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 originating from aberrant breast tissue. A case report and review of the literature

Carcinoma arising from ectopic breast tissue, either supernumerary breast or aberrant breast tissue, is extremely rare. Carcinoma occurs more frequently in the ectopic breast tissue of the axilla than in extra-axillary ectopic breast tissue. Here we report a case of an invasive lobular carcinoma arising from extra-axillary ectopic breast tissue and presenting as a subcutaneous nodule.     

Primary infiltrating ductal carcinoma arising in aberrant breast tissue of the axilla: a rare entity. Report of a case

A 52-year-old woman presented with a palpable nodule in the right axilla. Physical examination revealed a 2.5 x 2.5 cm, nontender, firm, brownish, and peripherally hyperemic mass with overlying skin retraction on the right anterior axillary fold. Bilateral mammogram was negative. Ultrasonography of the right axillary region showed a 1.8 x 1.1 cm, poorly defined hypoechoic mass with irregular margins and posterior acoustic shadowing. Fine-needle aspiration biopsy of the mass revealed malignant epithelial cells. The patient underwent a wide local excision of the right axillary lesion with en bloc axillary lymph node dissection. Histopathological examination revealed an infiltrating ductal carcinoma. Here we report this case of carcinoma originating from aberrant breast tissue in the axilla. It is suggested that subcutaneous lesions of uncertain origin around the periphery of the breast should be suspected for breast carcinoma and treated appropriately.     

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.     

Primary ectopic breast cancer presenting as a vulvar mass

Ectopic breast tissue is found along the primitive embryonic milk lines, which extend from the axilla to the groin. Rarely, its occurrence has been described in the vulva. We report a patient who developed primary adenocarcinoma of ectopic breast tissue in such a location and present a review of the pertinent medical literature. The predominant pathology is that of invasive ductal carcinoma; however, other tumor types have also been reported in accessory breast tissue. Its treatment usually entails surgical resection with lymph node dissection. Adjuvant therapy should be guided by the same principles as in orthotopic breast carcinoma.     

Ectopic breast cancer: Two case reports and review of the Japanese literature

Two cases of carcinoma involving ectopic breast tissue are reported, along with a review of the Japanese literature. A total of 65 cases of ectopic breast cancer have been reported; 59 of which occurred in the axilla. Total mastectomy with axillary dissection was performed in 29 cases, and tumor excision with or without nodal dissection was done in 30 cases. Outcome was known in 33 cases, and 5 cases had recurred at the time of this writing. Although the prognosis of ectopic breast cancer was difficult to establish with the limited follow-up data, all the 5 cases in our series with recurrence had axillary lymph node metastases at the time of surgery. Therefore, the complete excision of ectopic breast tissue with nodal dissection, and subsequent chemoendocrine therapy, especially in node-positive patients, is recommended as the treatment of choice.     

Ectopic breast tissue in axillary lymph node

Benign epithelial inclusions are uncommonly found in lymph nodes, and ectopic breast tissue in axillary lymph nodes is particularly uncommon. The patient is a 48-year-old woman who had an adenoma of the nipple removed 10 years previously. A swollen lymph node with amorphous calcifications in a clustered distribution on mammogram was found in the left axilla. Fine needle aspiration cytology showed only cystic change. Excisional biopsy was performed and microscopic examination demonstrated that the node contained benign mammary epithelial and glandular inclusions, and no evidence of malignancy. Such cases will be increasingly found due to the widespread use of mammography screening and biopsy of axillary sentinel lymph nodes. Ectopic breast tissue in lymph nodes may be mistaken for malig-nant lesions. It is most important to identify correctly the epithelial inclusions in lymph nodes to prevent an erroneous diagnosis.     

Ectopic breast tissue in axillary lymph node.

Benign epithelial inclusions are uncommonly found in lymph nodes, and ectopic breast tissue in axillary lymph nodes is particularly uncommon. The patient is a 48-year-old woman who had an adenoma of the nipple removed 10 years previously. A swollen lymph node with amorphous calcifications in a clustered distribution on mammogram was found in the left axilla. Fine needle aspiration cytology showed only cystic change. Excisional biopsy was performed and microscopic examination demonstrated that the node contained benign mammary epithelial and glandular inclusions, and no evidence of malignancy.Such cases will be increasingly found due to the widespread use of mammography screening and biopsy of axillary sentinel lymph nodes. Ectopic breast tissue in lymph nodes may be mistaken for malignant lesions. It is most important to identify correctly the epithelial inclusions in lymph nodes to prevent an erroneous diagnosis.     

Two cases of tubular adenoma of the breast

Two rare cases of a tubular adenoma of the breast are reported, together with a clinicopathological review of the pertinent literature. Only 14 cases of this histological type have so far been reported in Japan. Both patients were single women aged 22 and 34 years, respectively. In case 1, a mass was found in the axilla, and in case 2, a breast cancer was simultaneously found in the contralateral breast. In each patient, a mass that measured 2 cm in diameter was oval, elastic and firm and smooth on the surface. In each instance the result of the biopsy performed led to a diagnosis of a fibroadenoma. Microscopically, the tumor was sharply demarcated from the adjacent breast tissue and consisted of homogeneous epithelial cells with small tubular structures and a minimal stromal component.     

Positive and negative aspects of sentinel lymph node biopsy in breast cancer

The sentinel lymph node (SLN) is the first lymph node to receive lymphatic drainage from a tumor. SLN biopsy has become a mainstay of breast cancer management and is used when the axilla is clinically clear of disease. Staging of the axilla in breast cancer is used to predict prognosis and in planning adjuvant treatment. SLN biopsy is not used where there has been previous axillary or breast radiotherapy or surgery, locally advanced or inflammatory disease and stage IV disease. Controversies remain in several specific clinical situations, including management of the axilla following detection of a positive SLN. There are no sufficiently robust predictive tumor features to prevent completion axillary dissection in these cases. However, there is evidence that immediate axillary surgery for operable, clinically node-negative breast cancer provides no survival benefit and may be unnecessary for many women. SLN biopsy may have a role after neoadjuvant chemotherapy, sparing some women from axillary node dissection. Further work is required to ascertain SLN biopsy sensitivity prior to its routine use in the clinic for multicentric and multifocal disease.     

Accessory breast tissue in axilla masquerading as breast cancer recurrence

Ectopic or accessory breast tissue is most commonly located in the axilla, though it may be present anywhere along the milk line. Development is hormone dependent, similar to normal breast tissue. These lesions do not warrant any intervention unless they produce discomfort, thus their identification and distinction from other breast pathologies, both benign and malignant, is essential. We report a case with locally advanced breast cancer who presented with an ipsilateral axillary mass following surgery, radiotherapy, and chemotherapy. Subsequent evaluation with excision biopsy showed duct ectasia in axillary breast tissue and the patient was continued on hormone therapy with tamoxifen.     

Individualizing Axillary Management in Breast Cancer Treatment

Management of the axilla in patients with breast cancer has evolved significantly in the last century. The status of the axillary lymph nodes continues to provide important prognostic information. However, in contrast to the beliefs of Halsted, we now understand that surgical clearance of the axilla is not critical to long-term survival. Indeed, tumor biology and occult systemic metastases determine long-term survival after breast cancer treatment. Randomized controlled trials have demonstrated the safety and efficacy of sentinel lymph node biopsy in patients with early breast cancer and without clinical evidence of axillary involvement. Management of the axilla should be tailored to the individual patient’s clinical stage, patient and tumor characteristics, and treatment preferences. Special consideration should be given to the following situations: elderly patients, pregnancy, treatment of DCIS, prior axillary surgery, prophylactic mastectomy, inflammatory breast cancer, and neoadjuvant chemotherapy. Management of the axilla will continue to change as additional evidence from randomized controlled trials becomes available.     

Primary carcinoma of ectopic breast tissue

We describe a case of a 37-year-old woman with a left axillary mass. Often, the initial differential diagnosis of an axillary mass is not easy to make. We performed fine-needle aspiration of the axillary mass that revealed the presence of numerous epithelial neoplastic cells. A bilateral digital mammography, chest and abdomen computed tomography scan, and a magnetic resonance imaging scan (MRI) of the axillary region were performed. In our case, the MRI was able to exclude the presence of neoplastic tissue in the breast; moreover, it confirmed the presence of metastatic lymph nodes and recognized a second type of nodular lesion in the axilla, showing on the MRI a radiologic pattern similar to breast tissue.     

Clinicopathological study of 9 cases presenting axillary masses only

A clinicopathological study of 9 cases presenting axillary mass alone was reported. Histological diagnosis revealed 3 occult breast cancers, 2 apocrine gland adenocarcinomas of the skin, a carcinoma and a fibroadenoma in the axillary accessory breast, a neurogenic tumor in the axilla, and a benign lymphadenopathy. There were no clinical characteristics helpful in preoperative differential diagnosis. As the axilla includes the main lymphatic routes from the breast, the axillary tail of the breast and accessory breast, breast-associated tumors should be kept in mind in the management of patients with axillary mass as a sole clinical feature.     

Interventional MR-mammography: manipulator-assisted large core biopsy and interstitial laser therapy of tumors of the female breast]

The present study investigated the clinical application of magnetic resonance (MR)-guided breast interventions, such as manipulator-assisted large core breast biopsy (LCBB) inside a 1.5 T whole-body magnet and MR-guided interstitial laser therapy (ILT). Sixteen patients underwent LCBB and 1 additional patient underwent 4 sessions of ILT of a recurrent undifferentiated lymph node metastasis in the axilla using a Nd-YAG laser (1064 nm). Temperature changes of the tumor tissue during ILT were monitored using phase images of a gradient echo sequence (GRE) (TR/TE/FA = 25/12/30). In 5 patients the biopsy findings were histopathologically confirmed after open surgery. In 3 patients, the biopsy missed one tubular and one ductal carcinoma; one invasive carcinoma was underestimated. Eight patients with benign findings are still in the follow-up period. The heating zone during ILT was well delineated on subtracted phase images. No severe adverse events were observed with LCBB or ILT. MR-guided breast biopsies are feasible with the manipulator system inside a whole-body 1.5 Tesla MR scanner. GRE information is suitable for therapy monitoring during ILT within the tumor. Further studies are necessary to evaluate the accuracy of the manipulator system and the efficacy of ILT in the treatment of breast lesions.     

The benefits and limitations of sentinel lymph node biopsy

Opinion statement The status of the axilla is the single most important prognostic indicator of overall survival in patients with breast cancer. Staging is based on tumor size and on the presence of lymph node metastases. The number of lymph nodes, although prognostic, no longer impacts treatment options. Sentinel lymph node (SLN) mapping and dissection is a more sensitive and accurate technique for nodal evaluation and has been applied to staging of axillary lymph nodes in patients with breast cancer, providing prognostic information, with less surgical morbidity than with axillary lymph node dissection (ALND). When analyzed by an experienced pathologist with serial sectioning and immunohistochemical evaluation, SLN is the most accurate detection tool used in staging of breast cancer. In many centers that use these staging principles, ALND is no longer performed for histologically negative axillary SLNs. In addition, this technique may also be therapeutic because in most patients, the SLN is the only positive axillary node. SLN biopsy is justified in women with ductal carcinoma in situ who have a high risk of invasive carcinoma, such as those with large tumors, a mass, or high-grade lesions. SLN biopsy is performed in the setting of neoadjuvant chemotherapy and demonstrates accurate evaluation of the axilla in 90% of the cases. Women with locally advanced breast cancer may derive great benefit from a minimally invasive approach to the axilla because the extent of nodal involvement is unlikely to change further treatment. For clinically palpable nodes, ALND should be performed for therapeutic and local control. The use of sentinel node mapping in pregnancy is controversial. Vital blue dye is contraindicated in pregnant patients, although some have used radioactive colloid alone to map this subgroup of patients.     

Conservation of the axilla: an audit of sentinel lymph node biopsy after a new start

Background

Four hundred twenty-eight patients with a diagnosis of breast cancer were assessed. All patients underwent axillary ultrasonographic scanning preoperatively or at the time of initial breast imaging. Suspicious axillary glands underwent core needle biopsy under ultrasonographic guidance.

Patients and Methods

The majority of patients were in the age range of 40 to 80 years. Sentinel lymph node biopsy (SLNB) was performed in 360 patients.

Results

Sixty-eight patients had axillary clearance as a first axillary procedure. Of these patients, 55 had a preoperative diagnosis of a positive axillary gland in the axilla on ultrasonographically guided core needle biopsy, and 13 had clinically palpable axillary lymph glands. Seventy-one patients (21%) had a positive sentinel lymph node on histopathologic examination after hematoxylin and eosin (H & E) staining. Preoperative scans of the axilla had been reported as normal in these patients. In 68 patients, further axillary surgery was performed to clear the axilla; 24 of these patients (35%) had more positive glands in the axilla. In 44 patients (65%) the sentinel lymph glands were the only positive glands. Of 224 patients with a tumor size ≤ 20 mm, there were 30 patients (14%) who had a positive sentinel node. Of 136 patients with a tumor size > 20 mm, there were 41 patients (33%) with positive sentinel nodes.

Conclusions

Sentinel lymph node biopsy in breast cancer allowed conservation of the axilla in 80% (289/360) of patients with negative sentinel lymph nodes in this study. Preoperative ultrasonographically guided core needle biopsy reduced the need for a second operation in 55 patients (13%).     

Synchronous bilateral male breast cancer: a case report

Synchronous bilateral breast cancer is extremely rare in men and has not, up to date, been reported in Korea. A 54-year-old man presented with a palpable mass in the right breast. The right nipple was retracted and bilateral axillary accessory breasts and nipples were present. On physical examination, a 2 cm-sized mass was palpated directly under the right nipple, and, with squeezing, bloody discharge developed in a single duct of the left nipple. There was no palpable mass in the left breast, and axillary lymph nodes were not palpable. Physical examination of external genitalia revealed a unilateral undescended testis on the left side. Synchronous bilateral breast cancer was diagnosed using mammography, ultrasonography, and core-needle biopsy. Histopathological examination revealed invasive ductal carcinoma in the right breast and ductal carcinoma in situ in the left breast. Bilateral total mastectomy, sentinel lymph node biopsy, and excision of accessory breasts in the axilla were performed.     

Five-node biopsy of the axilla: an alternative to axillary dissection of levels I-II in operable breast cancer.

BACKGROUND: Axillary clearance of patients with early breast cancer is accompanied by a high risk of arm morbidity. Less invasive ways to establish the axillary nodal status are therefore of interest, especially in women with low risk of nodal metastases. METHODS: Four hundred and fifteen breast cancer patients (clinical stage T(0-3) N(0-1) M(0)) were operated in the axilla with a five-node biopsy followed in the same operation by a further dissection of levels I-II of the axilla in order to evaluate the accuracy of the five-node node biopsy compared with level I-II dissection. RESULTS: In all patients the sensitivity of the five-node biopsy was 97.3% with a negative predictive value of 98.5% and a negative likelihood ratio of 0.027. Among cases detected by screening (n=204) and those clinically detected (n=197) the sensitivity of the five-node biopsy was 95.8% and 97.9% respectively, with negative predictive values of 98.7% and 98.0% and negative likelihood ratios of 0.042 and 0.021 respectively. CONCLUSION: Five-node biopsy of the axilla has good accuracy for correctly staging the axilla in both clinically and screening-detected cases. Five-node biopsy is an alternative to axillary clearance and sentinel node biopsy in patients with operable breast cancer. Copyright Harcourt Publishers Limited.     

副乳腺浸润性导管癌1例并文献复习

目的：探讨副乳腺癌的诊断、鉴别诊断以及治疗方法。方法：报道腋窝副乳腺浸润性导管癌1例,结合文献对副乳腺癌的特点、临床表现、诊断、鉴别诊断、治疗以及预后进行探讨。结果：副乳腺癌的发病率较低,结合临床表现、镜下观察及免疫组化方法,可以明确诊断。注意与乳腺腋尾部癌、皮肤附件来源的肿瘤、腋下淋巴结转移癌、腋下淋巴结淋巴瘤等疾病进行鉴别诊断;治疗原则基本等同于乳腺癌的治疗。其预后较差,术后积极放化疗,有可能改善预后。结论：副乳腺癌相对少见。有副乳腺症者应加强自检,做到早期发现早期治疗。新辅助化疗联合手术治疗对提高患者的生存率很重要。