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    • Three publications described the use

    2018-10-29

    Three publications described the use of a “flow through” replant where the contralateral labial artery was anastomosed to a recipient vein to provide venous outflow. All of them showed venous congestion and needed medicinal or chemical leech engagement. It is worth mentioning that the “artery-to-vein” flow-through method was successful in the management of distal finger replantation for the absent venous drainage. Furthermore, the need for blood transfusion was not greater than that for other adjuvant techniques. This collection of reports would support the claim for the viability of the “artery only” lip replantation, which generally portends good outcomes with the addition of leech therapy and/or anticoagulation. Regardless of the methods used to relieve venous surfeit, the duration of this treatment can be empirically equated to the time required for angiogenic re-establishment of venous outflow pathways. Normal wound healing parameters suggest that this process is functional somewhere between the 4th and 6th days after replantation. Throughout various reports in the literature, medicinal or chemical leeches were usually employed for an average of 5 ∼ 6 days, which is in keeping with the physiologic basis for this rationale.
    Introduction In 2003, the World Health Organization (WHO) defined breast neuroendocrine carcinoma (BNEC) as a unique category of breast cancer. The diagnosis of BNEC required immunohistochemical (IHC) kainate receptors of neuroendocrine (NE) markers in more than 50% of breast tumors. The WHO also divided the BNECs into 3 subclasses, consisting of solid neuroendocrine carcinoma, small/oat cell carcinoma and large cell neuroendocrine carcinoma. Primary BNEC is a rare breast cancer, and the reported data vary from < 0.1% to 5% of all breast cancers. BNECs have multidirectional differentiation in morphology, including mucinous differentiation, overlapping in expression usual types of breast carcinoma. Here we present a case of solid BNEC diagnosed based on subtle histological characteristics and specific IHC expressions.
    Case report A 46-year-old woman, who had smoked for 20 years, had a right breast lump for 2 weeks. She underwent breast ultrasonography, which showed a heterogenous and hypoechoic mass about 2cm in diameter, without calcification or cystic degeneration, located at the 12 o’clock position, 5cm from the right nipple. Routine blood, urine biochemistry, CEA and CA153 examinations were within normal limits. She had a biopsy taken after ultrasonography and the subsequent frozen section of the breast lesion revealed malignant cells with crushed, obscured nuclear contours, arranged in irregular sheets against a dense fibrous background. A modified radical mastectomy with lymph node dissection was performed. The histological features of the tumor were similar to those of a usual invasive duct carcinoma, and histologically were grade II with scant tubular formation, intermediate-sized nuclei and rare mitoses. Nevertheless, the presence of a marked crush artifact of tumor cells in the frozen section, small monotonous tumor cells and rare mitoses of the infiltrating tumor aroused suspicion of a neuroendocrine nature. The tumor also contained a low-grade duct carcinoma in situ lesion (Fig. 1). IHC studies showed the tumor cells to be positive for both the estrogen receptor (ER) and progesterone receptor (PR) and negative for Her-2. The tumor exhibited, in addition, an IHC reaction to synaptophysin, chromogranin A, neurone-specific enolase (NSE) and CD56, and was thus shown to be a solid neuroendocrine carcinoma of the breast (Fig. 2). All 13 dissected axillary lymph nodes were free from metastasis and the post-operative computerized tomogram showed no secondary or remaining tumor in the body.
    Discussion Since Cubilla and Woodruff first described seven cases of breast carcinoid tumor with NE secretory activity in 1977, BNEC has become a distinct topic of breast cancer. In 1982, Azzapardi presented 14 cases of breast carcinoid tumors in which he noticed a wide range of morphological and histochemical appearances and a variable prognosis. These breast carcinoid tumors had 18% of nodal or distant metastases, which occurred only when the tumor was 2.5cm or larger and with ten or more mitoses/10HPF. The breast carcinoid tumors (now called neuroendocrine carcinoma) with high mitotic figures are classified into intermediate differentiated BNEC, such as alveolar carcinoma based on WHO classification. Recent studies demonstrated that the low-grade BNECs, such as solid BNECs, have a low percentage of lymph node metastasis and a low rate of recurrence and metastasis. Some BNECs with mucinous differentiation have also been shown to have good prognosis. Most BNECs, except small cell carcinoma and large cell carcinoma, have a better prognosis than the usual invasive breast cancers.