Rosen's Breast Pathology, 4e

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Unusual Clinical Presentation of Carcinoma

than in patients who do not have a complete response in their ALNs. 287 In both studies, patients who had complete regression of their axillary nodal metastases more often had less or no residual carcinoma in the breast. Among women with noninflammatory carcinoma, the presence of residual carcinoma in the breast did not have a negative effect on the relatively favorable prognosis associated with complete ALN response. The outcome for IBC patients treated in the modern era of trastuzumab and taxane-based chemotherapy remains modest. A retrospective study of 104 patients with non- metastatic IBC treated over a 10-year period (2000 to 2009) with a median follow-up time of 34 months showed that the 5-year OS for the entire cohort was 46%. 288 In this study, fifty-seven (55%) tumors were ER (−) and PR (−) negative, and 34 (33%) were HER2 ( + ). Seventy-five (72%) patients completed all intended therapy, of whom 67 (89%) received a taxane and 18/28 (64%) of HER2 ( + ) patients received trastuzumab. Despite the use of taxanes and trastuzumab, outcomes remain modest, particularly for those with ER (−) and PR (−) disease, and those without a pathologic complete response. Lastly, it should be remembered that various forms of mastitis and other types of neoplastic processes includ­ ing lymphoma and metastatic nonmammary carcinoma in the breast can mimic IBC. 289–291 Thus, it is crucial that the clinical diagnosis of IBC be documented by a biopsy of the skin or breast that demonstrates the presence of mammary carcinoma. RECURRENT CARCINOMA IN TRAM FLAP Approximately one in seven women in the United States who undergo mastectomy receive immediate breast reconstruc­ tion. 292 The latter procedure employs various techniques, including the TRAM flap. Women who are younger and are treated at tertiary settings are more likely to get immediate reconstruction, the advantages of which include less psycho­ logical consequences, more pleasing aesthetic results, and cost reductions. Thus, immediate breast reconstruction, includ­ ing the use of the TRAM flap procedure, is likely to increase in popularity. TRAM flap reconstruction performed after a mastectomy employs skin and subcutaneous tissue and rectus muscle from the abdominal wall to recreate the breast. This procedure has been in use for more than three decades. 293 Recurrent carcinoma may develop in the TRAM flap as an isolated event or as a manifestation of systemic spread. The reported TRAM recurrence rate ranges from 3.8% to 11.7%. 294–296 The latter series included patients who initially had stage III and stage IV tumors. Recurrent carcinoma in a TRAM flap usually presents as a palpable tumor, 296–298 but nonpalpable recurrences have been detected by mammogra­ phy. 299,300 Mammographic indicators of recurrent carcinoma include mass lesions, sometimes with a spiculated contour, and calcifications. Dystrophic calcification amid fat necro­ sis associated with flap construction may simulate recurrent carcinoma. 301

The primary carcinoma for which the mastectomy was performed has almost always been invasive ductal type, usu­ ally moderately to poorly differentiated. There have been infrequent instances in which the primary carcinoma was well-differentiated invasive ductal, or papillary, or giant pap­ illary 298,300,302 carcinoma. Recurrent carcinoma in the TRAM flap tissue usually duplicates the histologic appearance of the primary tumor. Recurrent carcinoma concurrently involv­ ing the mastectomy bed, TRAM flap, abdominal donor site, and precostal tunnel has been reported. 303 In a study of patients treated with postmastectomy ra­ diotherapy to the chest wall or TRAM flap, Huang et al. 304 found no significant difference in the incidences of compli­ cations, local recurrence, and distant metastases between those who have had a TRAM flap and those who did not have a TRAM reconstruction. An angiosarcoma developed 6 years subsequent to mastectomy and immediate TRAM flap construction followed by radiation, 305 and a leiomyos­ carcoma developed 20 years after a mastectomy and radia­ tion, and 10 years after a delayed TRAM flap construction. 306 Both sarcomas were attributed to radiation effect. Until the mechanism of carcinomatous involvement of TRAM flaps is elucidated, it should be regarded as a form of local recurrence. Long-term follow-up data in these cases are not known at this time; however, anecdotal evidence suggests that TRAM flap recurrences may be a harbinger of systemic spread. It should be understood that most local masses occur­ ring after autologous breast reconstruction are benign. In an analysis of 66 such masses occurring after 365 autologous breast flap reconstructions in 272 patients, performed over a 10-year period, the majority of these were fat necrosis. 307 Fat necrosis occurred in 54 (15%) breasts and represented 54/66 (82%) of the tumors. Recurrent carcinoma was diagnosed in 13 (3.6%) of the post-TRAM flap breasts. In this study, fac­ tors associated with carcinoma in postreconstruction masses were closer (less than 1 cm) surgical margins and tumoral involvement of lymphovascular channels. Furthermore, 51/54 (94.4%) instances of fat necrosis were diagnosed in the first postsurgical year and none after 2 years, whereas the mean time to the detection of recurrent carcinoma in a TRAM flap was 24 months. REFERENCES Carcinoma in Pregnancy and Lactation 1. Rovera F, Frattini F, Coglitore A, et al. Breast cancer in pregnancy. Breast J 2010;16:S22–S25. 2. Wallack MK, Wolf JA Jr, Bedwenek J, et al. Gestational carcinoma of the female breast. Curr Probl Cancer 1983;7:1–58. 3. Rosen PP, Lesser ML, Kinne DW, et al. Breast carcinoma in women 35 years of age or younger. Ann Surg 1984;199:133–142. 4. Birks DM, Crawford GM, Ellison LG, et al. Carcinoma of the breast in women 30 years of age or less. Surg Gynecol Obstet 1973;137:21–25. 5. Richards SR, Chang F, Moynihan V, et al. Metastatic breast cancer complicating pregnancy. J Reprod Med 1984;29:211–213. 6. Johannsson O, Loman N, Borg A, et al. Pregnancy-associated breast cancer in BRCA1 and BRCA2 germline mutation carriers. Lancet 1998;352:1359–1360.