Unusual Clinical Presentation of Carcinoma
915
prognosis overall, as well as when stratified by tumor size
and nodal status, the differences were not statistically signifi
cant (Figs. 33.22 and 33.23). These survival results in stage
II patients who presented with nodal metastases and an oc
cult primary are striking. Although there was no statistically
significantly difference, patients with palpable breast tumors
had a less favorable outcome despite similar treatment,
which included chemotherapy for both groups.
Four other studies also provided survival curve analyses
of patients with occult stage II carcinoma.
129,134,137,138
In a se
ries of 29 women, the 5- and 10-year DFS rates were 28% and
17%, respectively.
134
These authors reported similar results
for a comparison group of 127 patients who presented with
palpable mammary primary tumors, but gave no indication
as to how patients with “known” breast carcinoma were
chosen. Their patients with occult carcinoma did not have
substantially larger primary tumors or more numerous in
volved lymph nodes than have been reported in other recent
series, and the data provide no other obvious explanation
for the unusually poor survival rate of stage II patients in
both groups. Baron et al.
129
carried out a survival analysis
of 35 patients and found that 63% were alive disease free.
Their study did not include a matched series of women who
presented with palpable breast tumors.
Ellerbroek et al.
137
reported an OS rate of 71.8% at 5 years
and 65% at 10 years. This study included two features found
to be significantly associated with 5-year survival: axillary
dissection (performed, 88.9% survival; not performed,
46.7% survival) and gross residual tumor in axilla after sur
gery (absent, 79.9% survival; present, 20% survival). In this
study, there was not a statistically significant difference in
survival between patients treated by mastectomy and those
treated by breast conservation. Although patients who re
ceived adjuvant chemotherapy had a better 5-year survival
(92.9%) than those who did not receive systemic treatment
(63.5%), the difference was not statistically significant.
Survival rates at 5 and 10 years reported by Merson
et al.
138
were 76.6% and 58.3%, respectively. There was a
trend to a more favorable prognosis if metastases involved
not more than three ALNs when compared with women
with four or more nodal metastases, but the difference was
almost all patients in both groups received systemic adjuvant
chemotherapy. The distributions of primary tumor size and
of axillary nodal involvement in the two groups were very
similar. A comparison of follow-up results revealed a lower
frequency of recurrence and death due to breast carcinoma
among patients who presented with axillary metastases and
an occult primary tumor (Table 33.4). Survival curve analy
sis for the two groups is shown in Figure 33.21. Although
patients with occult lesions exhibited a more favorable
Ta b l e 3 3 . 4
Follow-up of Matched Patients with Occult and Palpable Breast Carcinomas
Number of Lymph Nodes with Metastases
Total
One to Three
Four or More
Patient Status
Occult (%)
Palpable (%)
Occult (%)
Palpable (%)
Occult (%)
Palpable (%)
NED
16 (73)
15 (36)
9 (75)
9 (38)
7 (70)
6 (33)
AWD
1 (5)
4 (10)
1 (8)
3 (13)
0 (0)
1 (6)
DOD
5 (23)
18 (43)
2 (17)
7 (29)
3 (30)
11 (61)
DOC
0 (0)
5 (12)
0 (0)
5 (21)
0 (0)
0 (0)
Total
22
42
12
24
10
18
From Rosen PP, Kimmel M. Occult breast carcinoma presenting with axillary lymph node metastases: a follow-up study of 48 patients.
Hum
Pathol
1990;21:518–523. Percentages rounded
FIG. 33.21.
Occult carcinoma, overall survival.
Kaplan–
Meier survival rate comparison of patients with clinically
occult primary tumors to stage-matched patients who
presented with a palpable breast tumor. Patients with
clinically unapparent (occult) primary tumors had a more
favorable survival, but the difference was not statistically
significant. (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.)
