Rosen's Breast Pathology, 4e

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Chapter 33

FIG. 33.19.  Metastatic nonmammary carcinoma. A: Poorly differentiated adenocarcinoma of the lung. B: Metastatic pulmonary carcinoma in an ALN. C,D: Serous ovarian carcinoma (C) metastatic in an ALN (D) .

lesion 130,131,138,168,169 or from foci of “healed” invasive carci­ noma (Fig. 33.18). Infrequent examples of infiltrating lobu­ lar, 130,131 medullary, 138,154,163,170 mucinous, 130 tubular, 138,149 and papillary, 130 and invasive micropapillary 151 carcinoma have been described. Analysis of hormone receptors in one series of primary tumors revealed positive levels of ER in 4 (36%) of 11 cases and of PR in 4 (44%) of 9. 138 Treatment In 1907, Halsted reported that up to 2 years might elapse before a primary tumor became clinically apparent in the breast if the patient did not undergo a biopsy or mastec­ tomy. 171 A more recent series included 17 patients with an untreated ipsilateral breast and a negative mammogram. 138 Nine (52%) developed a clinically apparent primary tu­ mor within 2 to 34 months (mean, 13 months). Two of the remaining eight patients died of progressive systemic disease without manifesting a mammary primary, and six remained disease free, with an average follow-up of 6 years. Another report included 13 patients who did not have breast surgery or radiotherapy. 137 Seven women (54%) de­ veloped a clinically evident primary tumor in the ipsilateral

breast 11 to 47 months after diagnosis of the axillary metas­ tasis (average, 27 months). Three of the carcinomas were in the upper outer quadrant, and two were in the upper inner quadrant. One lesion was subareolar, and diffuse involve­ ment was observed in the seventh woman. Others have ob­ served a subsequent primary tumor in the untreated breast in 2 (13%) of 15, 171 1 (20%) of 5, 172 and 7 (88%) of 8 173,174 patients after average follow-up of 7.7, 2.2, and 3.5 years, respectively. Currently after it has been determined that an excised lymph node contains metastatic adenocarcinoma consistent with mammary origin in the absence of clinical evidence of a nonmammary tumor, treatment should be based on the assumption that there is an invasive primary carcinoma in the ipsilateral breast. A survey of 776 members of the American Society of Breast Surgeons published in 2005 revealed the following preferred treatment options: mastectomy, 43%; whole-breast radiation, 37%; and other, 22%. 175 The “other” category in­ cluded observation until a primary lesion became evident, deference to patient choice, or various combinations of treatment involving chemotherapy, axillary dissection, ra­ diation, and mastectomy.