Benign phyllodes tumour in a transgender woman receiving hormonal therapy.

We present a case of a transwoman taking hormonal feminisation therapy for over 20 years, who underwent surgical excision of a benign phyllodes tumour of the breast. Hormones progesterone and oestrogen act on breast epithelium to increase proliferation. For ciswomen, endogenous and exogenous oestrogen exposure over a lifetime is associated with increased risk for certain benign and malignant breast pathologies. Transwomen taking hormonal therapy may also be at an increased risk of breast disease.

Necrotising cellulitis of the breast associated with a fungating mucinous adenocarcinoma.

Breast necrotising soft tissue infections (NSTIs) are rare surgical emergencies with limited cases described in the literature. Here, we discuss a unique case of a woman in her 70s who presented with newly diagnosed diabetes and a neglected right breast cancer associated with breast erythema, skin necrosis, crepitus on examination and breast soft tissue gas seen on CT requiring emergent total mastectomy with partial pectoralis muscle excision. Pathology revealed a 15 cm invasive mucinous adenocarcinoma and necrotising polymicrobial cellulitis with a large abscess cavity. She recovered from her surgery with strict glycaemic control and a 10-day course of antibiotics. Multidisciplinary tumour board recommended adjuvant anastrozole, abemaciclib and postmastectomy radiation to complete her oncological treatment. Although exceedingly rare, it is important that clinicians be aware of, promptly recognise and properly treat NSTIs of the breast, as correct care can be life-saving from both infection and malignancy.

Impact of Preoperative Extramammary Findings in Patients with Newly Diagnosed Breast Cancer.

BACKGROUND: Breast MRI has been associated with significant rates of false positive findings. We aimed to determine the frequency of extramammary findings (EMFs) in newly diagnosed breast cancer patients on breast MRI with contrast and assess the significance of these findings and need for additional imaging and follow-up. STUDY DESIGN: A retrospective review of patients diagnosed with breast cancer from October 2018 to October 2019 was performed. Clinicopathologic features were collected, including type of breast cancer, size, stage, and whether the patients had a breast MRI. Those who had MRI were included, and the MRI was reviewed to determine if EMFs were identified. Further imaging and follow-up were assessed and recorded. RESULTS: Of the 480 patients included in this cohort, 353 (74%) had invasive cancer, and the remainder had ductal carcinoma in situ. Two hundred ninety patients (60%) underwent MRI, and 53 of 290 (18%) had EMFs on MRI. Of these, 28 of 53 (53%) underwent additional imaging to further evaluate findings. Two invasive procedures were performed (fine needle aspiration and thymectomy), and 1 malignancy was identified in the thymus. No metastatic breast cancer was identified in any patient. CONCLUSIONS: MRIs are frequently obtained for newly diagnosed breast cancer patients, and additional findings, especially extramammary, can be stressful for patients, and potentially lead to treatment delay if further evaluation is warranted. Our results demonstrate that incidental EMFs discovered via breast MRI are common and often lead to additional imaging studies. However, no metastatic lesions were found, and only 1 separate malignancy was identified, which did not affect breast cancer management. In patients with early-stage breast cancer, EMFs yield a very low rate of malignancy, providing high levels of reassurance and supporting the option of proceeding with surgery or treatment without delay.

The Timing of Chemoprophylaxis in Autologous Microsurgical Breast Reconstruction.

BACKGROUND: Patients undergoing autologous breast reconstruction are at high risk of perioperative venous thromboembolic events. The efficacy of chemoprophylaxis in decreasing venous thromboembolic events is well established, but the timing of chemoprophylaxis remains controversial. The authors compare the incidence of bleeding following preoperative versus postoperative initiation of chemoprophylaxis in microvascular breast reconstruction. METHODS: A retrospective chart review was performed from August of 2010 to July of 2016. Initiation of chemoprophylaxis changed from postoperative to preoperative in 2013, dividing subjects into two groups. Patient demographics, comorbidities, and complications were reviewed. RESULTS: A total of 196 patients (311 flaps) were included in the study. A total of 105 patients (166 flaps) received preoperative enoxaparin (40 mg) and 91 patients (145 flaps) received postoperative chemoprophylaxis. A total of five patients required hematoma evacuation (2.6 percent). Of these, one hematoma (1 percent) occurred in the preoperative chemoprophylaxis group. Seven patients received blood transfusions: three in the preoperative group and four in the postoperative group (2.9 percent versus 4.4 percent; p = 0.419). There was a total of one flap failure, and there were no documented venous thromboembolic events in any of the groups. CONCLUSIONS: This study demonstrates that preoperative chemoprophylaxis can be used safely in patients undergoing microvascular breast reconstruction. The higher rate of bleeding in the postoperative group may be related to the onset of action of enoxaparin of 4 to 6 hours, which allows for intraoperative hemostasis in the preoperative group and possibly potentiating postoperative oozing when administered postoperatively. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Papillary lesions of the breast diagnosed by core needle biopsy: 71 cases with surgical follow-up.

BACKGROUND: Papillary breast lesions comprise a spectrum of histopathologic diagnoses ranging from benign papillomas to papillary carcinomas. There is ongoing controversy regarding the management of papillary lesions diagnosed by core needle biopsy (CNB). Some authors advocate observation of papillary lesions when the CNB is benign, while others recommend surgical excision of all papillary lesions. The current study assessed the adequacy of CNB in evaluating papillary breast lesions. METHODS: A search of the pathology database at our institution identified 122 papillary lesions diagnosed by CNB. The study population consisted of 71 papillary lesions that were subsequently surgically excised. RESULTS: Of the 71 papillary lesions excised, 8 were malignant, 16 were atypical, and 47 were benign at the time of CNB. Of the 47 papillary lesions thought to be benign, 13 (28%) revealed atypia and 4 (9%) revealed malignancy upon surgical excision. Of the 13 atypical papillary lesions on CNB, 7 lesions (54%) were associated with malignancy upon excision. Slightly over half the upgrades were due to finding atypia or malignancy in the tissue surrounding the papillary lesion. The total rate of upgrades from the CNB diagnosis to the excisional diagnosis was 38%. CONCLUSIONS: When a core biopsy of a papillary lesion is encountered, there is a strong likelihood of discovering atypia or malignancy in the index lesion or in close proximity. Therefore, surgical excision should be performed to avoid missing a malignancy and to allow for accurate breast cancer risk assessment that can impact survival and decisions regarding chemoprevention.

Incidence of complications in outpatient mastectomy with immediate reconstruction.

BACKGROUND: Although breast surgery, including mastectomy, is increasingly being performed on an outpatient basis, skepticism remains about the safety of outpatient mastectomy with immediate breast reconstruction. Studies have demonstrated a psychologic benefit to outpatient breast surgery in addition to the clear financial benefit. We sought to determine whether or not the postoperative complication rate after outpatient mastectomy with immediate reconstruction is low enough to consider the procedure safe and effective. STUDY DESIGN: Charts were retrospectively reviewed for all patients who underwent outpatient mastectomies with immediate breast reconstruction at St Vincent's Comprehensive Cancer Center between December 2000 and June 2004. The presence or absence of postoperative complications was determined from records during the postoperative period and subsequent office visit. RESULTS: Of 29 outpatient mastectomies with immediate reconstruction performed on 28 patients (one had independent procedures on each breast), only one procedure (3%) required subsequent admission to the hospital (for bleeding). Other complications included three seromas, two cases of cellulitis requiring antibiotics, and one hematoma. The overall complication rate was 24% (7 of 29), with only 14% (1 of 7) of the complications requiring hospitalization. CONCLUSIONS: These results demonstrate that outpatient mastectomy with immediate reconstruction is a safe and effective procedure for carefully selected patients. The complication rates for our patient population are similar to those in other published reports on outpatient operations, most notably, those of outpatient mastectomy without immediate reconstruction.

Clinicopathologic features and long-term outcomes of 293 phyllodes tumors of the breast.

BACKGROUND: Phyllodes tumors (PT) are rare fibroepithelial neoplasms of the breast with unpredictable behavior. We reviewed our single institution experience with PT over 51 years to identify factors predictive of local recurrence (LR) and metastasis. METHODS: From 1954 to 2005, a total of 352 cases of PT were identified; 293 had follow-up. All available pathology slides (90%) were rereviewed for margins, borders, fibroproliferation in the surrounding breast tissue, stromal pattern, stromal cellularity, frequency of mitoses, and necrosis. RESULTS: All cases occurred in women, with a median age of 42, with 203 originally categorized as benign and 90 as malignant. Median follow-up was 7.9 years. A total of 35 patients developed LR at a median of 2 years. In univariate analyses, a higher actuarial LR rate was associated with positive margins (P = .04), fibroproliferation (P = .001), and necrosis (P = .006). PT classified as malignant did not have a higher risk of LR (P = .79). Five patients developed distant disease at a median of 1.2 years. These patients constituted 71% of the seven patients who had uniformly aggressive pathologic features, including large tumor size (>or=7.0 cm), infiltrative borders, marked stromal overgrowth, marked stromal cellularity, high mitotic count, and necrosis. CONCLUSIONS: Positive margins, fibroproliferation in the surrounding breast tissue, and necrosis are associated with a marked increase in LR rates. Efforts should be made to achieve negative surgical margins to reduce risk of LR. Death from PT is rare (2%), and only PT that demonstrate uniformly aggressive pathologic features seem to be associated with mortality.

The distinctive role of positron emission tomography/computed tomography in breast carcinoma with brown adipose tissue 2-fluoro-2-deoxy-d-glucose uptake.

The diagnostic power of an integrated positron emission tomography/computed tomography (PET/CT) system for whole-body 2-fluoro-2-deoxy-d-glucose (FDG) imaging is clearly demonstrated in this case report. The precise anatomic localization of FDG uptake with CT in a PET/CT scan of a patient with known breast carcinoma helped identify a contralateral breast tumor with axillary lymph node metastasis despite the presence of extensive physiologic brown fat FDG uptake. Accordingly, the patient received appropriate surgical management and pathologic confirmation of the disease.

Acute toxicity of high-dose-rate intracavitary brachytherapy with the MammoSite applicator in patients with early-stage breast cancer.

BACKGROUND: Intracavitary brachytherapy with the MammoSite applicator as the sole radiation treatment in breast-conserving therapy is an option for women with early-stage breast cancer; we evaluated the acute toxicities associated with this treatment method. METHODS: Thirty-one patients with 32 stage I or II breast carcinomas underwent breast-conserving therapy, which included lumpectomy with negative margins, sentinel node biopsy, or axillary dissection, followed by brachytherapy with the MammoSite applicator. Acute radiation skin complications were graded on the day of radiotherapy completion and at weeks 2, 4, 6, and 12 after radiation treatment. Cosmesis was graded on the Harvard Scale at all follow-ups. RESULTS: The median follow-up was 11 months (range, 4-15 months). Twenty-seven of the 31 patients were treated with the device as the sole method of radiotherapy. No acute toxicities occurred during the 5 days of treatment. Nineteen patients (68%) had no to mild acute skin reactions, and 25% developed bright erythema and patchy moist desquamation. Two patients (7%) developed confluent moist desquamation within the first 4 weeks (grade 3); this healed by week 12. All skin reactions were localized to the area overlying the balloon. Sixteen percent (5 of 32) of all breasts with implants developed infection. Cosmesis was good to excellent in 86% of cases. CONCLUSIONS: Most acute skin toxicities were mild. Our infection rate was higher than in prior studies that used interstitial brachytherapy. Cosmesis was good to excellent in most patients. Breast brachytherapy with the MammoSite catheter was well tolerated; further investigations of breast brachytherapy with this system are warranted.

Retrospective analysis of sentinel node localization in multifocal, multicentric, palpable, or nonpalpable breast cancer.

UNLABELLED: Multicentric or multifocal breast cancer is considered as one of the limitations for sentinel lymph node (SLN) localization. We did a retrospective analysis to evaluate the success rate, sensitivity, accuracy, and negative predictive values of SLN localization in multicentric or multifocal breast lesions. METHODS: Fifty-nine patients with multifocal or multicentric breast lesions proven by either fine-needle aspiration (19/59), core biopsy (39/59), or lumpectomy (8/59) underwent SLN localization. Of these patients, 46 had SLN localization by both radiocolloid and blue dye, and 13 had SLN localization by radiocolloid alone. Approximately 10 MBq (99m)Tc-labeled unfiltered sulfur colloid in 0.3-0.4 mL were injected intradermally over the 1 or 2 breast tumor locations 2-4 h before surgery. During surgery, vital blue dye was injected intraparenchymally in 4-6 places around the tumor. All lymph nodes with counts of >10 times that of the background counts, whether or not blue dye positive, and all blue dye-positive lymph nodes, whether or not radiocolloid positive, were excised and labeled accordingly. All lymph nodes underwent frozen sectioning and were examined by hematoxylin and eosin and immunohistologic (cytokeratin) staining. RESULTS: Of the 59 patients, 48 had axillary lymph node dissection irrespective of the results of pathologic examination of the SLN. The success rate, sensitivity, negative predictive value, and accuracy were 93%, 100%, 100%, and 100% using the radiocolloid probe, 87%, 100%, 100%, and 100% using blue dye, and 93.5%, 100%, 100%, and 100% using combined methods, respectively. Concordance between blue dye and radiocolloid was 91% (the incidence of the number of sentinel nodes detected was 37.5%, 30.3%, 10.7%, and 21.4% for 1, 2, 3, and 4 or more lymph nodes, respectively). Metastatic lymph node involvement was found in 39.5% of patients. CONCLUSION: The sentinel node localization approach showed a high negative predictive value in breast cancer patients with multifocal or multicentric lesions, contrary to the common belief of significant false-negative results in these patients.

Randomized clinical trials in breast cancer.

Before the second half of this century, treatment approaches to breast cancer were radical and disfiguring. In the past four decades, however, multiple prospective randomized trials have made highly significant advances in the management of patients with this disease. These trials have established, in select patients, breast conservation therapy as a primary therapeutic procedure, and radiation therapy as a means to improve local control and survival. This article provides an overview of some of these trials.