912
Chapter 33
breast 11 to 47 months after diagnosis of the axillary metas
tasis (average, 27 months). Three of the carcinomas were in
the upper outer quadrant, and two were in the upper inner
quadrant. One lesion was subareolar, and diffuse involve
ment was observed in the seventh woman. Others have ob
served a subsequent primary tumor in the untreated breast
in 2 (13%) of 15,
171
1 (20%) of 5,
172
and 7 (88%) of 8
173,174
patients after average follow-up of 7.7, 2.2, and 3.5 years,
respectively.
Currently after it has been determined that an excised
lymph node contains metastatic adenocarcinoma consistent
with mammary origin in the absence of clinical evidence of
a nonmammary tumor, treatment should be based on the
assumption that there is an invasive primary carcinoma in
the ipsilateral breast.
A survey of 776 members of the American Society of
Breast Surgeons published in 2005 revealed the following
preferred treatment options: mastectomy, 43%; whole-breast
radiation, 37%; and other, 22%.
175
The “other” category in
cluded observation until a primary lesion became evident,
deference to patient choice, or various combinations of
treatment involving chemotherapy, axillary dissection, ra
diation, and mastectomy.
lesion
130,131,138,168,169
or from foci of “healed” invasive carci
noma (Fig. 33.18). Infrequent examples of infiltrating lobu
lar,
130,131
medullary,
138,154,163,170
mucinous,
130
tubular,
138,149
and papillary,
130
and invasive micropapillary
151
carcinoma
have been described. Analysis of hormone receptors in one
series of primary tumors revealed positive levels of ER in 4
(36%) of 11 cases and of PR in 4 (44%) of 9.
138
Treatment
In 1907, Halsted reported that up to 2 years might elapse
before a primary tumor became clinically apparent in the
breast if the patient did not undergo a biopsy or mastec
tomy.
171
A more recent series included 17 patients with an
untreated ipsilateral breast and a negative mammogram.
138
Nine (52%) developed a clinically apparent primary tu
mor within 2 to 34 months (mean, 13 months). Two of
the remaining eight patients died of progressive systemic
disease without manifesting a mammary primary, and six
remained disease free, with an average follow-up of 6 years.
Another report included 13 patients who did not have
breast surgery or radiotherapy.
137
Seven women (54%) de
veloped a clinically evident primary tumor in the ipsilateral
FIG. 33.19.
Metastatic nonmammary carcinoma.
A:
Poorly differentiated adenocarcinoma of the
lung.
B:
Metastatic pulmonary carcinoma in an ALN.
C,D:
Serous ovarian carcinoma
(C)
metastatic
in an ALN
(D)
.
