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Accessory Breast Cancer Patient: Follow-Up Case Report IAR Journal of Medical Case Reports ISSN Print : 2709-3220 | ISSN Online : 2709-3239 Frequency : Bi-Monthly Language : English Origin : Kenya Website : https://www.iarconsortium.org/journal-info/iarjmcr Case Report Accessory Breast Cancer Patient: Follow-Up Case Report Article History Abstract: Accessory breast is a congenital atavism condition.‎ Accessory breast tissue may be arising anywhere along the mammary line because of the failure of‎ Received: 05.09.2020 complete maturation during embryogenesis. The malignancy in accessory breast Accepted: 02.10.2020 tissue is considered as primary‎ breast cancer. Axillary breast cancer is not well Revision: 05. 10.2020 recognized site of primary breast cancer.‎‏ ‏ This case report for a 55 year-old Published: 10.10.2020 premenopausal female who presented with axillary immobile mass in her left axilla that diagnosed after extensive investigations as stage II B, ER, PR positive Author Details and HER neu positive poorly differentiated accessory‎ breast adenocarcinoma. ‎The patient was staged as stage II B and we followed NCCN guidelines 2013 for Iman Moustafa*1 and M Essam Badawy2 breast cancer in management, so our patient was surgically treated, followed by postoperative adjuvant chemotherapy in the form of 4 cycles doxorubicin and Authors Affiliations cyclophosphamide followed by 4 cycles of paclitaxel and 17 cycles trastuzumab. Subsequently radiotherapy was given followed by hormone therapy. We followed 1King Abdulaziz Medical City, AlHasa, Saudi up the patient for 6 years and she is doing well. Accessory breast cancer is a rare Arabia disease and misdiagnosis of these cases is very immense and lead to extensive unnecessary investigations. Physicians have to be aware about these cases. 2Mohammed Dossary Hospital, AL Khobar, Management of accessory breast cancer is according to the same guidelines for Saudi Arabia management of breast cancer. Follow up data should extensively encourage Corresponding Author* determining the prognosis of accessory breast cancer in comparison to usual Iman Moustafa breast cancer. How to Cite the Article: Keywords: "accessory", "ectopic", auxiliary"," breast cancer ". Iman Moustafa and M Essam Badawy (2020) Accessory Breast Cancer Patient: Follow-Up Case Report. IAR J Med Cse Rep . 1(1)1-7. INTRODUCTION Copyright @ 2020: This is an open-access article Accessory breast cancer is a rare disease developed from distributed under the terms of the Creative accessory breast tissue. Accessory breast tissue can be found along any Commons Attribution license which permits point of the mammary lines, including in the thoracic and abdominal unrestricted use, distribution, and reproduction region (67%) and down to the groin. Ectopic breast tissue can also be in any medium for non commercial use found in locations such as the face, back, and thighs, but the predominant (NonCommercial, or CC-BY-NC) provided the original author and source are credited. site is the axilla. The incidence of supernumerary breast and ectopic breast tissue around the world is 1–6% (Rizvi, G. et al., 2012). It affects 2–6% of females and 1–3% of males ‎but there is no definite incidence number for accessory breast malignancy; furthermore, reports for accessory breast cancer only include case reports and case series. Occurrence rates differ extensively according to ethnicity and gender, ranging from as low as 0.6% in Caucasians (relatively common among Asian women) to as high as 5% in Japanese females and Native ‎American ‎populations (Sookar, N. et al., 2018; & Laor, T. et al., 2004). The 1915 Kajava classification system classified accessory breasts as Class I–VIII according to anatomical structure, and is ‎still ‎used today (Table 1) (Famá, F. et al., 2016; & Amaranathan, A. et al., 2013). Table 1: Kajava classification 1915 Classes Description Glandular ‎tissue Nipple Areola Comment Class I Complete breast Class II ‎ Class III ‎ Class IV ‎ Class V ‎ Class VI ‎ Class VII ‎ Class VIII ‎ Hair Accessory breast tissue can be located along the chest wall, vulva, axilla, knee, lateral thigh, buttocks, face, ear, and neck. Changes or symptoms may be noticed during puberty, at different times of the menstrual cycle, or during Available: https://iarconsortium.org/journal-info/iarjmcr 1 Iman Moustafa and M Essam Badawy; IAR J Med Cse Rep; Vol-1, Iss- 1 (Sep-Oct, 2020): 1-7 pregnancy and breastfeeding in women. Of note, the accessory breast tissue is often not detected until puberty because it is activated by hormones (Jatoi, I., & Rody, A. 2016). CASE REPORT Figure 1: Histological examination of specimen. Sections Figure 2: The tumour cells in both mucinous and nonmucinous areas show large deposits of carcinoma replacing most of the show a positive staining for oestrogen receptor. lymph node structure. Figure 4:The tumor cells are arrange in solid sheets or lobules without glandular differentiation Figure 3: Left axillary mass Figure 5: Sections show large deposits of Figure 6: A large component of mucinous carcinoma is present in carcinoma replacing most of the lymph node one of these lymph node structure. 2 Iman Moustafa and M Essam Badawy; IAR J Med Cse Rep; Vol-1, Iss- 1 (Sep-Oct, 2020): 1-7 Figure 7: The tumor cells stain positively for CK7. ER (50%of tumor cells) Figure 8: The tumor cells stain positively for CK7,PR (5% of tumor cells) Figure 9: The tumor cells in both mucinous and Figure 10: The tumor cells in both mucinous and non mucinous non mucinous areas show a positive staining for ER areas show a positive staining for PR A 55-year-old is premenopausal female with arranged in solid sheets or lobules without glandular diabetes, a blood pressure of 130/70 mmHg, a weight of differentiation (Figure 1).‎Immunohistochemistry (IHC) 76 kg, and a height of 167 cm and no family history of methodology reported that the breast cancer. She was presented to the general surgery tumour ‎cells ‎stained ‎positively for pan-cytokeratins outpatient department on the 4th of December 2011. The (CK) (AE1/AE3), suggestive of lymph node patient had a history of left axillary immobile mass of micrometastases (Lerwill, M. F. 2004); CK7; epithelial around 3.0 x 2.0 cm (length/width) which had increased membrane antigen; ER, that formed 50% of tumour in size within the prior six months, but had no history of cells; and PR, ‎‎that formed 5% of tumour cells (Figure a lump in the breast or discharge from the nipple. The 2,7,8,9,10 ). patient mentioned that this axillary mass had been present since puberty but had been gradually increasing IHC results were exclusively positive; HER2, in size. The patient had a negative family history of BerEP4 (histologic stain used to aid in the diagnosis of malignancy and ultrasound (USG) breast screening was basal cell carcinoma), mammoglobulin (highly specific performed which showed no mass in the breast. for most breast cancers), CK5/6 (aid to differentiate Multiple lymph nodes were seen, however, in the left between mesothelioma and other forms of cancer), axilla, with the largest lymph node being 4.4 x 3.5 cm thyroid transcription factor-1 (sensitive marker for (Figure 4, 5, 6). pulmonary and thyroid adenocarcinomas), CD10 (sensitive immunohistochemical marker of normal On the 18th of January 2012, tissue biopsy was endometrial stroma), smooth muscle actin (aid in taken from the left axillary mass which measured 4.5 diagnosis of ovarian carcinoma), S100 (common cm in maximum diameter, weighed 30 g, and to which marker of neural tissue/lesions and bio-section showed a greyish-‎‎‎white solid cut surface melanoma), ‎chromogranin (aid in diagnosis of carcinoid with pinkish and yellowish areas (Figure 3). Four tumours), synaptophysin (neuroendocrine marker), blocks ‎representing ‎the ‎whole ‎cross-section of the CK20, P63 (rules out invasion in breast tumours by tumour were embedded in three ‎cassettes.‎‏ determining presence of myoepithelial cells), and P53 Microscopically the sections showed lobules of a all ‎showed ‎ anegative ‎reaction.‎ Therefore, malignant epithelial the ‎possibilities of neuroendocrine, primary lung, tumour ‎involving ‎the ‎subcutaneous ‎adipose ‎tissue, primary renal tumours‎, among ‎others ‎were dermis, and reaching up to the overlying epidermis. ‎It not ‎supported by the IHC results‎‏. Reports showed showed ‎large ‎areas of ‎partial or ‎complete ischaemic moderate to poorly differentiated adenocarcinoma in necrosis, scattered mitotic figures, and tumour cells favour of primary breast cancer (Table 2). 3 Iman Moustafa and M Essam Badawy; IAR J Med Cse Rep; Vol-1, Iss- 1 (Sep-Oct, 2020): 1-7 Table 2: Immunohistochemistry test results Test Reaction Comment CK AE /1/3 ✓ Suggestive of lymph node micrometastases. CK7 ✓ Oestrogen receptor (that formed 50% of tumour cells) and progesterone receptor (‎‎that formed 5% of tumour cells). EMA ✓ Epithelial membrane antigen. HER-‎‎2 ✓ Human epidermal growth factor receptor 2. BerEP4 Negative Histologic stain used to aid in the diagnosis of basal cell carcinoma. Mammoglobulin Negative Highly specific for most breast cancers. CK5/6 Negative Cytokeratin 5/6: help to differentiate between mesothelioma and other forms of cancer. TTF-‎‎1 Negative Thyroid transcription factor-1: sensitive marker for pulmonary and thyroid adenocarcinomas. CD10 Negative Sensitive immunohistochemically marker of normal endometrial stroma. Negative Smooth Muscle Actin aid in diagnosis of ovarian carcinoma. SMA S100 Negative Common marker of neural tissue/lesions and melanoma. CgA Negative Chromogranin help diagnose carcinoid tumours. Synaptophysin ‎Negative ‎ Common neuroendocrine marker. CK20 ‎Negative ‎ Cytokeratin 20. p63 ‎Negative (Rule out invasion in breast tumours by determining presence of myoepithelial cells). p53 ‎ ‎eNiaageN Tumour marker in early stages of lung, skin, head and neck, and oesophageal cancer. (CA 15-3) High Tumour marker for breast cancer. 7.101 CA 125 Normal Tumour marker for breast cancer. ‎ On the first ‏March‎1023, the patient was well. The patient then underwent radiotherapy and referred to medical oncologists for further management hormonal therapy (tamoxifen 20 mg oral daily). She and ‏workup. Chest, abdomen, and pelvis CT scans were underwent follow-up ‎every 6 months until present.
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