This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.The appearance of a mass in a reconstructed breast is always of concern for local recurrence of breast cancer and can cause worry and anxiety in a patient. We present an uncommon cause for a mass in a reconstructed breast

Dean, Nicola Ruth

Koh, Eugene

Watson, David Ian

Plastic & Reconstructive Surgery Global Open

Flinders Academic Commons

	 www.PRSGlobalOpen.com 1The appearance of a mass in a reconstructed breast is always of concern for local recurrence of breast cancer and can cause worry and anxi-ety in a patient. We present an uncommon cause for a mass in a reconstructed breast.CASE	REPORTA 57-year-old woman presented with a 6-week his-tory of a painful lump in her right chest wall after bi-lateral mastectomy and reconstruction. In 1991, she had undergone a right partial mastectomy with axil-lary clearance for a 13-mm grade III invasive cancer. There was no nodal involvement, and she received iridium implant brachytherapy and adjuvant exter-nal beam radiotherapy.Subsequent mammography in 2007 showed some suspicious microcalcifications in the contralateral (left) breast. An excision biopsy showed the presence of an intermediate-grade ductal carcinoma in situ.To achieve clearance of the ductal carcinoma in situ, she underwent complete left mastectomy and, at the same time, had a prophylactic right mastec-tomy and bilateral 2-stage reconstruction with tissue expander and implant. The procedure was compli-cated by a right-sided periprosthetic infection, which required removal of the implant on that side. She then underwent a free transverse rectus abdominis musculocutaneous (TRAM) flap to reconstruct the right breast in November 2007, and this was compli-cated by partial flap necrosis a month later, requir-ing debridement and split skin graft.In February 2009, the patient presented with dis-comfort in the reconstructed left breast secondary to mild capsular contracture with thin overlying tissues. To treat this, the patient opted to undergo further surgery to remove the implant and have a latissimus dorsi reconstruction augmented by a smaller im-plant. For 5 years, she remained symptom-free and happy with her reconstructed breasts, despite an objectively poor aesthetic result (Fig. 1). She then presented with pain in her right chest wall in 2014, 7 years after the TRAM flap breast reconstruction.Physical examination of the right chest wall revealed a hard mass, deep to the upper scar of the right breast reconstruction (Fig. 1). Serum bio-Disclosure: The authors have no financial  interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the Department of Plastic and Reconstructive Surgery, Flinders University, South Australia.Tumoral Calcinosis: An Uncommon Cause for a Mass in a Reconstructed BreastFrom the *Department of Plastic and Reconstructive Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia; †Department of Surgery, ‡Department of Anatomical Pathology, SA Pathology, and §Department of Pathology, Flinders University, Bedford Park, South Australia, Australia.Received for publication January 28, 2016; accepted March 1, 2016.Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.DOI: 10.1097/GOX.0000000000000687Koh et al.Eugene Koh, MBBS, MSSc*Nicola R. Dean, MBChB, PhD, FRACS(Plas)*David I. Watson, MD, FRACS†Christopher D. Carter, MBBS, FRCPA‡§Summary: Tumoral calcinosis is a rare clinical and histopathological syn-drome whose exact etiology is unknown. We present a case of a 57-year-old woman who presents with a painful lump in her right chest after bilateral breast reconstructions for bilateral asynchronous breast cancers. It is im-portant to be aware of all possible differential diagnoses in a patient pre-senting with a chest mass after mastectomy and reconstruction for breast cancer as not all lesions of this type represent recurrent cancer. (Plast Reconstr Surg Glob Open 2016;4:e700; doi: 10.1097/GOX.0000000000000687; Published online 5 May 2016.)BreastCase RepoRt2PRS Global Open • 2016chemistry did not reveal any metabolic or electrolyte abnormalities; calcium and phosphate values were in the normal range. Computed tomography of the chest demonstrated a bone-forming lesion at the an-terior end of the right third rib, measuring 2.1 × 2 × 2.8 cm, with little soft tissue component (Fig. 2). Positron emission tomography did not demonstrate a fluorodeoxyglucose-avid malignancy. Recurrent breast cancer was considered unlikely based on this imaging, with sarcoma considered more likely. She was then referred to a regional sarcoma service.The patient underwent resection of the affected segment of her right third rib at the regional sar-coma center. Macroscopically, extensive changes of radiotherapy and fibrosis were found. There was necrotic, caseating material within the bone, which was excised with the pleura intact. The patient then made an unremarkable recovery and remained symptom-free 12 months after the resection.RESULTSThe removed mass measured 38 × 14 × 14 mm. Mi-croscopically, the lesion represented a well-circum-scribed, lobulated deposit of calcific debris with a granular consistency consistent with hydroxyapatite (Fig. 3). There was no evidence of gout, pseudogout, or amyloid deposits. The lesion was centered in the soft tissue plane and involved skeletal muscle and nonspecialized fibrous connective tissue, including the periosteum and appeared to extend into the un-derlying rib by an erosive process rather than being osteocentric (Fig. 4).Fig. 1. the patient at a routine follow-up; the arrow marks the location of the right chest wall mass.Fig. 2. Computed tomography demonstrating a bone- forming lesion at the anterior end of the third rib.Fig. 3. Well-circumscribed, lobulated deposit of calcific debris with a granular consistency consistent with hydroxy-apatite within skeletal muscle.Fig. 4. Deposit of calcific debris with granular consistency consistent with hydroxyapatite within soft tissue and perios-teum and eroding the rib. 3Koh et al. • Tumoral CalcinosisThe calcific material was surrounded by dense hyalinized fibrous tissue, and there was a sparse his-tiocytic inflammatory reaction at the interface with the calcific deposit. Features of traumatic fat ne-crosis were not evident. There was no evidence of neoplasia. The affected rib showed nonspecific re-active changes and preserved hematopoietic activity. Although bony involvement was an unusual finding, the appearances were nevertheless interpreted as most in keeping with tumoral calcinosis.DISCUSSIONMasses can sometimes develop in reconstructed breasts and must be evaluated to determine their na-ture. In one series, breast masses occurred in 18.1% of reconstructed breasts.1 Fat necrosis is the most common cause of breast masses after autologous breast reconstruction, followed by recurrent carci-noma. Risk factors in the development of fat necrosis include perforator number and selection, smoking, postreconstruction radiotherapy, obesity, volume of transferred tissue, and hypertension.1 The incidence of fat necrosis has also been found to be higher in patients receiving brachytherapy when compared with patients receiving whole-breast irradiation.2There is currently no evidence that immediate re-construction impairs the detection of local recurrence in patients with early-stage breast cancer; however, the presence of autologous tissue can make it difficult to differentiate between a benign and a malignant lesion on clinical examination.1 Reddy et al3 found a similar incidence of locoregional recurrence in a series of 921 patients; 3.0% for all patients and 2.2% after recon-struction. Similarly, the time to detect recurrent disease was not significantly affected by breast reconstruction.Tumoral calcinosis is a rare clinical and histo-pathological syndrome characterized by calcium salt deposition in different periarticular soft tissue regions, its exact etiology is unknown, but treat-ment is by complete surgical excision.4–7 Regions most commonly affected by tumoral calcinosis are soft tissues of periarticular upper limb (shoulder and elbow) and hip regions.5 Slavin et al8 theorized that the lesion of tumoral calcinosis is created by the concurrence of 2 events: first, trauma that initiates a multistepped reaction to injury in juxta-articular soft tissues and skin, and second, a multifactorial eleva-tion of the serum calcium-phosphate product princi-pally caused by hyperphosphatemia.There are no reported cases of tumoral calcinosis of the rib after breast reconstruction in the litera-ture nor were there reported cases of tumoral cal-cinosis associated with external beam radiotherapy or brachytherapy. It has also been theorized that the process of tumoral calcinosis may begin with spon-taneous necrosis of fat, followed by granuloma for-mation and calcification, which may be relevant in this setting of autologous flap breast reconstruction complicated by partial flap necrosis.7CONCLUSIONSWe have presented a case of a rare cause for a mass in a reconstructed breast after mastectomy. Awareness of all possible differential diagnoses is im-portant as not all lesions of this type represent recur-rent cancer.Eugene Koh, MBBS, MSScFlinders Medical CentreFlinders DriveBedford Park, SA 5042AustraliaE-mail: Eugene.Koh@sa.gov.auREFERENCES 1. Casey WJ III, Rebecca AM, Silverman A, et al. Etiology of breast masses after autologous breast reconstruction. Ann Surg Oncol. 2013;20:607–614. 2. Ajkay N, Collett AE, Bloomquist EV, et al. A comparison of complication rates in early-stage breast cancer patients treated with brachytherapy versus whole-breast irradia-tion. Ann Surg Oncol. 2015;22:1140–1145. 3. Reddy S, Colakoglu S, Curtis MS, et al. Breast cancer re-currence following postmastectomy reconstruction com-pared to mastectomy with no reconstruction. Ann Plast Surg. 2011;66:466–471. 4. Lafferty FW, Reynolds ES, Pearson OH. Tumoral calci-nosis: a metabolic disease of obscure etiology. Am J Med. 1965;38:105–118. 5. Fathi I, Sakr M. Review of tumoral calcinosis: a rare clini-co-pathological entity. World J Clin Cases. 2014;2:409–414. 6. Xu C, Potter JA, Carter CD, et al. Idiopathic tumoral cal-cinosis in hand: a case report. Eplasty 2014;14:e28. 7. Smit GG, Schmaman A. Tumoral calcinosis. J Bone Joint Surg Br. 1967;49:698–703. 8. Slavin RE, Wen J, Barmada A. Tumoral calcinosis—a pathogenetic overview: a histological and ultrastructural study with a report of two new cases, one in infancy. Int J Surg Pathol. 2012;20:462–473.

Tumoral Calcinosis: An Uncommon Cause for a Mass in a Reconstructed Breast

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