Prognosis of Occult Breast Carcinoma Presenting as Isolated Axillary Nodal Metastasis

Best treatment options for occult breast cancer: A meta-analysis

Objectives

Occult breast cancer (OBC) is a rare malignant breast tumor. Because of the rare cases and limited clinical experience, a huge therapeutic difference has existed all over the world and standardized treatments have yet been established.

Methods

A meta-analysis was conducted using MEDLINE and Embase databases to identify the choice of OBC surgical procedures in all studies: (1) patients undergoing axillary lymph node dissection (ALND) or sentinel lymph node biopsy (SLNB) only; (2) patients undergoing ALND with radiotherapy (RT); (3) patients undergoing ALND with breast surgery (BS); (4) patients undergoing ALND with RT and BS; and (5) patients undergoing observation or RT only. The primary endpoints were mortality rates, the second endpoints were distant metastasis and locoregional recurrence.

Results

Among the 3,476 patients, 493 (14.2%) undergo ALND or SLNB only; 632 (18.2%) undergo ALND with RT; 1483 (42.7%) undergo ALND with BS; 467 (13.4%) undergo ALND RT and BS, and 401 (11.5%) undergo observation or RT only. After comparing the multiple groups, both groups 1 and 3 have higher mortality rates than group 4 (30.7% vs. 18.6%, p < 0.0001; 25.1% vs. 18.6%, p = 0.007), and group 1 has higher mortality rates than groups 2 and 3 (30.7% vs.14.7%, p < 0.00001; 30.7 vs. 19.4%, p < 0.0001). Group (1 + 3) had a prognosis advantage over group 5 (21.4% vs. 31.0%, p < 0.00001). There was no significant difference both in the distant recurrence rates and locoregional rates between group (1 + 3) and group (2 + 4) (21.0% vs. 9.7%, p = 0.06; 12.3% vs. 6.5%, p = 0.26).

Conclusion

On the basis of this meta-analysis, our study indicates that BS including modified radical mastectomy (MRM) and breast-conserving surgery (BCS) combined RT may appear as the optimal surgical approach in patients with OBC. RT cannot prolong both the time of distant metastasis and the local recurrences.

To scan or not to scan: effect of scanning the axilla of all patients undergoing diagnostic breast ultrasound

BACKGROUND

Breast ultrasonography is a useful modality in patients undergoing diagnostic and screening breast imaging. However, breast ultrasound has a high false positive rate and can be time-consuming to perform.

PURPOSE

The purpose of this study was to evaluate the clinical impact of incidental axillary findings found on diagnostic breast ultrasounds at a single multi-site institution that has a standard protocol of scanning the axilla for all breast ultrasound exams.

METHODS

All diagnostic breast ultrasounds were retrospectively reviewed from January 2017 to September 2019. Follow-up imaging, relevant clinical history, and pathology results were also reviewed. All positive axillary findings were divided into incidental or non-incidental findings depending on whether there was a direct clinical indication to scan the axilla. Descriptive statistics were performed with a 5% level of significance.

RESULTS

Of the 19,695 diagnostic ultrasounds performed during this timeframe, there were 91 (0.5%) incidental axillary findings given a BIRADS category 3 or 4, and none of these findings resulted in the diagnosis of an occult breast cancer. One biopsy-proven SLL/CLL lymphoma was diagnosed that was otherwise clinically occult.

CONCLUSION

Routine axillary scanning in all patients undergoing a diagnostic breast ultrasound at a large multi-site institution yields a low rate of incidental findings and has minimal impact on detection of cancer.

Axillary lymph node dissection plus radiotherapy may be an optimal strategy for patients with occult breast cancer

Background

Because of the rarity of occult breast cancer (OBC) and limited experience in OBC treatment, the optimal treatment strategy is unknown. This study aimed to compare the efficacy of axillary lymph node dissection (ALND) plus radiotherapy with that of mastectomy plus ALND in patients with OBC.

Methods

Relevant clinical data between January 2004 and December 2015 were retrospectively collected from the Surveillance, Epidemiology, and End Results database. The clinical characteristics and prognoses of patients who underwent ALND plus radiotherapy or mastectomy plus ALND were compared before and after propensity score matching.

Results

Overall, 569 eligible patients with OBC were included in this study. Of these, 247 patients underwent ALND plus radiotherapy and 322 underwent mastectomy plus ALND. The 5-year overall survival (OS) rates in the ALND plus radiotherapy group and the mastectomy plus ALND group were 89.2% and 80.6%, respectively; and the corresponding 5-year breast cancer-specific survival (BCSS) rates were 95.2% and 93.0%, respectively. After propensity score matching, the OS in the ALND plus radiotherapy group was significantly better than that in the mastectomy plus ALND group. In addition, further subgroup analyses revealed that ALND plus radiotherapy prolonged OS in the pN3 subgroup. Among patients receiving adjuvant chemotherapy, those who underwent ALND plus radiotherapy had better BCSS and OS than those who underwent mastectomy plus ALND.

Conclusions

ALND plus radiotherapy could improve the OS of patients with OBC, especially those with pN3 disease and those receiving chemotherapy. ALND combined with radiotherapy is the optimal treatment strategy for patients with imaging-negative OBC.

Occult Invasive Lobular Carcinoma Presenting as an Axillary Skin Metastatic Lesion Underwent Neoadjuvant Endocrine Therapy and Surgical Resection: A Case Report and Review of Literature

Introduction

Invasive lobular carcinoma (ILC) is the second most common type of breast cancer accounting for 5–15% of all breast cancer cases. It usually presents with nonspecific signs and symptoms. Occult breast cancer presenting as an axillary mass is rare, with prevalence of 0.3–1%, less likely with isolated cutaneous breast metastasis as a first presentation. There are limited data in the literature on patients who underwent endocrine therapy and complete surgical resection.

Case Presentation

A 54-year-old woman with left axillary skin swelling that had been persisting for 6 years was diagnosed with ILC 18 months ago presenting with an ulcerated axillary skin lesion and was managed with letrozole in another facility as she was estrogen receptor (ER) and progesterone receptor (PR) positive. She received letrozole for 18 months and had a partial response in the form of healing of the ulcer with persistent subcutaneous nodules. Her breast mammogram, ultrasound, and magnetic resonance imaging findings were unremarkable; however, there were few prominent left axillary lymph nodes. A biopsy of the left axillary lymph node was positive for malignancy, consistent with ILC. A skin punch biopsy of the axillary skin lesion showed ILC extending to the dermis with no background breast tissue. The patient underwent left modified radical mastectomy with excision of the left axillary skin lesion. The breast specimen comprised 0.4 mm of ILC as the primary malignancy and nine positive axillary lymph node malignancies. The patient received adjuvant radiotherapy and continued to receive letrozole. There were no signs of complications or recurrence during the follow-up period.

Conclusion

Ulcerated skin lesions in the axilla should raise concerns regarding breast cancer metastasis. In cases of isolated cutaneous breast metastases, surgical excision can be considered in combination with endocrine therapy.

Clinicopathological characteristics and treatment outcomes of occult breast cancer: a population-based study

Background

Occult breast cancer (OBC) is a special type of breast cancer. Because of its rarity, clinicopathological information is still insufficient, causing a controversial condition about its treatment recommendation. Thus, we aimed to clarify major clinicopathological information, treatment strategies and prognosis of OBC based on a large population.

Methods

We retrospectively collected adult female OBC population from Surveillance, Epidemiology, and End Results database. We divided the whole cohort into two groups based on surgical treatment in-breast. Descriptive analysis of 18 clinicopathological variables was conducted. Survival analysis was performed based on different clinicopathological factors. Univariate and multivariate Cox regression analysis was performed to identify potential independent predictor for prognosis of OBC.

Results

1189 OBC patients were in final analysis and most of them were diagnosed as an early-stage carcinoma. Patients received breast-conserving treatment (BCT) was nearly two times of ones received mastectomy. Patients receiving radiotherapy in BCT group were significantly more than patients receiving radiotherapy in mastectomy group (61.76 vs. 50.9%, P  <   0.001). After a median follow-up period of 62 months, 5-year and 10-year overall survival (OS) of all subjects was 81.6% and 68.8%, respectively. No significant difference in OS and breast-cancer specific survival (BCSS) was found between mastectomy and local breast-conserving surgery. Older age and larger number of positive lymph nodes causes a worse prognosis whereas radiotherapy brought a better clinical outcome for OBC patients.

Conclusions

OBC has a generally good prognosis. Less-intensive surgery does not negatively impact clinical outcomes of OBC while additional radiotherapy is totally beneficial to prolong OS and BCSS.

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.

The effect of local therapy on breast cancer-specific mortality of women with occult breast cancer and advanced nodal disease (N2/N3): a population analysis

PURPOSE

Current NCCN guidelines for occult breast cancer (OBC) recommend modified radical mastectomy, with the option for breast preservation with radiation instead of mastectomy for N1 patients. Our aim was to compare the effect of local therapy-mastectomy versus breast radiation-on breast cancer-specific mortality (BCSM) in a contemporary cohort of OBC patients of all nodal stages.

METHODS

Competing risk analyses were performed to evaluate the effect of local therapy, nodal stage, and other demographic and clinical prognostic variables on risk of BCSM for women registered in the SEER database with T0N+M0 breast cancer from 2004 to 2015.

RESULTS

Of the 353 women with OBC who underwent axillary nodal dissection, 152 received breast radiation and 201 underwent mastectomy. Overall, 57.5% had N1 disease, 54.4% had estrogen receptor (ER) positive tumors, 80.7% were white, and 88.1% received chemotherapy. Women treated with radiation were older (p < 0.001). The two groups were comparable with respect to all other variables analyzed. During a median follow-up of 66 months, 32 women died from breast cancer (radiation: 11, mastectomy: 21). Five-year cumulative incidence of BCSM was 8.0% ± 2.6% with radiation versus 10.9% ± 2.6% with mastectomy (p = 0.309). On multivariate analysis, independent predictors of BCSM included older age, higher N stage, and ER negativity, but the type of local therapy was not significantly associated with outcome.

CONCLUSIONS

These results suggest that breast preservation is a reasonable alternative to mastectomy for OBC patients, regardless of nodal stage.

Clinicopathological characteristics and treatment outcomes of occult breast cancer: a SEER population-based study

Background

Occult breast cancer (OBC) is a rare type of breast cancer that has not been well studied. The clinicopathological characteristics and treatment recommendations for OBC are based on a limited number of retrospective studies and thus remain controversial.

Patients and methods

We identified 479 OBC patients and 115,739 non-OBC patients from 2004 to 2014 in and the Surveillance, Epidemiology, and End Results (SEER) database. The clinicopathological characteristics and survival outcomes were compared between OBC and non-OBC patients. We used the propensity score 1:1 matching analysis to evaluate OBC vs non-OBC comparison using balanced groups with respect to the observed covariates. We further divided the OBC population into four groups based on different treatment strategies. Univariable and multivariable analyses were used to calculate and compare the four treatment outcomes within the OBC population.

Results

OBC patients were older, exhibited a more advanced stage, a higher rate of negative estrogen receptor and progesterone receptor status, a higher rate of HER2-positive status, and a higher rate of ≥10 positive lymph nodes, and were less likely to undergo surgical treatment than non-OBC patients. After adjustments for clinicopathological factors, the OBC patients exhibited a significantly better survival than the non-OBC patients (P<0.001). This result was confirmed in a 1:1 matched case–control analysis. Within the four OBC treatment groups, we observed no difference in survival among the mastectomy group, the breast-conserving surgery (BCS) group, and the axillary lymph node dissection (ALND)-only group. The multivariable analysis revealed that the sentinel lymph node dissection-only group had the worst prognosis (P<0.001). Conclusion: OBC has unique clinicopathological characteristics and a favorable prognosis compared with non-OBC. BCS plus ALND and radiotherapy showed a survival benefit that was similar to that of mastectomy for OBC patients.

Comparable Survival between Additional Radiotherapy and Local Surgery in Occult Breast Cancer after Axillary Lymph Node Dissection: A Population-based Analysis

Purpose: To investigate the clinical value of additional local treatment strategies in occult breast cancer (OBC) after axillary lymph node dissection (ALND). Methods: Patients diagnosed with OBC between 1990 and 2013 were included from the Surveillance, Epidemiology, and End Results registry database. The significant risk factors of cause-specific survival (CSS) and overall survival (OS) were identified using univariate and multivariate Cox regression analyses. Results: We identified 980 patients, including 219 (22.3%), 252 (25.7%), 263 (26.8%), and 246 (25.1%) of patients underwent ALND, ALND + radiotherapy (RT), ALND + surgery (S) (mastectomy or breast-conserving surgery), and ALND + S + RT, respectively. Patients with younger age, diagnosed before 2000, advanced nodal stage, ER-negative disease, and PR-negative disease were more likely to undergo additional local treatment compared with ALND only. The 10-year rate CSS of the ALND only group was 57.2%, while that of the ALND + RT, ALND + S, and ALND + S + RT groups was 78.0%, 81.0%, and 71.5%, respectively (p < 0.001). The 10-year OS rate in the ALND only, ALND + RT, ALND + S, and ALND + S + RT groups was 46.0%, 69.5%, 66.1%, and 67.0%, respectively (p < 0.001). Multivariate analysis indicated that older age, advanced nodal stage, and ALND only were independent risk factors for decreased CSS and OS. CSS and OS among the groups including ALND + RT, ALND + S, and ALND + S + RT were not significantly different. Conclusions: Additional local treatment (local surgery or RT) improves survival outcomes compared with ALND only in OBC after ALND. ALND + RT may be the optimal local treatment for OBC due to no different in survival outcomes and cosmesis is better.

Incidental Suspicious Regional Lymph Nodes on Breast Sonography: Is Sampling Necessary?

Suspicious regional lymph nodes may be incidentally identified on breast ultrasound examinations in patients who present for sonographic evaluation without a known or a suspected breast malignancy, and there is a paucity of data on whether biopsy should be performed. This study aims to characterize incidental sonographically detected suspicious regional lymph nodes and determine whether tissue sampling or follow-up imaging is required. A total of 40,773 consecutive breast ultrasounds were reviewed. Overall, 7 women with nonpalpable, incidental, suspicious axillary or supraclavicular lymph nodes in an otherwise unremarkable breast and without history of malignancy or systemic disease were identified. In all, 5 women with 6 nodes underwent ultrasound-guided fine needle aspiration and 2 women with 3 nodes were recommended follow-up ultrasound. Follow-up imaging, cytology, and all-cause clinical data were reviewed to evaluate outcomes. All 6 biopsied lymph nodes (mean = 1.5cm) were benign on cytology. Follow-up imaging was available for 3 nodes (mean = 2.6 years), with all-cause follow-up for all nodes of 2.2 years. In the follow-up group, 3 lymph nodes (mean = 1.6cm) were monitored (mean = 4.3 years) with all-cause follow-up of 4.7 years. No new cancers, growth, or suspicious features were found in these nodes during follow-up for either group of women. In conclusion, women without history of prior malignancy or systemic disease with incidentally detected, nonpalpable, suspicious regional lymph nodes with an otherwise normal breast ultrasound examination underwent fine needle aspiration or were recommended short-term follow-up ultrasound. No indeterminate features or malignancies were observed at the time of tissue sampling or developed over several years of follow-up. Avoiding sampling of these nodes would reduce patient morbidity and health care costs.

A unique presentation of occult primary breast cancer with a review of the literature

We are reporting a case of a 34-year-old woman with occult primary breast cancer discovered after initially presenting with neurological symptoms. She was successfully treated with neoadjuvant chemotherapy followed by definitive axillary lymph node dissection and ipsilateral whole breast radiotherapy. The case presented is unique due to the rarity of occult primary breast cancer, especially in light of her initial confounding neurological signs and symptoms, which highlights the importance of careful staging.

Perineural spread of salivary duct carcinoma to the internal auditory canal

Salivary duct carcinomas (SDCs) are high-grade malignant tumors exhibiting aggressive growth with early regional and distant metastasis. We report a case of SDC in a 63-year-old male with early recurrent disease in the cerebellopontine angle (CPA) after total parotidectomy and adjuvant radiotherapy. The tendency of the tumor to recur or metastasize despite radical surgical measures and radiotherapy continues to pose a therapeutic challenge.

Treatment and survival of patients with occult breast cancer with axillary lymph node metastasis: a nationwide retrospective study

BACKGROUND AND OBJECTIVES

Occult breast cancer (OBC) accounts for 0.3-1.0% of all breast cancers and is a rare presentation of the disease. The present retrospective study examined the overall survival and prognostic factors associated with OBC in Korea.

METHOD

The study included 142 OBC patients identified from the Korean Breast Cancer Society cancer registry from January 1990 to December 2009. All patients had pathologically positive axillary lymph nodes (N1-N3) and pathologically and radiologically negative in-breast lesions (T0/Tx) based on a retrospective review of the database.

RESULTS

No statistically significant differences in overall survival were observed between patients undergoing axillary lymph node dissection (ALND) only (80.8%), breast conserving surgery (BCS) with ALND (98.0%), and mastectomy with ALND (92.5%) with P-value of 0.061. Nodal status was a significant prognostic factor (P = 0.004) on univariate analysis. When compared with T1 patients group, T0/TxN1 patients showed better survival than T1N1 patients (hazard ratio [HR] 0.253; 95% confidence interval, 0.104-0.618; P = 0.003), but T0/TxN2, T0/TxN3 patients showed similar survival to T1N2, T1N3 patients.

CONCLUSIONS

OBC patients treated with ALND only showed comparable outcomes to those undergoing ALND combined with BCS or mastectomy. Nodal status may be an independent predictor of poor outcome in OBC patients.

Applications for breast magnetic resonance imaging

This article reviews the relevant data on breast magnetic resonance imaging (MRI) use in screening, the short-term surgical outcomes and long-term cancer outcomes associated with the use of MRI in breast cancer staging, the use of MRI in occult primary breast cancer, as well as MRI to assess eligibility for accelerated partial breast irradiation and to evaluate tumor response after neoadjuvant chemotherapy. MRI for screening is supported in specific high-risk populations, namely, women with BRCA1 or BRCA2 mutations, a family history suggesting a hereditary breast cancer syndrome, or a history of chest wall radiation.

Geographic and temporal trends in the management of occult primary breast cancer: a systematic review and meta-analysis

BACKGROUND

Management of occult primary breast cancer (OPBC), including the role of magnetic resonance imaging (MRI), is controversial. We conducted a pooled analysis of OPBC patients and a meta-analysis of MRI accuracy in OPBC in order to elucidate current practices.

METHODS

A literature search yielded 201 studies. Patient-level data for clinically/mammographically OPBC from studies published after 1993 and from our institution were pooled; logistic regression examined associations between patient/study data and outcomes, including treatments and recurrence. We report adjusted odds ratios (OR) and 95 % confidence intervals (95 % CI) significant at 2-tailed p < 0.05. Meta-analysis included data for patients who received MRIs for workup of clinically/mammographically OPBC. We report pooled sensitivity and specificity with 95 % CIs.

RESULTS

The pooled analysis included 92 patients (15 studies [n = 85] plus our institution [n = 7]). Patients from Asia were more likely to receive breast surgery (OR = 5.98, 95 % CI = 2.02-17.65) but not chemotherapy (OR = 0.32, 95 % CI = 0.13-0.82); patients from the United States were more likely to receive chemotherapy (OR = 13.08, 95 % CI = 2.64-64.78). Patients from studies published after 2003 were more likely to receive radiotherapy (OR = 3.86, 95 % CI = 1.41-10.55). Chemotherapy recipients were more likely to have distant recurrence (OR = 9.77, 95 % CI = 1.10-87.21). More patients with positive MRIs received chemotherapy than patients with negative MRIs (10 of 12 [83.3 %] vs 5 of 13 [38.5 %]; p = 0.0414). In the MRI-accuracy meta-analysis (10 studies, n = 262), pooled sensitivity and specificity were 96 % (95 % CI = 91-98 %) and 63 % (95 % CI = 42-81 %), respectively.

CONCLUSIONS

OPBC management varied geographically and over time. We recommend establishing an international OPBC patient registry to facilitate longitudinal study and develop global treatment standards.

Occult primary breast cancer at a comprehensive cancer center

BACKGROUND

Management of occult primary breast cancer (OPBC), that is, breast cancer that first presents through regional nodal or distant disease without clinical or mammographic evidence of disease in the breast, has been controversial and inconsistent. Here, we review OPBC patients treated at our institution.

METHODS

We conducted a retrospective review of women diagnosed with a first primary breast cancer between March 1999 and September 2010 to identify patients who presented with isolated axillary lymphadenopathy proven to be histologically consistent with primary breast malignancy but had no evidence of a breast mass on physical examination, mammography, or ultrasound. Descriptions of treatments received, recurrence, morbidity, and mortality as of October 2012 are reported.

RESULTS

Of 5533 patients reviewed, seven (0.1%) patients were identified. The median age was 65 y old (range, 40-72), and the median length of follow-up was 86 mo (range, 42-124). Four patients underwent modified radical mastectomy, one patient had a lumpectomy and axillary lymph node dissection, and two patients had axillary lymph node dissection without breast surgery. Four patients received adjuvant radiation therapy. All seven patients received chemotherapy. Three patients received endocrine therapy, and two patients received anti-HER2 therapy. At the last follow-up, all seven patients were alive with no evidence of disease.

CONCLUSIONS

Although there was some variation in the management of OPBC at our institution, our patients had excellent outcomes after multimodal treatment. Our results support a curative intent approach to the treatment of OPBC and illustrate the need for individualized treatment algorithms based on tumor biology and extent of the disease at diagnosis.

Miscellaneous syndromes and their management: occult breast cancer, breast cancer in pregnancy, male breast cancer, surgery in stage IV disease

Surgical therapy for occult breast cancer has traditionally centered on mastectomy; however, breast conservation with whole breast radiotherapy followed by axillary lymph node dissection has shown equivalent results. Patients with breast cancer in pregnancy can be safely and effectively treated; given a patient's pregnancy trimester and stage of breast cancer, a clinician must be able to guide therapy accordingly. Male breast cancer risk factors show strong association with BRCA2 mutations, as well as Klinefelter syndrome. Several retrospective trials of surgical therapy in stage IV breast cancer have associated a survival advantage with primary site tumor extirpation.

Treatment outcomes and unfavorable prognostic factors in patients with occult breast cancer

AIMS

The purpose of this study was to evaluate the treatment outcomes and prognostic factors in patients with occult breast cancer (OBC).

METHODS

We retrospectively analyzed 95 patients with OBC who were treated at our facility between January 1998 and June 2010. Of the 95 patients, 64 underwent mastectomy plus axillary lymph node dissection (ALND) with or without post-mastectomy radiation (Mast + ALND group), 13 underwent ALND followed by ipsilateral breast radiotherapy (BR + ALND group) and the remaining 18 were treated with ALND (ALND group).

RESULTS

Patients who underwent Mast + ALND or BR + ALND had significantly improved rates of locoregional recurrence-free survival (LRFS) and recurrence/metastasis-free survival (RFS) than patients who only underwent ALND (p < 0.05). There were no significant differences in the LRFS (p = 0.718), RFS (p = 0.935) and breast cancer-specific survival (BCSS) (p = 0.991) rates between the patients who underwent Mast + ALND compared with those who received BR + ALND. Multivariate analysis revealed that patients with four or more involved lymph nodes had significantly worse outcomes (p = 0.042, HR = 4.63, 95% CI = 1.66-32.47 for BCSS and p = 0.038, HR = 3.62, 95% CI = 1.08-20.77 for RFS).

CONCLUSIONS

Patients with OBC who received ALND and subsequent breast radiotherapy had similar outcomes to patients who underwent mastectomy. The presence of four or more involved lymph nodes may independently predict poor outcomes of OBC.

A case of HER-2-positive recurrent breast cancer showing a clinically complete response to trastuzumab-containing chemotherapy after primary treatment of triple-negative breast cancer

We report a case of HER-2-positive recurrent breast cancer showing a clinically complete response to trastuzumab-containing chemotherapy 6 years after primary treatment of triple-negative breast cancer. The primary tumor was negative for HER-2 as determined by immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) (1+, and ratio, 1.1), but examination of the recurrent lymph node metastasis showed positivity for HER-2 by FISH (ratio, 5.2). No lesions were detected in either her left breast or in other organs, and the patient was diagnosed as having HER-2-positive recurrent disease. Combination chemotherapy using weekly paclitaxel and trastuzumab was initiated, and a clinically complete response was achieved. This report suggests the benefit of routine evaluation of HER-2 status in recurrent breast cancer with the introduction of HER-2-targeting agents.

Breast magnetic resonance imaging: current clinical indications

Breast magnetic resonance (MR) is highly sensitive in the detection of invasive breast malignancies. As technology improves, as interpretations and reporting by radiologists become standardized through the development of guidelines by expert consortiums, and as scientific investigation continues, the indications and uses of breast MR as an adjunct to mammography continue to evolve. This article discusses the current clinical indications for breast MR including screening for breast cancer, diagnostic indications for breast MR, and MR guidance for interventional procedures.

The role of ipsilateral breast radiotherapy in management of occult primary breast cancer presenting as axillary lymphadenopathy

AIM

To assess the role of ipsilateral breast radiotherapy (IBR) in women with occult primary breast cancer presenting with axillary metastases (OPBC).

METHODS

Patients with axillary nodal metastases and histological diagnosis of breast cancer without palpable, mammographic or ultrasonographic evidence of a breast primary were identified from a prospectively maintained single institution database. Imaging, surgery, radiotherapy, recurrence and survival data were collected. Patients whose breast cancer primary was detected on MRI (but occult on clinical examination and other imaging) were excluded from the analyses of IBR and outcome, but were included in other exploratory analyses.

RESULTS

Fifty-five patients were included between 1975 and 2009. Median follow up was 68 months. Twenty patients had breast magnetic resonance imaging (MRI) in addition to other imaging. A primary breast cancer was detected in 7 of these 20. 48/55 patients had no detectable breast primary. 35/48 patients (73%) were treated with radiotherapy to the conserved breast, and 13/48 (27%) with observation. Patients who had IBR had better 5 year local recurrence free survival (LRFS) (84% versus 34%, p<0.001), and relapse free survival (RFS) (64% versus 34%, p=0.05), but no difference in overall survival (OS) (84% versus 85%, p=0.2). There was no difference in 5 year LRFS (80% versus 90%: p=0.3) between patients who received radiation of 50 Gy in 25 fractions versus ≥60 Gy.

CONCLUSION

Patients with OPBC should be managed with IBR and breast conservation, or mastectomy. Our data suggest it is not necessary to irradiate the breast to more than 50 Gy in 25 fractions.

Subcategorization of ultrasonographic BI-RADS category 4: positive predictive value and clinical factors affecting it

The objective of this study was to evaluate the positive predictive value (PPV) in ultrasonographically (US)-detected breast lesions of BI-RADS category 4a, 4b and 4c and to find how various clinical factors influenced the PPV of category 4. A total of 2142 women with 2430 breast lesions diagnosed on US as BI-RADS category 4 and underwent biopsy were included. Among them, 452 (18.6%) were pathologically confirmed as malignancy. PPV of each US BI-RADS subcategory was 7.6% (149/1963) for category 4a, 37.8% (68/180) for category 4b and 81.9% (235/287) for category 4c. Several clinical factors were more significantly seen in malignancy of category 4a and 4b, whereas none of the factors showed significance in category 4c. Subcategorization of category 4 is a feasible method in predicting malignancy in which patients' age, lack of multiplicity and symptoms affected the PPV of category 4 lesions.

Population-based analysis of occult primary breast cancer with axillary lymph node metastasis

BACKGROUND

Single-institution data suggest that treatment with radiation and axillary lymph node dissection (ALND) may be an appropriate alternative to mastectomy for T0N+ breast cancer. Population-based multi-institutional data supporting this approach are lacking.

METHODS

The cause-specific survival (CSS) and overall survival (OS) of women with T0N+M0 ductal, lobular, or mixed breast cancer in the Surveillance, Epidemiology, and End Results database from 1983 to 2006 were analyzed. Groups were defined as: 1) no ALND, mastectomy, or RT (observation); 2) ALND only; 3) mastectomy plus ALND with or without postmastectomy radiation (Mast); and 4) breast-conserving therapy (BCT) with ALND and radiation (BCT).

RESULTS

In total, 750 of 770,030 patients with breast cancer had T0N+M0 disease (incidence, 0.10%), and 596 of those patients underwent ALND (79.5%). Patients who underwent Mast or BCT (n = 470) had a 10-year OS rate of 64.9% compared with 58.5% for patients who underwent ALND only (n = 126; P = .02) and 47.5% for patients who underwent observation only (n = 94; P = .04). The 10-year CSS rate was 75.7% for patients who underwent BCT versus 73.9% for patients who underwent Mast (P = .55). In multivariate analysis of CSS for patients who underwent Mast or BCT, the following factors were correlated with an unfavorable outcome: positive estrogen receptor status (hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.24-0.96; P = .04), >/=10 positive lymph nodes (HR, 5.7; 95%CI, 2.4-13.4; P </= .01), and <10 resected lymph nodes (HR, 42.9; 95%CI, 1.2-7.1; P = .02). Mast did not improve CSS compared with BCT (HR, 1.09; 95%CI, 0.57-2.1; P = .79).

CONCLUSIONS

Definitive locoregional treatment with either Mast or BCT improved the outcome of patients with T0N+breast cancer, and no difference in survival was observed between the treatments. Cancer 2010. (c) 2010 American Cancer Society.

Axillary nodal metastases from carcinoma of unknown primary (CUPAx): a systematic review of published evidence

Axillary lymph node metastases from adeno carcinoma or poorly differentiated carcinoma of unknown primary (CUPAx) represent a rare clinical entity without consensus on its biology, management and outcome. We systematically reviewed published CUPAx series and identified 24 retrospective studies enrolling 689 patients from 1975 till 2006. CUPAx affected women at a mean age of 52 years, 66% of whom post-menopausal harbouring low-volume (N1, 48%) or high-volume (52%) nodal disease from ductal adenocarcinoma (83%). Among a total of 446 patients managed with mastectomy, a small breast primary was identified histologically in 321 (72% of cases). Hormone receptor protein expression was observed in 40-50% of cases, while HER2 overexpression in 31%. CUPAx patients were managed with axillary lymph node dissection coupled to mastectomy (59%), primary breast irradiation (26%) or observation (15%). Observation was associated with high locoregional relapse rates (42%) and risk of metastatic spread. Mastectomy or radiotherapy provided locoregional disease control in 75-85% of cases, while adjuvant systemic therapy was associated with a nonsignificant trend for improved survival in few series. Five-year survival ranged from 59.4 to 88% at a median follow-up of 62 months (mean 5-year survival 72%), with axillary tumour burden being the pivotal prognostic factor. CUPAx is associated with similar presentation, biology and outcome to resected node-positive overt breast cancer and should be treated accordingly.

Occult breast carcinoma presenting as gastrointestinal metastases

Occult breast cancer has frequently been described as presenting as axillary lymph node metastases but rarely as gastrointestinal metastases, Varadarajan et al. (2007). In extremely rare situations, cancerous lesions identified in the gastrointestinal tract have been determined to be metastatic lesions from primary breast cancers, Taal et al. (2000). We report a case of an occult lobular adenocarcinoma presenting as gastrointestinal metastases. It is essential that the possibility of lesions found in the gastrointestinal tract originating from distant or occult cancers be considered in order that appropriate therapeutic options may be discussed and considered early after diagnosis.

Cytogenetic abnormality 46,XX,add(21)(q11.2) in a patient with follicular dendritic cell sarcoma

The case of a patient with follicular dendritic cell (FDC) sarcoma with chromosomal aberration add(21)(q11.2) is described. Cytogenetic studies showed the karyotype 46,XX,add(21)(q11.2)[3]/46,XX[17], although the encoded protein involved was not clarified. The abnormal pattern was quite simple, and different from a previous report. The clinical course of the FDC sarcoma in this case has been indolent, as for most FDC sarcoma patients. Although this patient suffered from breast carcinoma 6 years after the onset of FDC sarcoma, the carcinoma showed different histological and phenotypic profiles.