Breast Cancer Awareness Drive

During my training in America, doctors there used to ask me “Why doesn’t India have a Breast Cancer Screening Program?”
Well today, I can proudly say that we are working towards it. You always have to take small steps to fulfill big dreams and that is what we did yesterday by launching the W Pratiksha Hospital Cancer Awareness Drive.
I was happy to see the media supporting the project and giving it the importance it deserves.
We are going to having regular camps in the surrounding villages for the next six months and anyone who would like to volunteer is most welcome.

It was heartening to see one of my treated patients (a breast cancer conqueror) being felicitated during the event. She shared her thoughts with the media as well and told them about the importance of early detection and management.

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Symptoms of Breast Cancer – Useful Illustration

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Breast Cancer is the most common cancer in Indian women, yet there is lack of awareness regarding this disease amongst many Indian women.

This is a simple but effective Illustration which highlights the symptoms of breast cancer. Any lady suffering from such symptoms should visit a breast surgeon immediately.

Illustration source – http://www.roche.com

Phyllodes tumor

Cystosarcoma phyllodes is a rare, predominantly benign tumor of the breast. Its name is derived from the Greek words sarcoma (“fleshy tumor”), and phyllon (“leaf”). Grossly, the tumor displays characteristics of a large, malignant sarcoma, takes on a leaflike appearance when sectioned, and displays epithelial, cystlike spaces when viewed histologically. Because most tumors are benign, the name may be misleading. Thus, the favored terminology is now phyllodes tumor.

Pathophysiology and etiology

Phyllodes tumor is the most commonly occurring nonepithelial neoplasm of the breast. It has a smooth, sharply demarcated texture and typically is freely movable. It is a relatively large tumor, with an average size of 5cm. The etiology of phyllodes tumors is unknown.

While most phyllodes tumors are benign, the possibility exists for underestimating their potential for malignancy. Moreover, some juvenile fibroadenomas in teenagers can look histologically like phyllodes tumors; however, they behave in a benign fashion similar to that of other fibroadenomas.

Because of limited data, the percentage of benign versus malignant phyllodes tumors is not well defined. Reports suggest, however, that about 85-90% of phyllodes tumors are benign and that approximately 10-15% are malignant.

Although the benign tumors do not metastasize, they have a tendency to grow aggressively and can recur locally. Like other sarcomas, the malignant tumors metastasize hematogenously. Unfortunately, the pathologic appearance of a phyllodes tumor does not always predict the neoplasm’s clinical behavior; in some cases, therefore, there is a degree of uncertainty about the lesion’s classification.

The characteristics of a malignant phyllodes tumor include the following:

  • Recurrent malignant tumors seem to be more aggressive than the original tumor
  • The lungs are the most common metastatic site, followed by the skeleton, heart, and liver
  • Symptoms of metastatic involvement can arise from as early as a few months to as late as 12 years after the initial therapy
  • No cures for systemic metastases exist

 

History & Physical Examination

Phyllodes tumors generally manifest as larger masses and display rapid growth. A small mass may rapidly increase in size in the few weeks before the patient seeks medical attention. Tumors rarely involve the nipple-areola complex or ulcerate to the skin. Patients with metastases may present with such symptoms as dyspnea, fatigue, and bone pain.

A firm, mobile, well-circumscribed, nontender breast mass is appreciated. Overlying skin may display a shiny appearance and be translucent enough to reveal underlying breast veins. A very large phyllodes tumor may erode through overlying skin and present as an external fungating breast mass.

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Image: Benign phyllodes on mammogram

 

Diagnosis

Open excisional breast biopsy for smaller lesions and incisional biopsy for large lesions are the definitive methods for diagnosing phyllodes tumors.

Fine-needle aspiration for cytologic examination usually is inadequate for the diagnosis of phyllodes tumors. Core biopsy is more reliable, but sampling errors may still occur, and it may still be difficult to distinguish the lesion from a fibroadenoma.

 Treatment

Complete excision, with accurate histologic examination and continued follow-up care, is the best way to treat phyllodes tumors. In most cases of cystosarcoma phyllodes, wide local excision is indicated, with a rim of normal tissue included.

The lesion should not be “shelled out,” as might be done with a fibroadenoma, or the recurrence rate will be unacceptably high.

If the tumor-to-breast ratio is sufficiently high to preclude a satisfactory cosmetic result with segmental excision, simple mastectomy with or without reconstruction, is an alternative. Axillary lymph nodes are involved in less than 10% cases with malignant phyllodes and axillary lymph node dissection is usually not required during surgery.

In patients with recurrent phyllodes tumors, re-excision should be performed. Adjuvant radiotherapy can be used to reduce recurrence rates.

Interesting Mammograms #3

Case 1: 44 year old lady with a rapidly enlarging lump in the right breast of 6 months duration. On examination, she had a 3×3 cm hard lump in the lower half of her right breast. Surprisingly, she had a 5×5 cm hard, fixed axillary lymph node.

Reason of sharing this mammogram: bulky axillary lymphadenopathy with the lymph nodes being larger than the primary.

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Case 2: Patient had a lesion in the left breast, which was biopsied. Wanted to point out the steri-strip (artifact) after biopsy.

Pre- biopsy
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Post- biopsy
IMG_20140910_144305

 

Information provided by:

Dr. Rohan Khandelwal

Consultant, Breast Oncosurgeon

W Pratiksha Hospital

Interesting Mammogram #2

Case: 45 year old lady that presented with a painless, progressive breast lump on the left side of 7 months duration.

On examination: A10x10 cms firm, mobile lump involving the entire left breast was palpable. There were dilated veins overlying the lump with no palpable axillary lymphadenopathy.

Mammogram is shown below:

image

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Mammogram was suggestive of an encapsulated lesion with smooth margins, probably a phyllodes tumor.

Tru-cut : Phyllodes tumor
HPE: Benign phyllodes

Learning objective: Benign encapsulated tumor on mammogram suggestive of phyllodes. Capsule is visualized as a radiolucent halo around the lump.

 

Information provided by:

Dr. Rohan Khandelwal

Consultant, Breast Oncosurgeon

W Pratiksha Hospital

Contraindications to Breast Conserving Surgery

Breast conserving surgery (BCS) is fast becoming popular but one should be aware of the the contraindications of this procedure in order to avoid high recurrence rates & complications.

Breast conserving surgery in simple words is lumptectomy (removal of the tumor with a normal rim of tissue). All patients following BCS require radiotherapy. Some of the contraindications of this procedure are related to the surgical aspect whereas others are contraindications for radiotherapy.

 

Absolute Contraindications

  1. Pregnancy – is a contraindication for radiotherapy, as it can lead to teratogenic effects.
  2. Two or more primary tumors in separate quadrants (multicentric tumors). Patients with multifocal tumors (two or more primaries in the same quadrant) can undergo BCS. [Fig 1]
  3. Diffuse malignant-appearing calcifications on mammogram 
  4. History of prior radiation to the breast area
  5. Persistent positive margins
  6. Inflammatory breast cancer

multifocal vs multicentric

 

Relative Contraindications

  1. History of collagen vascular disease – leads to increased radiotherapy associated complications
  2. Breast size to tumor size ratio [Fig 2] – Instead of the absolute size of the tumor, tumor/ breast ratio is a better indicator of whether the patient is eligible for BCS or not. Fig 2 – highlights two patients, both with identical tumor sizes but one patient has a large breast (leading to a small tumor/ breast ratio) whereas the other patient has a small breast (leading to a large tumor/ breast ratio). BCS is avoided in patients with large tumor to breast ratio as it leads to poor cosmetic outcome.

tumorbreastratio

 

Following are NOT contraindications to BCS:

  • Family history of breast cancer
  • Positive lymph nodes
  • Bilateral breast cancer
  • Lobular histology
  • Central quadrant tumor

Midline breast cancer without a lump in the breast: an extremely rare case

Sometimes breast cancer tends to surprise us and present in an unusual manner. In India, due to lack to awareness and a stigma attached with breast cancer, females from the rural set-up tend to present with locally advanced breast cancers. I happened to encounter one such case couple of years back and managing this case turned out to be quite challenging. We managed to publish this case in the Breast Disease Journal and it generated quite a discussion in all the forums where it was discussed. [Breast cancer presenting in the midline without a lesion in the breast: a therapeutic dilemma. Khandelwal R, Poovamma CU, Shilpy C, et al. Breast Dis. 2013 Jan 1;34(2):57-9.]

A 48- year- old post-menopausal lady presented to the Breast Clinic with complaints of a rapidly enlarging chest swelling for the last 8 months. The lesion had ulcerated one month back and she complained of a foul smelling discharge from the growth. There were no complaints of any lumps in the breast or axillae.

On examination, a 14 x 10 cms ulcero-proliferative lesion was seen over the midline of the chest extending 4 cms on either side of the midline. The lump had restricted mobility over the underlying chest wall. In addition, the patient had multiple, enlarged lymph nodes in both the axillae. No enlarged lymph nodes were felt in the supraclavicular fossa. No organomegaly was palpable in the abdomen.

Lesion over anterior chest wall

Lesion over anterior chest wall

A provisional diagnosis of soft tissue sarcoma of the chest wall was made but the presence of bilateral, hard axillary lymph nodes raised a suspicion of a breast carcinoma. Patient was then subjected to a CECT of the chest, which revealed a fungating soft tissue mass over the chest with bilateral axillary lymphadenopathy. MRI of the breasts failed to pick up any lesions in the breast. CT abdomen was unremarkable. A PET-CT done to look for distant metastasis, revealed a mildly hyper-metabolic anterior chest wall mass [SUV max 4.8] with bilateral axillary lymphadenopathy [SUV max 5.1]. There was no evidence of involvement of supraclavicular or internal mammary lymph nodes. No distal metastasis was observed on PET.

Following the imaging tests, an incisional biopsy of the lesion was performed, which to our surprise revealed an invasive ductal carcinoma (grade II) with DCIS. Immunohistochemistry revealed the tumor to be ER and PR positive but HER2 negative.

The case was extensively discussed in the tumor board and a decision was taken to treat the patient with neo-adjuvant chemotherapy. Patient received weekly Paclitaxel for six weeks, which was associated with a good response and the tumor regressed in size. A PET scan done following NACT revealed a residual lesion in the midline with bilateral axillary lymph nodes. PET scan did not reveal any lesions in the breast.

Following a good response to NACT, the patient was taken up for a wide local excision of the tumor with bilateral axillary dissection. As none of the breasts had any lesions, they were not addressed during the surgical procedure.  Patient had an uneventful post-operative period and three weeks later she was started on adjuvant chemotherapy, which was followed by radiotherapy to the chest wall.

Post Surgery

Post Surgery

Following completion of radiotherapy, the patient was started on Letrozole and was kept under regular follow-up. The patient remained symptom free for 1 year after surgery, after which she was lost to follow-up.

This was an extremely rare presentation of breast cancer and managing this patient was a therapeutic dilemma.

Importance of regular follow-up after Breast Cancer Treatment

It was quite sad to see this 68 year old lady come to the clinic yesterday. She was diagnosed with left breast cancer two years back and was treated with MRM, adjuvant chemotherapy and hormonal therapy at a private hospital. After her treatment was completed, she did not visit the oncologist again thinking that she has been cured and for the last 6 months she had been harboring this growth over the chest wall, which turned out to be a local recurrence.

Local recurrence after mastectomy

Local recurrence after mastectomy

Patients tend to think that when the treatment is over, they are cured of the disease, but that is not the case. Patients need to visit their oncologists/ doctors regularly after the completion of their treatment and this case points out the importance of correct and regular follow-up after breast cancer treatment.

The current guidelines regarding follow-up of breast cancer patients are:

  1. History & physical examination: Every three to six months for the first three years after the first treatment, every six to 12 months for years four and five, and every year thereafter.
  2. Mammography: If mastectomy has been done, then annual mammograms of the opposite breast. If  breast conservation has been done, then B/L mammography should be done annually.
  3.  Breast self-examination. Perform a breast self-examination every month. This procedure is not a substitute for a mammogram.
  4. Pelvic examination. If the patient is on Tamoxifen, annual gynecological check-up should be done because tamoxifen can increase the chances of uterine cancer.

One reason which deters patients from going on regular follow-ups is the fact that some doctors order unnecessary tests during these visits. One should be aware that the following tests are NOT recommended for regular follow-up care of breast cancer patients:

  • Blood tests like CBC, LFT, KFT
  • Chest x-ray
  • Bone scan
  • CT scan
  • FDG PET scan
  • Breast MRI
  • Breast cancer tumor markers – CA 15-3, CA. 27.29, CEA

Paget’s disease of the Breast

Paget’s disease of the breast or nipple is an eczematous condition involving the nipple and areolar skin, which is histologically characterized by the presence of malignant cells interspersed within the keratinocytes of the epidermis (cells of the skin). In approximately 90% of cases, the condition is associated with an in situ or invasive breast carcinoma.

Symptoms:

  • Chronic eczematous lesion involving the nipple (most common presentation) [highlighted in the image]
  • Nipple erythema or ulceration
  • Nipple inversion
  • Nipple discharge
  • Pruritus
  • As many as 40% of women have a palpable mass on presentation, and some may present with enlarged axillary lymph nodes.
Ulceration of the nipple

Ulceration of the nipple

Imaging:

90% patients who present with an underlying breast lump along with Paget’s have abnormal findings on mammography but only 50% patients who present with Paegt’s without a breast lump show mammographic abnormalities. Magnetic resonance imaging (MRI) is increasingly being used, particularly in cases without a palpable mass. MRI is particularly useful to establish extent of disease in patients in which breast-conserving surgery is being contemplated.

Pathology: The hallmark of Paget’s is the presence of neoplastic cells within the epidermis that show abundant clear cytoplasm and tend to spread individually in between the native keratinocytes (Image). They tend to display prominent nucleoli and frequent mitoses. In addition, they commonly show intracytoplasmic mucin-filled vacuoles, which are stained with a periodic-acid-Schiff or mucicarmine stain.

Paget cells seen in the epidermis

Paget cells seen in the epidermis

Paget cells are usually positive for markers of breast epithelium differentiation like:

  • Cytokeratin 7
  • CAM 5.2
  • Low-molecular-weight cytokeratins (negative for high-molecular-weight cytokeratins)
  • Vast majority of cases show strong overexpression of the HER2/neu proteinion of the gene
  • Positive for mucin
  • 18-20% of Paget’s cells express S100 protein but contrary to melanoma cells, HMB45 is consistently negative.

Toker cells are immunophenotypically similar to Paget cells, sharing expression of cytokeratin 7 and CAM 5.2, absence of high-molecular-weight cytokeratin expression, and negative S100- and HMB45-expression. They differ in the negative expression of mucin, HER2/neu, and epithelial membrane antigen. The similarities between Toker and Paget cells have suggested that the former may represent the cell that undergoes malignant transformation in the initial phases of PD. Toker cells can be present in normal patients as well.

The most accepted explanation for the development of PD is that Paget cells result from the migration of cells from the underlying adenocarcinoma through the epidermis, the so-called epidermotropic theory. This theory is supported by the existence of an underlying carcinoma in about 90% of cases of PD, which usually shares phenotypic similarities with Paget cells.

 

Differential Diagnosis:

  • Eczema – tends to be bilateral and responds to topical steroids
  • Nipple adenoma

Diagnosis: 

  • Wedge biopsy
  • Punch biopsy

Management: Management of PD depends on the underlying breast lump. Traditionally, the surgical procedure of choice has been a mastectomy but there are numerous studies which show that breast conservation surgery can be carried out in patients with PD. Prognosis in PD is largely determined by the underlying breast tumor.

 

Source: 1. Bland & Copeland – The Breast. 4th Edition 2. Michael Sabel – Essentials of Breast Surgery