Rosen's Breast Pathology, 4e

915

Unusual Clinical Presentation of Carcinoma

Ta b l e 3 3 . 4  Follow-up of Matched Patients with Occult and Palpable Breast Carcinomas Number of Lymph Nodes with Metastases Total One to Three

Four or More

Patient Status

Occult (%)

Palpable (%)

Occult (%)

Palpable (%)

Occult (%)

Palpable (%)

NED AWD DOD DOC Total

16 (73)

15 (36)

9 (75)

9 (38) 3 (13) 7 (29) 5 (21)

7 (70) 0 (0) 3 (30)

6 (33)

1 (5)

4 (10)

1 (8)

1 (6)

5 (23)

18 (43)

2 (17) 0 (0)

11 (61) 0 (0)

0 (0)

5 (12)

0 (0)

22 18 From 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. Percentages rounded 42 12 24 10

almost all patients in both groups received systemic adjuvant chemotherapy. The distributions of primary tumor size and of axillary nodal involvement in the two groups were very similar. A comparison of follow-up results revealed a lower frequency of recurrence and death due to breast carcinoma among patients who presented with axillary metastases and an occult primary tumor (Table 33.4). Survival curve analy­ sis for the two groups is shown in Figure 33.21. Although patients with occult lesions exhibited a more favorable

prognosis overall, as well as when stratified by tumor size and nodal status, the differences were not statistically signifi­ cant (Figs. 33.22 and 33.23). These survival results in stage II patients who presented with nodal metastases and an oc­ cult primary are striking. Although there was no statistically significantly difference, patients with palpable breast tumors had a less favorable outcome despite similar treatment, which included chemotherapy for both groups. Four other studies also provided survival curve analyses of patients with occult stage II carcinoma. 129,134,137,138 In a se­ ries of 29 women, the 5- and 10-year DFS rates were 28% and 17%, respectively. 134 These authors reported similar results for a comparison group of 127 patients who presented with palpable mammary primary tumors, but gave no indication as to how patients with “known” breast carcinoma were chosen. Their patients with occult carcinoma did not have substantially larger primary tumors or more numerous in­ volved lymph nodes than have been reported in other recent series, and the data provide no other obvious explanation for the unusually poor survival rate of stage II patients in both groups. Baron et al. 129 carried out a survival analysis of 35 patients and found that 63% were alive disease free. Their study did not include a matched series of women who presented with palpable breast tumors. Ellerbroek et al. 137 reported an OS rate of 71.8% at 5 years and 65% at 10 years. This study included two features found to be significantly associated with 5-year survival: axillary dissection (performed, 88.9% survival; not performed, 46.7% survival) and gross residual tumor in axilla after sur­ gery (absent, 79.9% survival; present, 20% survival). In this study, there was not a statistically significant difference in survival between patients treated by mastectomy and those treated by breast conservation. Although patients who re­ ceived adjuvant chemotherapy had a better 5-year survival (92.9%) than those who did not receive systemic treatment (63.5%), the difference was not statistically significant. Survival rates at 5 and 10 years reported by Merson et al. 138 were 76.6% and 58.3%, respectively. There was a trend to a more favorable prognosis if metastases involved not more than three ALNs when compared with women with four or more nodal metastases, but the difference was

FIG. 33.21.  Occult carcinoma, overall survival. Kaplan– Meier survival rate comparison of patients with clinically occult primary tumors to stage-matched patients who presented with a palpable breast tumor. Patients with clinically unapparent (occult) primary tumors had a more favorable survival, but the difference was not statistically significant. (Reproduced with permission from Rosen PP, Kimmel M. Occult breast carcinoma presenting with ALN metastases: a follow-up study of 48 patients. Hum Pathol 1990;21:518–523. Copyright W.B. Saunders Co.)