Angiosarcoma of the breast following radiotherapy after conservative breast surgery - a case report

Angiosarcoma of the breast following radiotherapy after conservative breast surgery - a case report

1176 Between January 2001 and December 2006, 43 patients, aged 35 to 39 years, were diagnosed with breast cancer. Records were reviewed to identify wh...

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1176 Between January 2001 and December 2006, 43 patients, aged 35 to 39 years, were diagnosed with breast cancer. Records were reviewed to identify where the diagnosis would have been missed if mammography had not been performed. In 2 patients (5%), breast cancer would have been missed if mammography had not been performed. In one, incidental calcification was identified in the breast contralateral to the presenting symptom, which was diagnosed to be intermediate grade ductal carcinoma in-situ (DCIS). The second presented with milky nipple discharge, with no palpable abnormality to prompt ultrasound. Mammography revealed two lesions both of which were high grade DCIS. During this time, 4 patients in this age group required guidewire localised excision of incidental mammographically identified suspicious lesions, away from their presenting lesion, for what proved to be benign lesions; 2 radial scars, 1 calcified fat necrosis and 1 sclerosing adenosis. Over this 6 year period, 2 cases of DCIS were identified mammographically which would not have been picked up by clinical examination and US alone. 1420 mammograms were performed in women of this age group, a detection rate of 0.14% which compares to a 0.8% detection rate in the NHS Breast Screening Program. Four patients had unnecessary operative excision biopsies for benign lesions identified incidentally by mammography. Should mammography be the initial imaging technique in patients in this age group? P42. Impact of Sentinel lymph node biopsy in decreasing hospital stay & axillary clearance: A single unit District General Hospital experience Apurva Sinha, M. Kishore, A. Siddiqui, K. Atkins, R. Nangalia George Eliot Hospital NHS Trust, College Street, Nuneaton, Warwickshire CV10 7DJ Introduction: Sentinel lymph node biopsy has decreased the morbidity and unnecessary lymph node dissection associated with the breast cancer surgery. We tried to evaluate the effectiveness of sentinel lymph node biopsy in decreasing the hospital stay and evaluate the patients who underwent successful sentinel node biopsy. Material and method: Data collected prospectively for all breast cancer patients who were planned to have sentinel lymph node biopsy from July 2006 to March 2008 (138 patients.), since the Breast unit got accreditation for sentinel lymph node biopsy. Result: For patients who underwent wide local excision or mastectomy with sentinel node biopsy, the average over night hospital stay was 1 day and the patients who underwent above mentioned procedure with axillary clearance was 2.25 days. 88.40% (122/138) patients had Sentinel node biopsy and 10.86%(15/138) had on table conversion to Axillary node clearance. The patients with negative histology after SLNB were 63.67%(88/138). The rate of negative lymph node positivity for patients who had on table axillary clearance was 13.33%(2/15). In our study we had one patient (0.72%) which failed sentinel node detection. Conclusion: It is quite evident from the study that the introduction of sentinel node biopsy in our unit has decreased the number of days of in hospital stay by 1.10 days and has also helped the Trust to reduce the bed pressure. It also showed that 63.67% of patients who underwent successful sentinel node biopsy avoided potential axillary dissection, thus decreasing the morbidity associated with axillary dissection.

ABSTRACTS Patients and Method: We retrospectively examined data from 102 consecutive patients (>35years), presenting to a symptomatic breast clinic with a palpable breast mass which subsequently was shown to be a breast cancer. All patients underwent both mammography and ultrasound, and the results were graded (M1-M5, U1-U5) at the time of initial investigation. Results:

Mammogram Grade

No of Patients

Ultrasound Grade

No of Patients

M1 M2 M3 M4 M5

8 3 14 27 50

U1 U2 U3 U4 U5

0 0 5 21 76

Mammograms of 11 patients were reported as being normal (M1) or showing benign changes (M2). All patients had abnormal ultrasounds (U3, U4, U5). Conclusion: We conclude that ultrasound is more discriminatory than mammography in determining whether a mass is malignant, and routinely should be incorporated with mammography as part of the triple assessment. P44. Factors affecting aesthetic outcome in screen detected breast cancer Roisin Dolan, L. Kelly, M. Kennedy, T. Gorey, M. Stokes, M. Kell Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland Introduction: Breast cancer screening mandates that the therapeutic outcome is acceptable to patients. Aesthesis is a critical measure of outcome in survivors. Many factors influence aesthetic outcome following breast cancer surgery, and these may be influenced by surgical planning. To explore this we examined outcome in patients following breast conserving surgery. Methods: We identified 100 patients following completion of treatment from the National Breast Screening Program. We utilised a previously validated questionnaire and further developed this to measure aesthetic outcome. Patients were invited to score their treatment plan and outcome on a 10-point scale. This was then correlated with surgical variables. Results: 75% of the initial sample responded. This final sample had a median age of 58.6 years (range 50-70) at the time of diagnosis. When asked to score their treatment 1-10 (poor-excellent) the mean score was 8.2 with a median of 9. For aesthetic outcome (score 1-5, very dissatisfied - completely satisfied) the mean score was 4.6. However, we identified reexcision of margins (RR ¼ 7.95, CI ¼ 2.28 to 26.81), excision of skin (RR ¼ 5.72, CI ¼ 2.06 to 15.14), smoking (RR ¼ 2.38, CI ¼ 1.04 to 4.87) and post-operative infection (RR ¼ 3.82, CI ¼ 1.20 to 11.25); as independently predictive of a poorer aesthetic result (p < 0.0001). Conclusion: Patients detected through population based screening score highly for overall satisfaction following therapy. Aesthetic outcome is good; however several factors correlate with a poorer aesthetic result. We propose that it is possible to achieve optimum oncological outcome with excellent aesthetic results, providing a better overall outcome, for patients undergoing treatment for breast cancer.

P43. Triple assessment of patients (> 35 years), presenting with a palpable breast mass should include ultrasound in addition to mammography Angela Brent, J. Pain, A. Evans Poole NHS Foundation Trust, Longfleet Road, Poole, Dorset, BH15 2JB

P45. Angiosarcoma of the breast following radiotherapy after conservative breast surgery - a case report V. Rao Wunnava, K. Fortes Mayer, P. Brookes, M. Heitman Manor Hospital, Moat Road, Walsall, WS2 9XS

Background: Mammography is the usual initial imaging investigation for patients (>35years) presenting with a breast mass. We investigated whether the routine addition of ultrasound as part of the triple assessment would improve diagnostic accuracy for malignancy.

Introduction: Radiation induced angiosarcomas (RIA) are rare tumours. They have been reported in women who had radiotherapy following conservative breast surgery. Diagnosis is delayed due to their benign appearance and mammography and ultrasound scan are usually not

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helpful. We report a case of RIA, who had radiotherapy for breast cancer following conservative breast surgery and axillary node sampling. Case Report: A 68 year woman underwent excision biopsy for a suspicious pea sized lump in upper outer quadrant of right breast in December 1999. Histology showed a grade 1 mucoid carcinoma, lesion extending up to the resected margins. She underwent wide cavity excision with axillary node sampling. Specimen showed 4 mm residual invasive mucinous carcinoma , nodes negative. She received adjuvant radiotherapy to breast and axilla, 40 Gy in 15 fractions followed by right breast boost of further 14 Gy in 5 fractions with 14 Mev electrons. She was discharged in March 2007. In July 2007 she presented with a spontaneous bruise on her right breast in the area of previous lumpectomy. A mammogram did not show any change from the previous film. Follow up in six months showed increased bruising and a thickened skin patch. A punch biopsy confirmed it to be highly suspicious of angiosarcoma. Mastectomy performed after staging investigations and histology proved it to be RIA grade 2, intermediately differentiated. Conclusion: RIA is difficult to diagnose due to its benign presentation. Any unusual cutaneous lesion should be investigated with generous tissue biopsy. Local recurrence is a poor prognostic factor. P46. Audit of the use of axillary ultrasound +/- FNA in staging the axilla in breast cancer Peter Jones, L. Meacok, S. Jones, P. Mills, A. Sever, J. Weeks Maidstone and Tunbridge Wells NHS Trust, Hermitage Lane, Barming, Maidstone, Kent, ME16 9QQ Introduction: Patients with diagnosed invasive breast cancer require nodal staging as a prognostic guide, to prevent axillary recurrence and determine further treatment. Sentinel lymph node biopsy(SLNB) is established in axillary staging in breast cancer. Identification of involved nodes by ultrasound/FNA may avoid inappropriate surgery. The purpose of this audit is the correlation of ultrasound findings with the surgical findings. Method and materials: In Maidstone all women with breast cancer have axillary ultrasound with FNA of nodes with a cortical thickness <2 mm, an eccentic cortex, irregular cortex or a ratio of length to width of <2. Only patients with normal axillary ultrasound or negative FNA results are offered (SLNB). Results: 224 cases with a negative axillary assessment underwent SLNB. Analysis of the histology of the nodes showed the following ultrasound/FNA results: True positive True negative False positive False negative

100% 80% 0% 20%

The average number of sentinel nodes retrieved was 2.12. The range was 1-8. In the false negative group there were 48 cases. 47 proceeded to level 3 clearance. One 86 year old with a single micrometastasis had no futher surgery. In 30 cases only the sentinel node/s were positive (only 1 node in 23 cases) and 14 had micrometastasis only. In the other 13 who have completed their surgery the number of positve nodes was 2-12 (mean 4.16) 14 of the 20 patients (70%) which proved to be false negative had micrometastasis(12) or isolated tumour cells(2) only. Conclusion: Pre-operative ultrasound-guided FNA of the axillary nodes is a valuable procedure that should be performed in all patients with primary invasive breast cancer P47. Comparison of blue dye alone with blue dye and radioisotope combined in the detection of axillary sentinel lymph nodes in women with invasive breast cancer Peter Jones, S. Jones, D. Fish, J. Donaldson Maidstone and Tunbridge Wells NHS Trust, Hermitage Lane, Barming, Maidstone, Kent, ME16 9QQ

Introduction: Sentinel lymph node biopsy (SLNB) is established as a reliable method of assessing the axillary nodal status in women with breast cancer. It avoids the complications of axillary node clearance in node negative patients whilst providing more accurate prognostic information than 4 node sampling. It can be performed with blue dye or radio-isotope alone or in combination. Methods and materials: 200 women with histologically confirmed invasive breast cancer, and a negative ultrasound/FNA axillary assessment, underwent SLNB.100 had a sub-areola injection of blue dye after induction of anaesthesia, and 100 had an additional sub-areolar injection of radio-isotope the day before surgery. Women receiving blue dye only went on to undergo a level 3 axillary node clearance (ANC) under the same anaesthetic as part of a validation study. Women with both blue dye and radio-isotope underwent ANC as a second procedure only if the SLNB was positive. Results:

% SLN found % SLN positive % SLN negative % no SNB found % false negative average no nodes range

Blue dye alone

Blue dye and isotope

90 14 86 10 3 2.3 1e7

99 16 83 1 X 2.13 1-7

Conclusion: Using blue dye alone it is possible to achieve the targets set by the New Start programme, but there is a higher incidence of failure to find the sentinel lymph node/s than when used in combination with radio-isotope (90%vs 99%).The use of combined blue dye with radio-isotope is recommended as the best way to find sentinel lymph nodes in women with breast cancer. P48. Vacuum-assisted percutaneous removal of breast papillomas and radial scars Peter Jones, S. Jones, D. Fish, P. Mills, A. Sever Maidstone and Tunbridge Wells NHS Trust, Hermitage Lane, Barming, Maidstone, Kent, ME16 9QQ Introduction: Image-guided removal of breast lesions has been described. The UK breast screening program pathology sub-group have defined a group of lesions with uncertain malignant potential (B3) when surgical excision is recommended. However large-core vacuum-assisted devices provide an alternative means of removal. We review the Maidstone experience in the vacuum-assisted removal of papillomas and radial scars. Methods and materials: Between August 2001 and December 2007, 36 breast lesions were removed using vacuum-assisted biopsy devices. The aim was complete removal. Follow-up was performed 4-60 months after removal. Lesion size, type, symptom resolution, recurrence and need for further surgery were assessed. Results: No case required further surgery. There were 23 (64%) papillomas measuring 4-22 mm. Stereotactic exision was performed in 3 patients and all others under ultrasound guidance using a hand-held device. Presenting symptom was nipple discharge in 9 cases, and recurrence was noted in 2 patients (8.7%).Remaining cases revealed no residual lesion or discharge.13 (36%) were radial scars measuring 6-15 mm. 5 lesions were removed under stereotactic guidance. Follow-up imaging revealed no residual lesions or recurrences. Conclusions: Image guided percutaneous removal of papillomas and radial scars is a safe practice and can be offered as an alternative to surgery. Papillomas can recur if removal is incomplete. P49. Is Systemic Thrombo-Embolic prophylaxis needed for Breast Surgery? Vummiti Muralikrishnan, J. Edwards, B. Sara, E. Davies, P. Mekhail Princess of Wales Hospital, Coity Road, Bridgend, Mid Glamorgan, CF31 1RQ