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.     

Multicentric Breast Cancer of the Axillary and Pectoral Breasts: A Case Report and Literature Review

Multicentric cancer of the pectoral and ectopic breasts is extremely rare, and diagnosing this malignancy remains challenging because axillary breast cancer is easily misdiagnosed as lymph node metastasis. Moreover, there are no established treatment guidelines for this disease. We present our experience with a multicentric breast cancer patient who showed different responses to neoadjuvant chemotherapy (NAC) and underwent surgical treatments that differed from those in previous studies. In our case, the preoperative imaging of both lesions and subsequent core needle biopsy of each lesion were crucial, as these procedures confirm the diagnosis and help decide the chemotherapy regimen based on the subtype. After NAC, the patient underwent right breast-conserving surgery, sentinel lymph node biopsy (SLNB), and excision of accessory breast tissue in the right axilla. SLNB should be the initial step in staging multicentric breast cancer, unless imaging scan shows evidence of lymph node metastasis.     

Tuberculosis of axillary lymph nodes with primary breast cancer

A rare case of tuberculosis of axillary lymph nodes occurring with primary breast cancer is presented. A 78-year-old woman with no history of pulmonary tuberculosis was admitted to our hospital to undergo examination for a lump in her right breast. The tumor was in the upper outer quadrant of the right breast. On palpation, the tumor was 1.2 cm in diameter and axillary lymph node swelling was noted. Mammography disclosed a spiculated mass and swelling and calcification of the axillary lymph nodes. Sonography showed an irregular hypoechoic mass in the right breast and lymph node swelling in the right axilla, indicating breast cancer with axillary lymph nodes metastases. Chest X-ray showed clustered calcifications in the right axilla and a granular shadow in the right upper lobe. Breast conserving therapy was carried out. Invasive papillotubular carcinoma of the right breast and granulomas with calcification of lymph nodes, compatible with tuberculosis, was diagnosed. Tubercle bacillis were detected by culture of lymph nodes. This case suggests that X-ray is useful for diagnosing lymph node tuberculosis. Lymph node tuberculosis should be suspected when lymph node swelling is noted and X-ray shows clustered calcifications in axillary lymph nodes.     

A case of occult breast carcinoma with irradiation therapy and axillary lymph node dissection

A 78-year-old woman was seen at the hospital for a swollen left axillary node. There was an elastic hard mass measuring 0.7 cm in diameter in the left axilla, but no breast mass was palpable in the bilateral breasts. Mammography did not reveal any tumor and calcification, and there was no abnormalities on breast ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI). Aspiration biopsy cytology of the left axillary node revealed adenocarcinoma. Systemic examination failed to reveal primary lesion. Thus, to make the diagnosis, we enucleated the axillary nodule. Immunohistochemical staining for the excisional specimen revealed an estrogen receptor, progesterone receptor and gross cystic disease fluid protein-15 (GCDFP-15) was strongly positive, so we diagnosed it as an occult breast carcinoma. After obtaining her informed consent, the patient underwent left axillary lymph node dissection and irradiation therapy of the left breast. The patient has been disease-free under adjuvant chemoendocrine therapy. We treated the occult breast carcinoma with radiation therapy of the breast and axillary lymph node dissection, and provided a review of the literature.     

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.     

Axillary sentinel lymph node biopsy after neoadjuvant chemotherapy for carcinoma of the breast

BACKGROUND:

The timing and accuracy of axillary sentinel lymph node biopsy (SLNB) in patients who are receiving neoadjuvant chemotherapy (NACT) for breast cancer are controversial. To examine the accuracy of SLNB after NACT, the authors performed SLNB after chemotherapy on all of patients who received NACT at their institution starting in January 1997.

METHODS:

Seventy‐nine women who underwent NACT between 1997 and 2008 comprised this study and were divided as follows: 4 women had stage I disease, 60 women had stage II disease, and 15 women had stage III disease, including 10 women who had multicentric disease. Thirty‐nine women (49.4%) had clinical evidence of axillary metastasis (N1‐N2) at the time of diagnosis. The regimen, the duration of treatment, and the number of cycles of NACT depended on clinical response. The choice of breast conservation therapy or mastectomy was based on the patient's response to treatment and patient preference. All patients underwent SLNB after NACT.

RESULTS:

Seventy‐three patients underwent breast conservation therapy, and 6 patients underwent mastectomy. Sentinel lymph nodes were identified in 98.7% of patients (in 1 patient, SLNB failed to capture 1 proven axillary metastasis), and 29 patients underwent full axillary lymph node dissection. Fourteen patients (17.7%) had no residual carcinoma (invasive or ductal carcinoma in situ) in their breast, 5 patients (6.3%) had residual ductal carcinoma in situ (only), and 60 patients (75.9%) had residual invasive carcinoma. One false‐negative SLNB was reported in the group of 23 patients who underwent full axillary dissection after a negative SLNB. No patient had a subsequent axillary recurrence.

CONCLUSIONS:

SLNB after NACT was feasible in virtually all patients and accurately selected patients who required complete level I and II axillary dissection. NACT frequently downstaged the axilla, converting patients with N1‐N2 lymph node status to N0 status and also avoiding full axillary dissection in these patients. Cancer 2010. © 2010 American Cancer Society.     

Isoechoic axillary lymph node metastases of mucinous carcinoma of the Breast: A case report

We report a case of isoechoic axillary lymph node metastasis of mucinous carcinoma (so-called pure mucinous carcinoma) of the breast. A 47-year-old premenopausal woman was referred to our hospital with a 2 years history of mass and distortion of her left breast and with recent worsening of her symptoms. Ultrasonography demonstrated a well-circumscribed mass, about 5 cm in diameter, which was isoechoic compared to the surrounding fat tissue. Distal enhancement was also recognized. A left axillary ultrasonographic scan demonstrated four nodules, which were indistinct because of their isoechogenicity compared to the surrounding tissue. Based on a preoperative diagnosis of mucinous carcinoma of the left breast with left axillary lymph nodes metastases, left mastectomy and left axillary nodal dissection were performed. Mucinous carcinoma with axillary lymph node metastases was diagnosed histologically. The lymph node metastases showed histological findings identical to those of the primary tumor, which was considered to be the reason for their isoechogenicity. Although lymph node metastasis of mucinous carcinoma of the breast is rare, ultrasonographers should perform careful scanning when the primary breast mass is suspicious for mucinous carcinoma, because lymph node metastases of mucinous carcinoma can be more indistinct and difficult to detect than those of other types of breast cancer.     

Sentinel lymph node mapping of a breast cancer of the vulva: Case report and literature review

Ectopic breast tissue is rare and typically presents as an axillary mass. Previous reports have identified ectopic breast tissue in the vulva, but malignancy is exceedingly uncommon. We present a 62 years old with locally advanced breast carcinoma arising in the vulva demonstrates the utilization of sentinel lymph node mapping to identify metastatic lymph nodes previously unable to be identified via traditional surgical exploration. Our case supports the principles of adjuvant therapy for breast cancer to be applied to ectopic breast cancer arising in the vulva. A literature review highlights common key points in similar cases to guide management.     

Axillary metastasis as first symptom of occult breast cancer: a case report

Axillary lymph node metastasis from an occult breast carcinoma is a rare occurrence. We report this condition in a 59-year-old woman who presented with a swelling in the right axilla. No breast mass was clinically evident. Mammography, ultrasonography and multiple random fine-needle breast biopsies yielded no pathological findings. No extramammary primary lesions were present. Axillary sampling was performed and histological examination revealed the presence of metastatic adenocarcinoma in three of the 12 dissected lymph nodes. Estrogen receptors were positive and immunohistochemistry pointed to a breast origin. All these data were suggestive of occult breast cancer. The patient refused any further treatment but accepted clinical and radiological follow-up. Eight years later mammography revealed in the same breast a 10-mm nodule containing microcalcifications, which was not evident at physical examination. The patient underwent a lumpectomy. Intraoperative histology was positive for breast carcinoma and complete axillary clearance was performed. Histological examination revealed a lobular invasive breast carcinoma and the presence of micrometastasis in one of the 23 removed lymph nodes. The patient was given radiotherapy to the breast and axilla and tamoxifen. At present, one year after the appearance of the primary tumor, she is free of disease. Based on this case report we suggest an eclectic approach in the management of patients with axillary metastasis from occult breast cancer, depending on the clinical, pathological and biological findings.     

The risk of nodal metastases in breast cancer patients with clinically negative lymph nodes: a population-based analysis

A population-based study was performed to assess the likelihood of axillary lymph node metastases in patients with clinically negative lymph nodes, according to patient age, tumor size and site, estrogen receptor status, histologic type and mode of detection. Data were obtained from the population-based Eindhoven Cancer Registry. During the period 1984–1997, 7680 patients with invasive breast cancer were documented, 6663 of whom underwent axillary dissection. Of the 5125 patients who were known to have clinically negative lymph nodes and underwent axillary dissection, 1748 (34%) had positive lymph nodes at pathological examination. After multivariate analysis, histologic type, tumor size, tumor site and the number of lymph nodes in the axillary specimen remained as independent predictors of the risk of nodal involvement (P<0.001). Lower risks were found for patients with medullary or tubular carcinoma, smaller tumors, a tumor in the medial part of the breast and patients with less than 16 nodes examined. This study gives reliable estimates of the risk of finding positive lymph nodes in patients with a clinically negative axilla. Such information is useful when considering the need for axillary dissection and to predict the risk of a false-negative result when performing sentinel lymph nodebiopsy.     

Is It Contralateral Axillary Metastasis or Occult Breast Cancer?: A Confusing Case Report

We report the case of a 43-year-old woman with primary left breast cancer presenting metastatic lymphadenopathy in the contralateral axilla. This patient represents a diagnostic and therapeutic challenge because primary breast cancer, occult contralateral breast cancer, and extra-mammary primary lesion can all be the source of the contralateral axillary metastasis. Left breast-conserving surgery, left sentinel lymph node biopsy, right breast mass excision, and right axillary lymph node dissection were performed. Immunohistochemical analysis revealed that the left breast cancer specimen was positive for estrogen receptor (ER) and progesterone receptor (PR), but negative for human epidermal growth factor receptor 2 (HER2). In contrast, the right axillary lymphadenopathy specimen was negative for ER and PR, but positive for HER2. Further investigation revealed no evidence of occult primary cancers or extra-mammary tumors. After surgical intervention, the patient was treated with adjuvant chemotherapy, adjuvant radiation therapy, and targeted therapy with trastuzumab. Two years after diagnosis, she is free of disease and presently being treated with tamoxifen.Key Words: Breast carcinoma, Occult primary tumor, Contralateral axillary lymph node metastasis, Immunohistochemistry     

隐匿性乳腺癌诊治探讨

目的探讨隐匿性乳腺癌诊断和治疗方法。方法对我院1991年8月至2001年7月收治的11例隐匿性乳腺癌患者进行回顾性研究。结果本组11例均为女性，年龄最小44岁，最大70岁，中位年龄55岁。首发症状均为腋窝肿物，左侧4例，右侧7例。合并锁骨上淋巴结转移2例。查乳腺钼靶片8例、CT2例均阴性。查乳腺超声8例，发现同侧乳腺肿物3例。手术行改良根治术4例，腋窝淋巴清扫3例，腋窝肿物切除2例，锁骨上淋巴结活检2例。术后按乳腺癌治疗方案行放化疗和内分泌治疗。随访8个月至9年6个月。死亡3例，5年生存率54．5％（6／11）。结论对于女性患者经病理证实的腋窝淋巴结转移性腺癌。如无其他脏器原发癌证据，即使乳腺未发现肿物亦应考虑为隐匿性乳腺癌，受体测定有助于诊断。治疗应根据乳腺癌治疗规范进行综合治疗。手术可行改良根治或根治性保乳术，对于乳腺无原发癌证据者可行腋窝淋巴清扫术。     

Clinical applications of positron emission tomography in sarcoma management

The standard of care in the management of the axilla for a woman with breast cancer was traditionally a level I and II axillary lymph node dissection (ALND). Since the pivotal studies in the mid-1990s, sentinel lymph node biopsy (SLNB) in breast carcinoma has come to replace ALND in women with clinically negative axillas. With the increased use of SLNB in women who present with breast carcinoma, the role of completion ALND for a positive sentinel lymph node has been challenged. We review the literature available and discuss future directions in identifying a subgroup who may avoid an ALND.     

Axillary mass suspected to be occult breast carcinoma: a case study of skipped axillary lymph node metastasis from endometrial carcinoma in which core-needle biopsy was useful for diagnosis

A 55-year-old Japanese woman presented with metrorrhagia and was diagnosed with endometrial carcinoma. Chest computed tomography (CT), ultrasonography (US) and magnetic resonance imaging (MRI) showed a left axillary mass. Regarding the diagnosis of the axillary mass, lymph node metastasis from the uterus was first suspected. Metastasis from the breast, lung, thyroid or stomach was considered next. On a general search including positron emission tomography (PET)-CT, there was no abnormality except endometrial carcinoma and the left axillary mass. Skipped axillary lymph node metastasis of endometrial carcinoma is extremely rare, with a reported incidence of 0.03% of endometrial carcinoma cases. The differential diagnosis was double carcinoma of the uterus and breast. We carried out US-guided core needle biopsy (CNB) of the axillary mass, and the histopathological findings suggested axillary lymph node metastasis from endometrioid carcinoma. US-guided CNB is a valid method for accurate diagnosis of an axillary mass.     

Breast cancer metastasis and lymph node lymphocyte-macrophage interaction

A lymphocyte-macrophage interaction, known as the lymphocyte clustering phenomenon, was studied in axillary lymph node preparations from 27 breast cancer patients. The study was carried out in primary tissue cultures of lymph nodes and the lymphocyte-macrophage interactions were quantitated with respect to cancer positive and cancer negative axilla. The results indicate that there is a significantly higher (p< 0.025) lymphocyte-macrophage interaction in negative node preparations from negative axilla of infiltrating ductal carcinoma patients. This new approach to lymph node lymphocyte evaluation may provide assistance in determining the extent of the disease process.     

Unknown primary carcinoma, diagnosed as inflammatory breast cancer,and successfully treated with trastuzumab and vinorelbine

Occult breast cancer presenting with axillary lymph node metastases is uncommon, and inflammatory breast cancer (IBC), as a subtype, is quite rare. Here we describe a case of IBC, which arose as an unknown primary carcinoma; the patient presented with axillary lymph node metastasis, and was successfully treated with trastuzumab and vinorelbine. Specifically, a 55-year-old woman presented with right axillary lymphadenopathy. Although she underwent various examinations, the primary site of the disease was not revealed. Axillary lymph node dissection was performed, and the lesion was diagnosed as a poorly differentiated adenocarcinoma. The patient chose to be treated by alternative medicine. About 6 months later, she was referred to our hospital, due to marked bilateral neck and axillary lymph node swelling. She presented withdiffuse right breast enlargement, redness, and peau d’orange. Computed tomography (CT) of the breast showed skin thickening and swelling of the right breast.F-18 Fluorodeoxyglucose positron emission tomography (FDG-PET) showed FDG uptake in the right breast. The patient was clinically diagnosed with IBC. Because overexpression of the human epidermal growth factor receptor 2 (HER2) was found in the specimen from her right axillary lymph node, she was treated with trastuzumab and vinorelbine. Two months after the start of chemotherapy, CT revealed a complete response in the lymph nodes, and the skin thickening and parenchymal edema of the right breast had improved. FDG-PET was also performed at this time, and revealed no FDG uptake in either the right breast or the lymph nodes.     

Phyllodes tumor arising in ectopic breast tissue of the axilla

We examined a 31-year-old woman with a solid mass in her left axilla. Physical examination and ultrasonography confirmed a 2 cm well-defined mass. Fine needle aspiration biopsy suggested fibroadenoma of breast. Excisional biopsy revealed benign phyllodes tumor of the ectopic breast tissue. Phyllodes tumor in ectopic breast tissue is an extremely rare occurrence. Only nine cases have been reported, including tumors of the vulva, inguinal region and axilla. This is the second case in the axillary region.     

IV-DSA is a new diagnostic tool for axillary lymph node metastasis in breast cancer patients

BACKGROUND AND OBJECTIVE: The aim of this study is to know whether intravenous digital subtraction angiography (IV-DSA) is useful to detect axillary lymph node metastasis of breast cancer and to evaluate the anigiogenesis of lymph nodes in the axilla. PATIENTS AND METHODS: Forty three primary breast cancer patients (N0: 26 cases, N1: 5 cases, N2: 2 cases) who underwent IV-DSA between January and November 2000 were included in the study. Infinix CB apparatus (Toshiba, Japan) was used to collect IV-DSA images and when a mass became stained in the axilla, it was considered to be metastatic. The angiogenesis was studied by examining microvessel density (MVD) after lymph node immunostaining for factor VIII. Primary tumor was detected by IV-DSA in all 43 cases. RESULTS: Axillary lymph node metastases were detected by IV-DSA in 34.9% of cases (15/43), and by pathology in 37.2% (16/43). The sensitivity, specificity, and accuracy of the diagnostic method were 75.0% (12/16), 88.9% (24/27), and 83.7% (36/43), respectively. MVD, calculated after immunostaining for factor VIII, was significantly lower in the in metastatic region of lymph nodes identified by DSA (88.5 +/- 35.0) than in metastasis-free lymph nodes (141.1 +/- 34.0, P < 0.0001). CONCLUSIONS: IV-DSA is useful in the diagnosis of axillary lymph node metastasis of breast cancer. Our results suggest that the primary factors involved in the mechanism of DSA display may be different from high/low MVC values.     

Contralateral uptake and metastases in sentinel lymph node mapping for recurrent breast cancer

BACKGROUND AND OBJECTIVES: Sentinel lymph node mapping as a constitutive component in the staging process for invasive breast cancer continues to gain acceptance. We have identified two patients with recurrent invasive breast cancer in whom contralateral sentinel lymph node uptake and metastases, respectively, were detected. Such findings have not been previously reported in our review of the medical literature between 1966 and October 2004. METHODS: Sentinel lymph node mapping was performed on two patients with recurrent invasive breast cancer at our institution. At the time of their index diagnosis, both had received breast conserving surgery and an axillary lymph node dissection with post-operative radiotherapy (RT). All lymph nodes and margins of resection were without tumor. Both patients remained with no evidence of disease for years until routine serial screening mammography was interpreted as suspicious. Each underwent a stereotactic biopsy of the ipsilateral breast corresponding to the mammographic abnormality. Pathology confirmed invasive ductal carcinoma. Both patients refused the recommended salvage mastectomy. PRINCIPAL RESULTS: During a second attempt at breast conservation, sentinel lymph node mapping--which is typically contraindicated for patients with prior axillary surgery--revealed contralateral axillary uptake for both patients. The respective contralateral sentinel node was excised with pathology revealing no tumor in one case, and a microscopic focus of metastatic carcinoma in the second case. MAJOR CONCLUSION: Some patients may benefit from sentinel lymph node mapping prior to salvage mastectomy. Identifying uptake in a contralateral sentinel lymph node may change the multi-disciplinary management of recurrent invasive breast cancer to include a contralateral axillary dissection, chemotherapy, and/or RT to the contralateral axilla.     

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.