Rosen's Breast Pathology, 4e

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Chapter 33

FIG. 33.22.  Occult carcinoma, tumor size and survival. Kaplan–Meier survival rate comparison of matched patients stratified by primary tumor size. The differences are not statistically significant; ( left ) T1 tumors, ( right ) T2 tumors. (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.)

not statistically significant. Prognosis also appeared to be better in the group that underwent mastectomy or breast ir­ radiation when compared with patients who had no treat­ ment of the breast ( p = 0.06). Adjuvant systemic therapy did not significantly influence survival. Read et al. 170 also reported a lower frequency of local breast recurrence and a lower systemic recurrence rate in women with three or fewer nodal metastases after breast irradiation and axillary dissec­ tion. In this latter series, DFS was higher in the group that received systemic adjuvant therapy, but the difference from untreated patients was not statistically significant. Several studies have compared the outcomes of patients with occult breast carcinoma treated by mastectomy with those who had breast preservation and radiation. 129,137,138 Sur­ vival rates did not differ significantly for the two treatment groups. Breast recurrences have been reported in 19% and 23% of patients treated with mammary radiation. 132,137 In one of these reports the intervals between the diagnosis of the axil­ lary metastasis and the detection of the primary breast carci­ noma were 8, 44, and 106 months. 137 In a recently published study, 31 occult breast carcinomas that were ER negative, PR- negative and HER2-negative (so-called “triple-negative” carci­ nomas) had the highest risk of recurrence and death in a series of 80 ­patients treated at the European Institute of Oncology. 179 In conclusion, available data indicate that patients with stage II disease who present with an axillary nodal metas­ tasis and an inapparent breast primary have a prognosis similar to and possibly better than that of patients with stage II disease who present with a palpable breast carci­ noma. This probably reflects the fact that the majority of the stage II patients with clinically and, in some cases, ra­ diographically occult carcinomas prove to have relatively small invasive tumors detected in their breast by imaging

studies or on pathologic examination of a surgical speci­ men. The ­actual pathologically determined tumor (size), regional node ­(involvement), (distant) metastases (TNM) stage is probably a more ­important determinant of prog­ nosis than the ­apparent clinical stage when the patient is first examined. MRI imaging is very useful for detecting an occult primary carcinoma in the breast if none is evident on mammography. Two cases of occult breast carcinomas manifesting as ALN metastases in men have been reported. 180 CARCINOMA IN ECTOPIC BREAST TISSUE Ectopic breast tissue is subject to various proliferative and nonproliferative changes that occur in the mammary gland proper. 181,182 “Adenomas” have been described in ectopic breast tissue, most commonly in the axilla 183 and vulva. 184,185 These lesions develop for the most part during pregnancy or lactation, and represent nodules of lactational hyperplasia that assume an adenomatous form. 186 The tumors measured from 1.0 to 6.0 cm. Bilateral vulvar FA have been reported. 185 Patients with vulvar FA have generally been between 20 and 50 years of age. A benign PT that originated in vulvar mam­ mary tissue has been described in a 20-year-old woman. 187 PT of anogenital mammary-like glands in a 41-year-old male, presenting with anal bleeding, has been described. 188 Breast tissue surrounding the tumor showed fibrocystic changes, in­ cluding apocrine metaplasia and papillomatosis. The lesion recurred locally 8 months after excisional biopsy. Carcinoma has been described arising in axillary 182,189–190 and vulvar 189–195 breast tissue. Intra et al. 195 described awoman with synchronous intraductal carcinoma in the breast and