Unusual Clinical Presentation of Carcinoma
929
The primary carcinoma for which the mastectomy was
performed has almost always been invasive ductal type, usu
ally moderately to poorly differentiated. There have been
infrequent instances in which the primary carcinoma was
well-differentiated invasive ductal, or papillary, or giant pap
illary
298,300,302
carcinoma. Recurrent carcinoma in the TRAM
flap tissue usually duplicates the histologic appearance of the
primary tumor. Recurrent carcinoma concurrently involv
ing the mastectomy bed, TRAM flap, abdominal donor site,
and precostal tunnel has been reported.
303
In a study of patients treated with postmastectomy ra
diotherapy to the chest wall or TRAM flap, Huang et al.
304
found no significant difference in the incidences of compli
cations, local recurrence, and distant metastases between
those who have had a TRAM flap and those who did not
have a TRAM reconstruction. An angiosarcoma developed
6 years subsequent to mastectomy and immediate TRAM
flap construction followed by radiation,
305
and a leiomyos
carcoma developed 20 years after a mastectomy and radia
tion, and 10 years after a delayed TRAM flap construction.
306
Both sarcomas were attributed to radiation effect.
Until the mechanism of carcinomatous involvement of
TRAM flaps is elucidated, it should be regarded as a form
of local recurrence. Long-term follow-up data in these cases
are not known at this time; however, anecdotal evidence
suggests that TRAM flap recurrences may be a harbinger of
systemic spread.
It should be understood that most local masses occur
ring after autologous breast reconstruction are benign. In an
analysis of 66 such masses occurring after 365 autologous
breast flap reconstructions in 272 patients, performed over a
10-year period, the majority of these were fat necrosis.
307
Fat
necrosis occurred in 54 (15%) breasts and represented 54/66
(82%) of the tumors. Recurrent carcinoma was diagnosed in
13 (3.6%) of the post-TRAM flap breasts. In this study, fac
tors associated with carcinoma in postreconstruction masses
were closer (less than 1 cm) surgical margins and tumoral
involvement of lymphovascular channels. Furthermore,
51/54 (94.4%) instances of fat necrosis were diagnosed in
the first postsurgical year and none after 2 years, whereas
the mean time to the detection of recurrent carcinoma in a
TRAM flap was 24 months.
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1983;7:1–58.
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than in patients who do not have a complete response in
their ALNs.
287
In both studies, patients who had complete
regression of their axillary nodal metastases more often had
less or no residual carcinoma in the breast. Among women
with noninflammatory carcinoma, the presence of residual
carcinoma in the breast did not have a negative effect on
the relatively favorable prognosis associated with complete
ALN response.
The outcome for IBC patients treated in the modern era
of trastuzumab and taxane-based chemotherapy remains
modest. A retrospective study of 104 patients with non-
metastatic IBC treated over a 10-year period (2000 to 2009)
with a median follow-up time of 34 months showed that the
5-year OS for the entire cohort was 46%.
288
In this study,
fifty-seven (55%) tumors were ER (−) and PR (−) negative,
and 34 (33%) were HER2 (
+
). Seventy-five (72%) patients
completed all intended therapy, of whom 67 (89%) received
a taxane and 18/28 (64%) of HER2 (
+
) patients received
trastuzumab. Despite the use of taxanes and trastuzumab,
outcomes remain modest, particularly for those with ER (−)
and PR (−) disease, and those without a pathologic complete
response.
Lastly, it should be remembered that various forms of
mastitis and other types of neoplastic processes includ
ing lymphoma and metastatic nonmammary carcinoma in
the breast can mimic IBC.
289–291
Thus, it is crucial that the
clinical diagnosis of IBC be documented by a biopsy of the
skin or breast that demonstrates the presence of mammary
carcinoma.
RECURRENT CARCINOMA IN TRAM FLAP
Approximately one in seven women in the United States who
undergo mastectomy receive immediate breast reconstruc
tion.
292
The latter procedure employs various techniques,
including the TRAM flap. Women who are younger and are
treated at tertiary settings are more likely to get immediate
reconstruction, the advantages of which include less psycho
logical consequences, more pleasing aesthetic results, and cost
reductions. Thus, immediate breast reconstruction, includ
ing the use of the TRAM flap procedure, is likely to increase
in popularity. TRAM flap reconstruction performed after a
mastectomy employs skin and subcutaneous tissue and rectus
muscle from the abdominal wall to recreate the breast. This
procedure has been in use for more than three decades.
293
Recurrent carcinoma may develop in the TRAM flap as
an isolated event or as a manifestation of systemic spread.
The reported TRAM recurrence rate ranges from 3.8% to
11.7%.
294–296
The latter series included patients who initially
had stage III and stage IV tumors. Recurrent carcinoma in
a TRAM flap usually presents as a palpable tumor,
296–298
but
nonpalpable recurrences have been detected by mammogra
phy.
299,300
Mammographic indicators of recurrent carcinoma
include mass lesions, sometimes with a spiculated contour,
and calcifications. Dystrophic calcification amid fat necro
sis associated with flap construction may simulate recurrent
carcinoma.
301
