James Bristol

Breast metastases from colorectal carcinoma

A case history is presented of a 53-year-old woman with an incidental finding of a breast lump, identified after having had chemotherapy for lung metastases from a rectal carcinoma. Clinical examination, ultrasound, mammography, fine needle aspiration and core biopsies could not prove definitively whether the breast lump represented a metastasis from colorectal carcinoma. Following local excision, the final diagnosis of metastatic colorectal carcinoma to the breast was based on the absence of any site of origin within the breast (i.e. no surrounding DCIS) and on the expression of cytokeratin CK7 and CK20 on immunohistochemistry. Postoperative chemotherapy was initiated. Four months later, although without local recurrence in the breast, the patient developed cutaneous metastatic deposits and active treatment was stopped. A review of other cases of breast metastases from extramammary sources is presented. Possible mechanisms for this rare and unusual phenomenon are discussed.

Breast implant associated anaplastic large cell lymphoma: The UK experience. Recommendations on its management and implications for informed consent

BACKGROUND Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare, Non-Hodgkin lymphoma arising in the capsule of breast implants. BIA-ALCL presents as a recurrent effusion and/or mass. Tumours exhibit CD30 expression and are negative for Anaplastic Lymphoma Kinase (ALK). We report the multi-disciplinary management of the UK series and how the stage of disease may be used to stratify treatment. METHODS Between 2012 and 2016, 23 cases of BIA-ALCL were diagnosed in 15 regional centres throughout the UK. Data on breast implant surgeries, clinical features, treatment and follow-up were available for 18 patients. RESULTS The mean lead-time from initial implant insertion to diagnosis was 10 years (range: 3-16). All cases were observed in patients with textured breast implants or expanders. Fifteen patients with breast implants presented with stage I disease (capsule confined), and were treated with implant removal and capsulectomy. One patient received adjuvant chest-wall radiotherapy. Three patients presented with extra-capsular masses (stage IIA). In addition to explantation, capsulectomy and excision of the mass, all patients received neo-/adjuvant chemotherapy with CHOP as first line. One patient progressed on CHOP but achieved pathological complete response (pCR) with Brentuximab Vedotin. After a mean follow-up of 23 months (range: 1-56) all patients reported here remain disease-free. DISCUSSION BIA-ALCL is a rare neoplasm with a good prognosis. Our data support the recommendation that stage I disease be managed with surgery alone. Adjuvant chemotherapy may be required for more invasive disease and our experience has shown the efficacy of Brentuximab as a second line treatment.

Choosing chemotherapy: who says “yes please”?.

Abstract #5091 Introduction:
 Increasing numbers of patients are being offered adjuvant chemotherapy for early breast cancer. In the United Kingdom, the National Health Service provides cancer treatment free at the point of delivery. So what makes people decide whether to have chemotherapy?
 Methods:
 We examined the decision made by patients treated in our centre in 2007. Data were obtained from our prospectively collected database about age, prognosis (Nottingham Prognosis Index/Score - NPI), ER, HER2 status, and residential ZIP code. The UK Government Index of Multiple Deprivation (ID2000, Office for National Statistics) is based on the 2000 national census and provides two measures, the ID 2000 score and the ID2000 Rank (1 to 8414 in England and Wales). We matched ID2000 scores and ranks to ZIP codes. Low ID2000 scores and ranks are seen in affluent areas. Chemotherapy uptake was examined by age, NPI, ER, HER2 status and ID2000 using Stat View 5.0® software (SAS Institute).
 Results:
 282 patients (279 women and 3 men) with invasive breast carcinoma were treated in 2007 at our centre. 135 (47.9%) were offered chemotherapy. 103/135 (76.3%) decided to have chemotherapy and 32/135 (23.7%) declined.
 Chemotherapy was more commonly accepted by patients of young age (Mann Whitney U, p=0.0003), high NPI (Mann Whitney U, p=0.0012) and with HER2 positive tumours (Chi 2 test, p=0.05). ER status (Chi 2 test, p=0.27) and deprivation (Mann Whitney U, ID2000 score p=0.46, ID2000 rank p=0.46) had no effect on whether patients chose to have chemotherapy.
 Conclusion:
 Significant numbers of patients are now being offered adjuvant chemotherapy. Most patients accept chemotherapy when this is offered, although a significant minority (23.7%) decline the offer. Younger patients and those with poorer prognosis are more likely to accept this. Social deprivation, however, is not an influence in patient choice, when the patient has care 9free at the point of delivery9. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5091.

Abstract P5-03-02: Breast implant associated anaplastic large cell lymphoma (BIA-ALCL)– The UK experience and first reported case of neoadjuvant brentuximab

Introduction The incidence of BIA-ALCL is on the rise. It is a recognised rare risk of breast implants. It commonly presents with a sudden, dramatic seroma around an implant, or occasionally a breast mass. Diagnosis is based on cellular morphology and staining positive for CD30 and negative for anaplastic lymphoma kinase (ALK). The aetiology and management of BIA-ALCL remains unclear. Clemens et al. suggest the conventional Ann-Arbor staging system and aggressive local and systemic treatments may not be appropriate. In the majority of cases, BIA-ALCL is confined to the seroma or the inner aspect of the capsule, so total capsulectomy alone may be sufficient. Systemic therapy may only be required in the minority where disease extends beyond the capsule. We present the UK BIA-ALCL data using the new specific staging system. Results We report 11 cases of BIA-ALCL from seven regional centres. Treatment was multidisciplinary between breast/plastic surgery and haemato-oncology and based on best available evidence and expert opinion. Mean lead-time from implant to diagnosis was 10 years. Using the new classification, eight Stage I cases that presented with recurrent seroma were treated successfully with implant removal and total capsulectomy. Four patients had bilateral breast augmentation (BBA); two had bilateral risk-reducing mastectomies (RRM) with implant reconstruction; two had a unilateral mastectomy and implant reconstruction for breast cancer, one of which had previously received adjuvant chemo- radio- and endocrine therapy. All but one patient with bilateral implants had surgery to remove both implants and ipsilateral total capsulectomy. Of these, three also had contralateral capsulectomy and the pathology was benign. One patient had unilateral capsulectomy and bilateral exchange of implants. Three patients presented with Stage IIA disease. One had previous RRM and implant reconstruction and presented with a mass. Treatment was CHOP+ (Echelon2 trial), radiotherapy and implant removal, she remains well at two years. One patient with previous BBA following a routine implant exchange developed a BIA-ALCL mass at the drain site. She was treated with local excision, adjuvant CHOP and radiotherapy. She is well at four years. The third patient had BBA and presented with a mass adjacent to the implant and progressed rapidly through neoadjuvant CHOP to develop life threatening chest wall/thoracic cavity involvement. She achieved complete pathological response with six cycles of Brentuximab followed by bilateral total capsulectomy and implant removal. This is the first reported case of neo-adjuvant antibody therapy in BIA-ALCL. Discussion Our data support the published literature demonstrating the majority of BIA-ALCL is stage I/II and can be safely managed with surgery alone. Chemotherapy was targeted at patients with more advanced local disease. Brentuximab, a monoclonal antibody is not licenced for BIA-ALCL but is used in refractory in ALCL. BIA-ALCL related death, although rare, is due to uncontrolled local disease progression. Conclusion BIA-ALCL cases must be staged according to the new system to avoid overtreatment. Brentuximab should be considered first line therapy for locally advanced BIA-ALCL. Citation Format: Johnson L, O9Donoghue J, Stark H, Collis N, Lennard A, Butterworth M, McLean N, Youssef M, Gui G, Lyburn I, Bristol J, Hurren J, Smith S, Jacklin R, Cunningham D, MacNeill F. Breast implant associated anaplastic large cell lymphoma (BIA-ALCL)– The UK experience and first reported case of neoadjuvant brentuximab [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-03-02.

Let’s keep clinical breast examination until the breast service is reconfigured

I am unsure whether examining a patient can ever be “bad medicine.”1 Nonetheless, the tenor of the argument is correct. Times have changed: within the secondary tier, as Spence indicates, it is (or should be) unusual for patients with breast symptoms …