Phylloides tumor: findings on mammography, sonography, and aspiration cytology in 10 cases.

Phylloides tumor is a rare fibroepithelial breast tumor that occasionally has unpredictable clinical behavior. In nine cases of histologically benign tumors and one case of malignant phylloides tumor, the findings on physical examination, mammography, sonography, and aspiration biopsy were correlated retrospectively with the histologic diagnosis of resected specimens. Mammograms showed a round or lobulated benign-appearing opacity in nine cases; one small tumor was missed mammographically. Sonography depicted all tumors as mostly solid masses. Sonographic features included low-level internal echoes, either uniform or scattered; smooth contours; and no significant posterior shadowing. Intramural cysts were shown in six cases. Neither mammography nor sonography allowed reliable differentiation between benign and malignant phylloides tumors. Aspiration biopsy permitted accurate diagnosis of seven benign tumors. The malignant phylloides tumor was classified as a malignant tumor, but the definite differentiation from a carcinoma could not be made. Two histologically benign phylloides tumors were misdiagnosed as carcinomas. Although uncommon, phylloides tumor should be considered in the differential diagnosis of mammographically benign-appearing breast masses, especially if sonography shows intramural cysts within a well-defined solid lesion. Aspiration cytology is unreliable because of the inhomogeneity of the tumor; both intraoperative frozen section and permanent sections are needed for correct histologic diagnosis.     

Diagnostic Radiation Oncology:¶Malignant Cystosarcoma Phylloides

BACKGROUND: Cystosarcoma phylloides is a rare, mostly benign tumor of the breast. In most cases curative treatment is possible with complete surgical excision of the lesions. However, there is a high local recurrence rate up to 46%. There are only few reported successful treatments with radiotherapy in cystosarcoma phylloides. Radiotherapy is indicated in patients with locoregional recurrent disease and those with symptomatic metastases. PATIENT: We present a case of a 54-year-old woman with a painless mass in the right breast. Clinical examination showed a large, firm tumor and axillary lymph node metastases. The patient underwent mastectomy and axillary lymph node dissection. Histopathology showed a cystosarcoma phylloides measuring 30 x 25 x 19 cm as well as lymph node metastases measuring 9.5 cm. Despite a R0 resection the patient developed 4 thoracic wall recurrences within 2 years. At 18 months there were additional multiple pulmonary and pleural lesions with a maximum diameter of 6.5 cm. Subsequently the patient received polychemotherapy. There was a significant response of the thoracic wall disease as well as of the pulmonary and pleural lesions. Six months later there was further progress of the thoracic wall disease and the pulmonary lesions. Following this the patient underwent radiation therapy of her right thoracic wall with 50 Gy which lead clinically to a quick response. For the past 5 months there has been no evidence of thoracic wall disease recurrence. CONCLUSION: This is an unusual case of cystosarcoma phylloides and response to different therapeutic modalities. Cystosarcoma phylloides showed to be a radiosensitive tumor. Thus postopertive radiation therapy is indicated to prevent local recurrences.     

乳腺叶状肿瘤的诊断和治疗

目的研究乳腺叶状肿瘤的基本的组织特征、病理诊断、鉴别诊断和分类标准,筛选各型肿瘤外科治疗的适宜术式,寻找临床和病理预后因素。方法对203例乳腺叶状瘤的病理形态学特征、临床因素和不同术式的疗效,按统计学软件SPSS（10．0）要求,建立数据库作Cluster、Focater、Logistic及Cox regression分析。结果203例叶状肿瘤可分为良性、交界和恶性三型,分别为133、42和28例;局部复发分别为28、19和18例;因瘤死亡分别为0、2和16例;在131例随访5年以上的病例中,5年生存率分别为1000A、92％和33．3％。结论肿瘤性坏死具有重要的诊断价值。肿瘤性坏死、生长方式、异型性和核分裂数是在无错判条件下的肿瘤病理诊断参数集,亦是目前文献中最简化的诊断方案。良性、交界性和恶性叶状肿瘤应废止以往常用的肿物单纯切除术式;对于良性和交界性肿瘤至少应选择肿物连同周围2cm正常乳腺组织一并切除的扩大切除术;复发的交界性和恶性肿瘤要选择乳房单纯切除术式。叶状肿瘤的病理组织学等级（类型）与肿瘤的局部复发和因瘤死亡有统计学线性关系（P〈0．01）;肿瘤的浸润性生长方式与肿瘤的复发有线性关系（P〈0．01）;肿瘤性坏死和核分裂数值是独立的预后因素;术式等11个临床病理因素为单风险预后因素。     

乳腺导管内乳头状瘤病103例报告

目的分析乳腺导管内乳头状瘤病与乳腺癌的关系并提出治疗方法。方法回顾性分析103例乳腺导管内乳头状瘤病，从临床特征、病理特点及治疗效果等方面进行分析、总结。结果103例中，女性102例，男性1例，全部依靠病理确诊。首诊误诊率高(62．1％)。局部切除18例，区段小叶切除62例，单纯切除术12例，伴有局部癌变者行乳癌改良根治术9例、单纯切除术2例。13年内复发12例，达11．7％，癌变7例，达6．8％。结论本病与乳腺癌的关系密切，其鉴别仍依靠组织病理学方法，治疗应予手术切除。     

Diagnostic Radiation Oncology:?Malignant Cystosarcoma Phylloides

Background: Cystosarcoma phylloides is a rare, mostly benign tumor of the breast. In most cases curative treatment is possible with complete surgical excision of the lesions. However, there is a high local recurrence rate up to 46%. There are only few reported successful treatments radiotherapy in cystoarcoma phylloides. Radiotherapy is indicated in patients with locoregional recurrent disease and those with symptomatic metastases. Patient: We present a case of a 54-year-old women with a painless mass in the right breast. Clinical examination showed a large, firm tumor and axillary lymph node metastases. The patient underwent mastectomy and axillary lymph node dissection. Histopathology showed a cystosarcoma phylloides measuring 30 2 25 2 19 cm as well as lymph nodes metastases measuring 9.5 cm. Despite a R₀ resection the patient developed 4 thoracic wall recurrences within 2 years. At 18 months there were additional multiple pulmonary and pleural lesions with a maximum diameter of 6.5 cm. Subsequently the patient received polychemotherapy. There was a significant response of the thoracic wall disease as well as of the pulmonary and pleural lesions. Six months later there was further progress of the thoracic wall disease and the pulmonary lesions. Following this the patient underwent radiation therapy of her right thoracic wall with 50 Gy which lead clinically to a quick response. For the past 5 months there has been no evidence of thoracic wall disease recurrence. Conclusion: This is an unusual case of cystosarcoma phylloides and response to different therapeutic modalities. Cystosarcoma phylloides showed to be a radiosensitive tumor. Thus postoperative radiation therapy is indicated to prevent local recurrences. Hintergrund: Das Cystosarcoma phylloides ist ein seltener, meist benigner Mammatumor. In den meisten Fällen kann er durch eine komplette chirurgische Exzision der Läsionen geheilt werden. Der Tumor zeigt jedoch eine hohe Lokalrezidivrate bis 46%. In der Literatur liegen nur wenige Daten zur erfolgreichen Strahlentherapie beim Cystosarcoma phylloides vor. Die Strahlentherapie ist indiziert bei lokoregionären Rezidiven und bei symptomatischen Metastasen. Patientin: Wir berichten über eine 54-jährige Frau, die sich mit einer schmerzlosen Schwellung der rechten Brust vorstellte. Bei der klinischen Untersuchung zeigte sich ein großer, derber Tumor mit axilliären Lymphknotenmetastasen. Es erfolgte eine Ablatio mammae mit Axilladissektion. Histopathologisch ergab sich ein 30 2 25 2 19 cm großes Cystoarcoma phylloides sowie Lymphknotenmetasen von 9,5 cm. Obwohl es sich um eine R₀-Resektion handelte, kam es innerhalb von zwei Jahren zu vier Thoraxwandrezidiven. Nach 18 Monaten fanden sich zusätzich rechts pulmonal und pleural mehrere weichteildichte Herde mit einem maximalen Durchmesser von 6,5 cm (Abbildung 1). Daraufhin wurde eine Polychemotherapie durchgeführt. Es kam zu einem deutlichen Regress des Thoraxwandrezidivs sowie der pulmonalen und pleuralen Herde. Sechs Monate später trat erneut ein Progress des Thoraxwandrezidivs und der pulmonalen Herde auf (Abbildung 2). Es wurde daraufhin eine Strahlentherapie der rechten Thoraxwand mit 50 Gy durchgeführt, was klinisch zu einem raschen partiellen Regress des Rezidivs führte. Seit fünf Monaten ist es im Bereich der Thoraxwand zu keiner neuen Tumorprogredienz gekommen. Schlussfolgerung: Dies ist ein ungewöhnlicher Fall eines Cystosarcoma phylloides mit Ansprechen auf unterschiedliche Therapien. Das Cystosarcoma phylloides erwies sich als ein radiosensitiver Tumor. Deshalb ist zur Verhinderung eines Lokalrezidivs eine postoperative Radiotherapie indiziert.     

Combination of conservative surgery and irradiation for cancer of the breast.

In patients with relatively advanced local or axillary disease, or both, a simple mastectomy followed by irradiation gives the best local and regional control rates. From the existing data, one can state unreservedly that women with early breast cancer take no chance on their life by having a treatment method which preserves the breast. In conjunction with the wedge excision, even if the axilla is clinically negative, a dissection of the low and central axilla brings enough information to decide on elective chemotherapy.     

Clinical results of a radiotherapy-surgery program analyzed in relation to risk factors in cancer of the breast

In the Radio Institute "O. Alberti" of Brescia from 1.1.73 to 31.12.79, 976 patients were treated with postoperative radiotherapy after radical mastectomy. The impact of therapy has been observed on the NED survival and evaluated for prognostic factors. The involvement of axillary lymph nodes appears to be the most relevant prognostic factor; the hormonal perimenopausal status was associated with a poorer prognosis both regarding the high frequency of axillary metastatic nodes and because in N+ 1-3 cases the probability of relapse is different and higher in comparison to post and premenopausal status. The site of origin of the primary tumor does not appear to be a significant prognostic factor related to the same number of nodes involved. Direct correspondence exists between diameter of the primary tumor and metastatic regional nodes. In N- patients the evaluated prognostic factors are not significant; in N+ patients the cases with a significantly different risk of relapse were identified for N+ 1-3 by the perimenopausal status and for N+ greater than or equal to 4 by the diameter of tumor. Postoperative radiotherapy alone seems to be able to modify the prognosis of operable breast cancer. The combination of local radiotherapy and adjuvant medical therapy could be a logical approach not only in order to improve the local control but also to prevent metastases.     

Current status of radiotherapy following ablative and breast-sparing treatment of breast cancer

After a total mastectomy in cases of a high risk of loco-regional recurrence the postoperative irradiation of the chest wall is indicated in the following situations: Inflammatory type of carcinoma, tumor stage T3-T4, extended multifocal and multicentric primary tumor. After radical axillary surgery even in patients with positive nodes irradiation is not necessary except in cases where all axillary nodes are involved or with invasion of the axillary tissue. The supra- and infraclavicular lymph drainage regions caudal to the operated area (clip) should be irradiated with 50 Gy providing both an enlarged or subtotal involvement can be diagnosed. The irradiation of the retrosternal lymph-drainage system with 45-50 Gy is indicated as follows: Medial or central tumor site, extensive involvement of the axillary nodes and advanced stages of the primary tumor (T2-T4). Axillary irradiation alone cannot serve as a substitute for surgery. After segmental mastectomy without postoperative radiotherapy a local failure rate of 30% is to be expected during a 5 year period. After surgery with adjuvant postoperative irradiation the local failure rate can be reduced to about 5%: 50-60 Gy should be applied. In case of an unfavourable histology an additional boost dose is recommended. The objective of breast cancer irradiation is to achieve freedom of loco-regional recurrence. The survival can be improved occasionally after local irradiation, theoretically improvement of survival can be achieved in 7-10% at the most.     

Phyllodes tumors of the breast

The aim of this study was to describe the clinical, mammographic, and sonographic findings of phyllodes tumor of the breast and correlate them to the benign or malignant pathological nature of the lesion and its clinical behavior. We retrospectively reviewed the clinical, radiologic, and pathologic findings of 12 cases of phyllodes tumors diagnosed in our hospital in the past 6 years, 6 of which were malignant. The surgical management and clinical course of the patients were also reviewed. Mammographically, soft tissue masses ranging from 2.5 to 15 cm were present in all patients. One patient had a mixed fat and water density mass and 2 patients had masses associated with coarse calcifications. At sonography, all tumors were well circumscribed; two of them were homogeneously hypoechoic, and the rest had heterogeneous internal echoes. Eight patients showed internal cystic areas. None of these characteristics proved to be useful in ascertaining the benign or malignant nature of the tumor. At surgery, 5 patients underwent mastectomy and 7 patients local excision of the tumor. Three of the later tumors, one benign and two malignant, recurred after several months. Fine-needle aspiration biopsy suggested the diagnosis of phyllodes tumor in only 3 cases. After surgery, six tumors were classified as benign and six as malignant, three of which being of low-grade malignancy. None of the clinical or radiologic characteristics of the tumors were useful in predicting their histological nature or their behavior after surgery. Preoperative fine-needle aspiration biopsy often misdiagnosed the tumor as benign fibroadenoma. Only the histopathologic features of the excised mass proved to be helpful in assessing malignancy. Received: 3 July 1997; Revision received: 18 December 1997; Accepted: 28 April 1998     

原发性小肠肿瘤的外科治疗及其预后

 目的 探讨原发性小肠肿瘤的临床特点、诊断及外科治疗经验。方法 回顾性分析2010-05至2015-05于我院经手术治疗的87例原发性小肠肿瘤的临床资料,分析其临床表现、病理结果、手术情况、术后并发症及预后。结果 87例原发性小肠肿瘤均经病理确诊。常见临床表现有腹痛(51例)、消化道出血(29例)、腹部包块(12例)、肠梗阻(17例)、黄疸(3例),6例为查体发现。良性26例,恶性61例;26例良性肿瘤均行肿瘤及肠管局部切除,恶性肿瘤行根治性切除49例,姑息性切除4例,短路手术6例。59例获得随访,随访时间为6个月至5年,其中良性肿瘤23例,复发3例,恶性肿瘤36例,原位复发11例。结论 小肠肿瘤临床表现不典型,早期诊断困难,手术切除是主要的治疗手段。     

乳腺癌术后发生肝脏转移的相关危险因素分析

目的分析乳腺癌术后发生肝脏转移的临床特点,探讨影响乳腺癌术后肝脏转移的相关危险因素。方法回顾性分析我院2002年3月~2005年3月收治的640例女性乳腺癌患者术后发生肝脏转移的情况,采用χ2检验对肝脏转移的影响因素进行单因素分析,并将各影响因素利用Logistic回归方程进行多因素分析。结果 48例肝脏转移病例单因素分析显示：患者的原发灶大小、TNM临床分期、淋巴结转移情况、雌激素受体情况和HER2表达情况与乳腺癌术后肝脏转移的发生有统计学意义（P〈0.05）;通过Logistic多因素回归分析发现：TNM临床分期、淋巴结转移数目、雌激受体情况和HER2表达情况是影响乳腺癌术后肝脏转移发生的主要因素。结论初诊时临床分期、淋巴结转移数目、雌激素受体情况和HER2是乳腺癌术后发生肝脏转移的主要危险因素。     

Neue Erkenntnisse über Tumorzellinaktivierung und histologische Beurteilbarkeit nach Radiofrequenztherapie Einzelfallbeobachtung und In-vitro-Nachweis einer neuen Hypothese

In a study, a radiofrequency (RF) treatment was performed on a patient with a small breast cancer after vacuum biopsy. As usual in cases with a malignant diagnosis, surgical excision and axillary dissection followed. Histopathology revealed some residual tumor in the margin of the cavity. It could not be distinguished from vital tumor on the hematotoxylin eosin (HE) stain. Based on the correlation of MRI and histopathology after subsequent surgical excision, we did, however, presume that the residual was contained within the zone of inactivation. Thus the hypothesis arose that, if too high temperatures can be avoided, it might be possible to inactivate tumor cells without significantly impairing histopathologic assessment. This hypothesis was supported by the following in vitro experiment performed on a fresh specimen: An RF treatment was performed using temperatures up to 70 degrees C only. Half of the specimen underwent HE-staining, the other half vitality testing. The results indicate that if a given temperature range is strictly observed it appears possible to inactivate tissue before tissue sampling, since histopathologic diagnosis will not be impaired. Further technologic improvements may eventually allow to develop a pre-treatment method which might permit to avoid potential hematogenous tumor spread during subsequent biopsy.     

Value of lymphography in teratoid testicular tumors (author's transl)

In 72 patients with malignant testicular tumors lymphograms were reviewed and correlated with the microscopic findings of the resected lymphnodes. In 55 patients (76%) the roentgenographic diagnosis was confirmed by histology. In 6 patients lymphography was false positive as microscopic examination of the resected lymphnodes showed. In 4 patients lymphography was considered negative but metastatic disease proven microscopically from retroperitoneal lymphnodes. Out of 7 patients with questionable positive lymphograms 2 had retroperitoneal metastases confirmed by microscopic examination. The limits, errors and value of lymphography in patients with testicular tumors are discussed.     

Value and limits of different method in diagnosis and differential diagnosis of retroperitoneal tumors within the lymphatic systems (author's transl)]

The demonstration of retroperitoneal intralymphatic primary or secondary tumors requires a progressive radiological investigation beginning with simple methods and advancing to more complicated ones. Radiological lymphography is a method which is superior due to its ability to demonstrate small structures in lymphatic vessels and lymphnodes. However, the usefulness of lymphography is limited partially to the retroperitoneal lymphatic system and to gross changes. To improve diagnostic accuracy further diagnostic measures are needed, namely intravenous urography, venocavography, lumbar venography of catheter, sonotomography of the upper abdomen and lymphatic scintigraphy. Exstirpation of lymphnodes- possibly by explorative laparotomy- and histopathological examination enables an extact assessment of lymphnodes of microscopical dimension as determination of the tumor type. The value and limits of complementary methods and the criteria for the diagnosis and differential diagnosis of metastatic lymphnodes and lymphoreticular systemic diseases are discussed. The significance of lymphography for evaluation of topographic expansion of pathological lymphnode changes, the further course of the disease and the effect of therapy according to the authors' experience are presented. It is stressed that the value of lymphography in diagnosing the type of disease is limited.     

Surgical technics in breast-sparing treatment of breast cancer

Current surgical techniques in conservative treatment of breast cancer are shown: quadrantectomy, tumorectomy, axillary dissection. Therapeutic problems in such treatment are tumor size (bigger than 2 cm diameter) and the measures to be taken regarding metastatic axillary lymph nodes. Specially important is the histological evaluation of the tumor excision to guarantee a tumor-free rim. Good cooperation between surgeon, pathologist, and radiotherapist must be stressed.     

早期乳腺癌外科保守性手术治疗的疗效观察

目的　探讨早期乳腺癌保守性外科治疗的效果。方法　对临床早期乳腺癌 1 2 5例行乳房象限切除术加腋淋巴结清扫术 ,其中 0期 3例 ,Ⅰ期 89例 ,Ⅱ期 33例 ,全组患者术后乳房放疗 1 0 2例 ,未放疗 2 3例 ,浸润性癌围手术期化疗 7周 ,腋淋巴结阳性术后常规放疗 ,此后 6～ 1 2个月内追加 1 2～ 1 6次化疗。ER阳性服用TAM 2～ 5年。此外 ,选用同期 0～Ⅱ期仿根治术或根治术常规综合治疗 95例作对照观察。结果　 ( 1 )病理检查 :1 2 5个象限切除标本中断端阳性 1 0例( 80 % ) ,均以管内癌形式出现。腋淋巴结平均检出 1 6 8枚 ,阳性率 1 5 2 % ;( 2 )生存情况 :1 2 5例随诊 ,>3年 85例 ,>5年 6 3例 ,全部存活 ,仅 1例术后 2 5年局部复发 ,1例术后 2年骨转移带瘤生存 :随诊 <3年 4 0例 ,1例术后 1年肺转移带瘤生存 ;对照组 95例 ,1例肺转移死亡。结论　早期乳腺癌保守性外科治疗与仿根治术 ,根治术效果相似且能保持乳房良好外形 ,是Ⅰ ,Ⅱ期乳癌理想的治疗方法     

MRI of the breast: state of the art

Contrast-enhanced MRI of the breast is probably the most sensitive method to detect breast pathology. It is best used to improve the sensitivity of mammography and sonography in selected patient groups with high breast cancer prevalence, where conventional methods are known to be less sensitive. Despite the high sensitivity of MRI, 5–12 % of invasive carcinomas are not recognized during MRI, because of lack of the typical criteria of carcinoma. MRI is probably inferior to mammography in detecting ductal in-situ carcinoma or very small carcinomas (< 3 mm), because the neo-angiogenesis induced by these small carcinomas is too faint to be detected by contrast-enhanced MRI. These tumours cannot be excluded by a normal MRI examination. MRI is non-specific as the distinction of benign and malignant breast lesions is unreliable. Only in selected cases (fat- or blood-containing lesions) may it improve the specificity of mammography and sonography. Mostly image-guided core biopsy is by far the most specific and least expensive method to establish a definitive diagnosis. For lesions exclusively detected by contrast-enhanced MRI, simple and reliable localisation devices are urgently needed. Presently accepted indications for MRI of the breast are: patients with silicone implants after mastectomy or augmentation mammoplasty (detection of recurrence/prothesis rupture/silicon leakage); patients whose breasts are difficult to evaluate by combined mammography and sonography, who have had breast conservation therapy (local recurrence), or who have proven carcinoma in one breast (multifocality/-centricity or contralateral breast carcinoma) or proven axillary lymph node metastases from an unknown primary tumor, especially when these are hormone receptor positive; patients with extensive postoperative scarring. In the future, genetically defined high breast cancer risk may become an indication. Received 7 October 1997; Revision received 14 November 1997; Accepted 17 November 1997     

CT导向下125I粒子植入治疗肝门区肝癌

目的评价CT导向下125I粒子植入治疗肝门区肝癌及淋巴结的临床价值.方法本组病例32例,其中肝门区肝细胞癌(HCC)8例,肝门区胆管癌(HC)12例,肝转移瘤6例,肝门区淋巴结转移6例.14例侵犯肝门胆管致肝内胆管扩张,22例合并肝硬化.全部病例经CT、MRI检查或病理穿刺活检证实.病灶平均直径为4.2 cm.采用TPS计算布源,在CT导向下将125I粒子植入瘤灶内,采用0.6～0.9 mCi活度的12I粒子相隔1.0～1.5 cm平面播植.结果2例死于远处转移,3例死于肝功能衰竭,全组中位生存时间10个月.2个月后CT复查,完全缓解(CR)2例;部分缓解(PR)20例;无变化(NC)5例;进展(pD)5例.总有效率(CR+PR)68.8%.2个月随访过程中发现7颗粒子在肝脏内游走,3颗粒子迁徙至肺内;1例出现气胸,肺压缩在30%以下,白细胞轻度下降1例.未见大出血、胆汁瘘、肠瘘、肠出血等严重并发症.结论CT导向下放射性粒子植入治疗肝门区肿瘤及淋巴结创伤小,并发症发生率低,生活质量改善明显,近期效果好,是治疗中晚期肝门区肿瘤及淋巴结的简单、安全、有效的方法.     

Successful Preoperative Chemoembolization in the Treatment of a Giant Malignant Phyllodes Tumor

The malignant phyllodes tumor is a relatively rare neoplasm and has not previously been a therapeutic target of interventional radiology. Herein, we report a successful case of preoperative chemoembolization of a giant malignant phyllodes tumor. The objective was to achieve sufficient tumor shrinkage before surgery to avoid the requirement for skin grafting after resection. Intra-arterial epirubicin infusion and subsequent embolization with Embosphere Microspheres (BioSphere Medical, Rockland, MA, USA) was undertaken three times over the course of 6 weeks and was well tolerated. The patient underwent surgery without skin grafting. Neither local recurrence nor distant metastasis was observed at 6 months after surgery.     

Hypermetabolic Axillary Mass on 18F FDG PET/CT: Breast Cancer Arising from Accessory Breast Tissue

Differential diagnosis among several causes of axillary malignant mass is important. The most common cause of palpable malignant axillary mass is metastatic lymphadenopathy. Although carcinoma arising from ectopic breast tissue is rare, the diagnosis should be kept in mind when evaluating malignant axillary mass. In this report we present a case with carcinoma arising from ectopic breast tissue. ¹⁸F FDG PET/CT was performed for the purpose of localizing primary breast cancer lesion and systemic evaluation. PET/CT showed hypermetabolic lesions only in the right axilla. There is no evidence of malignancy in both breasts. When nuclear physicians encounter a hypermetabolic axillary mass indicating malignant lesion without evidence of primary breast malignant lesion, carcinoma arising from ectopic breast tissue should be included in the differential diagnosis.