Breast Disease

Diagnosis of a clinical entity like pregnancy associated breast cancer (PABC) is as demanding and challenging as its rarity. Increasing incidence and controversy that exists in the literature upon prognosis, tumor aggressiveness and underlying mechanisms, highlight the importance of optimizing the diagnostic strategy in women with PABC. Adjustment of standard approach for breast cancer by modifying management methods and options plays key role in decision making. Knowledge of diagnostic modalities and their limitations, in accordance with awareness of physiologic hormone-induced changes of pregnancy and lactation, is the fundamental method of diagnosis in PABC. Thorough triple assessment (history/clinical examination, imaging and cytology/histology) enforces healthcare providers with all essential tools to avoid detrimental delay in diagnosis and to confront with their own hesitation to take action due to limited experience of the disease.

BACKGROUND: Breast cancer clinical trials prove better outcomes for anthracycline-taxane regimes albeit of a higher hematologic toxicity. Original trials may under-estimate febrile neutropenia (FN) event rates.

OBJECTIVE: To describe the occurrence of FN events related to FEC-D for breast cancer treatment in the real-life setting.

METHODS: Retrospective analysis of 189 patients with non-metastatic breast cancer consecutively treated with FEC-D (3 cycles of 5-FU, Epirubicin and Cyclophosphamide followed by 3 cycles of Docetaxel) at our Center during 33 months. FN and related dose delay and reduction, regimen change, G-CSF prophylaxis and hospitalization were analyzed.

RESULTS: Fifty-one patients (27%) developed at least one episode of FN during FEC-D, 21% during Docetaxel cycles. There were 61 (5.6%) FN episodes in 1100 cycles of FEC-D administered, 77% occurred during Docetaxel cycles (46% on the first D cycle). G-CSF was used in 5.8% of cycles. Hospital admission needed in 54.1% of FN events, 16.4% prompted dose reduction and 23% next cycle delay. There were no FN related deaths.

CONCLUSIONS: G-CSF prophylaxis is recommended for chemotherapy regimens associated with a FN rate higher than 20%. Based on our FN rates, we now recommend primary G-CSF prophylaxis during the administration of cycles 4 to 6 in FEC-D.

AIM: Puerperal milk stasis is one of the most common puerperal complication that directly affects breastfeeding. Massage treatment with topical cactus and aloe for puerperal milk stasis might be a superior treatment, and it does not affect breastfeeding.

METHODS: The intervention group was treated with massages with cactus and aloe cold compresses, and the control group was treated with massage treatment or cactus and aloe cold compresses alone. We evaluated the efficacies of the treatments through comparisons of the feeding patterns, hardness, and pain after treatment between the three groups.

RESULTS: We found that breastfeeding rates were significantly increased in the massage combine with combined with cactus and aloe cold compress group (P < 0.05 for both). Breast hardness and pain were reduced to greater extents in massage combine with combined with cactus and aloe cold compress group than in the massage or cold compress group (P < 0.05).

CONCLUSIONS: Massage treatment with topical cactus and aloe topical effectively improved the pain status, hard lump of puerperal milk stasis and increase breastfeeding rate.

BACKGROUND: Breast diseases are rising in incidence especially in developing countries. However, most research focuses on breast cancer. Analysing the spectrum of breast disease will enable establishment of efficient breast clinics within an existing general surgery out-patient department with minimal additional investment or personnel whilst providing quality care.

OBJECTIVES: To study the spectrum of breast disease in an urban general surgical centre in India. To use a `Clinic-within-a-Clinic' model to provide affordable care and accurate early diagnosis to patients with breast disorders.

MATERIALS & METHODS: A prospective study was conducted over 1 year at M. S. Ramaiah Hospital, Bangalore by a single general surgical unit. 903 patients who presented to the OPD with a variety of breast-related symptoms were included in the study (896 women and 7 men). Relevant history was taken; the patients were then examined and investigated according to our protocol and patterns were recognized.

RESULTS: Benign breast disease formed the majority of the cases (640 patients, 70.87%). The 21-30 years age group had the most patients (272 patients, 30.12%). ANDI was the commonest diagnosis (522 patients, 57.8%). 92 patients (10.18%) were diagnosed with cancer. More than 50% of these were less than 50 years of age. Majority of the patients (511 patients, 56.58%) could be managed conservatively. The cost of diagnosis and treatment was found to be a small fraction of that in specialized breast units of western countries using our `Clinic-within-a-clinic' model.

CONCLUSION: Research on the demographic and clinical pattern of breast disease can help establish and efficient, effective and affordable diagnostic and therapeutic systems in developing nations.

OBJECTIVE: To review the diagnostic and therapeutic challenges associated with treating isolated primary breast tuberculosis through discussion of our series of seven cases.

BACKGROUND: Although breast is an uncommon site of occurrence of tuberculosis and isolated primary breast tuberculosis is an even rarer entity, its importance lies in distinguishing it from more common pathologies like abscesses or malignancy and avoiding unnecessary erroneous surgical intervention. The spectrum and presentation is wide and varied and we present our experience in managing seven such cases.

MATERIALS AND METHODS: A retrospective analysis of all the cases of histopathologically proven primary breast tuberculosis in the last three years at M.S. Ramaiah Hospital (2012-2014) was done. Analysis was in terms of mode of presentation, clinical features, diagnostic modalities used for evaluation and confirmation of the diagnosis, medical treatment and surgical intervention, if any. Special emphasis was placed on dilemmas in diagnosis and difficulties encountered during treatment. All cases were followed up till cure.

RESULTS: Patients most commonly presented with a breast abscess, painful breast lumps and recurrent abscesses. Other foci of tuberculosis were ruled out in all of these patients. Majority were treated exclusively with anti-tubercular therapy (although regimens varied), but those with abscesses underwent incision and drainage. All cases were treated and followed up till cure.

DISCUSSION: The challenges associated with primary breast tuberculosis are multiple, including which anti-tubercular therapy regimen to use, when to surgically intervene (as the breast is a cosmetically important area) and treating atypical mycobacteria. We provide a detailed discussion of the challenges we faced and review of literature.

Concomitant breast cancer metastasis and tubercular lymphadenitis in axillary lymph node is an extremely rare occurrence. Axillary lymph node metastasis is the most important factor in the staging of breast carcinoma and the number of axillary nodes showing metastases alters the stage. As tuberculosis also produces nodal enlargement, this can mimic or complicate the staging of malignant disease. Dual pathology in an organ can lead to difficulties in interpretation and inappropriate treatment of tuberculosis as well as carcinoma breast. Moreover, fine needle aspiration cytology (FNAC) from such cases may be misleading if only one of the diseases is picked up. Therefore, the need for multiple attempts at FNAC should be stressed upon for all palpable lumps. We report a case of infiltrating duct carcinoma breast in a 45-year-old female where tuberculosis was discovered in axillary lymph nodes in addition to metastases. As the present case led to incidental discovery of tuberculosis with tumor metastasis, it reinforces the possibility of a coexistent lesion in the pathologists' mind, especially in regions endemic for tuberculosis.

Carcinoma breast is common tumor which tends to metastasize to different organs but diagnostic difficulty may arise if known case of carcinoma eventually presents with another secondary malignancy with clinical features which closely mimics with metastatic carcinoma. This overlapping of symptoms may lead to delayed diagnosis of secondary malignancy with worsening of the condition of patient due to lack of specific treatment.

The present case is being reported where a known case of primary breast carcinoma presented with scapular erosions suggesting metastasis. However, despite treatment her worsening condition necessitated further work up revealing multiple myeloma. The case signifies the pitfall due to overlapping of symptoms and draws attention to the fact that every known case of primary carcinoma suggestive of metastasis should also be investigated in light of another secondary malignancy. Early diagnosis of secondary malignancy followed by specific treatment would be helpful in improved prognosis of the patient.

Bisphosphonates are widely used both in the multidisciplinary management of bone metastases, especially osteolytic lesions from solid tumors or multiple myeloma, and of osteoporosis.

Aseptic osteonecrosis, especially of the jaw, is among the well-known, although uncommon, side effects of bisphosphonates. Osteonecrosis of other bones has been very rarely reported with the use of bisphosphonates.

We describe a rare case of osteonecrosis of the distal femur associated with the use of bisphosphonates in a 74 years old female patient with metastatic breast cancer.

A 49 year-old female underwent breast MRI for further evaluation of a single projection mammographic finding. MR showed normal breast tissue; however, a 3 cm right lung mass was incidentally discovered, and later confirmed by chest CT. Four years after upper lobectomy, lymphadenectomy, and chemoradiation for stage IIIA non-small cell lung cancer, she presented with a breast rash. Punch biopsy of the breast rash showed metastatic adenocarcinoma consistent with lung primary. One year later, diffuse bilateral breast edema and pleomorphic calcifications were present on mammogram. Pathology revealed multifocal intralymphatic adenocarcinoma, consistent with metastasis from lung primary. This unusual case illustrates an incidentally discovered lung carcinoma found on breast MR that, over time, spread to the breast via the lymphatic system.

Carcinosarcoma of the breast is an extremely rare and highly aggressive breast tumor.

It has two distinct malignant cell lines involving epithelial (carcinomatous) and mesenchymal (sarcomatous) components. The literature on the topic is sparse. We report a rare case of carcinosarcoma of the breast containing a small fraction of a pancytokeratin positive sarcomatous-appearing cell population i.e. a metaplastic cell population. The patient was treated with a multidisciplinary approach.

Ectopic breast carcinoma in the axillary region is rare with an incidence ranging from 0.3-6%. We report a case of infiltrating duct carcinoma in an adult female arising in aberrant breast tissue in the axilla diagnosed on fine needle aspiration cytology. There was history of recent increase in size of the lump which was otherwise present for the past 5 years. This case highlights the role fine needle aspiration cytology can play in the early diagnosis of malignant transformation of lumps.