Unusual Clinical Presentation of Carcinoma
895
14.6, and 19.9 years after diagnosis. It should be noted that
virtually all patients were treated by mastectomy and none
received systemic adjuvant therapy.
A larger series of patients 30 years or younger at diagno
sis, consisting of 185 women, was reported by Xiong et al.
58
The distribution of patients by stage was as follows: stage I,
11%; stage II, 45%; stage III, 38%; and stage IV, 6%. Treat
ment consisted of various combinations of mastectomy or
breast-conserving surgery with adjuvant or neoadjuvant
chemotherapy and radiotherapy. The 5-year OS rates by
stage were stage I, 87%; stage II, 60%; stage III, 42%; and
stage IV, 16%. When compared with control patients identi
fied in the National Cancer Data Base, women diagnosed at
age 30 or younger had poorer 5-year OS rates.
A retrospective case-controlled study by Peng et al.
59
concluded that diagnosis at or before 35 years of age was
an independent negative prognostic risk factor. They com
pared 551 women 35 years or younger who had operable
breast carcinoma to a cohort of women 36 to 50 years of age
at diagnosis matched for year of diagnosis, family history,
pathologic stage at diagnosis, hormone receptor status and
adjuvant therapy. The younger women had a significantly
shorter disease-free interval to first recurrence (median 23.2
vs. 28.4 months), a lower DFS (63.7% vs. 74.7%), and lesser
OS (79.5% vs. 85.6%).
Liukkonen et al.
60
studied 212 Finnish women treated
between 1997 and 2007 for breast carcinoma who were
younger than 35 years. At diagnosis, 117 (55%) had axil
lary nodal metastases and 14 (7%) had distant metastases.
One hundred and forty (65%) women were treated with
mastectomy and 68 with breast conservation surgery. Post
operative treatment included chemotherapy, endocrine
therapy, and radiation, singly or in combination. Local
recurrence occurred in 10 (15%) of women treated with
breast conservation surgery, and 8 (6%) of patients treated
from a statewide tumor registry for patients treated between
1985 and 1992 suggest that age-related differences in prog
nosis are influenced by the stage at diagnosis.
54
Patients Younger Than 40 Years
Simmons et al.
55
investigated the incidence of breast carci
noma in women younger than 25 years of age by review
ing data from a Minnesota county between 1935 and 2005
for histologically confirmed cases. The four cases diagnosed
over the 1,201,539 person-years yielded an annual age-
adjusted incidence of 3.2 per million (95% CI, 0.1 to 6.2).
Since all patients were in the 20- to 24-year age group, the
age-specific incidence in this subset was 16.2 per million.
The authors noted that delay in diagnosis was a common
feature in these cases.
Kothari et al.
56
reported on 15 women 25 years or younger
at the time of diagnosis. Two patients had intraductal carci
noma. None of the invasive carcinomas in 13 patients were
low grade. Nine (69%) of the 13 women with invasive carci
noma died as a result of recurrent carcinoma—with a me
dian DFS of 86 months. There was no statistically significant
difference in overall survival (OS) between women 25 years
or younger and those 26 to 35 years of age at the time of
diagnosis.
Feldman and Welch
57
studied 29 women who were
younger than 30 years when diagnosed and treated for breast
carcinoma. The patients were identified between 1953 and
1983 in the records of an urban teaching hospital. Age at
diagnosis ranged from 20 to 29 years. Seven patients (26%)
were pregnant at the time of diagnosis. Delay in diagnosis
was probably a factor in the prognosis of these patients since
the stage at diagnosis was II or higher in 26 of 27 cases with
documented data. Twenty-two patients (76%) died of breast
carcinoma, including three who developed recurrences 12.7,
FIG. 33.1.
Breast carcinoma in pregnancy.
A:
Metastatic breast carcinoma in the placenta. Clus-
ters of metastatic carcinoma cells (
arrows
) are present in the intervillous spaces.
B:
The patient had
a poorly differentiated invasive ductal breast carcinoma (
upper right
), late in the second trimester
of pregnancy, with a partial pathologic response to chemotherapy.
A
B
