Granular cell tumor of the breast: A case report describing dynamic MR mammography

A case of granular cell tumor of the breast in a 36-year-old woman is reported. The patient presented with a hard mass, 1.5 cm in diameter in the upper-outer quadrant of the left breast. Physical examination and ultrasonography suggested the presence of breast carcinoma. An aspiration biopsy cytology (ABC) specimen was evaluated as class II, and dynamic magnetic resonance (MR) mammography indicated a benign tumor. Granular cell tumor was finally diagnosed on examination of an excisional biopsy specimen. Granular cell tumor of the breast can mimic breast carcinoma on physical examination, mammography, ultrasonography, and even gross inspection. Dynamic MR mammography has the potential distinguish this condition from carcinoma. Awareness of this disease and prudent use of diagnostic procedures, including MR mammography, will help prevent misdiagnosis and unnecessary surgery.     

Ultrasonography-Guided Surgical Clip Placement for Tumor Localization in Patients Undergoing Neoadjuvant Chemotherapy for Breast Cancer

Purpose

We investigated the feasibility of using surgical clips as markers for tumor localization and their effect on the imaging evaluation of treatment responses after neoadjuvant chemotherapy (NAC).

Methods

A total of 16 breast cancers confirmed by needle biopsy in 15 patients were included in this study from October 2012 to June 2014. Under ultrasonography (US)-guidance, the surgical clips were placed prior to NAC. Additional mammography, breast US, and breast magnetic resonance examinations were performed within 10 days before surgery. The time period from marker insertion to operation date was documented. Images acquired via the three modalities were evalu-ated for the following parameters: location of clip, clip migration (>1 cm), the presence of complications from clip placement, and the effect of clips on the assessment of treatment.

Results

The mean time period was 128.6±34.4 days (median, 132.0 days) from the date of clip insertion to the date of surgery. The mean number of inserted clips was 2.3±0.7 (median, 2.0). Clip migration was not visualized by imaging in any patient, and there were no complications reported. Surgical clips did not negatively affect the assessment of treatment responses to NAC.

Conclusion

Surgical clips may replace commercial tissue markers for tumor localization in breast cancer patients undergoing NAC without migration. Surgical clips are well tolerated and safe for the patient, easily visualized on imaging, do not interfere with treatment response, and are cost-effective.     

乳腺癌前哨淋巴结活检的临床意义(附30例报告)

目的　探讨开展乳腺癌前哨淋巴结活检 (sentinellymphnodebiopsy ,SLNB)的必要性、可行性、准确性及临床应用价值。方法　术前在乳腺肿瘤下方注射 37MBq放射性胶体99mTc DX ,同时运用核素淋巴显像和γ计数器探测仪探测两种检测方法 ,识别出放射性同位素浓聚的前哨淋巴结(sentinellymphnode ,SLN) ,并用皮肤墨水在相应的皮肤上做出标记。术中根据体表标记切除SLN ,后行腋窝淋巴结解剖 (axilarylymphnodedissection ,ALND) ,两标本同时送病理检查 ,了解其符合率 ,并评价SLNB的可行性。结果　 30例均进行了SLN识别定位 ,活检后经病理检查有 2例错误。 1例未取到SLN ,故SLN的检出率为 96 .7% ;1例SLN病理呈假阴性。按目前国外SLNB的评价标准 ,本组SLNB的敏感度为 88.9% ,准确性为 93.3% ,假阳性率为 0 ,假阴性率为 11.1%。结论　乳腺癌SLNB目前在国内外仍处于研究阶段 ,随着研究的扩大与深入将可能取代常规的ALND。     

Intraductal Migration of a Breast Tissue Marker Placed under Ultrasound Guidance during COVID-Induced Delay of Surgery

Breast tissue markers are common in current clinical practice and are susceptible to migration. Herein, we present the case of a 47-year-old woman with invasive breast carcinoma diagnosed through ultrasound-guided core biopsy, who underwent placement of a breast marker (HydroMARK^®) under ultrasound guidance 30 days after core biopsy and with subsequent marker migration to the nipple. The correct position of the marker was documented by mammography after its placement and by magnetic resonance imaging (MRI) after neoadjuvant chemotherapy. Migration of the marker to the nipple was evident only by mammography on the day of surgery. We hypothesized that an intraductal path was the route of marker migration in this patient. Marked ductal ectasia evident on MRI and histopathologic examination supported this hypothesis. To the best of our knowledge, this is the first published case of intraductal migration of a breast tissue marker.     

Bilateral Metachronous Paget's Disease of the Accessory Breasts in a Male

Bilateral axillary Paget''s disease in men is a rare occurrence with limited reports on its diagnosis, treatment, and prognosis. Here, we report the case of a 55-year-old Korean male, who presented with a palpable mass and eczematous skin lesion on the left axilla. An incisional biopsy and histopathologic examination indicated invasive ductal carcinoma with Paget''s disease arising in the accessory breast. Magnetic resonance imaging and positron emission tomography revealed no malignancy in the normal breast and other organs. The patient was subjected to a wide excision, wherein the left axillary lymph node was dissected, followed by the administration of adjuvant chemotherapy and radiation therapy. After 17 months of disease-free survival, the patient was diagnosed with Paget''s disease of the contralateral accessory breast. He underwent wide excision surgery along with radiation therapy. To the best of our knowledge, this is the first report of bilateral extramammary Paget''s disease in a male.     

Evaluation of breast sentinel lymph node coverage by standard radiation therapy fields

BACKGROUND: Biopsy of the breast sentinel lymph node (SLN) is now a standard staging procedure for early-stage invasive breast cancer. The anatomic location of the breast SLN and its relationship to standard radiation fields has not been described. METHODS AND MATERIALS: A retrospective review of radiotherapy treatment planning data sets was performed in patients with breast cancer who had undergone SLN biopsy, and those with a surgical clip at the SLN biopsy site were identified. The location of the clip was evaluated relative to vertebral body level on an anterior-posterior digitally reconstructed radiograph, treated whole-breast tangential radiation fields, and standard axillary fields in 106 data sets meeting these criteria. RESULTS: The breast SLN varied in vertebral body level position, ranging from T2 to T7 but most commonly opposite T4. The SLN clip was located below the base of the clavicle in 90%, and hence would be excluded from standard axillary radiotherapy fields where the inferior border is placed at this level. The clip was within the irradiated whole-breast tangent fields in 78%, beneath the superior-posterior corner multileaf collimators in 12%, and outside the tangent field borders in 10%. CONCLUSIONS: Standard axillary fields do not encompass the lymph nodes at highest risk of containing tumor in breast cancer patients. Elimination of the superior-posterior corner MLCs from the tangent field design would result in inclusion of the breast SLN in 90% of patients treated with standard whole-breast irradiation.     

Percutaneous endoscopy-guided biopsy of an intracystic tumor with a mammary ductoscopy

BACKGROUND: Intracystic abnormalities of the breast may result from debris, intracystic papilloma, or rarely breast cancer. Intracystic tumors cannot be diagnosed based on imaging examinations or fine needle aspiration alone, and therefore excisional biopsy must be performed. We have treated many cases who had nipple discharge with mammary ductoscopy since 1992, and we have used this method to diagnose intracystic tumors. METHODS: An endoscope was inserted into the cyst percutaneously, and the intracystic tumor was biopsied using forceps. RESULTS: Six intracystic tumors were biopsied with the endoscope. Four of six cases were cancer, and two were benign papillomas. CONCLUSION: We were able to visualize and accurately biopsy intracystic tumors of the breast using mammary ductoscopy.     

Recent advances and current controversies in the management of DCIS of the breast

Ductal carcinoma in situ (DCIS) is commonly diagnosed today, mainly due to widespread use of screening mammography. Despite a better understanding of its biological behavior, many issues regarding its optimal management remain controversial. The biological behavior of DCIS has been associated with distinct molecular and histological features (such as expression of COX2, Ki67, c-erbB2, p53 mutation, presence or absence of comedonecrosis, nuclear grade, hormone receptor status, etc.). Recent advances in the diagnosis of DCIS include using magnetic resonance imaging, and the use of stereotactic-guided directional vacuum-assisted biopsy (DVAB). Ductoscopy and ductal lavage have a limited role in the management of DCIS. Surgical treatment of DCIS includes simple local excision to various forms of wider excision (segmental resection or quadrantectomy), or even mastectomy (either simple or skin-sparing). Radiotherapy following breast-conserving surgery significantly reduces local recurrence rates. Axillary lymph node dissection is not required for the management of DCIS; however, during the last decade, sentinel lymph node biopsy is increasingly used to exclude the presence of axillary metastases (when invasive disease is present within the DCIS). This approach has many advantages (including the avoidance of a second surgery if invasive disease is diagnosed within the DCIS) and should be considered when there is an increased probability for the presence of invasive breast cancer within the DCIS. The role of other minimally invasive methods (such as the "therapeutic" application of the DVAB technique, radiofrequency ablation, laser therapy, cryotherapy and brachytherapy) in the management of small DCIS remains unproven. Tamoxifen should be considered in the management of selected patients with DCIS, such as patients with hormone receptor positive DCIS, young patients, and patients without risk factors for potential side effects. Additionally, and controversial, there is evidence that aromatase inhibitors may be better than tamoxifen in the management of DCIS.     

A case of adenoid cystic carcinoma (acc) of the Breast and review of the utility of preoperative imaging diagnose

A case of adenoid cystic carcinoma (ACC) of the breast in a 66-year-old woman is reported herein. ACC accounts for about 0.1% of all breast cancers. Our patient presented with a small, elastic and hard mass, measuring 2.0x2.0 cm, between both outer quadrants of the right breast. Although physical examination, ultrasonography and magnetic resonance (MR) mammography suggested a benign tumor, aspiration biopsy cytology (ABC) was performed twice, and the second ABC specimen was evaluated as suspicious for breast carcinoma. Breast conserving surgery with a level II lymph node dissection was subsequently performed. There was no lymph node metastases and estrogen receptor (ER) status was negative. Light microscopy revealed various growth patterns, with the cells showing biphasic cellularity. According to immunohistochemical analyses, CEA, actin and vimentin were positive, S-100 protein was negative, and the cytokeratin reaction was partially positive. Therefore, ACC of the breast was diagnosed. Although ACC of the breast is a rare neoplasm, it should be considered in the differential diagnosis even if various diagnostic imaging studies suggest a benign tumor of the breast. Awareness of this tumor will help prevent misdiagnosis.     

Mucocele-like tumor of the breast: a case report and assessment of aspirated cytological specimens

Background: Mucocele-like tumor (MLT) is a rare benign condition, and often misdiagnosed as mucinous carcinoma. Methods: We encountered a 31-year-old woman with MLT of the breast. The patient presented with an elastic hard mass, 0.5 cm in diameter, located in the upper outer quadrant of the right breast. Results: Physical examination as well as ultrasonography and mammography indicated a benign lesion. However, mucinous carcinoma was suspected based on aspiration biopsy cytology. MLT was finally diagnosed on excisional biopsy. Conclusions: Awareness of this breast disease helps to prevent misdiagnosis and unnecessary surgery.     

Fluorescence navigation with indocyanine green for detecting sentinel lymph nodes in breast cancer

BACKGROUND: Sentinel lymph node biopsy using a vital dye is a convenient and safe method to assess lymph node status in breast cancer. However, intensive training is necessary to obtain a satisfactory detection rate and to avoid false-negative results. This paper presents a novel method using indocyanine green fluorescence imaging to detect sentinel lymph nodes. METHODS: Fluorescence images were obtained using a charge coupled device camera with a cut filter as the detector, and light emitting diodes at 760 nm as the light source. When indocyanine green was injected around the areola, subcutaneous lymphatic channels draining from the areola to the axilla were visible by fluorescence within a few minutes. The sentinel lymph node was then dissected by fluorescence navigation. RESULTS: Sentinel lymph node biopsy using the present method was performed on eighteen patients. Subcutaneous lymphatics were detectable by fluorescence in all patients, and sentinel nodes were successfully identified in 17 of 18 cases (detection rate:94%). It was possible to detect the lymphatic channels and nodes receiving indocyanine green with higher sensitivity by the fluorescence signal than by the green color. CONCLUSION: Sentinel node biopsy guided by indocyanine green fluorescence imaging is a promising technique for further clinical exploration.     

Sudden hemorrhage of the breast caused by breast cancer: a case report and review of the literature

A rare case of sudden hemorrhage caused by breast cancer is reported. A 71-year-old woman noted bleeding from her left breast. Physical examination of the left breast showed a localized open cavity accompanied by bleeding and coagulation. The patient had no history of breast trauma or anticoagulation therapy. Incisional biopsy followed by histological examination resulted in a diagnosis of granulation tissue with no cancer cells present. Mammography and ultrasonography indicated probable breast cancer. As a result, a second incisional biopsy was performed, which suggested invasive ductal carcinoma without histological skin invasion. A modified radical mastectomy was performed under a diagnosis of stage II breast cancer. Breast cancer with sudden hemorrhage is rare. We review the literature and discuss the cause of this unusual manifestation.     

Clinical utility of proton magnetic resonance spectroscopy in characterizing breast lesions

Proton magnetic resonance spectroscopy ((1)H MRS) of the breast has been proposed as an adjunct to the magnetic resonance imaging (MRI) examination to improve the specificity of distinguishing malignant breast tumors from benign breast tumors. In this review, we carry out a pooled analysis of the clinical breast (1)H MRS studies undertaken to date to determine the factors that influence the diagnostic performance of this method. In total, five studies of breast (1)H MRS from four independent centers around the world have been published to date. Altogether, 153 tumors were examined, 100 of which were confirmed histologically to be malignant and 53 of which were benign. The lesions presenting a detectable composite choline signal in their corresponding (1)H MR spectra were diagnosed as malignant, whereas the lesions with no choline signal were diagnosed as benign. The sensitivity and specificity of breast (1)H MRS for detecting breast cancer were 83% (95% confidence interval [CI] = 73% to 89%) and 85% (95% CI = 71% to 93%), respectively, and both values could be as high as 92% after technical exclusions. In a subgroup of 20 young women, the sensitivity and the specificity of the method approached 100%. The factors limiting the sensitivity of the examination were mainly technical. The use of the composite choline signal as a marker for malignancy in breast (1)H MRS is a robust method with highly reliable interpretation, because it is based on the appearance of a single peak. The method is likely to provide even better results with technologic advances in breast MRS that lead to the improved detection of the composite choline signal.     

Prospective evaluation of pectoralis muscle invasion of breast cancer by MR imaging

BACKGROUND: Assessment of pectoralis muscle invasion is important for treatment planning for breast cancer. We evaluated the usefulness of breast magnetic resonance (MR) imaging for the detection of tumor invasion of the pectoralis muscle in breast cancer patients. MATERIALS AND METHODS: A total of 306 breast MR examinations were performed preoperatively. Three-dimensional gradient echo sequences, at a section thickness of 1.5 or 2 mm were obtained with administration of gadolinium-DTPA. All patients underwent surgery. RESULTS: In 33 breasts, disruption of the fat plane between tumor and muscle was noted. Seven of 33 cases showed muscle enhancement contiguous to enhanced tumors. Pathology reports indicated that 5 of 7 of the tumors involved muscle invasion. Of the 2 false positive cases, one showed muscle enhancement because of a previous biopsy, and the other was incorrectly interpreted as showing muscle enhancement. Of the 26 breasts which did not demonstrate muscle enhancement, none were found at surgery to have tumor involvement. CONCLUSION: Enhancement of the pectoralis muscle correlates well with muscle invasion, but there are a few potential pitfalls. Disruption of the fat plane between tumor and muscle, without muscle enhancement, might not indicate tumor involvement of the pectoralis muscle.     

A case of solid neuroendocrine carcinoma of the breast in a 40-year-old Woman

We report a case of neuroendocrine carcinoma in a 40-year-old woman who presented with two lumps in her left breast. Mammography failed to reveal any lesions because she had so-called dense breasts, but ultrasonography showed 4 irregular hypoechoic masses. Magnetic resonance imaging also showed 4 homogeneous lobulated tumors with early contrast enhancement, suggesting malignancy. Core needle biopsy and subsequent immunohistochemical examination of the specimens was performed. Neuroendocrine carcinoma was diagnosed. The tumor cells were diffusely positive for chromogranin A and synaptophysin, and some were positive for CD56. We performed total mastectomy with sentinel lymph node biopsy, which showed no metastasis. Recurrence has not been detected at 36 months after surgery.     

Wire guided localisation for targeted axillary node dissection is accurate in axillary staging in node positive breast cancer following neoadjuvant chemotherapy

AimThis study investigated whether wire localisation of the histologically proven positive, clipped axillary lymph node (ALN) with subsequent targeted axillary dissection (TAD) following neoadjuvant chemotherapy (NACT) improves axillary staging in breast cancer.Materials and methodsWe performed a retrospective review of patients with primary breast cancer and core biopsy proven metastatic ALNs, that had an excellent nodal radiological response following NACT, treated at our centre between January 2016 and December 2018. The initial cohort of patients (Group 1) underwent sentinel lymph node biopsy (SLNB), with a minimum of three nodes were sampled. The subsequent cohort (Group 2) had a marker clip inserted in the metastatic ALN prior to NACT. This cohort underwent wire guided excision of the clipped node in addition to SLNB, with a minimum of three nodes sampled.ResultsA total of 47 patients were identified. Group 1 comprised 22 patients with a sentinel lymph node (SLN) identification rate (IR) of 95%. 25 patients (Group 2) underwent wire guided clip location and the SLN IR was 100% with a 92% clipped node IR. Evidence of pathological complete response (pCR) in the clipped node was associated with pCR in other nodes.ConclusionTargeted axillary dissection is a feasible technique following excellent response to NACT in selected patients with limited volume ALN metastasis, at diagnosis. The identification of the positive ALN during surgery is vital and the IR can be improved by clipping the node prior to NACT and wire guided localisation at the time of surgery.     

A case of occult contralateral breast cancer incidentally detected by contrast-enhanced mri; report of a case with review of literature

We encountered a case of occult contralateral breast cancer, previously undetected by conventional imaging such as mammography (MMG) and ultrasonography (US), but incidentally detected by contrast-enhanced magnetic resonance imaging (CE-MRI). We present it here with a review of the literature. A 67-year-old Japanese woman was referred to our hospital in October 2000 because of a 1.5 cm right breast lump detected in a medical checkup. MMG, US and fine needle aspiration cytology revealed a cancerous lesion during the right breast. No mass lesion was palpable nor was any detected by MMG or US in the left breast. Bilateral breast CE-MRI was performed for more detailed evaluation. Consequently, an occult contralateral breast cancerous lesion was detected incidentally by CE-MRI, with the images showing rapid initial enhancement of time to signal intensity curves. Before surgery, bilateral breast lesions were diagnosed as invasive ductal carcinoma by open biopsy. She underwent bilateral breast conserving surgery with bilateral axillary lymph node dissection. The postoperative course was uneventful and no recurrence has been noted as of January 18th, 2004. CE-MRI of the contralateral breast should be of value as a routine screen in those patients with a known or suspected malignancy in one breast considering the limits of breast cancer detection by such conventional modalities as MMG and US.     

MR Elastography of the Breast: Evolution of Technique,Case Examples,and Future Directions

Recognizing that breast cancers present as firm, stiff lesions, the foundation of breast magnetic resonance elastography (MRE) is to combine tissue stiffness parameters with sensitive breast MR contrast-enhanced imaging. Breast MRE is a non-ionizing, cross-sectional MR imaging technique that provides for quantitative viscoelastic properties, including tissue stiffness, elasticity, and viscosity, of breast tissues. Currently, the technique continues to evolve as research surrounding the use of MRE in breast tissue is still developing. In the setting of a newly diagnosed cancer, associated desmoplasia, stiffening of the surrounding stroma, and necrosis are known to be prognostic factors that can add diagnostic information to patient treatment algorithms. In fact, mechanical properties of the tissue might also influence breast cancer risk. For these reasons, exploration of breast MRE has great clinical value. In this review, we will: (1) address the evolution of the various MRE techniques; (2) provide a brief overview of the current clinical studies in breast MRE with interspersed case examples; and (3) suggest directions for future research.     

Intramammary extension of breast cancer: Diagnosis with MR mammography

Purpose  Intramammary extension of breast cancer was investigated using contrast-enhanced magnetic resonance (MR) imaging by comparing MR findings with the histopathology of specimens used for pretreatment planning. Materials and Methods  Thirty-nine breast cancers were examined. The dynamic protocol was performed with a 2- or 3-dimensional fast spin echo sequence (1.5 T), once before and 2-5 times immediately after Gd-DTPA administration with an original fat suppression technique. The findings were correlated with the histopathology. Results  All main tumors showed early enhancement. All with direct invasion histopathologically showed spicular enhancement. The four patients who had separate nodular enhancement showed satellite lesions histopathologically. Three-typed MR findings were found to be indicative of an intraductal component. Conclusion  Various forms of breast cancer were reliably demonstrated using MR imaging. MR imaging could be useful for the pretreatment planning for patients with breast cancer.     

The Results of a Breast Cancer Screening Camp at a District Level in Rural India

Background: Breast cancer in developing countries is on the rise. There are currently no guidelines to screen women at risk in India. Since mammography in the western world is a well-accepted screening tool to prevent late presentation of breast cancer and improve mortality, it is intuitive to adopt mammography as a screening tool of choice. However, it is expensive and fraught with logistical issues in developing countries like India.Materials and Methods: Our breast cancer screening camp was done at a local district hospital in India after approval from the director and administrators. After initial training of local health care workers, a one-day camp was held. Clinical breast examination, mammograms, as well as diagnostic evaluation with ultrasound and fine needle aspiration biopsy were utilized. Results: Out of total 68 women screened only 2 women with previous history of breast cancer were diagnosed with breast cancer recurrence. None of the women in othergroups were diagnosed with breast cancer despite suspicious lesions either on clinical exam, mammogram or ultrasound. Most suspicious lesions were fibroadenomas. The average cost of screening women who underwentmammography, ultrasound and fine needle aspiration was $30 dollars, whereas it was $16 in women who had simple clinical breast examination. Conclusions: Local camps act as catalysts for women to seek medical attentionor discuss with local health care workers concerns of discovering new lumps or developing breast symptoms.Our camp did diagnose recurrence of breast cancer in two previously treated breast cancer patients, who were promptly referred to a regional cancer hospital. Further studies are needed in countries like India to identify the best screening tool to decrease the presentation of breast cancer in advanced stages and to reduce mortality.