Unusual Clinical Presentation of Carcinoma
905
for contralateral breast carcinoma
129,131
or developed subse
quent carcinoma in the contralateral breast.
129,132
One patient
had an augmentation prosthesis in the breast that harbored a
subclinical carcinoma.
129
Huston et al.
155
studied seven women
who developed contralateral axillary nodal metastases. The
median interval between treatment of the initial carcinoma and
subsequent contralateral axillary metastases was 71 months.
All had adjuvant chemotherapy and five underwent axillary
dissection. There were no axillary recurrences after a median
follow-up of 35 months, at which time five women were alive,
two with recurrent carcinoma, and two had died of metastatic
carcinoma. It is possible that the prior contralateral carcinoma
is the source of axillary metastases in many of these situations,
but in some instances an occult primary may give rise to the
newly apparent nodal metastases.
139
Clonal analysis may be employed to evaluate metastatic
carcinoma in contralateral ALNs if material from the ipsi
lateral tumor is available for comparison. In the majority
of cases, clonal analysis of the carcinomas in both breasts
of patients with bilateral tumors has demonstrated cyto
genetic differences indicative of independent origin of the
lesions.
156,157
Rarely, the pattern of the clonal abnormalities
in both tumors suggests metastatic spread from one breast
to the other.
157
A similar conclusion would be supported by
finding that a primary carcinoma and a metastatic tumor
at another site such as the chest wall or contralateral ALNs
shared the same karyotypic abnormalities.
156
in pooled results from 10 studies published until 2008.
148
In another pooled study published in 2010, the specificity
of MRI was 31% on pooled data (range, 22% to 50%) from
seven studies.
149
However, not all lesions detected by MRI
in this setting prove to be carcinoma. Buchanan et al.
136
re
ported false-positive MRI studies in 15 of 69 patients, and
in another series, MRI yielded a false-positive result in 2 of
15 cases.
150
The diagnostic yield is low in patients with a neg
ative mammogram and a negative MRI,
136
a situation that led
the European Society of Breast Cancer Specialists to recom
mend that surgical treatment be avoided if MRI of the breast
is negative.
148
Positive MRI findings should be investigated
by biopsy. In a high proportion of cases, lesions detected by
mammography can be localized by sonography, making them
amenable to sonographically directed needle core biopsy.
151
Occasionally, nodal enlargement occurs in the contralat
eral axilla of a patient treated previously for mammary car
cinoma.
139,152
This phenomenon was observed in 52 (3.6%)
of 1,440 patients in one series.
153
Most of these patients were
judged to have systemic disease. Six of the 52 patients (0.04%)
were treated by contralateral mastectomy, and 2 had a primary
tumor in the contralateral breast. Breslow
154
reported that 6
(0.39%) of 1,543 patients with unilateral breast carcinoma sub
sequently developed carcinoma in contralateral ALNs, and that
a primary tumor was detected in four of the opposite breasts.
In a series of patients presenting with axillary metastases from
subclinical breast carcinoma, about 8%were previously treated
FIG. 33.9.
Phyllodes tumor, benign, with intraductal and
invasive ductal carcinoma.
A,B:
Cribriform intraductal car-
cinoma is next to IDC.
C:
Isolated cells (
arrows
) of IDC are
highlighted by a CK immunostain in a benign PT. Glandular
components of the PT are also cytokeratin positive (CK7).
