Rosen's Breast Pathology, 4e

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Chapter 33

Several later studies also described a relatively favorable clinical course for patients treated by mastectomy and axil­ lary dissection. Patel et al. 134 reported that 29% of patients died of disease, suggesting that the “prognosis is as good as or better than it is for palpable breast cancer with axillary metastases.” Two follow-up studies from Memorial Hospi­ tal in New York reported that 23% 129 and 25% 135 of patients died of breast carcinoma. In reports based on smaller series, 9% 131 and 12% 133 of patients had recurrent carcinoma and/ or died of breast carcinoma. Survival results for a series of 48 patients are shown in Ta­ ble 33.3. 135 Follow-up ranged from 5 to 267 months (mean, 71; median, 60). Among patients alive and disease free, fol­ low-up ranged from 33 to 367 months (median, 64 months; mean, 73 months). The intervals between diagnosis of breast carcinoma and the deaths of two patients of causes other than mammary carcinoma were 91 and 204 months. Two other patients surviving with recurrent carcinoma were alive 53 to 166 months after the original diagnosis of carcinoma in an ALN. Patients who died of metastatic carcinoma survived 5 to 68 months (median, 26 months; mean, 31 months). Overall, 29 of the 48 patients (60%) remained alive and disease free. Two women (4%) died of causes other than mammary carcinoma, and the status of 2 patients (4%) was unknown. Recurrences occurred in 15 cases (31%), including 12 ­patients (25%) who died of metastatic breast carcinoma. There was not a statistically significant difference in the fre­ quency of recurrence or of death due to breast carcinoma between patients with one to three positive lymph nodes and those with four or more affected nodes, although the recur­ rence rate was higher in the latter group. Twenty-two of the patients in the preceding study found to have a measurable primary tumor at mastectomy were chosen for a case-control analysis of survival. 135 Match­ ing was based on tumor size (  0.5 cm in T category), total number of involved lymph nodes (one to three vs. four or more, selected for closest total count), tumor type, and age at diagnosis. All patients were treated by mastectomy, and

76%. 132,138,170,177,178 A primary tumor was detected clinically during follow-up in the ipsilateral breast of 7% to 33% of these patients. Prognosis The first large series of patients with occult breast carci­ noma presenting as axillary nodal metastases with follow-up from a single institution, the Mayo Clinic, was published in 1954. 174 This article included the first reported example of this condition in a man. Follow-up of 25 patients revealed that 9 patients (36%) died of breast carcinoma, 3 (12%) died of other causes, and 13 (52%) remained well. The authors concluded that these patients had “a better prognosis than is observed for the average carcinoma of the breast with nodal metastasis.” Ta b l e 3 3 . 2  Primary Carcinomas Found in Breast No. (%) * Invasive 22 (79) Invasive duct (65) Invasive lobular (6) Medullary (6) Colloid (3) Noninvasive 7 (21) Intraductal (12) In situ lobular (6) Intraductal and in situ lobular (3) Adapted from Rosen PP, Kimmel M. Occult breast carcinoma pre- senting with axillary lymph node metastases: a follow-up study of 48 patients. Hum Pathol 1990;21:518–523. * Percentages rounded.

Ta b l e 3 3 . 3  Follow-up of Patients with Occult Breast Carcinoma

Number of Involved Lymph Nodes a

Total Patients

One to Three

Four or More

Unknown

# (%) * 29 (60)

# (%) 12 (60)

# (%) 14 (70)

# (%) 3 (38)

Status

NED AWD DOD DOC UNK Total

3 (6)

1 (5)

1 (5)

1 (12)

12 (25)

5 (25)

4 (20)

3 (38)

2 (4) 2 (4)

1 (5) 1 (5)

1 (5) 0 (0)

0 0) 1 (12)

48 8 NED, alive, no evidence of disease; AWD, alive with disease; DOC, dead of other causes; UNK, unknown; DOD, dead of disease. a Includes lymph node(s) removed for diagnosis and those obtained by axillary dissection. * Percentages rounded. Based on Rosen PP, Kimmel M. Occult breast carcinoma presenting with axillary lymph node metastases: a follow-up study of 48 patients. Hum Pathol 1990;21:518–523. 20 20