Rosen's Breast Pathology, 4e

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Chapter 33

FIG. 33.8.  Phyllodes tumor, benign, with intraductal carcinoma. A,B: Cribriform DCIS has replaced some of the epithelium. C: Another example of Benign PT with cribri- form DCIS. Inset shows detail.

C

nearly 50% of patients, 133,135 with about 25% having a mater­ nal first-degree relative affected. 129 The initial clinical presentation is enlargement of one or more ALNs. An abnormality may be reported on clinical ex­ amination of the ipsilateral breast in 25% of patients, but it is often not regarded as suspicious, or on follow-up it may not correlate with the location in the breast where carcinoma is ultimately detected. 131,133,140 This observation is consistent with data compiled by Rosen et al., 141 who studied nearly 3,500 patients with palpable breast lesions and were studied by mammography. Carcinoma was diagnosed in 64 women. The palpable lesion proved to be carcinoma in 54 of these cases, but in 10 women the palpable tumor was benign, and carcinoma was a nonpalpable lesion detected by mammography alone. In this series, none of the patients was initially examined because of axillary nodal involvement, but the study demonstrated the capacity of mammography to detect clinically occult carci­ noma in the presence of a benign, palpable mass. Clinical Evaluation To rule out an extramammary tumor or other metastases, most women have been studied with a variety of techni­ ques. 131,133,134 Marcantonio and Libshitz 142 demonstrated ALN enlargement by computed tomography (CT) in pa­ tients with pulmonary carcinoma and proved the presence of metastatic carcinoma by biopsy in six cases, confirming

the lung as one of the alternate primary sites for an occult carcinoma that presents with axillary metastases. Mammography has revealed abnormalities in12%, 131 25%, 134 26.5%, 129 31%, 138 and 35% 133,140 of patients exam­ ined. Tartter et al. 143 compared women with false-negative and positive mammograms. The two groups were similar with respect to tumor differentiation, tumor size, and ER status. However, women with false-negative mammography had a lower frequency of intraductal carcinoma and signifi­ cantly more frequent metastases in ALNs. Some investiga­ tors have excluded patients with significant mammographic abnormalities from the syndrome of subclinical carcinoma presenting with ALN metastases, 132,144 but others found no consistent correlation between the location of the radio­ logic abnormality and the site at which a carcinoma was ultimately located. 133 If mastectomy is delayed, repeat mam­ mograms of patients who initially had negative studies may reveal new findings suggestive of carcinoma. 140 In one study, the interval until the detection of a breast abnormality clini­ cally or by mammography was 6 to 39 months, with a mean of 15 months in women who did not undergo a mastec­ tomy. 145 The presence of mammographically detectable cal­ cifications in metastatic carcinoma in ALNs may be a clue to the diagnosis of a subclinical ­mammary carcinoma. 146,147 MRI has proven to be an effective method for detecting occult carcinomas that are not evident mammographically. MRI detected occult carcinoma in 143 of 234 (61%) patients