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A case of recurrent apocrine carcinoma of the axilla is presented. Following numerous excisions and exairesis of the regional glands, treatment with Tamoxifen was tried unsuccessfully. Local radiation therapy proved efficient. It is suggested that primary local radiation therapy be used as a supplement to aggressive surgery in the treatment of these tumors.
Mammary carcinoma arising in ectopic breast tissue is an uncommon occurrence. Most reported cases have involved ductal carcinoma, but other types, such as medullary, papillary, and lobular carcinomas, have been described. For pathologists, the diagnosis of mammary carcinoma arising in ectopic breast tissue can be difficult, especially in the axilla, where carcinoma of adnexal origin must be excluded. We describe a 46-year-old woman who developed invasive (juvenile) secretory carcinoma in ectopic right axillary breast tissue and micrometastatic carcinoma in an ipsilateral axillary lymph node. The carcinoma arose in a right axillary mass that had been present for 8 years, from which she had secreted fluid during prior breast-feeding. To our knowledge, this is the first report of secretory carcinoma arising in axillary breast tissue to be documented in the current literature.
Identification of the sentinel lymph nodes in patients with breast cancer is often hampered by high radioactivity from the injection site, since the distance between the injection site and regional lymph nodes is quite short in these patients. We investigated the usefulness of the modified oblique view of the axilla (MOVA) method introduced by Haigh et al., aiming at better discrimination of the target and higher resolution. Compared with the standard anterior view (SAV) of the supine position and conventional oblique view (COV) imaging, MOVA was able to obtain a longer distance between the injection site and axillary lymph nodes in 20 of 21 lymph nodes. MOVA provided more effective information for visual evaluation of the geometry of axillary lymph nodes in half the cases, and one lymph node was detected only with MOVA. In contrast, SAV provided better imaging in one patient. Although our results support the usefulness of MOVA, the combined application of MOVA and SAV is desirable, since sentinel lymph node detection with the gamma-probe is performed in the supine position during surgery.
Clinical examinations and imaging methods are not sufficiently reliable for an exact staging of axillary nodes in breast cancer. The sentinel node biopsy concept is a minimally invasive procedure to locate and remove the first and important nodes responsible for draining a tumor. Histologic examinations using immunohistochemical methods permit more accurate staging than hematoxylin and eosin staining alone. Between 4/1997 and 9/1998 a total of 62 patients with 65 breast cancers underwent surgery. The sentinel node procedure with radio tracers and/or blue dye was performed in patients with clinically negative or unclear positive findings in the axilla, with a primary tumor size less than 5 cm; 11 patients had received preoperative chemotherapy. The sentinel node biopsy was followed by axillary dissection in 44 cases. In 58 (89%) cases we found one or more (on an average 1.4) sentinel nodes with radio tracers (in 73%) and/or the blue dye method (in 85%). Axillary nodal status was correctly predicted in 43 of 44 (97.7%) cases; only in one patient was the sentinel node false negative. After preoperative chemotherapy sentinel nodes were found in 9 cases; all of these were predictive. Micrometastases were found in two patients only after cytokeratine staining. Our results concur with the experience of other study groups in regard of sentinel node biopsy. The sentinel node concept is a fascinating method; its importance in breast cancer treatment appears to be comparable with introduction of breast saving surgery in the 1980's.
A rare muscular anomaly was found in the right arm of a 92-year-old man at Nagoya University in 1995. The anomalous muscle had two heads, one ventral and one dorsal. The ventral head was a continuation of the abdominal part of the pectoralis major muscle, and the dorsal head arose from the lateral surface of the latissimus dorsi muscle. The two heads united at the medical surface of the upper third of the arm to form a common tendon, which descended on the medial surface of the upper arm parallel with a long tendon of the coracobrachialis muscle and attached to the medial epicondyle of the humerus. This anomalous muscle was supplied by the most caudal branch of the pectoral ansa (caudal pectoral nerve) and the intercostobrachial nerve (Th2). This pectoral nerve first innervated the ventral head, and next the greater part of the dorsal head. The intercostobrachial nerve (Th2) innervated a small part of the dorsal head. The present anomaly looked quite similar to the case reported by Yokoh as the coexistence of the chondroepitrochlearis and the dorsoepitrochlearis muscles. However, judging from the muscular origin, insertion and innervation, the ventral head was considered to be the chondroepitrochlearis muscle, whereas the dorsal head was not dorsoepitrochlearis muscle but an aberrant type of the muscular arch of axilla.
INTRODUCTION: Breast cancer is the most frequent cancer occurring in women. These cancers may rarely develop within ectopic breast tissue. We report a case of ectopic axillary lobular carcinoma presenting as an isolated skin lesion with prolonged evolution. CASE-REPORT: A 62 year-old women had a cutaneous lesion located in her left axilla for the past 4 years. The skin biopsy showed an infiltrating lobular carcinoma. A mammogram and an MRI were as unremarkable as two past mammograms performed since the beginning of the skin lesion. Surgical resection with lymph node dissection, associated with radiotherapy and hormonotherapy with tamoxifen, led to complete remission. DISCUSSION: Ectopic breast tissue is subject to physiological and pathologic changes such as benign or malignant tumours. Cancer occurring in ectopic breast tissue remains rare but this diagnosis must be suspected when confronted with a skin lesion or mass located near the normal breasts.
OBJECTIVES: This study was designed to assess the clinical, sonographic and histopathological response of axillary lymph node metastasis to neoadjuvant chemotherapy in patients with locally advanced breast cancer. MATERIAL AND METHODS: Forty patients with locally advanced breast cancer (LABC) with clinically palpable or sonographically detectable axillary nodes were studied. FNAC of the primary tumor and axillary nodes was done and patients were started on neoadjuvant chemotherapy. Axillary nodes were assessed clinically and sonographically for response after 3 cycles of chemotherapy. All patients underwent total mastectomy with axillary clearance and the lymph nodes in the specimen were examined for metastasis. RESULTS: 47% patients had complete clinical nodal response, while 19% showed complete sonographic response. Complete pathological nodal response was documented in 22% of patients. Ultrasonography was found to be more sensitive than clinical examination in assessing complete nodal response. 10% of the patients had complete pathological response of both primary tumor and axillary nodes. There was significant correlation between pathological response of primary tumor and lymph nodes (P=0.004). Patients with complete sonographic or clinical response were found to have no or minimal residual disease in axilla and hence axillary dissection may be avoided in them.
In this paper we report on a 67-year old woman suffering from long-term rheumatoid arthritis. She was admitted to hospital because of a hard tumour with the size of a fist in her left axilla. The supposed tumour was proved by conventional radiological and CT examination as an excessive manifestation of the basic disease in the left shoulder joint.
A case of extraskeletal osteosarcoma arising in the axilla in a 77-year-old woman is described. Because of its association with an ipsilateral breast carcinoma, the axillary mass was at first assumed to be a lymph node with metastatic breast carcinoma. The occurrence of extraskeletal osteosarcoma in the axillary is rare and association with breast carcinoma has never, to our knowledge, been described.
Basal cell carcinoma is the most common malignant skin tumor in the elderly. It occurs predominantly in the head and neck region. As is well known, skin exposed to sunlight is the most frequent location, but basal cell carcinoma can arise elsewhere. This report describes a 81-year old woman who developed a basal cell carcinoma of the adenoid subtype in the axilla. Before surgical excision, the lesion was diagnosed cytologically. This diagnosis was confirmed by histology. Cytologic examination of skin lesions whose size and location allow this procedure appears to be the sole conservative means of achieving a presurgical diagnosis. The technique is simple. The morphologic differential diagnosis of basal cell carcinoma is discussed.
The authors report a case of soft tissue tumor discovered fortuitously in a 52 year old woman. This lesion was in the axilla and on standard films was seen as a well-defined radiotransparent zone, accompanied by a typical spiculated bone reaction of the lateral edge of the scapula. CT and MRI confirmed the fatty and noninvasive nature of the lesion. Histopathological examination of the operative specimen showed it to be a parostal lipoma.
Even if one can find in the literature many contra indications to nerve blocks, this case with a pseudarthrosis of the humerus and severe scars in the axilla shows that non-inflammatory pathologic-anatomical changes need not prevent a brachial plexus block. Prerequisites are the ability to palpate the axillary artery and a reliable technique.
Apocrine tumors from the axilla of 12 patients were studied clinically and pathologically. Based on histologic features, two tumors were classified as adenomas and ten as adenocarcinomas. All of the neoplasms were characterized by a glandular arrangement of large cells with abundant eosinophillic cytoplasm and evidence of decapitation secretion. The cytoplasm of the tumor cells contained PAS-positive, diastase-resistant granules. Intracytoplasmic particles of iron were demonstrable in three of ten tumors. Follow-up was available for all 12 patients. The two patients with apocrine adenoma are alive and well. Two patients with adenocarcinoma died of unrelated causes shortly after diagnosis. Of the remaining eight patients with adenocarcinoma, three have died of disease, and one is living with skeletal metastasis. A correlation appears to exist between tumor differentiation and prognosis.
We report a case of carcinoma originating from accessory breast tissue of axilla and review 33 reported cases of carcinoma in heterotopic breast tissue. Although the incidence of accessory breast cancer is not high, early diagnosis and treatment are necessary, keeping in mind the possibility of this carcinoma when subcutaneous nodules of uncertain origin are found around the breast. Surgical treatment which must at least include wide local extirpation including the surrounding tissues and dissection of the axillary lymph nodes is necessary and adjunctive chemotherapy and irradiation appear to be useful.
Skin biopsy is the method of choice for the diagnosis of Lafora's disease. The presence of PAS (+) inclusions characteristic of Lafora's disease has been thought to be more evident in aprocrine glands of the axillary skin than in the duct cells of the eccrine glands. We describe 4 patients with Lafora's disease diagnosed by axilla skin biopsy, confirming the usefulness of this procedure.
Axillary lymph node dissection, which is now mandatory in the conservative breast cancer surgery and classically involves Berg's two lower levels, is burdened with numerous complications. In 1988 and 1989, two technical modifications were introduced and are described here: padding of the axilla as preventive treatment of postoperative lymphocele and, more recently, functional axillary lymphadenectomy (FAL) in which the medial cutaneous nerve of the arm, the two perforating intercostal nerves and above all the lateral thoracic pedicle (external mammary artery and vein) are spared. These two technical innovations, more respectful of anatomy, are aimed at reducing the morbidity of conservative breast cancer at a time when detection enables breast cancers to be treated at an increasingly early stage, which results in a increase of negative axillary dissections. The postoperative period is simplified (no drainage, immediate mobilization), and the hospital stay is reduced to 2 days. Complementary treatments can thus be started early on, without any functional or cosmetic damage while the number of lymph nodes removes remains the same as in the conventional axillary dissection technique. The authors describe the operative procedures and analyse the 100 cases of conservative breast cancer they have treated with padding and FAL. These two technical modifications are now systematically used by them in the management of breast cancers.
METHODS: The presurgical, noninvasive staging of axillary nodes for metastases was prospectively investigated in 68 patients who were diagnosed with primary breast cancer using PET with 18F-fluorodeoxyglucose (FDG). Four patients had bilateral nodules; therefore, the total number of evaluable cases was 72. Visual analyses of attenuation-corrected PET images and standardized uptake values (SUVs) of FDG uptake in carcinomas were compared with histopathological surgical findings. The SUV distribution differences between carcinomas with and without axillary metastases were evaluated by means of statistical and receiver operating characteristics analyses. RESULTS: PET correctly classified 64 of the 72 cases; four false-positive and four false-negative PET results were found. The overall sensitivity, specificity and accuracy of PET for axillary metastases were 85%, 91% and 89%, respectively. With respect to the clinical axillary stage of the patients (TNM, or tumor-node-metastasis, classification), we obtained the following results: N0 patients, sensitivity = 70%, specificity = 92%, accuracy = 86%; N1a patients, sensitivity = 85.5%, specificity = 100%, accuracy = 95%; and N1b-2 patients, sensitivity = 100%, specificity = 67%, accuracy = 87%. The median SUV in carcinomas with axillary metastases (4.6) was significantly higher than that in carcinomas without metastases (2.9), but there was a great SUV overlap between the two groups (interquartile ranges = 2.7-7.2 and 1.9-4.5, respectively). Analysis of the receiver operating characteristics curve showed that a high sensitivity of SUV in predicting axillary metastases was associated with a very low specificity and vice versa. With the best SUV cutoff value of 2.9, the sensitivity and specificity were 74% and 56%, respectively. CONCLUSION: PET showed good overall diagnostic accuracy in the detection of axillary metastases (86%). The very high accuracy (95%) in N1a patients is of particular importance. False-negative PET findings, however, can be encountered. SUVs of breast carcinoma cannot predict the spread of the disease to the axilla, even if higher values are often associated with axillary metastases. Any decision on the use of PET in the presurgical staging of breast cancer should be incorporated into a more general debate on axillary management. In selected patients with a very low probability of axillary metastases (T1a), in whom axillary surgery can already be avoided according to data from follow-up studies, 18F-FDG PET could be proposed as a noninvasive imaging modality to improve the diagnosis of axillary relapses.
Much has been written on micrometastases to the axilla in breast cancer but there is no consensus as to their size. In this study three levels of nodal tumour-load are defined following measurement of nodal tumour area on histology. The two cut-points described are both of clinical interest. The smallest deposits, up to 0.0001 cm2, include embolic growth on the afferent side of the node, which is, as reported previously, of poor prognosis. In such cases post-operative prognosis approaches that in the "node-positive", here defined as cases with an axillary tumour-load of 0.5 cm2 or more. Between these two groups is a collection of cases, 40% of the total series, with a prognosis similar to the node-negative. It is suggested that the deposits in this intermediate group should be termed micrometastases, the high risk cases with embolic growth reported as such and those with larger deposits as node-positive.