a scar or chronic wound and is characterised by an aggressive course. We present a clinical case of ulcerated skin carcinoma of the breast arising in an 80-year-old woman, who at history taking reported a burn occurring 30 years earlier on the breast skin, with subsequent chronic ulcerative scar formation. The definitive histological examination identified a "squamous-cell carcinoma of the breast skin". We have assessed this case and reviewed the literature on Marjolin's ulcer. The patient presented a metastatic relapse of local disease after aggressive surgical treatment. In the clinical history of patients with chronic ulcers it is important to analyse the morphological changes with biopsies and subsequently with the most appropriate diagnostic techniques for the purposes of early initiation of a therapeutic program, since, in the advanced stages, even an aggressive surgical treatment may prove inadequate.     

Mucoepidermoid Carcinoma in a Breast Affected by Burn Scars: Comprehensive Literature Review and Case Report

SUMMARY: Background: Mucoepidermoid carcinoma (MEC), which is primarily found in the salivary glands, is rarely seen in the breast. These tumors usually develop from squamous and mucus-secreting cells. Histological grading is an important prognostic factor. Case Report: We present herein a case of a 69-year-old female patient with a painful mass in the left breast. Of importance is that, in addition to MEC, the patient had a wide area of scar tissue secondary to a burn that completely occupied the left bottom quadrant of the abdomen and retracted the left nipple up to the left upper quadrant. Fine needle aspiration biopsy was negative, and a lumpectomy was performed. Because the pathology results were consistent with MEC, modified radical mastectomy with subsequent adjuvant chemotherapy and radiotherapy was performed. The patient remained disease-free for 12 months after the treatment. In addition to a discussion of this case, we performed a review of the clinicopathological characteristics of 30 cases with breast MEC reported in the English language literature between 1979 and 2010. Conclusions: MEC of the breast is a rarely seen tumor, and this is the first report of MEC in a breast affected by burn scars.     

Immediate breast reconstruction with the transverse rectus abdominis musculocutaneous flap after skin-sparing mastectomy

Immediate breast reconstruction with the transverse rectus abdominis musculocutaneous (TRAM) flap after skin-sparing mastectomy is becoming an increasingly performed procedure in patients with ductal carcinoma in situ, early invasive breast cancer, and prophylactic mastectomy. Through a periareolar approach, it is possible to remove the breast parenchyma along with the nipple areola complex, preserving almost all the original skin envelope and the inframmamary fold. The TRAM flap is used to recreate the volume and shape of the original breast. This technique has higher quality and easier reconstruction. The major disadvantages, extensive scar and donor site skin color mismatch, are reduced to a minimum level because the former is limited at the natural border of the nipple areola and the latter can be effectively concealed with proper nipple reconstruction. Thirty-one patients with a mean age of 39 years (range, 26-50 years) who had undergone unilateral or bilateral mastectomy for early breast cancer and immediate breast reconstruction with the pedicled TRAM flap were retrospectively reviewed. Requirements for the skin-sparing mastectomy technique include suitability of donor site tissue for autologous tissue, early breast cancer or ductal carcinoma in situ, and adequate size and shape matching of the contralateral breast. There was no observed local recur- rence during the follow-up period (mean, 20 months; range, 11-30 months). Complications at the recipient site include mastectomy skin flap partial necrosis in 2 patients and cellulitis of the transferred flap in 1 patient. No total or partial flap necrosis was observed. One patient developed abdominal bulging 1 month after the operation, during the administration of chemotherapy. All reconstruction was considered very satisfactory from an aesthetic perspective by the surgeon and the patient. The nicer aesthetic result with oncological safety is achieved with immediate breast reconstruction with the TRAM flap after skin-sparing mastectomy. The risk of local recurrence is not higher compared with more radical surgical techniques.