Farid Ahmed

Adverse reaction; patent blue turning patient blue.

The authors report a severe anaphylactic reaction to Patent Blue V dye used in sentinel node biopsy for lymphatic mapping during breast cancer surgery to stage the axilla. Patent Blue dye is the most widely used in the UK; however, adverse reactions have been reported with the blue dye previously. This case highlights that reactions may not always be immediately evident and to be vigilant in all patients that have undergone procedures using blue dye. If the patients are not responding appropriately particularly during an anaesthetic, one must always think of a possible adverse reaction to the dye. All surgical patients should give consent for adverse reactions to patent blue dye preoperatively. Alternative agents such as methylene blue are considered.

An unusual breast lump: osseous metaplasia

We present a rare case of osseous metaplasia in the breast with no other associated breast pathology. A 46-year-old HIV-positive lady presented to the breast clinic with new onset intermittent left-sided mastalgia. Clinical examination revealed an indeterminate mass in the left breast with palpable left axillary lymphadenopathy. Mammography and ultrasonography were suggestive of a possible malignancy, with the latter also detecting the presence of abnormal nodes in the axilla. An ultrasound-guided core biopsy of the breast lesion showed only hyalinised normal breast tissue on two occasions. Owing to the diagnostic uncertainty, the patient underwent a wire-guided excision biopsy of the breast lesion, with the final histology demonstrating bone matrix deposition with viable osteocytes within lacunae and associated osteoclasts with spindle cells, consistent with osseous metaplasia. A core biopsy of the axillary lymph nodes was normal. The patient was therefore reassured and discharged from the clinic.

CK19 testing prior to OSNA analysis: to stain or not to stain?

Dear Editor, We read with interest the article by Vilardell et al. [1] where lymph node metastasis was missed in a patient with a cytokeratin-19 (CK19)-negative breast cancer. Sentinel node biopsy (SNB) is currently the standard practice for staging the axilla [2], with one-step nucleic acid amplification (OSNA) becoming more widely accepted [3] and used in clinical practice. OSNA detects metastasis by quantifying the presence of CK19 mRNA, in theory irrespectively whether this is expressed or not. There are limited data regarding the true incidence of CK19-negative tumours. The authors estimate this to be about 3 %, which is probably similar to anecdotal data in our practice. Our institution was second in the UK to adopt OSNA analysis routinely in its practice. Since May 2010, nearly 600 such procedures have been performed. However, in contrast with Vilardell, we identified a patient who, despite both the core biopsy and the subsequent breast excision specimen testing negative for CK19 expression, was found to have SNB micrometastasis on OSNA analysis. The tumour biopsy confirmed an oestrogen and progesterone receptor-positive ductal carcinoma (ER8/8, PR 6/8), with negative HER2 immunohistochemistry. Retrospective Ki67 proliferative index was found at 10 %, confirming the tumour’s luminal A immunophenotype. CK19 was negative despite repeated testing in the presence of positive controls. Intraoperative full-node OSNA analysis of two sentinel nodes showed one negative lymph node and one with micrometastasis (820 copies of CK19 mRNA). As per hospital practice at the time, the patient proceeded to completion axillary lymph node dissection. Final histology confirmed a 10-mm grade 2 invasive ductal carcinoma, with few foci of ductal carcinoma in situ. Ten further lymph nodes were identified, with no evidence of metastatic disease. Testing for CK19 expression on the excision specimen was negative. Despite being used for a few years now, the OSNAmethod is still relatively new, and updated figures are published regularly. The discrepancy between the OSNA and the imprint cytology results in the case of Vilardell could also be due to tissue allocation bias or due to the false-negative rate of the OSNA method. The latter however is limited to less than 2 % [3]. Moreover, the size of the “malignant cells” on imprint cytology has not been stated suggesting that overinterpretation has not been discounted as a possibility. Our patient’s result may only be representing detection of extremely low-volume disease. It may however be falsely positive. Again, the OSNA false-positivity rate is similarly low, but, importantly, true rates are very difficult to assess. Indeed, as the authors suggest, more documentation is needed to assess the expression of CK19 in breast cancer and its implication on the OSNA results. However, a study to look at the presence or absence of CK19 mRNA, rather than its expression, as detected by immunohistochemistry, may be more appropriate. We suspect that CK19 mRNAnegative tumours will be a small fraction of the CK19negative tumours, which are already rare, and therefore may make routine CK19 testing prior to OSNA processing unnecessary. D. D. Remoundos (*) :M. Joshi : F. Ahmed :G. H. Cunnick Department of Breast Surgery, Wycombe Hospital, Buckinghamshire Healthcare NHS Trust, Queen Alexandra Road, High Wycombe HP11 2TT, UK e-mail: dr223@cantab.net

The efficacy of tamoxifen in the treatment of primary gynecomastia: an observational study of tamoxifen versus observation alone.

To the Editor: Gynecomastia is a common condition defined as overdevelopment of male breast tissue resulting from a relative overactivity of estrogen (1). It may be primary or secondary to drug use, liver disease, chronic renal failure, malignancy or genetic disorders (1–3). Although most gynecomastia is asymptomatic, it can result in a painful, unsightly swelling behind the areola, which leads some men to pursue diagnosis and treatment (4). We present an observational study of the effects of tamoxifen and observation alone in the treatment of gynecomastia. We recruited consecutive patients presenting at the breast outpatient clinic of a district general hospital with clinical and radiological evidence of gynecomastia. Recruitment took place over a 3 year period. Associated symptoms, drug history and any pre-existing medical condition which may have resulted in secondary gynecomastia were recorded for each patient. Investigations performed included ultrasound, beta HCG, alpha-fetoprotein, and testosterone levels, liver function tests, and urea and creatinine levels. Patients with evidence of secondary gynecomastia were excluded from the study. All patients were offered either 20 mg tamoxifen once daily or observation alone. All those who chose observation were offered tamoxifen if their symptoms had failed to resolve after 3 months. End points were complete or partial resolution of the lump as judged by a single observer. A total of 54 patients presented to the breast clinic with gynecomastia. Seven patients with secondary gynecomastia were excluded, leaving a total of 47 patients with primary gynecomastia, who entered in to the study (Fig. 1). The median age was 50 years with a range of 14–81. The median duration of the swelling was 10.9 months. Two of the patients who opted for observation failed to attend after their initial consultation and were therefore not included in the results. Forty-five patients completed the study. Twenty-three patients opted for tamoxifen treatment as first line. Seventeen of these patients (74%) showed a response. Of the 22 patients who opted for observation only, only seven (32%) showed improvement. Fifteen of the patients who failed to show improvement after observation opted for treatment with tamoxifen. Of these 15 patients, 13 responded to tamoxifen (87%). In total, 38 patients underwent treatment with tamoxifen for a mean duration of 5.88 months. If all patients receiving tamoxifen during the study are considered together, 79% demonstrated complete or partial resolution of their lump. Of the eight patients who failed to respond to tamoxifen, three underwent surgery. There were no complications or side effects of treatment. Although gynecomastia may in many cases be selflimiting, it can cause a great deal of psychological morbidity and although some men simply accept reassurance, others are desperate for treatment. The traditional management of gynecomastia has been observation, analgesia or surgery. Surgery incurs a risk of infection, hematoma, nipple necrosis, and poor cosmesis and has been associated in some studies with a high degree of patient dissatisfaction (1,2,4–7). For this reason, surgery should be the last, rather than the first resort. Tamoxifen is a selective estrogen receptor modulator, which has been used safely and with good effect in the treatment of gynecomastia (3–6,8–13). Studies have shown little evidence of side effects or adverse long-term consequences of tamoxifen use (3,13). It appears to be most effective in the early treatment of small volume gynecomastia (2). Address correspondence and reprint requests to: Ruth James, Milton Keynes General Hospital General Surgery, Standing Way Eaglestone Milton Keynes, MK12 5HW, UK, or e-mail: ruthjames@doctors.org.uk.

Bone formation within a breast abscess.

We present a rare case of osseous metaplasia in a poorly healing breast abscess. An 87-year-old woman was referred to the breast surgery clinic with a painful lump in her right breast. Initial imaging and core biopsy suggested a breast abscess. Despite several courses of antibiotics and repeated attempts at aspiration the painful lesion persisted. It was eventually surgically excised in its entirety and final histopathology showed the presence of bone formation within the abscess. The patients symptoms subsequently resolved. To the best of our knowledge, this is the first case in the literature, of osseous metaplasia within a breast abscess in the absence of malignancy.

A rare cause of axillary lymphadenopathy: Kikuchi's disease.

A healthy 19-year-old woman presented to her general practitioner with a 2-month history of a right axillary lump. There were no breast lesions and a general clinical examination was unremarkable. The lump was thought to be an enlarged lymph node so the patient was given several courses of antibiotics with little benefit. Tests for lymphoma and systemic lupus erythematosis (SLE) were negative. The patient was subsequently referred to the breast clinic …