904
Chapter 33
the lung as one of the alternate primary sites for an occult
carcinoma that presents with axillary metastases.
Mammography has revealed abnormalities in12%,
131
25%,
134
26.5%,
129
31%,
138
and 35%
133,140
of patients exam
ined. Tartter et al.
143
compared women with false-negative
and positive mammograms. The two groups were similar
with respect to tumor differentiation, tumor size, and ER
status. However, women with false-negative mammography
had a lower frequency of intraductal carcinoma and signifi
cantly more frequent metastases in ALNs. Some investiga
tors have excluded patients with significant mammographic
abnormalities from the syndrome of subclinical carcinoma
presenting with ALN metastases,
132,144
but others found no
consistent correlation between the location of the radio
logic abnormality and the site at which a carcinoma was
ultimately located.
133
If mastectomy is delayed, repeat mam
mograms of patients who initially had negative studies may
reveal new findings suggestive of carcinoma.
140
In one study,
the interval until the detection of a breast abnormality clini
cally or by mammography was 6 to 39 months, with a mean
of 15 months in women who did not undergo a mastec
tomy.
145
The presence of mammographically detectable cal
cifications in metastatic carcinoma in ALNs may be a clue
to the diagnosis of a subclinical mammary carcinoma.
146,147
MRI has proven to be an effective method for detecting
occult carcinomas that are not evident mammographically.
MRI detected occult carcinoma in 143 of 234 (61%) patients
nearly 50% of patients,
133,135
with about 25% having a mater
nal first-degree relative affected.
129
The initial clinical presentation is enlargement of one or
more ALNs. An abnormality may be reported on clinical ex
amination of the ipsilateral breast in 25% of patients, but it is
often not regarded as suspicious, or on follow-up it may not
correlate with the location in the breast where carcinoma is
ultimately detected.
131,133,140
This observation is consistent
with data compiled by Rosen et al.,
141
who studied nearly
3,500 patients with palpable breast lesions and were studied by
mammography. Carcinoma was diagnosed in 64 women. The
palpable lesion proved to be carcinoma in 54 of these cases, but
in 10 women the palpable tumor was benign, and carcinoma
was a nonpalpable lesion detected by mammography alone. In
this series, none of the patients was initially examined because
of axillary nodal involvement, but the study demonstrated the
capacity of mammography to detect clinically occult carci
noma in the presence of a benign, palpable mass.
Clinical Evaluation
To rule out an extramammary tumor or other metastases,
most women have been studied with a variety of techni
ques.
131,133,134
Marcantonio and Libshitz
142
demonstrated
ALN enlargement by computed tomography (CT) in pa
tients with pulmonary carcinoma and proved the presence
of metastatic carcinoma by biopsy in six cases, confirming
FIG. 33.8.
Phyllodes tumor, benign, with intraductal
carcinoma.
A,B:
Cribriform DCIS has replaced some of the
epithelium.
C:
Another example of Benign PT with cribri-
form DCIS. Inset shows detail.
C
