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Malaysian Journal of Medical Sciences
School of Medical Sciences, Universiti Sains Malaysia
ISSN: 1394-195X
Vol. 18, Num. 2, 2011, pp. 82-84
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Malaysian Journal of Medical Sciences, Vol. 18, No. 2, 2011, pp. 82-84
Case
Report
Isolated Ipsilateral Nipple Recurrence: Important Lessons
to Learn
Shahrun Niza
Abdullah Suhami1, Rohaizak Muhammad1,
Ibrahim Naqiyah1, Srijit Das2,
Noraidah Masir3
1 Department of
Surgery, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaakub Latiff,
Bandar Tun Razak, 56000 Kuala Lumpur, Malaysia
2 Department of
Anatomy, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaakub Latiff,
Bandar Tun Razak, 56000 Kuala Lumpur, Malaysia
3 Department
of Pathology, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaakub
Latiff, Bandar Tun Razak, 56000 Kuala Lumpur, Malaysia
Correspondence: Professor Dr Rohaizak Muhammad BSc (St Andrews Univ),
MBChB (Glasg), MS (UKM), FRCS (Glasg)
Department of Surgery Universiti Kebangsaan Malaysia Medical Centre Jalan
Yaakub Latiff, Bandar Tun Razak 56000 Kuala Lumpur Malaysia Tel: +603-9170 2315
Fax: +603-9173 7831 Email: rohaizak@hotmail.com
Submitted: 27 Aug 2010
Accepted: 20 Dec 2010
Code Number: mj11028
Abstract
Most breast cancer recurrences occur in the
surgical scars or within other quadrants of the same breast. Isolated tumour
recurrence occurring in the nipple after breast-conserving surgery and
radiotherapy is extremely unusual. The reason for this is unknown, but is
speculated to be due to involved surgical margins or an occult involvement
of the nippleareolar complex in a breast cancer of the same breast. We present
a case of a 44-year-old Indian woman who had recurrent tumour over her right
nipple after an ipsilateral breast-conserving surgery that was followed by
adjuvant chemotherapy and radiotherapy. There was no typical malignancy
features from the mammogram. However, histopathological study confirmed a
malignant growth that infiltrated into the dermis and the underneath breast
tissue. Completion mastectomy was then performed and the patient was later
treated with Taxane-based chemotherapy. Nipple
recurrence after breast-conserving surgery and adjuvant radiotherapy may be
confused with other nipple conditions such as Pagets disease of the breast.
Comprehensive assessments, which include mammogram and biopsy, have proved
that such recurrence do occur, as presented in this case. This warrants a specific
management strategy.
Keywords:
breast-conserving surgery, diagnosis, nipple,
recurrence, surgical oncology.
Introduction
Breast-conserving surgery is used to treat early
breast cancer (16). Among the risks involved using this strategy is
ipsilateral breast tumour recurrence, which requires further radical treatment
including completion mastectomy. The incidence of local recurrence from
breast-conserving surgery in early breast cancer is reported to be as high
as 14.3% (3). The tumour may recur at the surgical scar or the surrounding
quadrants of the affected breast. The reason for such phenomenon is unknown,
but unclear resection margins or unidentified occult tumor tissue may be the
cause. We report our experience of managing isolated ipsilateral nipple
recurrence occurring after breast-conserving surgery. The case involved a
complete re-assessment of the local recurrence using radiological and
histopathological examinations.
Case Report
A 44-year-old woman had breast-conserving surgery
for a T2N1M0 right breast infiltrating ductal carcinoma on October 2007. She
had no significant high risk factor for breast cancer or any past medical
history. The tumour was located at the right upper quadrant of the breast.
Mammogram and fine-needle aspiration biopsy showed malignancy. The
histopathological examination showed a grade 3 tumour measuring 4.5 × 3.0 ×
3.5 cm. The entire surgical margins were free. An axillary dissection
showed 1 of the 17 lymph nodes had metastasis. The tumour was negative for
estrogen receptor (ER) and progesterone receptor (PR) but was strongly positive
(3+) for c-erb-2 oncoprotein. The patient completed 6 cycles of FEC
(5-fluorouracil, epirubicin, cyclophosphamide) adjuvant chemotherapy, followed
by 40 Gy of radiotherapy given in 15 fractions and a booster dose of 10 Gy
in 5 fractions afterwards. At 5-month follow-up, she developed an ipsilateral
nipple
pain with bloody discharge. A 1.0-cm, rounded, ulcerative growth appeared over
the nipple. A subsequent mammogram did not show any malignant features, but
histopathological examination from a wedge biopsy confirmed a recurrent infiltrating
ductal carcinoma with similar histological features to her previous primary
breast carcinoma. There was no evidence of distance metastasis. A completion
right mastectomy was performed. The final histology was of grade 3, ER
negative, PR negative, and c-erb-2 oncoprotein, again, strongly positive. Six
axillary lymph nodes were further recovered this time and 3 of them were
involved. The patient received another 4 cycles of Taxane-based chemotherapy,
and currently under regular follow-up without evidence of further recurrence.
Discussion
Isolated local recurrence over the nipple at
ipsilateral breast after breast-conserving surgery or nipple sparing mastectomy
is rare (12). There was only 1 case reported in the literature (13), even
though some authors have reported local recurrence of breast cancer in the
form of Pagets disease of the nipple (7,8), which suggested an underlying tumour
recurrence in the ipsilateral breast, occurring 516 months after radiotherapy.
However, our case was different; the patient presented with a nodulo-ulcerative
lesion that developed 5 months after breast-conserving surgery. It was not a
Pagets disease of the nipple, and her mammogram was normal. The similarity
of the histopathological studies between the first and second tumour had brought
about the diagnosis of a local tumour recurrence. Furthermore, the tumour
recurred only 5 months after the first surgery. This tumour was of the
aggressive type based on its high grade, ER and PR negativity, and c-erb-2
oncoprotein positivity. This explains the loco-regional recurrence despite
adjuvant chemotherapy and radiotherapy.
The real reason for an isolated ipsilateral nipple
recurrence after a breast-conserving surgery remains a mystery. It is believed
that unclear surgical margins, implantation phenomenon, or occult tumour at
the nippleareolar complex (9) may give rise to this phenomenon. The incidence of
occult nipple involvement may be as low as 5.6% to 50.0 % (9). Studies have
discrepancies on parameters that might predict nipple involvement. Several
studies showed that the tumour grade, size, and stage, tumournipple distance,
and c-erb-2 positivity were significant predictors for occult nipple
involvement in breast cancer (11,14,15),
but other studies reported contrasting findings (9,10). However, all of
them agreed that the location of the tumour has an influence on nipple
involvement (911,14,15). The incidence of nipple recurrence is higher for
tumours located at the central or retroareolar area (10,11,14,15) compared
with other 4 quadrants of the breast. Therefore, the decision to perform
breast-conserving surgical procedures should not be based on the tumour
location alone, but also on the size and stage of the cancer as well as the
immunohistochemistry results and c-erb-2 status. This case increases our
awareness of nipple recurrence and the importance of carefully selecting the
appropriate breast conservation patients for nipple preservation.
Conclusion
A true infiltrating lesion as presented above is
very rare. Comprehensive assessments such as mammogram and biopsy have proven
that such recurrences do occur; this warrants a different management strategy.
Tumour stage, grade, and location may play a vital role in predicting occult
nipple involvement in breast cancer. Breast cancer patients must be carefully
selected for breast-conserving surgery; failure to do so may later results in
nipple recurrence.
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