Dermatofibrosarcoma protuberans (DFSP) is a rare, low-grade, fibroblastic mesenchymal tumor derived from the dermis. Breast is an uncommon site with an incidence of only 0.8-4.5% and an overall population incidence at any site of 4.2-4.5 per million. Surgical excision with 2-3 cm margin is the gold standard treatment. Selected cases are subjected to radiotherapy or systemic therapy with Imatinib. Due to the rare presentation, we report a similar case of DFSP on the left breast in a 42-year-old woman, who was initially diagnosed with benign phyllodes tumor of the left breast and final histopathology report of the wide local excision specimen diagnosed DFSP of the breast.
Pseudoangiomatous stromal hyperplasia (PASH) is a benign breast lesion frequently discovered incidentally during imaging or biopsy for other conditions. We present two cases of PASH associated with fibroadenomas in premenopausal women, both presenting as palpable, symptomatic breast masses. In the first case, a 26-year-old woman exhibited a 5.2 cm hypoechoic lesion, initially diagnosed as PASH on core biopsy, later confirmed as fibroadenoma with PASH components post-excision. The second case involved a 37-year-old woman with a painful 5.6 cm mass, diagnosed similarly via biopsy, and later confirmed as fibroadenoma fully colonized by PASH after surgical removal. Both cases highlight the diagnostic challenge in distinguishing PASH from fibroadenomas, given overlapping clinical and imaging features. Hormonal factors, particularly contraceptive use, may contribute to PASH development. Management remains controversial, with surgery indicated for symptomatic lesions, while conservative approaches may suffice for smaller, asymptomatic cases. Based on our findings and current literature, we propose a management algorithm to guide clinicians in differentiating cases warranting surgical intervention from those suitable for monitoring. Further studies are needed to validate this approach.
The increasing use of cardiac artificial devices, such as cardiac implantable electronic devices (CIED) and left ventricular assist devices (LVAD), results in longer life expectancy and thus may eventually coincide with a risk of cancer diagnosis and requirement for radiotherapy. Safe irradiation dose limits are better studied and reported for CIEDs, but data on LVAD irradiation are scarce. We present a case of a patient diagnosed with breast cancer who developed heart failure and was given an LVAD, received appropriate oncological care including chemotherapy, surgery, and, after careful multidisciplinary review, radiotherapy. The patient's right-sided initial stage II (T1N1) disease necessitated radiation treatment to the chest wall and regional lymphatic nodal areas. Meticulous radiotherapy planning and treatment delivery were performed, and daily LVAD performance checks were done. Maximum and mean doses received by the LVAD system were 767 cGy and 227 cGy, respectively, for the whole treatment period (5000 cGy/25 fractions). During radiotherapy and after 41 months of follow-up, no VLAD malfunction was observed. As this case shows, having an LVAD does not appear to be a contraindication for radiotherapy delivery. Possible risks and consequences should be evaluated in a multidisciplinary setting.
Objective:Regional nodal irradiation (RNI) is one of the main causes of breast cancer-related lymphedema (BCRL). However, studies on the relationship between the radiation dose to the axillary-lateral thoracic vessel juncture (ALTJ) region and BCRL have reported conflicting results. Based on these findings, we aimed to evaluate the clinical relevance of the dose to the ALTJ region in our patient cohort. Materials and Methods:Patients diagnosed with breast cancer and who were treated at Koç University Hospital between 2016 and 2022 and received RNI were included. BCRL was defined as a difference in arm circumference between the ipsilateral and contralateral limb >2.5 cm at any single encounter or ≥2 cm on ≥2 visits. ALTJ was retrospectively contoured, and doses were recorded as equivalent dose (α/β = 3). Results:Of the 129 patients (median age 49 years) who met the inclusion criteria, 12 (9.3%) had lymphedema. Two-thirds of the patients (66.7%) were stage II, and one-third (33.3%) were stage III. The median follow-up was 22 months. The median (range) ALTJ Dmean dose was 18.11 (1.87-50) Gy, the median ALTJ Dmax was 44.53 (12.8-71.1) Gy, and the median ALTJ V35 was 38% (1-100%). No significant association was determined between ALTJ parameters and BCRL. Conclusion:There is insufficient data to define ALTJ as an OAR for decreasing BCRL risk. It is not appropriate to define dose and target based on ALTJ. Prospective studies with larger patient populations are needed to clarify the relationship between ALTJ and lymphedema.
Objective:Breast cancer management has significantly evolved, particularly in surgical techniques, but breast surgery training remains unstandardized worldwide. This study, promoted by the Senologic International Society (SIS) and the French National Academy of Surgery (FNAS) aimed to evaluate training variability in the world and to provide ten recommendations to improve breast surgery training. Materials and Methods:A 32-question electronic survey was sent between July-August 2023 to the SIS and FNAS network, covering personal experience, training practices, accreditation programs, and fellowship requirements. Results:A total of 121 breast specialists from 42 countries participated, including mainly general surgeons (56%) and gynecologists (23%). Most respondents (66%) had over 15 years of experience, and 75% were male. While 50% reported that breast surgery fellowships were not mandatory, countries with requirements often stipulated a one or two-year experience and a minimum cases number. Multidisciplinary training was often lacking, with only half of countries requiring rotations in radiology, oncology, or pathology. Disparities in training quality and accreditation were evident, particularly in regions without formal breast surgery programs. Conclusion:High-volume centers and specialized surgeons consistently demonstrated improved outcomes, including lower mortality and recurrence rates for patients treated for breast cancer. Rising breast cancer incidence, combined with advances in surgical and multidisciplinary care, highlights the urgency for standardized training. Evidence shows that structured programs with volume thresholds, multidisciplinary approach, and modern surgical techniques improve patient survival and satisfaction. The survey underscores the need for international guidelines to ensure equitable, high-quality care. SIS and FNAS recommend a standardized breast surgery education framework with ten actionable proposals to address disparities, optimize training, and enhance global care quality.
Primary breast leiomyosarcoma is an extremely rare malignancy, accounting for approximately 1% of breast tumors and less than 5% of soft tissue sarcomas. Due to its rarity, standardized treatment guidelines remain unclear. We report the case of a 38-year-old woman who presented with a 3 cm, freely mobile breast nodule, initially classified as American College of Radiology Breast Imaging Reporting and Data System 4 on imaging. Core needle biopsy confirmed primary breast leiomyosarcoma, with histopathological and immunohistochemical analysis revealing strong positivity for α-smooth muscle actin, desmin, and H-caldesmon, consistent with smooth muscle differentiation. Epithelial, neural, and vascular markers were negative, ruling out differential diagnoses. The Ki-67 index was 15%, indicating moderate proliferative activity. Staging classified the tumor as T2N0M0 (Stage IIA, the American Joint Committee on Cancer 8th edition), and the patient underwent radical mastectomy with sentinel lymph node exploration, followed by adjuvant radiotherapy. Despite the aggressive nature of leiomyosarcomas, this case exhibited favorable prognostic factors, including small tumor size, intermediate grade, negative margins, and no lymphatic spread, suggesting a less aggressive course. After four years of follow-up, the patient remains free of complications, underscoring the importance of long-term monitoring and the need for further research to refine therapeutic approaches.
Gestational gigantomastia (GG) is a rare condition characterized by excessive and rapid breast enlargement during pregnancy, resulting in significant physical discomfort, functional limitations, and significant psychological impact. We present a case of a 33-year-old multiparous woman in her third pregnancy, who developed severe bilateral GG by 16 weeks of gestation. Despite initial conservative management, including analgesia and pharmacological (bromocriptine) therapy, the condition worsened causing functional impairment and recurrent mastitis requiring repeated hospital admissions. The pregnancy was electively induced due to physical limitations at 35 weeks of gestation; however, the labour was complicated by obstruction, necessitating an emergency Cesarean section. Postpartum the patient developed severe lactational mastitis complicated by sepsis necessitating intensive care unit admission. After recovery and cessation of breastfeeding, she elected to undergo Wise-pattern bilateral reduction mammoplasty with free nipple-areolar complex grafting four months into her postpartum period. The procedure provided substantial functional relief and a favorable esthetic outcome. This case highlights the potential complexity of managing GG and the need for individualized care. Although conservative treatments may offer temporary relief, surgical intervention is often necessary in severe cases.
Objective:High mobility group box 1 (HMGB1) is a nonhistone chromatin-associated protein involved in chromatin remodeling, transcription, DNA replication, and repair. The purpose of this study was to assess the relationship between tissue expression of HMGB1, clinical outcomes, and histopathological characteristics in patients with breast cancer. Materials and Methods:The study included 282 patients with breast cancer. An in vitro diagnostic HMGB1 antibody was applied to the slides of tumor specimens. Results:Overexpression of HMGB1 was found in tumor cells of 123 (43.6%) patients. HMGB1 was only expressed in the nucleus in most tumors (88.7%), while in 32 (11.3%) tumors HMBG1 expression was cytoplasmic and/or extracellular. Severe inflammatory infiltration of the peritumoral stroma was observed in 76 (27%) patients. There was a correlation between remarkable inflammatory cell infiltration in the tumor microenvironment and HMGB1 overexpression, regardless of the molecular subtype, as well as the extranuclear location of HMGB1 expression (p = 0.023). HMGB1 expression was not found to be associated with overall or disease-free survival. However, axillary lymph node metastasis was significantly more common in tumors with intense inflammation (p = 0.024). Conclusion:The proportion of breast cancer patients with HMGB1 expression was lower in the present study than that reported previously. Furthermore, we did not detect a relationship between HMGB1 expression and prognosis. However, the relationship between HMGB1 expression and prognosis had been previously reported only in aggressive breast cancers. It is suggested that understanding the significance of HMGB1 expression in breast cancer may open new treatment opportunities, especially in aggressive and/or triple negative tumors.
Objective:Breast myofibroblastoma (BM) is a rare, benign mesenchymal tumor primarily affecting older men and postmenopausal women. This study analyzed the clinicopathologic features, immunohistochemical profiles, and treatment outcomes of five BM cases diagnosed at a single institution over a period of 20 years. Materials and Methods:A retrospective review was conducted for five patients diagnosed with BM between 1998 and 2024. Data included age, clinical presentation, tumor size, histopathologic findings, immunohistochemical profiles, treatment approaches, and follow-up outcomes. Results:The median age at diagnosis was 68 years, with a mean tumor size of 5.06 cm. Clinical presentation included palpable, painless masses in two patients and an incidental finding in one, while data were unavailable for two cases. Histopathology showed well-circumscribed, unencapsulated tumors composed of spindle cells with admixed adipose tissue and collagen bundles. Immunohistochemically, all tumors were positive for desmin and CD34, with variable smooth muscle actin expression and negative S100 staining. No cases exhibited nuclear beta-catenin staining or 13q14 deletions. All patients underwent surgical excision, with one requiring re-excision due to tumor abutting margins. No recurrences were observed during follow-up (2-18 months). Conclusion:BM is a benign tumor with favorable outcomes following surgical excision. This study underscores the variability in immunohistochemical staining and the importance of distinguishing BM from other spindle cell tumors. Increased numbers of published cases and refining diagnostic markers may be important to improve clinical management and reduce diagnostic uncertainty.
Objective:Over the recent years, machine learning (ML) models have been increasingly used in predicting breast cancer survival because of improvements in ML algorithms. However, cancer researchers still face a significant challenge in accurately predicting breast cancer patients' survival rates. The purpose was to predict breast cancer survival using a Bayesian network. Materials and Methods:This retrospective study included 2,995 patients diagnosed with breast cancer and subsequently hospitalized between January 1, 2012, and December 30, 2024. SPSS Modeler version 18.0 was used to build prediction models. The data were randomly split into a training set (2,097 cases, 70%) and a test set (898 cases, 30%) for developing the Bayesian network model and predicting the overall survival of patients diagnosed with breast cancer. The model included demographic variables (age, marital status, and governorate), laboratory/clinical variables (hemoglobin level, white blood cell count, presence of hypertension, and diabetes mellitus) and the outcome variable, patient survival status (binary value: survived/died). The discriminative ability of models was evaluated by accuracy and the area under the curve (AUC) in terms of superior predictive performance for breast cancer outcomes. Results:The Bayesian model exhibited the best discriminatory performance among the nine models, with an AUC of 0.859 and the highest accuracy of 96.661%. In the context of feature importance, white blood cell value at the time of diagnosis was the most important feature for predicting the survival of breast cancer. Patients who had below-normal hemoglobin and above-normal white blood count values had a higher death probability than patients who had normal white blood count and hemoglobin values. The presence of hypertension and diabetes mellitus in patients with breast cancer led to a reduced survival probability. Conclusion:The Bayesian model outperformed the other models in predicting the survival probability of breast cancer. Routine laboratory testing and demographic data can be included in a ML model to predict breast cancer survival. Accurate prediction of breast cancer survival is vital for clinical decision-making.
Objective:To compare the oncological safety and the cosmetic outcome of the techniques anterior intercostal artery perforator (AICAP), lateral intercostal artery perforator (LICAP) and thoracodorsal artery perforator (TDAP) flap as a volume replacement technique to eliminate deformity and preserve breast cosmesis by filling the excised defect. Materials and Methods:This prospective study included women with lower outer quadrant, lower inner quadrant, and upper outer quadrant tumors who underwent upfront or post-neoadjuvant chemotherapy breast conserving surgery with immediate volume replacement surgery. Patients were allocated into three groups at a ratio of 1:1: Group A (n = 10): women who underwent LICAP flap, group B (n = 10): Women who underwent AICAP, and group C (n = 10): Women who underwent TDAP flap procedures. Results:Regarding postoperative complications, wound infection took place in only one (10%) patient in LICAP group and one (10%) patient in the AICAP group; seroma occurred in only one (10%) patient in LICAP group and one (10%) patient in the TDAP group; and fat necrosis occurred in only one (10%) patient in the TDAP group. Incidence of wound infection, seroma, and fat necrosis was insignificantly different among the studied groups. Breast distortion occurred in one (10%) patient in the AICAP group and not observed in the other groups, and partial flap necrosis occurred in one (10%) patient in the LICAP group and one (10%) patient in the AICAP group and was not observed in the TDAP group. Incidence of distortion and partial flap necrosis were insignificantly different between the studied groups. The conservative treatment of breast cancer core results, surgeon's assessment, patient's satisfaction and breast Q scores did not differ between the three groups. Conclusion:A better cosmetic outcome than level II oncoplastic techniques, the perforator fasciocutaneous flaps, LICAP, AICAP, and TDAP, were effective and safe options for immediate breast reconstruction after breast-conserving surgery. All three techniques showed similar surgical outcomes, low complication rates, and good aesthetic results. Patient satisfaction was high, with no significant differences between the groups.
Breast lymphedema is a common but underdiagnosed condition that affects the quality of life of patients. It may be caused by any pathology that disrupts lymphatic drainage in the breast. We present the case of a woman with axillary lymph node tuberculous infection with breast edema, clinically and radiographically indistinguishable from tuberculous mastitis. After six months of comprehensive antituberculosis pharmacological treatment, the persistence of breast edema required repeating diagnostic tests searching for malignancy, all of which were negative. Rehabilitation treatment with complex physical therapy improved the patient's clinical and symptomatic condition. Clinical suspicion of secondary lymphedema is crucial to avoid unnecessary diagnostic procedures and ensure adequate and timely treatment.
Objective:Aromatherapy is widely used in the management of symptoms caused by interventional procedures. This randomized controlled trial evaluated the effectiveness of lavender and lavender-peppermint aromatherapy before breast biopsy for reducing women's pain and anxiety. Materials and Methods:This trial was conducted in the breast outpatient clinic of a university hospital in İstanbul between July 2021 and March 2023. Patients were randomly assigned to one of two intervention groups; lavender or lavender-peppermint or the control group. Twenty minutes before the breast biopsy, a small pad impregnated with lavender or lavender-peppermint essential oil was attached to each patient at shoulder level, allowing for inhalation. The patients' anxiety and pain levels were assessed before and after the biopsy procedure using the state anxiety inventory and visual analogue scale, respectively. Results:Study population was 135 patients, equally divided between lavender, lavender-peppermint or control groups (each n = 45). The mean age of the patients was 46.30±10.31 years, 76% were married, 65.9% were employed, and 64.4% underwent thick-needle biopsy. After the biopsy, reported anxiety and pain levels had decreased significantly more in the aromatherapy groups compared to the control group (p<0.05). However, no significant difference was found between the lavender and lavender-peppermint groups in terms of anxiety and pain reduction (p>0.05). Anxiety and pain levels were positively correlated (r = 0.406; p<0.001). Conclusion:The use of lavender and lavender-peppermint essential oil via inhalation before breast biopsy was effective in reducing reported anxiety and pain levels. Implementing lavender and lavender-peppermint essential oil inhalation before interventional procedures may offer a simple and cost-effective approach to improving patient outcomes.
Objective:While prognostic and predictive factors in breast cancer are well established, data on aggressive behavior in luminal A subtype breast cancers are limited. The aim of this study was to investigate histomorphological and clinicopathological parameters that may predict treatment resistance and aggressive behavior in luminal A subtype, as well as the expression of two key proteins, PTEN and p53, involved in breast carcinoma development. Materials and Methods:We included breast carcinoma cases diagnosed at a Turkish University Hospital between 2016 and 2017. Tumor tissue with internal control was available for all cases. PTEN and p53 expression were evaluated immunohistochemically, based on staining strength and percentage. Results:Of the 114 cases diagnosed in the study period, 18 (%) were recurrent and 5 (%) were Luminal A subtype. We observed significantly lower overall and disease-free survival in patients with ≤50% tumor infiltrating lymphocytes density, which was present in all recurrent cases. PTEN immunoreactivity scores were <6 in all recurrent luminal A cases, but no significant difference was found between recurrent and non-recurrent cases (p>0.05). The p53 H-score for luminal A was significantly lower than in luminal B, triple negative, and human epidermal growth factor receptor 2+ groups (p<0.05). Furthermore, p53 H-scores <50 were more common in grade 2 tumors than in grade 3 (p<0.05). Conclusion:PTEN loss, observed in all recurrent luminal A cases and 77.1% of all cases, supports its role as a tumor suppressor. The findings suggest that PTEN expression loss may be a prognostic marker, and immune-modulating treatments should be considered for breast cancer patients.
Objective:The utility of three-dimensional surface imaging (3DSI) for measuring breast volume in the upright position has not been established. Materials and Methods:First, the accuracy of 3DSI measurements was evaluated using plastic models with known breast volumes. Then, the breast volumes of 30 patients were measured using 3DSI in the upright position, computed tomography (CT) in the supine position, magnetic resonance imaging (MRI) in the prone position, and mammography (MMG) of the compressed breast. To determine the impact of 3DSI measurements, the correlation coefficients between 3DSI and CT, between MMG and CT, and between MRI and CT were calculated. Results:The accuracy of 3DSI measurements was confirmed using plastic models. The correlation coefficients between 3DSI and CT, between MRI and CT, and between MMG and CT were 0.83, 0.997, and 0.84, respectively. Although the breast volume measured by 3DSI was closely associated with that measured by CT, this correlation was weaker than that between the MRI- and CT-measured volumes and comparable with that between the MMG- and CT-measured volumes. Conclusion:3DSI can be used to measure breast volume in the upright position with clinically acceptable accuracy for the evaluation of cosmetic surgical outcomes.
The mammary angiosarcoma is a rare malignant mesenchymal tumor that develops from the vascular tissue of the breast. It represents 0.004 to 1% of all malignant breast tumors and 8 to 10% of breast sarcomas. It can be primary in a 40-year-old woman or radiation-induced in an older woman who has undergone conservative treatment for breast cancer, including conservative surgery and adjuvant radiotherapy. Herein, we present four cases involving breast angiosarcoma in young and relatively older women and the different treatment they received. Our discussion encompasses the epidemiological, diagnostic, and therapeutic facets of this rare and aggressive tumor type.
Primary giant cell tumors (GCTs) of soft tissue of the breast are extremely rare breast tumors, with only ten cases previously reported in the English literature. They are not suspected clinically, and clinically and histopathologically too, can mimic breast carcinoma or phyllodes tumor, and cause diagnostic dilemma. It is important to correctly recognize these tumors, due to management implications. Hereby, we present a case of 58 year old female with GCT of the breast presenting as a malignant breast tumor.
