916
Chapter 33
studies or on pathologic examination of a surgical speci
men. The actual pathologically determined tumor (size),
regional node (involvement), (distant) metastases (TNM)
stage is probably a more important determinant of prog
nosis than the apparent clinical stage when the patient is
first examined. MRI imaging is very useful for detecting an
occult primary carcinoma in the breast if none is evident on
mammography.
Two cases of occult breast carcinomas manifesting as
ALN metastases in men have been reported.
180
CARCINOMA IN ECTOPIC BREAST TISSUE
Ectopic breast tissue is subject to various proliferative and
nonproliferative changes that occur in the mammary gland
proper.
181,182
“Adenomas” have been described in ectopic
breast tissue, most commonly in the axilla
183
and vulva.
184,185
These lesions develop for the most part during pregnancy or
lactation, and represent nodules of lactational hyperplasia
that assume an adenomatous form.
186
The tumors measured
from 1.0 to 6.0 cm. Bilateral vulvar FA have been reported.
185
Patients with vulvar FA have generally been between 20 and
50 years of age. A benign PT that originated in vulvar mam
mary tissue has been described in a 20-year-old woman.
187
PT of anogenital mammary-like glands in a 41-year-old male,
presenting with anal bleeding, has been described.
188
Breast
tissue surrounding the tumor showed fibrocystic changes, in
cluding apocrine metaplasia and papillomatosis. The lesion
recurred locally 8 months after excisional biopsy.
Carcinoma has been described arising in axillary
182,189–190
and vulvar
189–195
breast tissue. Intra et al.
195
described awoman
with synchronous intraductal carcinoma in the breast and
FIG. 33.22.
Occult carcinoma, tumor size and survival.
Kaplan–Meier survival rate comparison of
matched patients stratified by primary tumor size. The differences are not statistically significant;
(
left
) T1 tumors, (
right
) T2 tumors. (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.)
not statistically significant. Prognosis also appeared to be
better in the group that underwent mastectomy or breast ir
radiation when compared with patients who had no treat
ment of the breast (
p
=
0.06). Adjuvant systemic therapy
did not significantly influence survival. Read et al.
170
also
reported a lower frequency of local breast recurrence and a
lower systemic recurrence rate in women with three or fewer
nodal metastases after breast irradiation and axillary dissec
tion. In this latter series, DFS was higher in the group that
received systemic adjuvant therapy, but the difference from
untreated patients was not statistically significant.
Several studies have compared the outcomes of patients
with occult breast carcinoma treated by mastectomy with
those who had breast preservation and radiation.
129,137,138
Sur
vival rates did not differ significantly for the two treatment
groups. Breast recurrences have been reported in 19% and
23% of patients treated with mammary radiation.
132,137
In one
of these reports the intervals between the diagnosis of the axil
lary metastasis and the detection of the primary breast carci
noma were 8, 44, and 106 months.
137
In a recently published
study, 31 occult breast carcinomas that were ER negative, PR-
negative and HER2-negative (so-called “triple-negative” carci
nomas) had the highest risk of recurrence and death in a series
of 80 patients treated at the European Institute of Oncology.
179
In conclusion, available data indicate that patients with
stage II disease who present with an axillary nodal metas
tasis and an inapparent breast primary have a prognosis
similar to and possibly better than that of patients with
stage II disease who present with a palpable breast carci
noma. This probably reflects the fact that the majority of
the stage II patients with clinically and, in some cases, ra
diographically occult carcinomas prove to have relatively
small invasive tumors detected in their breast by imaging
