Authored by Maha Abdel Hadi
The aim is to shed light on a rare form of
breast cancer occurring at the axillary tail of spence. Presentations
may be delayed as many differential
diagnoses may be considered. Diagnostic imaging will include the
mammography, ultrasound, MRI and tissue diagnosis. We report three cases
with
similar clinical and histological presentations despite the age
difference. Standard radiological and histopathological evaluations were
employed to
reach the diagnosis of invasive ductal carcinoma (IDC) of the axillary
tail.
Axillary Breast cancer is a rare entity accounting for 0.1-
2% of all breast cancer cases. It is typically composed of poorly
differentiated IDC with occasionally areas of squamous or
mesenchymal carcinoma [1]. Axillary malignancy is challenging
as there are many differential diagnoses that may require careful
evaluation process. The reported differential diagnoses are occult
breast carcinoma, accessory breast cancer, axillary tail breast
cancer, lymphoma or non-breast metastatic lymphadenopathy [2].
Case 1
A 28 years old female presented with enlarging left axillary
swelling noticed 3months post-partum of her first pregnancy. She
was reassured for 9 months attributing it to lactational changes.
There was associated progressive pain and limitation of movement
of the left shoulder. Menarche at age 14 with regular menstruation
and pregnancy with no associated co-morbidities. General
examination was unremarkable. Local examination revealed
bilateral nodular breasts with no palpable masses. There was a
palpable left axillary firm, limited mobility 2x3cm mass with no
associated tenderness or skin changes.
Ultrasound and mammogram revealed normal bilateral breasts
with an axillary tail mass extending to the left axilla with multiple
matted axillary nodes on imaging. CT scan confirmed the findings.
Core biopsy of the lesion revealed IDC Patient underwent Excision
of Axillary tail with axillary node dissection sparing the breast
followed by adjuvant chemo-radiotherapy regimens.
Case 2
A 32 years old female presented with enlarging right lateral
painless breast swelling of 4 months duration. Otherwise she was
completely asymptomatic. Menarche at age 12 years with regular
menstruation and normal single pregnancy with no associated
co-morbidities. General examination was unremarkable. Local
examination revealed bilateral nodular breasts with no palpable
masses. There was a palpable right non tender axillary tail firm,
fixed 3x3cm mass with no associated skin changes. Palpable axillary
mobile nodes in the ipsilateral axilla. Ultrasound and mammogram
revealed a well circumscribed axillary tail mass extending to axillae
with multiple nodes on. CT scan confirmed the findings. Core
biopsy of the lesion was reported IDC. Patient underwent Excision
of Axillary tail with axillary node dissection sparing the breast
followed by adjuvant chemo-radiotherapy regimens.
Case 3
A 69 years old single female, a Known case of schizophrenia and
bronchial asthma and both controlled on medication. She Presented
with a large left axillary mass of one-year duration with progressive
increase in size. There was associated hyperpigmentation of
the overlying skin otherwise no associated pain or discharge.
Menopause at age of 50 years with no history of hormonal
replacement therapy. General examination: obese, anxious female
otherwise the general examination was unremarkable Local
examination: revealed bilateral symmetrical large breasts. The
right breast was unremarkable. Left breast: Normal anterior aspect
and nipple. There appeared a large breast tail 6x7cm firm, nontender
fixed mass, associated with thick purple colored skin with
peau d’ orange.
Ultrasound showed a large heterogeneously hypoechoic highly
vascular left axillary mass measuring approximately about 10×5.0
cm with cystic changes and thickened skin. Highly suggestive of
malignancy (Figures 2).
Mammogram was a limited study due to technical reasons
demonstrating part of the axillary mass with fat stranding and skin
thickening (Figure 3).
Contrast enhanced CT scan both axial and sagittal views of
the chest, abdomen and pelvis showing left axillary tail/axilla
demonstrated a large irregular heterogeneously enhancing mass
with central necrosis measuring 10× 7.7× 10cm at anteroposterior,
transverse and craniocaudal diameters respectively attached to
the skin with skin invasion. The mass appeared separable from the
breast tissue with fat stranding and subcutaneous edema. Multiple
Matted ipsilateral axillary lymph nodes with central necrosis were
also noted.
Due to the rare occurrence of the carcinoma of the axillary
tail it remains an under-recognized entity [1,2]. It possesses a
typical clinical, pathological and prognostic feature, promoting the
likelihood of nodal metastasis which impacts negatively on both
disease progression and survival [3]. Patients usually discover the
mass on self-examination and seek medical advice. The standard
investigations with ultrasound and mammography are useful
modalities yet to anatomical nature of the axillae some limitations
are encountered. More sophisticated modalities such as MRI and
PET-CT provide accurate delineation facilitating the diagnosis
especially in challenging cases [4,5].
IDC is the commonest histological diagnosis especially in
malignancies arising from the ectopic breast tissue. Occasionally
the diagnosis maybe challenging as other diagnoses such as
adnexal skin carcinomas may be difficult to differentiate [6]. The
treatment is straight forward with no dispute regarding the axillary
dissection. However, mastectomy versus wide local Excision (WLE)
remains. Even though recommendations of mastectomy remain, the
majority feel that WLE may be adequate [7,8].
Axillary tail breast cancer is rare and challenging entity that
may need special attention in clinical, imaging and pathological
practice.
None.
No conflict of interest.
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