Sentinel lymph node biopsy after nipple-sparing mastectomy in early postoperative period: Is it feasible?

Background: Axillary lymph node status is one of the most important prognostic factors for breast cancer. Sentinel lymph node biopsy (SLNB) after mastectomy is highly controversial. There is not enough data about SLNB in the early period after nipple-sparing mastectomy (NSM). This study investigated the feasibility of SLNB in the early postoperative period of NSM. Materials and Methods: Patients who were operated on for breast cancer in Acibadem Maslak Hospital between 2009 and 2018 were searched retrospectively. Results of SLNB as the second session in patients whose final pathology report revealed breast carcinoma after contralateral/bilateral prophylactic mastectomy and mastectomy for benign lesions were evaluated. Results: In the early period (median 14 days) after NSM, SLNB was performed by intradermal radioisotope injection in five patients with occult breast cancer in contralateral/bilateral prophylactic mastectomy and in one patient with preoperatively suspicious mass which yielded breast cancer at final pathology. In five (80%) patients, SLNB was performed, whereas in one patient axillary lymph node dissection (ALND) was performed due to the undetectability of SLN. In one patient, micrometastasis was observed, whereas no metastasis was observed in other patients including the one who underwent ALND. No complication due to SLNB was detected. No recurrence and distant metastasis were detected in a mean follow-up of 42.82 (19-70) months. While SLNB did not change the treatment of patients with contralateral occult carcinoma, other patients had hormonal therapy due to negative SLNB. Conclusion: SLNB in the early postoperative period of NSM can be performed by intradermal radioisotope injection. However, further studies are needed to determine the feasibility of SLNB in the early postoperative period of NSM.

Clinicopathologic characteristics of malignant non-hematopoietic tumors first presented as an axillary mass with emphasis on occult breast carcinoma.

BACKGROUND: Non-hematopoietic malignancies first presented as an axillary mass constitute a unique clinical presentation. We investigated the incidence of various types of malignancies and aimed to define clinicopathologic variables that may assist in the diagnosis, with focus on occult breast carcinoma (OBC). DESIGN: We reviewed the pathology reports of cases with non-hematopoietic malignancies of the axillary region in our institution between 2000 and 2016. We included patients who presented first with axillary mass and with the absence of a known primary. We recorded patients' age and gender, tumor characteristics including size, histologic type, number of positive lymph nodes, and the clinical management. Then we focused on BC which were divided into OBC or primary BC (PBC). RESULTS: There were 100 cases that met our criteria (28 melanoma, 7 sarcoma and 65 carcinoma). For carcinoma cases, there were 42 BC (19 OBC, 17 PBC, and 6 possible OBC), 17 non-BC, and 6 carcinoma of unknown primary (CUP). Tumors found incidentally were more likely to be of breast primary (p = 0.01). Larger tumor size (in mm) favored melanoma or sarcoma over BC, non-BC carcinoma or CUP with median and range 61 (15, 180), 60 (23, 80), 30 (15, 75), 31 (17, 90), 26 (20, 55), respectively (p < 0.001). There were no differences in the histopathologic findings or clinical presentation. CONCLUSIONS: More than half of the patients with axillary malignancy have a tumor of non-breast origin. Therefore, clinical and pathologic studies are warranted to identify the primary site.

Characterization of invisible breast cancers in digital mammography and tomosynthesis: radio-pathological correlation. / Caracterización de cánceres de mama sintomáticos invisibles en mamografía digital y tomosíntesis: correlación radiopatológica.

OBJECTIVE: To review the radio-pathologic features of symptomatic breast cancers not detected at digital mammography (DM) and digital breast tomosynthesis (DBT). MATERIAL AND METHODS: Retrospective analysis of 169 lesions from symptomatic patients with breast cancer that were studied with DM, DBT, ultrasound (US) and magnetic resonance (MR). We identified occult lesions (true false negatives) in DM and DBT. Clinical data, density, US and MR findings were analyzed as well as histopathological results. RESULTS: We identified seven occult lesions in DM and DBT. 57% (4/7) of the lesions were identified in high-density breasts (type c and d), and the rest of them in breasts of density type b. Six carcinomas were identified at US and MR (BI-RADS 4 masses); the remaining lesion was only identified at MR. The tumor size was larger than 3cm at MRI in 57% of the lesions. All tumors were ductal infiltrating carcinomas, six of them with high stromal proportion. According to molecular classification, we found only one triple-negative breast cancer, the other lesions were luminal-type. We analyzed the tumor margins of two resected carcinomas that were not treated with neoadjuvant chemotherapy, both lesions presented margins that displaced the adjacent parenchyma without infiltrating it. CONCLUSION: Occult breast carcinomas in DM and DBT accounted for 4% of lesions detected in patients with symptoms. They were mostly masses, all of them presented the diagnosis of infiltrating ductal carcinoma (with predominance of the luminal immunophenotype) and were detected in breasts of density type b, c and d.

Incidental breast carcinoma in reduction mammoplasty.

AIM: The objective of this study was to analyze the incidence and treatment options of occult cancer or atypical lesions found in the histopathological examination of reduction mammoplasty (RM) specimens. The role of preoperative mammography and systematic histopathological examination are discussed. METHODS: We performed a retrospective single-center database review of all patients who underwent a RM between January 2005 and December 2014. Preoperative examination, histopathological findings and follow-up were documented. RESULTS: A total of 1045 patients underwent RM, of which 97% were bilateral (1021). All patients received a mammography and routine clinical examination to exclude cancer preoperatively. The overall mean patient age was 40.2 years (14.2-73.4). A total of 19 patients (1.18%) had significant histopathological findings, all of whom were over 40 years of age. There were 4 incidental carcinomas (0.38%), of which 2 were DCIS (0.19%) and 2 invasive ductal carcinomas (0.19%). CONCLUSIONS: Incidence of postoperative diagnosis of occult breast cancer in RM specimens remains low, but poses significant therapeutic challenges. While emphasis should lay on preoperative diagnostics, routine histological analysis of RM specimens is recommended.

[Axillary lymph node metastases with an occult breast: About 16 cases from a cohort of 7770 patients]. / Envahissement ganglionnaire axillaire sans tumeur primitive mammaire retrouvée : à propos de 16cas issus d'une cohorte de 7770patientes.

OBJECTIVES: Isolated axillary lymph node metastases is an unusual clinical presentation of breast carcinoma. We studied its different issues. METHODS: This study is a follow-up study of 16patients, treated between 1996 and 2012, presenting with axillary metastases with an occult breast carcinoma, which could not be identified by physical examination nor by a conventional imaging or a breast MRI. Clinical characteristics, histological analysis, treatment, monitoring and five-year survival rate were studied. RESULTS: The incidence of this kind of breast cancer was 0.20%. A breast MRI was performed in 75% of the patients. The histology of these tumors showed a rate of hormono-sensibility of 50% and an HER2 overexpression of 44%. Sixty-nine percent of the patients had no breast surgery or radiotherapy; global five-year survival rate for these women was 77.4%±11.5. CONCLUSION: The survival rates of this study should lead the practitioner to choose a less aggressive breast therapy. Moreover, the histological characteristics explain the high metastatic potential of these tumors, and relate them to the HER2+ subclass of gene expression patterns of breast carcinomas.

Analyses of treatment outcomes and prognostic factors for occult breast cancer / 中国肿瘤临床

Objective:Occult breast cancer (OBC) accounts for 0.3%-1.0%of all breast cancers. Because of the rarity of this dis-ease, its treatment and prognosis remain unclear. Our study evaluated the treatment outcomes and prognostic factors associated with OBC. Methods:A total of 82 patients diagnosed with OBC based on available criteria were treated at the Cancer Hospital of Chinese Academy of Medical Sciences, Beijing, China, between January 1968 and June 2014. Except for 16 patients who were treated by needle biopsy or excisional biopsy only and were subsequently excluded, all of the cases reported were included in the study. Of the remaining 66 patients, one was male. Patient data, tumor characteristics, and treatment and outcome variables were evaluated. Overall survival (OS) and disease-free survival (DFS) were analyzed. A unicentric retrospective review of 66 patients with OBC was performed. Re-sults:The median follow-up was 75.5 months (7.0-328.0). No significant differences in OS and DFS were observed between patients who underwent mastectomy plus axillary lymph node dissection (Mast+ALND) and those who underwent breast conservation surgery (P>0.05). Univariate analysis revealed that nodal status is a significant prognosis factor of DFS (P=0.031). Conclusion:No significant difference in treatment outcomes between mastectomy+ALND and breast conservation surgery was observed. Nodal status may be an independent predictor of poor outcomes in OBC patients.

Incidental atypical proliferative lesions in reduction mammoplasty specimens in patients with a history of breast cancer.

We recently reported the prevalence of atypical proliferative lesions (APL) in reduction mammoplasty specimens from patients that were treated mainly for macromastia with no known history of breast cancer. The current study is to investigate the prevalence of APLs in breast reduction specimens from patients with a history of breast cancer and compare it to that from patients without a history of breast cancer. A retrospective chart review of pathology records on patients that underwent reduction mammoplasty from 2006 to 2012 generated 179 cases. Laterality, specimen weight, number of blocks submitted and presence of APL were recorded and analyzed. We defined APL as invasive carcinoma, ductal (DCIS) or lobular carcinoma in situ, atypical ductal or lobular hyperplasia (ADH or ALH), and flat epithelial atypia (FEA). The presence of papillomas, radial scars and fibroadenomas were also recorded. At least 1 APL was identified in 23 (12.8%) of 179 specimens including invasive lobular carcinoma (n = 3), DCIS (n = 1), ADH/FEA (n = 9) and lobular carcinoma in situ/ALH (n = 10). The most common APL in this cohort was lobular neoplasia (5.6%) followed by ADH and FEA (5.0%). Invasive carcinoma and DCIS was identified in 2.3% of this cohort. In conclusion, the frequency of detection of APLs in patients with history of breast cancer is significantly higher than that in patients without history of breast cancer (12.8% versus 4.3%). Our data assessed the prevalence of APLs in this setting and, therefore, provide new information on decision-making for contralateral breast reduction in patients with history of breast cancer.

Sentinel lymph node biopsy for risk-reducing mastectomy.

Risk-reducing mastectomy (RRM) confers 90-95% decreased risk of breast cancer, and may reduce mortality, especially in high-risk groups such as BRCA carriers. Risk of occult disease in RRM specimen is ~5%. This demands axillary staging: sentinel lymph node (SLN) biopsy is no longer possible, axillary clearance confers significant risks and may prove negative. Contemporaneous SLN biopsy allows axillary staging with minimal further dissection. Women undergoing RRM and SLN biopsy between June 2005 and July 2010 were reviewed retrospectively from our prospectively maintained database of 1,522 SLN procedures in 1,498 patients. SLN(s) localized using routine tracer methods. SLNs and mastectomy specimens underwent routine histologic examination. Eighty-three RRMs with SLN biopsy were performed in 71 patients (12 bilateral). Indications for RRM: contralateral invasive (55), in situ (5) disease, BRCA 1/2 mutation (12), and strong family history (10). Mean number of SLNs: 1.35. Occult disease was detected in four cases (4.8%), with one case of occult invasive lobular carcinoma (1.2%). Remaining occult disease was lobular in situ neoplasia (LISN). SLNs were negative in all cases. Our findings are comparable to those in the literature: 4.8% rate of occult disease overall, 1.2% invasive. The significant risk with SLN biopsy is lymphoedema, quoted around 7%. We have had no reports of symptomatic lymphoedema in patients undergoing RRM and SLN biopsy. We propose that SLN at the time of mastectomy requires only limited further dissection, and confers minimal risk compared with secondary axillary surgery.

[Occult primary MALT lymphoma of the breast diagnosed and treated by reduction mammaplasty. An exceptional case report and review of the literature]. / Lymphome du MALT primitif du sein découvert fortuitement et traité par la réduction mammaire. À propos d'un cas exceptionnel et revue de la littérature.

Primary Mucosa-associated Lymphoid Tissue (MALT) lymphoma of the breast is a very rare disease. We report here a case of occult primary MALT lymphoma of the breast diagnosed from a mammaplasty specimen. Primary tumor resection during the mammaplasty surgery was the only treatment of this lymphoma, and there was no recurrence at five years. The clinical and radiologic presentation of primary MALT lymphoma of the breast is similar to epithelial breast carcinoma, and the main diagnostic criteria are microscopic examination and immunohistochemistry. The prognosis of breast primary MALT lymphomas is good after local treatment by surgery and/or radiotherapy, and surgery shouldn't be too aggressive. In this case, no other treatment was indicated after the first surgical procedure. To our knowledge, this is the first case report in the literature of occult primary MALT lymphoma of the breast diagnosed from a mammaplasty specimen. This allows us to highlight the need for systematic microscopic examination of mammaplasty specimens conducted by an experienced pathologist, especially as preoperative examinations are not able to detect all occult breast carcinomas.

Incidental atypical proliferative lesions in reduction mammoplasty specimens: analysis of 2498 cases from 2 tertiary women's health centers.

Atypical proliferative lesions (APLs) are occasionally found in breast reduction specimens. The aim of the study was to investigate the prevalence of APL in reduction mammoplasty specimens from patients who were treated mainly for macromastia. A retrospective medical record review of pathology records on patients who underwent reduction mammoplasty from 2006 to 2012 generated 2498 cases. The sole exclusion criterion was a history of invasive and/or ductal carcinoma in situ (DCIS). Laterality, specimen weight, number of blocks submitted, and presence of APL were recorded and analyzed. We defined APL as invasive carcinoma, DCIS or lobular carcinoma in situ, atypical ductal (ADH) or lobular hyperplasia, and flat epithelial atypia (FEA). The presence of papillomas, radial scars, and fibroadenomas was also recorded. At least 1 APL was identified in 107 (4.3%) of 2498 reduction mammoplasty specimens including invasive duct carcinoma (n = 2), DCIS (n = 4), ADH/FEA (n = 47), and lobular carcinoma in situ/atypical lobular hyperplasia (n = 54). One hundred four (97%) of the 107 patients underwent bilateral, and 3 (3%) underwent unilateral reductions. In conclusion, the frequency of detection of APLs in patients with no history of breast cancer is low (4.3%). Detection of invasive and DCIS lesions is extraordinarily low at 0.2%. The most common APL is lobular neoplasia (2.2%), whereas ADH and FEA are seen in 1.9%. Our findings provide data on the distribution of these lesions in this setting, as well as some insight into their prevalence in the general population. A protocol for submitting tissues from these specimens is also proposed.

Occult breast cancer during reduction mammoplasty: case report.

AIM: Breast carcinoma occurring in routine reduction mammaplasty is rare. MATERIAL OF STUDY: In our Breast Unit each patient eligible for any breast surgery is routinely evaluated by preoperative breast imaging. We reported the clinical case of a woman with an infiltrating lobular breast cancer detected during surgical reduction mammaplasty despite a negative preoperative bilateral mammography. RESULTS: The clinical case was discussed at multidisciplinary breast cancer meeting in order to evaluate the different therapeutic options. In conjunction with general surgeons, oncologists, radiologists and radiotherapists, and upon patient's ultimate decision, a conservative tumor approach was chosen: first-level axillary node dissection followed by adjuvant chemotherapy and hormonotherapy. DISCUSSION: The mean frequency of breast cancer detection during reduction mammaplasty ranges from 0.06% up to 4%. There are many possible treatment choices for these patients ranging from radical mastectomy to more conservative approaches dealing with lumpectomy followed by radiation therapy or chemotherapy and radiation therapy alone. The therapeutical plan must be discussed by a multidisciplinary team and many tumors and patients characteristics should be evaluated in the decision making process. CONCLUSION: All patients selected for breast aesthetical surgery must be screened, during preoperative workup, for breast cancer. Combination of three diagnostic modalities increases sensitivity and reaches the diagnostic accuracy of 93.2%. The reported case stresses the importance of an oncological approach to breast surgery even in case of planned aesthetical procedures.

Carcinoma oculto da mama / Occult breast carcinoma

Objetivo: Rever o estado de arte relativo a: conceito, diagnóstico, tratamento e prognóstico do carcinoma oculto da mama. Método: Procedeu-se a revisão das publicações do período de 2002 a 2007, nas bases de dados MedLine, BIREME, LILACS e Cochrane, que incluíssem conceito, diagnósticos provável e definitivo, tratamento e prognóstico de carcinoma oculto da mama. Entre os 72 artigos localizados, 43 foram excluídos por falta de pelo menos um dos critérios de inclusão. Desenvolvimento: O carcinoma oculto da mama caracteriza-se por ser uma entidade clínica rara, não detectável aos exames físico e radiológico da mama, que se apresenta como linfadenopatia axilar. Seu diagnóstico definitivo, de exclusão, exige: conhecimento dos diagnósticos diferenciais, imagem por ressonância magnética, histopatologia e imunoistoquímica de material de linfadenectomia com pesquisa dos fatores de crescimento endotelial vascular C e D, positivos em 75% e 81,9%, respectivamente. Mais recentemente, a cintimamografia tem sido empregada para localização do tumor e a tomografia por emissão de pósitrons ainda não é indicada. O tratamento deve ser individualizado segundo análise dos fatores de risco e do painel prognóstico. Inclui linfadenectomia associada à radioterapia e à adjuvância, podendo ser empregada mastectomia radical com ou sem reconstrução imediata. A sobrevida em 10 anos varia de 50% a 71%, segundo o painel prognóstico.

Objective: To revue current trends in the definition, diagnosis, treatment and prognosis of occult breast carcinoma. Method: Publications from 2002 and 2007, on MedLine, BIREME, LILACS and Cochrane databases were reviewed, according to inclusion criteria of definition, probable diagnosis and definitive diagnosis, treatment and prognosis of occult breast carcinoma. Amongst 72 localized articles, 43 were excluded due to absence of at least one inclusion criterium. Development: Occult breast carcinoma is characterized as a rare clinical entity, undetectable by physical and radiological exams, with first symptoms consisting on axillary limphadepathy. Its definitive diagnosis, determined by exclusion, requires: knowledge of differential diagnosis, magnetic resonance images, histopathology and immune histochemistry analyzes of sample obtained by limphadenectomy, including research of endothelial vascular growth factors C and D, because they are positive for 75% and 81.9% of cases, respectively. Recently, cintimamography has been used for tumor localization, but positron tomography is not yet indicated. Treatment must be individualized according to risk factor analyzes and prognostic panel. It includes lymphadenectomy associated to radiotherapy and adjuvancy, but radical mastectomy with or without immediate reconstruction may be used. The 10 years survey varies from 50% and 71%, according to prognostic panel.