Giles Cunnick

Rare Species of Actinomyces as Causative Pathogens in Breast Abscess

Abstract:  Actinomyces species are commensal flora usually found in the oropharynx, gastrointestinal tract, and female genital tract. Primary actinomycosis of the breast is an unusual condition, where the most commonly isolated pathogen has been Actinomyces israelii. In recent years, other Actinomyces strains have been found associated with breast disease. We present the first reported cases of breast infection caused by the rare species, Actinomyces turicensis and Actinomyces radingae. Both infections displayed chronicity and abscess formation. In the first case, the infection was refractory to recurrent aspirations and initial antibiotic therapy. In the second case, aspiration and prolonged antibiotic therapy was required to overcome the chronic infection.

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.

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.

Prognostic factors for male breast cancer: A breast center's 10-year experience.

Male breast cancer (MBC) is rare and accounts for 1% all breast cancers. Approximately, 350 men are diagnosed with the condition each year within the UK and its incidence is increasing. However, due to the rare nature of the disease, MBC has been poorly studied in relation to female breast cancer (FBC). We aimed to investigate the prognosis of MBC in our centers past 10‐year experience, and to compare the patient, tumor, and treatment differences between men who were treated successfully and those who suffered breast cancer recurrence or all‐cause mortality. We undertook a prospective cohort study of all patients diagnosed with MBC over a 10‐year period from 1 January 2005 until 31 December 2014. The identifiers of all men were prospectively recorded over the study period and at the end of this study, the clinical notes were retrieved and reviewed. Outcome and treatment‐related information was extracted from the clinical notes. The primary outcome measure of interest was adverse outcome, defined as ipsilateral disease recurrence, contralateral breast cancer occurrence, metastatic disease, or all‐cause mortality. A total of 30 primary cases of MBC were identified; 27 unilateral and 3 bilateral cases. All patients were treated with mastectomy and either sentinel lymph node biopsy or axillary clearance, followed by adjuvant endocrine therapy. Radiotherapy and chemotherapy were reserved for cases of metastatic disease or high risk of recurrence. Of these, 24 patients adhered to adjuvant endocrine therapy, six had adjuvant chemotherapy, and 16 patients had adjuvant radiotherapy. No patients were lost to follow‐up. The mean age was 68.3 years (SD 11.8) and patient characteristics are shown in Table 1. All patients were followed up annually with surveillance contralateral imaging and clinical examination. Five patients had an adverse outcome, of which three patients had a subsequent recurrence (10%) and two died from their disease (7%). Of the five patients with adverse outcome, three patients had invasive ductal carcinoma and two had invasive cribiform carcinoma. Tumor size and nodal status did not reach statistical significance (P = 0.13 and 0.14, respectively) for adverse outcome (Table 2). There is limited evidence on the prognosis of MBC; however, it is generally worse than for FBC. MBC is predominantly ER‐positive, suggesting that underlying endocrine factors may play an important role in pathogenesis. In more recent years, a number of other receptors have also been identified with MBC such as glucocorticoid, androgen, HER2, and EGF receptors although the prognostic value of these receptors is still poorly understood. While not identified in our cohort, axillary nodal involvement and tumor size have previously been identified as key prognostic determinants for MBC. Although there is heterogeneous evidence on the prognosis of men with breast cancer, their prognosis is generally worse than their female counterparts. The reason for this is unclear, but since this difference in prognosis appears to be independent of cancer stage, underlying biological differences may be the reason. We were limited in our analyses by our small sample size. However, this is an inherent limitation when investigating rare diseases and the number of cases recorded at our institution is in proportion to the national incidence of the disease. The evidence base for MBC arises from either non-randomized observational studies such as the one that we present in this paper, or has been inferred by proxy from non-randomized studies of FBC participants, which may not be appropriate. More research is needed to further characterize the pathophysiology and treatment response in MBC. Received: 31 July 2017 | Accepted: 1 August 2017 DOI: 10.1111/tbj.13081

Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study.

Idiopathic gynecomastia is a benign breast disorder characterized by overdevelopment of male breast tissue. It can cause discomfort and concern, resulting in patients seeking diagnosis and treatment. We aimed to evaluate the efficacy of tamoxifen therapy in resolving this condition.

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 …