A case of ectopic breast cancer with a literature review

A 63-year-old woman was referred to our hospital because of a right axillary nodule in 2004. Physical examination showed a spherical nodule measuring 0.5 cm in diameter in the right axilla. No mass was palpable in either breast. Mammograms were normal. Ultrasonography revealed a subcutaneous hypoechoic mass 0.7 mm in maximum diameter in the right axilla. The patient underwent an excisional biopsy. Histological examination revealed an invasive ductal carcinoma (scirrhous carcinoma) in ectopic breast tissue. The patient subsequently underwent a wide local excision of the tissue surrounding the biopsy scar, with axillary lymph node dissection. Histologically, no residual tumor or nodal metastasis was found. Postoperatively, she received endocrine therapy and remains well, without any evidence of recurrence 4 years 10 months after operation. Cancer of the ectopic breast tissue is rare, and most cases present as a solitary axillary mass. Long-term outcomes remain unclear. We present a case of breast carcinoma in the axillary ectopic mammary gland and summarize the clinical features of 94 cases, including ours, in Japan. We also compare long-term survival between ectopic breast cancer and usual breast cancer according to TNM T stage and lymph node metastasis.     

Carcinoma of the axillary breast

A review of the world literature regarding carcinoma of ectopic breast tissue along with the addition of one cases is reported. A total of 90 cases of carcinoma of ectopic breast tissue were found, 64 of which occurred in the axilla. The combined survival beyond the 4-year post-treatment period was 9.4%. No survival advantage was found for radical or modified radical mastectomy over that of local excision combined with axillary dissection or radiation. The addition of radiation therapy to either type of mastectomy provided no additional benefit. The correct preoperative diagnosis was rarely made. Outcome was reported in 42 cases; 28 survived longer than 1 year, with 12 recurrences at the time of reporting, and 6 were alive with no evidence of disease at 4 years or longer. Improved prognosis requires diagnostic suspicion and early biopsy of unidentified lesions of the axilla or embryonic milk line.     

The forgotten node: Axillary surgery mandates expertise

The therapeutic role of axillary dissection in breast cancer is gradually abandoned. However, in some cases axillary dissection is still indicated, and this mandates expertise in planning the operation according to imaging, understanding of current methods of axillary marking, and expertise in performing a more radical resection. In this comment we describe cases of gross nodal disease that was left behind at the time of axillary dissection and was later noted on a radiation planning CT.     

Regional nodal irradiation in the conservative treatment of breast cancer

At this institution conservative treatment of breast cancer was begun in the 1960's. The following analysis represents our experience through 1984 with specific reference to the management of the regional lymph nodes. A total of 432 patients with clinical stage I and II breast cancer were treated between 1962 and 1984 with lumpectomy and radiation therapy. The breast was treated with tangential fields to a median dose of 4800 cGy and electron conedown to a total tumor bed dose of 6400 cGy. Axillary dissection was not routinely performed, particularly in the earlier years. More recently, axillary dissection has been used with increasing frequency if it was felt that the results of the dissection would influence systemic treatment. One hundred eighty-seven patients (43%) underwent axillary dissection (30% pathologically positive) and routinely received regional nodal irradiation (median dose 4600 cGy) to the internal mammary and supraclavicular lymph nodes. Two hundred forty-five patients (57%) did not undergo axillary dissection and routinely received regional nodal irradiation to the internal mammary, supraclavicular, and entire axillary regions to a total median dose of 4600 cGy. As of May 1989 with a median follow-up of 7.5 years, there have been a total of 12 nodal failures for an actuarial nodal control rate of 97% at 5 years and 96% at 10 years. The actuarial 5-year regional nodal control rate was the same for both the group of patients receiving regional RT alone without axillary dissection and the group of patients receiving axillary dissection and supraclavicular/internal mammary radiation. There has been minimal morbidity associated with this treatment policy. We conclude that regional nodal irradiation as described above, with or without axillary dissection, results in a high rate of regional nodal control and minimal treatment morbidity in patients undergoing conservative treatment of early stage breast cancer.     

The outcome of patients with breast cancer who underwent breast conserving treatment with or without immediate volume replacement with autogenous tissue

Background  Breast conserving treatment (BCT) is accepted as an appropriate therapy for most patients with stage I and stage II breast cancer. However, BCT is associated with a relatively high incidence of local recurrence, and aesthetically unacceptable results occur in some patients. A novel method of immediate volume replacement using autogenous tissue has been developed to strike a balance between adequate excision and cosmesis. We determined the oncological outcome in patients with breast cancer treated with wide excision, immediate volume replacement with autogenous tissue, and axillary dissection followed by radiotherapy. Methods  One hundred fifty-three patients with TIS, stage I, II, or III breast cancer underwent wide excision and axillary dissection. The surgical margin of excised breast tissue was examined histologically during surgery. If involved, the breast tissue adjacent to the primary site was excised. When the margin of re-excision was positive, patients underwent modified radical mastectomy with or without breast reconstruction. After wide excision, immediate volume replacement with autogenous tissue was performed, unless the deformity was corrected by undermining and conization of the residual breast tissue. Postoperatively, all patients received breast irradiation. Results  Eighteen patients underwent modified radical mastectomy. The surgical margin was negative in 132 of the 135 patients who underwent BCT. The crude local recurrence rate was 0.7% (1/135). Estimated overall and disease-free 5-year survival rates were 96% and 94%, respectively. Conclusions  Wide excision with tumor-free margins and axillary dissection followed by breast irradiation provides adequate local control in many patients with breast cancer. Immediate breast volume replacement with autogenous tissue may avoid some unpleasant cosmetic results associated with extensive local resection. Our technique eliminates the need for mastectomy in selected patients.     

Radiation-induced long thoracic nerve palsy

The incidence of long thoracic nerve palsy after radical mastectomy has been documented to be approximately 10%. No cases have been reported after the more recent treatment for breast cancer, lumpectomy with axillary dissection. This more recent surgical procedure is customarily followed by aggressive radiation therapy to the remaining breast tissue. This is the first case report of a patient with radiation-induced long thoracic nerve palsy. The patient was a young woman who underwent left breast quadrantectomy and axillary dissection for breast cancer. After radiation therapy, she had isolated left long thoracic nerve palsy. The diagnosis was confirmed by electrodiagnostic studies. Almost full recovery occurred after 5 months.     

Variation in axillary node dissection influences the degree of nodal involvement in breast cancer patients

BACKGROUND AND OBJECTIVES: The number of positive axillary lymph nodes predicts prognosis and is often important in determining adjuvant chemotherapy in breast cancer patients. This study was undertaken to determine if differences in the extent of axillary node dissection would alter the number of reported positive nodes. METHODS: The study population consisted of 302 patients with invasive breast cancer who underwent complete (level I/II/III) axillary lymph node dissection. Assuming that all patients had undergone a level I/II dissection, it was determined how frequently a patient's nodal category (0, 1-3, 4-9, >10 positive nodes) would have been altered if a level I or level I/II/III dissection were performed. RESULTS: Assuming that all 302 patients had undergone a level I/II dissection, performing only level I dissection would have resulted in a change in nodal category in 15.9% of all patients and 36.1% of patients with positive nodes. The corresponding changes for a level I/II/III dissection would have been 4.3% and 9.5%, respectively. CONCLUSIONS: Variations in the level of axillary node dissection for breast cancer can result in significant changes in the number of positive axillary nodes. This can potentially bias adjuvant chemotherapy recommendations if treatment decisions are based on this prognostic factor.     

Palpation of the axillary nodes in breast cancer: What does the surgeon feel?

Summary The findings on routine pre-operative palpation of the axilla in patients with infiltrative breast carcinoma are compared to the results of histological quantitation of the nodal lymphoid tissue and its tumour deposits in 91 consecutive cases in which a standardized axillary dissection had been carried out. The study demonstrates that lymphoid tissue, even when present in large amounts (up to 6 cm² on histology), is seldom palpable. What the clinician identifies in favourable cases is the tumour deposit itself. When little lymphoid tissue is present very small tumour deposits (0.2cm²) may be found on palpation, but large deposits (1 cm²) may be missed when surrounded by sufficient lymphoid tissue. These findings go far to explain the well documented unreliability of the nodal findings on axillary palpation in breast cancer.     

Conservative treatment versus mastectomy in breast cancer tumors with macroscopic diameter of 20 millimeters or less. The experience of the Institut Gustave-Roussy

A clinical trial was conducted at the Institut Gustave Roussy between October 1972 and December 1980 to compare mastectomy with local excision plus Cobalt-irradiation, in patients with breast cancer tumors of 20 mm in diameter or less at macroscopic examination. Low-axillary dissection and extemporaneous histologic examination were carried out for all patients. If one or more positive nodes were found, complete axillary dissection was performed. The study included 179 patients. No significant difference was detected in either overall or relapse-free survival between the two groups, although the conservatively treated group showed slightly better results. The results of conservative treatment were esthetically satisfactory in 92% of the cases. The trial included a second randomization for the patients with positive axillary nodes to assess the value of nodal area irradiation; 72 patients were studied in this part of the trial. No significant differences were found between the two groups after adjustment for the number of positive axillary nodes, although the no-nodal irradiation group showed better results and less complications than the nodal irradiation group.     

Oncologic and cosmetic outcome in patients with breast cancer treated with wide excision,transposition of adipose tissue with latissimus dorsi muscle,and axillary dissection followed by radiotherapy

We evaluated the oncologic and cosmetic outcome in patients with breast cancer treated with wide excision, transposition of adipose tissue with latissimus dorsi muscle (LDM), and axillary dissection followed by radiotherapy. In this study, a wide excision of breast tissue was performed to obtain tumor-free margins. The subsequent breast deformity was not corrected in six patients in the early phase of the study (Group 1), and in 16 patients in the late phase (Group 2) in which the breast deformity was not remarkable at the time of operation. Breast deformity was corrected by transposing adipose tissue with LDM on a vascular pedicle in the remaining 51 patients (Group 3). Five year survival was 100%. Two patients developed distant metastases. None were found to have local recurrence. Fifty percent of the Group 1 patients, 69% of the Group 2 patients, and 67% of the Group 3 patients had an excellent or good cosmetic result. However, when the cosmetic results were evaluated in patients who underwent transposition and had small breasts, the results were excellent or good in 76%, compared to 38% in the patients who had reconstructions who had large breasts. The difference was statistically significant (p = 0.0309). Therefore, it was confirmed that wide excision and axillary dissection followed by breast radiation could provide adequate local control, but frequently resulted in breast deformity. However, transposition of adipose tissue may be useful to correct the breast deformity, especially in women with small breasts.     

Feasibility of targeted axillary dissection for de-escalation of surgical treatment after neoadjuvant chemotherapy in breast cancer

BackgroundTargeted axillary dissection, which combines sentinel lymph node biopsy with removal of the proven involved node noted during the staging process, has been shown to improve axillary staging and decrease false negative rates after neoadjuvant chemotherapy in patients with breast cancer.Objective(s)The main goal of this study was to assess the ability to identify and remove the clipped node and the false negative rate of targeted axillary dissection.MethodsWe performed a prospective study among patients with biopsy-confirmed nodal metastases who received neoadjuvant chemotherapy. A clip was placed on the sample node prior systemic therapy. After neoadjuvant chemotherapy, all patients underwent sentinel lymph node biopsy (dual tracer), localization and excision of the clipped node and axillary lymph node dissection. The clipped node was preoperatively localized in all cases placing an iodine-125 seed guided by ultrasound. The pathology of the sentinel nodes and clipped node was compared with other nodes.ResultsA total of 455 patients with invasive breast cancer were studied. Of the 148 patients with NAC, 32 met the eligibility criteria and were enrolled in the study. Mean age at diagnosis was 52.3 years. Systematic lymphadenectomy was performed in all patients, with an average of 14.3 lymph nodes removed. Detection rate of the clipped node alone was 96.9%, and 100% for targeted axillary dissection. Ability of clipped node alone to predict nodal status showed a FNR of 10,5% while SLNB alone performed by dual tracer and targeted axillary dissection, showed FNRs of 5.3% and 5.0%, respectively. Sentinel lymph nodes matched clipped node in 23 patients (74.2%).Conclusion (s)In node positive breast cancer patients, targeted axillary dissection is a reliably approach for axillary staging after neoadjuvant chemotherapy. The preoperative location of the clipped node is mandatory to increase the detection rate and optimize the results of the technique.     

The role of axillary lymph node dissection in breast cancer management

Although it is generally accepted that axillary dissection provides no survival advantage in patients with breast cancer, it is commonly regarded as a reliable method of assessing nodal status and treating regional disease. However, it is time to consider eliminating routine axillary dissection in patients who are clinically node-negative. A sentinel lymph node biopsy may assess axillary nodal status while obviating a full axillary dissection. At present, axillary dissection remains the standard approach for the surgical management of all patients with invasive carcinoma of the breast, regardless of tumor size or patient age, though it is unnecessary for patients with small intraductal carcinomas.     

Mastopathy of the accessory breast in the bilateral axillary regions occurring concurrently with advanced breast cancer

Summary We herein report a 41-year-old Japanese woman who demonstrated advanced cancer in the left breast occurring concurrently with mastopathy of the accessory breast tissue in the bilateral axillary regions, which appeared to be metastatic lymphadenopathy. A preoperative examination, including a mammogram, US, and CT, did not provide us with a definite diagnosis of the axillary masses: it was essential to diagnose the masses preoperatively since a bilateral mastectomy with nodal dissection is called for if the right axillary masses are metastatic from a cancer in the right breast. An intraoperative cytological examination from the bilateral axillary masses revealed adenosis with fibrocystic changes in the accessory breast tissue. We therefore performed a modified radical mastectomy only on the left side. The patient was thus saved from an unnecessary mastectomy of the right breast.Based on our experience, we wish to emphasize that the accessory breast tissue should be considered for a differential diagnosis when evaluating the axillary masses in order to avoid over-surgery, especially when a patient has been diagnosed to have massive breast cancer. An intraoperative cytological examination is strongly recommended to reach a final diagnosis in such confusing cases.     

Is dissection of the internerve tissue during axillary lymphadenectomy for breast cancer necessary?

AIMS: The study evaluates the necessity of dissecting the tissue between the long thoracic and thoracodorsal nerves (internerve tissue) during axillary dissection in breast cancer surgery. By reviewing the lymph node yield and the metastatic rate in the internerve tissue, we examine whether the internerve tissue could be left in situ to minimize the risk of nerve injury. METHODS: A prospective study was conducted on 30 consecutive women undergoing axillary lymphadenectomy for breast cancer. The internerve tissue remaining was excised separately after a routine axillary dissection and was examined by the same pathologist. RESULTS: Twenty (67%) of 30 internerve specimens contained lymph nodes; the internerve nodes were positive for carcinoma in three cases (10%). In one case the lymph node in the internerve tissue was the only metastatic node in the axilla. CONCLUSIONS: There is a significant incidence of lymph nodes (67%) and axillary node metastases (10%) in the tissue lying between the long thoracic and thoracodorsal nerves. Therefore excision of this internerve tissue is strongly recommended in order to optimize decision making regarding adjuvant treatment and oucome in women with operable breast cancer.     

隐匿性乳腺癌36例诊治分析

回顾分析临沂市肿瘤医院乳腺外科收治的36例隐匿性乳腺癌(OBC)患者的临床资料,并结合文献进行讨论。所有病例腋下肿物均经切检病理确诊。乳腺钼靶检查2例诊断为乳腺癌,3例患者为可疑乳腺癌;乳房彩超检查1例诊为乳腺癌,3例患者为可疑乳腺癌。行改良根治术28例,乳腺癌根治术4例,保留乳房手术2例,腋窝淋巴结清除加全乳放疗2例。30例患者获得随访,15例生存时间>5年。回顾分析结果提示,对腋下肿块应行切除活检以明确诊断;乳腺钼靶、彩超及腋下肿物激素受体检测有一定价值;乳腺核磁共振扫描能够提高OBC的检出率。手术方式宜采用改良根治术或保留乳房后全乳照射,并辅以化疗及内分泌治疗等以提高长期生存率。     

The sentinel node biopsy after previous breast surgery: preliminary results on 543 patients treated at the European Institute of Oncology

Background. Sentinel lymph node biopsy (SLNB) is an accurate alternative to complete axillary lymph node dissection (ALND) in clinically node-negative breast cancer patients. A previous breast biopsy has been considered a relative contraindication to SLNB. We examined the accuracy of SLNB by following the axillary relapses after the procedure in patients who had undergone a breast biopsy before SLNB.Patients and Methods. Up to December 2003, 4351 patients with the diagnosis of invasive breast cancer underwent SLNB at the European Institute of Oncology. Already, 543 of these patients had undergone a breast biopsy; from June 1997 to January 2004, these patients received SLNB by lymphoscintigraphy performed on the biopsy area. We followed these patients with a clinical assessment every 6 months and instrumental examinations every year, particularly focusing on the research of axillary relapse of disease.Results. In 70.4% of cases, the sentinel node was negative, and only three cases underwent further axillary dissection. The sentinel node was identified in 99% of cases and this was the only positive node in 61.5% of cases with positive axillary nodes. The median follow-up was 2 years; 4 nodal recurrences were observed: 3 axillary lymph node relapses and 1 loco-regional.Conclusions. SLNB accuracy after a previous breast biopsy is comparable with the results obtained in validation studies. SLNB after a previous breast biopsy can be considered a standard procedure. Lymphoscintigraphy identifies the sentinel node in 99% of patients.     

Prognosis of breast cancer patients treated with sentinel node biopsy in Japan

BACKGROUND: Sentinel node biopsy predicts accurate pathological nodal staging. The survival of node-negative breast cancer patients should be evaluated between the patients treated with sentinel node biopsy alone and those treated with axillary lymph node dissection. METHODS: Ninety-seven patients with negative axillary nodes underwent sentinel node biopsy immediately followed by axillary lymph node dissection between January 1998 and June 1999 (the ALND group). Since then, if sentinel lymph nodes were negative on the frozen-section diagnosis, 112 patients underwent sentinel node biopsy alone without axillary lymph node dissection between July 1999 and December 2000 (the SNB group). We retrospectively observed the outcome of the two study groups. RESULTS: Median follow-up was 52 months in all patients. Relapse-free survival rates at 3 years in the ALND and SNB groups were 94% and 93%, respectively. Five of the 112 patients in the SNB group had overt axillary metastases. Three of them with axillary metastases alone were treated with delayed axillary lymph node dissection. These three patients have been free of other events for 3 years after local salvage treatment. CONCLUSIONS: Sentinel node biopsy will emerge as a standard method to diagnose axillary nodal staging for clinically node-negative breast cancer patients.     

Prognosis of occult breast carcinoma presenting as isolated axillary nodal metastasis

Axillary metastasis from an occult breast carcinoma is an uncommon presentation and presents a therapeutic dilemma. The objective of this study is to describe the presenting clinical features, management approach and treatment outcomes for occult breast carcinoma. We conducted a retrospective review of patients who presented with axillary nodal metastases from an occult breast carcinoma between 1997 and 2004 at the Roswell Park Cancer Institute; 2,150 patients were diagnosed and treated for breast cancer during this period. After excluding stage I and IV patients, we identified 642 who had disease metastatic to lymph nodes, 10 of these had no primary tumor in the breast despite a thorough evaluation including bilateral mammography and breast ultrasound. Of these, 7 had undergone breast magnetic resonance imaging as well. All patients underwent axillary nodal dissection. The breast was managed with radiotherapy alone in 8 patients, wide local excision with radiation therapy in 1 patient and 1 patient underwent mastectomy. No patient had a recurrence with a median 57 months of follow-up. Breast conservation with radiation therapy alone can be considered as a management option for women with occult breast cancer presenting with axillary nodal metastasis.     

A case of secretory carcinoma of the breast in an adult

This report describes a case of secretory carcinoma of the breast in the adult. The patient, a 56-year-old female, had a tumor, 1 cm in size, in the upper outer quadrant of her left breast, and Patey's modified radical mastectomy was performed. No nodal metastases were found. Although secretory carcinoma of the breast has been called "juvenile carcinoma", 27 adult cases have been reported previously in the English and Japanese literature. It is reported to have a good prognosis but surgical therapy with an axillary node dissection is recommended, since axillary metastases have been found in approximately 30% of the recorded cases.     

隐匿性乳腺癌的诊断和治疗

目的 探讨隐匿性乳腺癌的诊断、治疗及预后.方法 收集23例隐匿性乳腺癌患者的临床和随访资料,并进行分析.结果 23例患者均为女性,平均57.7岁.术前行影像学检查22例,其中行乳腺超声检查17例,8例发现可疑结节;行乳腺钼靶摄片9例,阳性3例;行乳腺MRI检查2例,1例发现异常钙化.20例行同侧乳腺癌改良根治术,16例进行化疗,4例放疗.随访期间,2例患者发生肺转移,其中1例多处转移.结论 术前排除其他部位原发癌的可能后,表现为腋窝淋巴结转移癌的患者即可诊断隐匿性乳腺癌.对隐匿性乳腺癌,乳腺必须进行治疗,可行乳腺癌改良根治术或腋窝淋巴结清扫+全乳放疗.