Over the past 50 years, a variety of surgical procedures have been advocated for the treatment of operable breast cancer, ranging from local excision to supraradical mastectomy. Today, the surgical treatment of breast cancer remains highly contentious. We review the historical development of breast cancer surgery and analyse the available evidence supporting conservative procedures. We also express our opinions on the treatment of early breast cancer and illustrate the changing patterns of surgery with our experience at National University Hospital.
A detailed cytomorphologic study was done on fine needle aspiration smears from 651 benign breast lumps. Cytological categorization enabled the distinction of proliferative from non-proliferative and infective lesions in the majority of the cases. Lumpectomy provided the histological diagnosis in 584 cases, most of which were proliferative lesions. Gross cystic disease and fibroadenoma were the most common lesions encountered. Microcysts with apocrine change, sclerosing adenosis, proliferative disease without atypia, atypical ductal hyperplasia, atypical lobular hyperplasia, and lobular carcinoma in situ were associated with the dominant lesion in many of the cases. In all these cases, retrospective analysis of the cytological smears was done in an attempt to identify cytological features which may indicate these lesions.
A 32-year-old pregnant lady presented with a rapidly enlarging right breast mass. A fine needle aspiration was suggestive of a malignant phylloides tumour. However histopathological examination after mastectomy revealed a moderately differentiated angiosarcoma. The histopathological and cytological features of this rare tumour together with the diagnostic pitfalls are discussed.
Presentation of breast cancer during pregnancy is a rare situation and one that requires a multidisciplinary approach involving an obstetrician, surgeon and oncologist. Management should be along the same principles as in non-pregnant patients and delay is not justifiable. Mastectomy and axillary clearance is the best option, followed by chemotherapy, which is safe after the first trimester. Radiation if required should be delayed until after delivery of the baby. We present here our experience with 6 patients who presented with breast cancer during pregnancy. Five patients refused any treatment until after delivery, while one underwent only a mastectomy and axillary clearance. The outcome was poor; all of them died between 14 months and 52 months. The poor outcome probably reflects the late stage at presentation in four of the patients (State 3 and 4) rather than the delay in treatment, while delay in treatment in the two who presented with early cancer (Stage 1 and 2) led to a more advanced stage after delivery.
Pure mucinous carcinoma (MC) of the breast is a relatively uncommon variant of breast carcinoma with distinctive histological and cytological features. In this study we have analysed fine needle aspiration (FNA) cytological material from 28 cases of MC of breast and correlated the cytomorphological features with histopathology. The 28 patients consisted of 27 females and one male patient. 14 patients were Chinese, 10 were Indian and four were Malay. Their ages ranged from 38 to 90 with a mean at 52 years. The left breast was involved in 17 and the right in 11 cases. The duration of the lump varied from two weeks to 10 years. The cytological picture was characterized by abundant extracellular mucin giving a "sea of mucin" or "whirlpools of mucin" effect, in which were seen floating clusters of tumour cells with relatively bland cytological features. Myxo-vascular fragments were seen in 12 cases. Dissociated tumour cells showed a plasmacytoid appearance with eccentric nuclei. In four cases, the mucin was scanty in amount and the cellularity was high while in two cases, the cellularity was very low. Psammoma bodies were seen in cytological smears in one case. Histological study of excision or mastectomy specimens confirmed all 28 cases to be pure MC. Knowledge of the distinctive cytomorphological appearance of MC would enable correct identification of these lesions as malignant and prompt treatment that could further enhance the survival of these prognostically good breast cancers.
Biliary cystadenoma is a rare neoplasm of the biliary ductal system. Surgical management yields an excellent result. We present a case of recurrent biliary cystadenoma in the left lobe of the liver. The cyst was successfully treated with hepatic segmentectomy. The lobulated smoothly marginated septated cystic lesion noted on computed tomography (CT) were highlighted and the other imaging studies, differential diagnosis and management were reviewed.
Breast ductal carcinoma in-situ (DCIS) is increasingly being diagnosed as a result of screening mammography and better pathological recognition. With this and the rising breast cancer incidence in Singapore, DCIS is poised to become a bigger part of surgical practice. Principles of screening, diagnosis and management of DCIS have also been rapidly evolving. Against this background, a clinicopathological audit of recent cases of DCIS in our centre was performed.
Breast Surgery International (BSI) was formed in 1999 as an integrated society within the International Surgical Society ISS/SIC. One goal is to promote breast surgery world wide and focus on the situation in the developing countries. An edited summary of a symposium on locally advanced breast cancer (LABC) and the current situation in two African countries and in Malaysia is reported. Diagnosis, management and treatment options differ from recommendations that prevail due to lack of resources, lack of access to facilities and cultural and socioeconomic barriers. Younger age at onset, more men are affected and locally advanced breast cancer dominates the clinical panorama. A rational treatment plan for LABC should have chemotherapy, surgery, radiotherapy and hormonal therapy as armaments. A unique opportunity exists for international interchange within a professional organization such as BSI, for providing training opportunities, for clinical and experimental studies of the world' s most common female malignancy.
Skin-sparing mastectomy is still in its infancy in Malaysia. The option of skin-sparing mastectomy is rarely given to patients as many general surgeons perform the conventional mastectomy. This could also be compounded by the lack of awareness amongst the local surgeons on the safety, surgical technique and treatment outcome of this relatively new procedure. This case report demonstrates the feasibility of this procedure performed on a Malaysian patient with a comparable outcome of those reported in the Western countries.
Fasciolosis is an uncommon disease in this region, as are parasitic infections of the breast. This report describes a 56-year-old man with a previous history of liver abscess presenting with a painful breast mass. He underwent a mastectomy and is well. The pathological findings revealed chronic granulomatous mastitis with Fasciola spp. ova. The literature on this very rare condition is reviewed.
Metastasising ability connotes one of the most important life-threatening properties of malignant neoplasms. Recent studies indicate that CD44 proteins, multifunctional cell adhesion molecules which contribute to "homing" of lymphocytes to lymph nodes as well as cell-cell and cell-matrix interactions, are potential markers of tumour progression. However, whether CD44 expression by human tumours contribute to increased metastatic risk remains controversial. In an attempt to clarify its role in breast cancer, we have investigated the correlation between CD44 expression by breast carcinoma and the presence of axillary lymph node metastases. CD44 expression was detected using a standard immunoperoxidase method on formalin-fixed, paraffin-embedded, primary infiltrating ductal breast carcinoma tissues taken from 60 female patients who underwent mastectomy with axillary node clearance. Tumours were graded according to the modified Bloom and Richardson criteria. 62% of patients had histologically-proven lymph node metastasis. 40% of primary cancers exhibited cytoplasmic membrane immunopositivity for CD44. 46% of primary tumours which have metastasied to axillary lymph nodes were CD44 positive whereas 30% of tumours which have not metastasised expressed CD44. CD44 positivity was expressed by 20% of grade 1, 31% grade 2 and 58% grade 3 tumours. Our results suggest that CD44 may have a role in the progression of breast cancer and emphasise the need to investigate its interaction with other mechanisms of cancer advancement.
OBJECTIVE: The aim of this study was to investigate if preemptive local infiltration (PLA) with ropivacaine could improve postoperative pain and determine its effect on drain output postmastectomy with axillary dissection.
METHODS: This was a prospective, randomized trial comprising 30 women allocated to two groups: one to receive postoperative wound infiltration (POW) of 20 mL of 0.2% (40 mg) ropivacaine (Naropin) versus PLA with 20 mL of 0.2% ropivacaine (Naropin) diluted with 80 mL of 0.9% saline, total volume 100 mL. A visual analogue scale (0-100 mm) and angle of shoulder abduction were used for evaluation of pain. Postoperatively, all patients received oral ibuprofen 400 mg tds.
RESULTS: There was no significant difference in postoperative pain for the first 3 days between the two groups. There were wider shoulder abduction angles in the 1st and 3rd postoperative days in the PLA group, but this was not significant. Operative time was significantly shorter in the PLA group than in the POW group (69.34+/-59.37 minutes vs. 109.67+/-26.96 minutes; p=0.02). The axillary drain was removed earlier in the preemptive group, 5.4+/-1.55 days versus 6.8+/-2.04 days in the postoperative group (p=0.04).
CONCLUSION: We found no difference in postoperative pain between preemptive tumescent ropivacaine infiltration and postoperative ropivacaine wound infiltration.
The determination of tumour-free margin in breast cancer is crucial in deciding subsequent patient management. To exemplify the phenomenon of margin contraction during specimen preparation for histopathological analysis, we quantified the shrinkage of breast specimens as a result of formalin fixation.
Radiotherapy has an established role in reducing the local relapses in breast cancer patients. The objective of this review was to investigate whether radiotherapy or its omission after breast surgery has measurable consequences on local tumor recurrence and patient survival. The late excess of cardiac deaths has also been published in various reports but important advances in the delivery of radiotherapy have overcome this problem to the extent that, excess cardiac deaths do not appear to be occurring in more recent trials. In this article some recent data, suggesting that radiotherapy following mastectomy and/or breast conserving surgery has a beneficial effect on survival is reviewed. Omission of radiotherapy is associated with a large increase in risk of ipsilateral breast tumor recurrence and with a small increase in the risk of patient's mortality.
Neuroendocrine carcinomas of the breast are uncommon tumors known to occur in the elderly. While focal neuroendocrine differentiation may be noted in many ductal and lobular carcinomas, the term neuroendocrine carcinoma is to be applied when more than 50% of the tumor shows such differentiation. This case report details the cytological features of a neuroendocrine carcinoma that was encountered in our hospital. The fine needle aspiration (FNA) smears showed discohesive polygonal cells with abundant cytoplasm, many of which contained eosinophilic granules located at one pole. Histology of the mastectomy and axillary lymph nodes specimen from this patient showed features of neuroendocrine carcinoma--solid type, with metastasis, confirmed with immunohistochemistry. The patient is disease free seven months after surgery. This case highlights the need to closely observe cytological details to identify this rare tumor that may otherwise appear to be invasive duct carcinoma--not otherwise specified on FNA. The implications of diagnosing neuroendocrine differentiation for prognosis and management are also discussed.
INTRODUCTION: CA15-3 is a well-known tumour marker for breast cancer. Currently it is not recommended for screening or diagnosis of breast cancer and its main application is in monitoring response to treatment in women with metastatic breast cancer. The aim of this study was to correlate serum CA15-3 at presentation with the stage of disease and overall survival in women with breast cancer in the University Malaya Medical Centre.
METHODS: This is a retrospective study of 437 women who had CA15-3 levels determined at initial presentation of breast cancer to UMMC between Jan 1999 and Oct 2003.
RESULTS: Of those patients who were adequately staged, CA15-3 was found to be elevated (defined as >51 U/ml) in 0% of Stage 1, 7.9% of Stage 2, 36.7% of Stage 3 and 68.6% of Stage 4 cases. In a subset of 331 patients with survival data, patients with normal CA15-3 had a 85% five year overall survival rate compared to 38% in their counterparts with elevation of the tumor marker. The level of elevation was also significantly related to survival; patients with values more than 200 U/ml exhibited only a 28% five year survival. The association of elevated CA15-3 at initial presentation with poor outcome was maintained over univariate and multivariate analyses.
CONCLUSION: Estimation of CA15-3 at presentation of breast cancer is important as it is an independent prognostic indicator and may prompt the physician to investigate for metastases if elevated.
INTRODUCTION: Mastectomy is an essential but disfiguring operation in cancer treatment. The negative impact on body image can however be prevented by immediate reconstruction.
AIM: The aim of this study was to determine the reasons why patients choose to have or not to have immediate breast reconstruction.
METHODOLOGY: This is a cross sectional descriptive study of breast cancer patients post-mastectomy who had and had not undergone immediate breast reconstruction. The patients were asked a series of questions to ascertain the reasons why they chose or did not choose immediate breast reconstruction.
RESULTS: 136 patients in total were interviewed of which 23 had undergone immediate breast reconstruction. 36.8% of the patients had been offered reconstruction. In the non-reconstructed group, the main reason for not having reconstruction were fear of additional surgery. In the group that had reconstruction done, the main reason was to feel whole again. Low on the list were reasons such as trying to improve marital or sexual relations.
CONCLUSION: Only a third of patients undergoing mastectomy were offered immediate reconstruction. In public hospitals in developing countries, limited operating time and availability of plastic surgery services are major barriers to more women being offered the option.