Axillary lymph node metastases from unknown primary: A French multicentre study

Occult primary breast cancer: Two cases report and literature review

INTRODUCTION AND IMPORTANCE

Occult breast cancer (OBC) is defined as a clinically recognizable metastatic carcinoma arising from an undetectable primary breast tumor.

PRESENTATION OF CASE

We report in this work 2 cases of occult breast cancer treated at the Mohammed VI center of onco-gynecology of the CHU of Casablanca.

CLINICAL DISCUSSION

Significant advances in breast imaging have occurred since its description, decreasing its incidence. However current management is based upon old studies, with variable clinical, radiological and pathological definitions of OBC.

CONCLUSION

The introduction of better diagnostic techniques and more detailed pathology continue to impact the true incidence of OBC.

SUMMARY

Carcinoma of unknown primary is an intriguing clinical phenomenon that is defined as biopsy-proven metastasis of a malignant tumor in the absence of an identifiable primary site after a complete clinical workup. Carcinoma of unknown primary accounts for approximately 3 to 5% of all cancer diagnoses, and consists of a heterogeneous group of tumors that have acquired the ability to metastasize before the development of a clinically evident primary lesion. Clinical and radiological examinations represent the first steps in the diagnostic algorithm for Carcinoma of unknown primary syndrome. However, histological and immunohistochemical analyses, together with evaluation by a multidisciplinary team and adequate therapy are essential for the diagnosis and treatment of Carcinoma of unknown primary syndrome of OBC. We report in this work 2 cases of occult breast cancer treated at the Mohammed VI center of onco-gynecology of the CHU of Casablanca; A multidisciplinary approach including surgery, radiotherapy, hormonal and biological therapy was implemented. Currently, 10 month after the first presentation, the two patient received ipsilateral breast radiotherapy and sequential adjuvant chemotherapy followed by hormone therapy. Evolution was marked by good control.

Systematic review of synchronous contralateral axillary metastases in breast cancer: really M1 disease?

OBJECTIVE

The objective of the study is to assess and quantify the effect of the appearance of synchronous contralateral axillary on breast cancer survival. Breast cancer with contralateral axillary metastases (CAM) is classified as a metastatic disease. There are few cases reported and a lack of evidence of the significance of CAM when synchronous appearance with a primary tumor and no other site of disease.

METHODS

A systematic review following PRISMA guidelines to evaluate the prognosis of patients with synchronous CAM without other metastatic diseases comparing with metastatic disease is conducted through a search in PubMed, Embase, Clinical Key, and Cochrane Library databases. We present one case. The median age, follow-up, clinico-pathological characteristics, status of lymph nodes, treatments, and outcomes are analyzed.

RESULTS

A total of 23 articles (10 case reports and 13 case series) with a total 68 patients, including our case. Median age was 48 years old. Median follow-up was 27 months. Overall survival of the series was 71.4%. Twenty-one of 49 patients reported (36.2%) were alive without disease, fourteen (28.6%) were alive with disease while the rest fourteen (28.6%) died. Inflammatory presentation and ipsilateral axilla status were related to overall survival.

CONCLUSIONS

Synchronous CAM in breast cancer show better outcomes in terms of overall survival than other metastatic diseases. The absence of comparative studies may not allow definitive conclusions, meanwhile, together with other authors we suggest treatment with curative intention. More studies may lead to consider a modification of TNM system.

Axillary Nodal Metastases from Carcinoma of Unknown Primary (CUPAx): Role of Contrast-Enhanced Spectral Mammography (CESM) in Detecting Occult Breast Cancer

Axillary lymph node metastases of occult breast cancer (CUPAx) is an unusual condition that represents both a diagnostic and therapeutic challenge. The first steps in the diagnostic work-up of patients with CUPAx are the histological analysis of the lymph node metastasis and the execution of basic breast diagnostic imaging (mammography and ultrasound). In the case of occult breast cancer, breast Magnetic Resonance (MR) must be performed. Breast MR identifies a suspicious lesion in many patients and second-look ultrasound detects a corresponding ultrasound alteration in about half of cases, allowing the performance of a US-guided biopsy. In the case of an MR-only lesion, MR-guided biopsy is mandatory. We present a case of CUPAx in which contrast-enhanced spectral mammography (CESM) is used to help the detection of occult breast cancer and to guide stereotactic vacuum breast biopsy (VABB). CESM is a new breast imaging technique that is proving to have good performance in breast cancer detection and that is showing potential in the identification of occult breast cancer in a CUPAx setting. The use of an innovative and personalized breast imaging approach in breast cancer patients improves diagnostic possibilities and promises to become the focus in decision strategies.

Cancer of Unknown Primary Presenting as Bone-Predominant or Lymph Node-Only Disease: A Clinicopathologic Portrait

BACKGROUND

Cancer of unknown primary (CUP) presenting as bone-predominant (BCUP) or lymph node-only disease (LNCUP) represents two clinically distinct subsets of nonvisceral CUP. These present a diagnostic challenge with a large differential of putative primary cancers and defy the "one-treatment-fits-all" approach.

MATERIALS AND METHODS

We identified patients with BCUP (n = 29) and LNCUP (n = 63) using a prospectively collected CUP database and tumor registry of patients seen at MD Anderson Cancer Center between 2001 to 2017. Clinicopathological characteristics, treatments, and outcomes were abstracted. A control group of non-BCUP/LNCUP cases (n = 443) from the database was used for comparison. Kaplan-Meier method was used to estimate overall survival and compared using log-rank test.

RESULTS

In this cohort, 64% and 60% patients had disseminated disease at diagnosis and 39% and 23% had Culine poor-risk disease in BCUP and LNCUP, respectively. Median overall survival (OS) for BCUP was 14.5 months and for LNCUP was 32.6 months. For BCUP, gemcitabine plus platinum was the most common initial chemotherapy (54%). For LNCUP, carboplatin plus paclitaxel was the most common initial chemotherapy (38%). Radiation was given to 74% of patients with BCUP and 37% of those with LNCUP. On multivariate analysis, poor-risk Culine group (hazard ratio [HR], 1.76; p < .001) and high neutrophil-to-lymphocyte ratio (HR, 2.38, p < .001) were associated with worse OS.

CONCLUSION

BCUP and LNCUP are rare subsets within CUP with varying prognosis. Poor-risk Culine group and high neutrophil-to-lymphocyte ratio are associated with poor survival. Select patients with limited metastases can have long-term survival with aggressive multimodality treatment. Careful clinicopathological review can facilitate chances of site-directed therapy.

IMPLICATIONS FOR PRACTICE

Cancer of unknown primary (CUP) rarely presents as bone-predominant (BCUP) or lymph node-only (LNCUP) disease. This article describes a cohort of each and compares with a larger CUP cohort. Patients with BCUP have unique issues with fractures and pain, often receiving radiation. Overall survival of 14.5 months was similar to a larger CUP comparison cohort. Patients with LNCUP had improved overall survival at 32.6 months, with longer survival in patients without disseminated disease. Culine poor-risk group and neutrophil-to-lymphocyte ratio were associated with worse overall survival. Tips regarding diagnosis and management of these rare malignant subsets are provided.