Reconstruction after mastectomy for breast carcinoma with implants or myocutaneous flaps is a widely used surgical technique. Recurrence of breast carcinoma after these procedures is uncommon. Most recurrences occur in the skin or scar site of the mastectomy and are readily detectable by physical examination. There are rare reported cases of recurrent carcinoma occurring within the flaps that are usually diagnosed with the aid of imaging and subsequent pathologic examination. In most cases, these recurrences represent invasive or in situ ductal carcinoma. We report an additional 2 cases of breast carcinoma recurring within the myocutaneous flap, both of which exhibited uncommon histologic features not previously reported.

There are many options for postmastectomy reconstruction for breast carcinoma that have been shown to be oncologically safe1–6 and psychologically beneficial, including autologous reconstruction with the transverse rectus abdominis myocutaneous (TRAM) flap. This flap uses the lower abdominal skin, subcutaneous fat, and rectus muscle to reconstruct the breast.7 Recurrent breast cancer after reconstruction with a prosthesis or flap has been reported in up to 20% of cases.2–4,6,8–15 Most of these recurrences become clinically evident as palpable nodules in the native skin or scar site without involving the TRAM flap and are readily diagnosed by physical examination alone. There are rare reports of recurrences arising directly within TRAM flaps, which are diagnosed by mammography or other imaging modalities.8,10,12,14,15 We report 2 instances of recurrent breast carcinoma arising directly within the TRAM flap and review the literature regarding this uncommon occurrence.

Case 1

A 58-year-old woman with a history of bilateral breast augmentation presented in November 1998 with a mass in the upper outer quadrant of the left breast that was visualized on ultrasound and mammography. The excisional biopsy specimen consisted of a tan-yellow centrally firm mass measuring up to 1.0 cm. Microscopic examination showed foci of solid intermediate-grade ductal carcinoma in situ (DCIS) and moderately differentiated invasive ductal carcinoma. The carcinoma was estrogen and progesterone receptor positive.

A second palpable mass was identified in the upper inner quadrant of the same breast by physical examination. An excisional biopsy revealed a 1.3-cm central cystic cavity containing a papillary mass with fluid. Histologic examination showed an intracystic papillary carcinoma with complete lack of immunoreactivity for myoepithelial markers (smooth muscle actin, p63, and myosin) throughout the lesion (Figure 1). A 2-mm focus of moderately differentiated invasive ductal carcinoma was also identified in the surrounding fibrous reaction. The invasive ductal carcinoma was estrogen and progesterone receptor positive by immunohistochemistry.

Figure 1.

Case 1. Papillary carcinoma from excisional biopsy in December 1998 (hematoxylin-eosin, original magnification ×20). Figure 2. Case 1. Recurrent papillary carcinoma in transverse rectus abdominis myocutaneous flap in August 2002. Note the orderly structure of this metastatic carcinoma. Pectoralis muscle is seen in the upper left corner (hematoxylin-eosin, original magnification ×4). Figure 3. Case 2. Recurrent invasive ductal carcinoma with spindled and neuroendocrine features. The primary tumor displayed the same histologic features (hematoxylin-eosin, original magnification ×20)

Figure 1.

Case 1. Papillary carcinoma from excisional biopsy in December 1998 (hematoxylin-eosin, original magnification ×20). Figure 2. Case 1. Recurrent papillary carcinoma in transverse rectus abdominis myocutaneous flap in August 2002. Note the orderly structure of this metastatic carcinoma. Pectoralis muscle is seen in the upper left corner (hematoxylin-eosin, original magnification ×4). Figure 3. Case 2. Recurrent invasive ductal carcinoma with spindled and neuroendocrine features. The primary tumor displayed the same histologic features (hematoxylin-eosin, original magnification ×20)

Close modal

Because of the presence of multicentric disease, a modified radical mastectomy with axillary lymph node dissection and immediate TRAM flap reconstruction was subsequently performed. No residual invasive ductal or papillary carcinoma was identified in the mastectomy specimen. Foci of DCIS with low nuclear grade, solid and cribriform growth pattern, and apocrine features were seen in random sections remote from the 2 biopsy cavities and margins. Ten sections from the deep and superficial resection margins were free of carcinoma, and 12 axillary lymph nodes were negative for metastatic disease.

The patient refused additional therapy at this time and was subsequently lost to follow-up. Approximately 3½ years later, the patient presented with a 2.5-cm palpable mass arising within the TRAM flap. An excisional biopsy of the mass showed a multicystic papillary carcinoma in fibrofatty tissue and skeletal muscle (Figure 2), morphologically similar to the papillary carcinoma seen in the prior excisional biopsy of the upper inner quadrant. In addition, a 1- to 2-mm focus of invasive papillary carcinoma was identified in adipose tissue. No breast tissue was seen in the specimen. These findings were consistent with a recurrence of papillary carcinoma in the TRAM flap. The patient refused additional metastatic workup, chemotherapy, and radiotherapy.

Case 2

A 46-year-old woman presented with bloody discharge from the left nipple in July 1998. An excisional biopsy was performed, during which the surgeon noted markedly dilated ducts filled with clotted blood and diffuse firm nodular tissue in the subareolar region, extending to the upper outer quadrant. All the nodular tissue and dilated ducts with surrounding tissue were excised. The 9.0-cm specimen showed widespread DCIS of solid type with high nuclear grade and focal neuroendocrine features, including spindled growth pattern. The DCIS was immunoreactive for estrogen receptor, progesterone receptor, chromogranin, and synaptophysin. No invasive carcinoma was present. A left mastectomy with immediate TRAM flap reconstruction was performed. The mastectomy specimen revealed residual DCIS adjacent to the biopsy site in the upper outer quadrant. The biopsy site was distant from the margins. No invasive carcinoma was seen. Two sections, one each from the deep margin (including striated muscle) and skin, were negative for carcinoma. One intramammary lymph node was negative for carcinoma. The patient received no adjuvant therapy at this time.

Approximately 3 years after mastectomy and reconstruction, the patient presented with a palpable nodule in the left TRAM flap. Excisional biopsy showed carcinoma with spindled growth pattern and neuroendocrine cytologic features in adipose tissue (Figure 3). Positive staining for CAM 5.2, estrogen receptor, progesterone receptor, chromogranin, and synaptophysin confirmed that the tumor was a recurrence of the primary carcinoma in the upper outer quadrant. The tumor was entirely invasive and lacked immunoreactivity for myoepithelial (CD10, smooth muscle actin, and p63) and basement membrane (collagen type IV and laminin) markers. Negative staining for thyroid transcription factor 1 ruled out metastasis from a primary lung tumor. No breast tissue was seen in the specimen. As part of a metastatic disease workup, a computed tomographic scan of the thorax was performed, which showed a 13-mm nodule in the right lower lobe. Fine-needle aspiration cytology of the lung lesion showed metastatic breast carcinoma with an immunohistochemical profile identical to that of the recurrent lesion in the TRAM flap. The patient received hormonal therapy.

Immediate reconstruction after mastectomy for carcinoma is considered to be an oncologically safe procedure, which also has been shown to be beneficial to patients' psychological well-being.1–3,7 Reconstruction with a prosthesis or autologous myocutaneous flap does not appear to adversely affect survival or the incidence of local recurrence.1–6,13 Local recurrence rates after immediate TRAM flap reconstruction have been reported to range from 4.2% to 11.7%, and most recurrences are detected within the first 5 years after surgery.1–6,13 The clinical presentation of locally recurrent breast carcinoma varies and includes palpable nodules in the skin or suture line, erythematous rash, or thickening of the skin. Some recurrences have presented deep to the pectoralis major muscle and, although few in number, are considered chest wall recurrences.16 A case has also been reported of carcinoma en cuirasse—diffuse carcinomatous infiltration of the skin and subcutaneous tissue of the chest extending beyond limits of conventional surgical boundaries—with invasion of bilateral TRAM flaps.9 

Most of these local recurrences do not appear to be within the TRAM flap itself, but have involved the skin or subcutaneous tissue with subsequent secondary invasion of the flap. Tumor from the mastectomy flap may invade the TRAM flap and erroneously seem to originate from it.

The incidence of recurrent carcinoma presenting as a lesion within the TRAM flap is low. The first case was described by Mund et al8 as a nonpalpable lesion detected only on screening mammography. Subsequently, 4 reports describing 20 cases of recurrent breast carcinoma in TRAM flaps and their pathologic and radiologic characteristics have been published (Table).10,12,14,15 The recurrences were detected 2 to 10 years after the initial mastectomy. Seventeen of the total 21 cases presented as palpable masses in the flap. In 16 of the 21 cases, mammography showed features suspicious for carcinoma similar to those seen in carcinoma of native breast. Pathologic examination of the original tumor in 13 cases showed high-grade DCIS, 3 of which showed definite or questionable microinvasion. Five of these cases showed tumor present less than 1 mm from the resection margin. Pathologic findings of these 13 recurrences showed invasive ductal carcinoma, 5 with surrounding high-grade DCIS. Eight cases showed invasive ductal carcinoma, 1 with metastatic disease in axillary lymph nodes.

Published Cases of Recurrent Breast Carcinoma in Transverse Rectus Abdominis Myocutaneous (TRAM) Flaps*

Published Cases of Recurrent Breast Carcinoma in Transverse Rectus Abdominis Myocutaneous (TRAM) Flaps*
Published Cases of Recurrent Breast Carcinoma in Transverse Rectus Abdominis Myocutaneous (TRAM) Flaps*

The causes of TRAM flap recurrences have been debated. Slavin et al3 performed lymphoscintigraphy of the TRAM flap and found that the initial drainage of the flap was medial, conforming to the anatomy of the deep superior epigastric vascular pedicle and its internal mammary origin. Dye was also seen going to the axillary lymph nodes. The authors hypothesized that lymphatic channels from the native skin traversed the flap and flowed toward the axilla. Therefore, residual carcinoma in native skin could spread to the TRAM flap via these new lymphatics. In the report by Shaikh et al,14 all 3 recurrences were in the medial aspect of the reconstructed breast, correlating with the deep superior epigastric vascular pedicle, supporting the theory that tumor cells from residual skin traveled via lymphatics. Other possible sources of recurrence are residual breast tissue with development of carcinoma, tumor seeding at the time of surgery, and persistence of tumor in the operative field and lymphatics. Also, recurrences may represent metastatic spread to the TRAM by tumor cells in circulation or from another metastatic site.

In the present 2 cases, residual breast tissue was not identified in the recurrence specimens. The original mastectomy specimens did not show angiolymphatic invasion, and resection margins were free of carcinoma. These observations suggest that residual carcinoma in the mastectomy skin envelope may have invaded the flaps via new lymphatics or vessels. Tumor may also have seeded the flaps at the time of insertion after mastectomy. Despite the lack of metastases in axillary lymph nodes at the time of mastectomy, carcinoma may have been harbored in the vascular system in case 1 and later seeded the flaps. In case 2, invasive carcinoma may not have been seen because of inadequate sampling. The lung metastases with coincidental TRAM flap recurrence were probably a manifestation of systemic spread from a previously nondetected invasive focus.

The significance of TRAM recurrences was recently addressed by Langstein et al.16 Their study showed decreased survival, increased systemic metastases, and decreased disease-free interval in patients who developed recurrences in the chest wall versus in the skin. According to their definitions, TRAM recurrences would fall in the chest wall category, and patients would have a worse prognosis than those with skin recurrences.

Transverse rectus abdominis myocutaneous flap recurrences are rare, and many that have been reported may not represent an actual recurrence within the flap itself. The 2 new reported cases show recurrences within TRAM flaps with interesting histologic findings recapitulating the original tumor. Whether these recurrences represent metastases or local recurrence is still under investigation. Neither case showed any residual breast tissue in the TRAM resection specimen, which favors a metastatic origin for the recurrent carcinoma.

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The authors have no relevant financial interest in the products or companies described in this article.

Author notes

Reprints: Sandra J. Shin, MD, Department of Pathology and Laboratory Medicine, Weill Medical College of Cornell University, Starr 1028, 525 E 68th St, New York, NY 10021 ([email protected])