The role of ipsilateral breast radiotherapy in management of occult primary breast cancer presenting as axillary lymphadenopathy

Clinicopathologic features and genomic profiling of female axillary lymph node metastases from adenocarcinoma or poorly differentiated carcinoma of unknown primary

PURPOSE

Axillary lymph node metastases from adenocarcinoma or poorly differentiated carcinoma of unknown primary (CUPAx) is a rare disease in women. This retrospective study intended to examine the clinicopathological features of CUPAx and compared CUPAx genetically with axillary lymph node metastases from breast cancer (BCAx), investigating differences in their biological behavior.

METHODS

We conducted the clinical and prognostic analysis of 58 CUPAx patients in West China Hospital spanning from 2009 to 2021. Gemonic profiling of 12 CUPAx patients and 16 BCAx patients was conducted by the FoundationOne CDx (F1CDx) platform. Moreover, we also compared the gene mutation spectrum and relevant pathways between the two groups and both TCGA and COSMIC databases.

RESULTS

The majority of the 58 CUPAx patients were HR-/HER2- subtype. Most patients received mastectomy combined radiotherapy (50 Gy/25f). CUPAx patients who received mastectomy instead of breast-conserving surgery had a more favorable overall prognosis. Radiotherapy in chest wall/breast and supraclavicular/infraclavicular fossa was the independent prognostic factor (HR = 0.05, 95%CI = 0.00-0.93, P = 0.04). In 28 sequencing samples (CUPAx, n = 12, BCAx, n = 16) and 401 TCGA-BRCA patients, IRS2 only mutated in CUPAx (33.33%) but amplified in BCAx (11.11%) and TCGA-BRCA (1.5%). Pathway analysis revealed that BCAx had more NOTCH pathway mutations than CUPAx. Enrichment analysis showed that CUPAx enriched more in mammary development and PML bodies than BCAx, but less in the positive regulation of kinase activity.

CONCLUSIONS

More active treatment methods, like chemotherapy, mastectomy and postoperative radiotherapy, could improve the prognosis of CUPAx. The differential mutation genes of CUPAx and BCAx might be associated with their respective biological behaviors like invasiveness and prognosis.

Occult primary breast cancer: Two cases report and literature review

INTRODUCTION AND IMPORTANCE

Occult breast cancer (OBC) is defined as a clinically recognizable metastatic carcinoma arising from an undetectable primary breast tumor.

PRESENTATION OF CASE

We report in this work 2 cases of occult breast cancer treated at the Mohammed VI center of onco-gynecology of the CHU of Casablanca.

CLINICAL DISCUSSION

Significant advances in breast imaging have occurred since its description, decreasing its incidence. However current management is based upon old studies, with variable clinical, radiological and pathological definitions of OBC.

CONCLUSION

The introduction of better diagnostic techniques and more detailed pathology continue to impact the true incidence of OBC.

SUMMARY

Carcinoma of unknown primary is an intriguing clinical phenomenon that is defined as biopsy-proven metastasis of a malignant tumor in the absence of an identifiable primary site after a complete clinical workup. Carcinoma of unknown primary accounts for approximately 3 to 5% of all cancer diagnoses, and consists of a heterogeneous group of tumors that have acquired the ability to metastasize before the development of a clinically evident primary lesion. Clinical and radiological examinations represent the first steps in the diagnostic algorithm for Carcinoma of unknown primary syndrome. However, histological and immunohistochemical analyses, together with evaluation by a multidisciplinary team and adequate therapy are essential for the diagnosis and treatment of Carcinoma of unknown primary syndrome of OBC. We report in this work 2 cases of occult breast cancer treated at the Mohammed VI center of onco-gynecology of the CHU of Casablanca; A multidisciplinary approach including surgery, radiotherapy, hormonal and biological therapy was implemented. Currently, 10 month after the first presentation, the two patient received ipsilateral breast radiotherapy and sequential adjuvant chemotherapy followed by hormone therapy. Evolution was marked by good control.

Analysis of Prognoses according to Breast MRI Results in Patients with Axillary Lymph Node Metastases from an Unknown Primary Origin

PURPOSE

To compare the prognosis of patients with axillary adenocarcinoma from an unknown primary (ACUPax) origin with negative MRI results and those with MRI-detected primary breast cancers.

MATERIALS AND METHODS

The breast MRI images of 32 patients with ACUPax without signs of primary breast cancer on mammography and ultrasound (US) were analyzed. Spot compression-magnification mammography and second-look US were performed for the area of MRI abnormality in patients with positive results; any positive findings corresponding to the MRI abnormality were confirmed by biopsy. If suspicious MRI lesions could not be localized on mammography or US, MR-guided biopsy or excision biopsy after MR-guided localization was performed. We compared the prognosis of patients with negative breast MRI with that for patients with MRI-detected primary breast cancers.

RESULTS

Primary breast cancers were confirmed in 8 (25%) patients after breast MRI. Primary breast cancers were not detected on MRI in 24 (75%) patients, including five cases of false-positive MRI results. Twenty-three patients underwent axillary lymph node dissection (ALND) followed by whole breast radiation therapy (WBRT) and chemotherapy (n=17) or subsequent chemotherapy only (n=2). Recurrence or distant metastasis did not occur during follow up in 7/8 patients with MRI-detected primary breast cancers and 22/24 patients with negative MRI results. Regional recurrence or distant metastasis did not occur in any MR-negative patient who received adjuvant chemotherapy after ALND and WBRT.

CONCLUSION

The prognoses of MR-negative patients with ACUPax who received ALND and WBRT followed by chemotherapy were as good as those of patients with MRI-detected primary breast cancers.

Prognosis of patients with axillary lymph node metastases from occult breast cancer: analysis of multicenter data

Purpose

This study was conducted to evaluate prognosis of patients with level I/II axillary lymph node metastases from occult breast cancer (OBC).

Materials and Methods

Data of 53 patients with OBC who received axillary lymph node dissection (ALND) positive/negative (+/–) breast-conserving surgery between 2001 and 2013 were retrospectively collected at seven hospitals in Korea. The median number of positive lymph nodes (+LNs) was 2. Seventeen patients (32.1%) had >3 +LNs. A total of 48 patients (90.6%) received radiotherapy. Extents of radiotherapy were as follows: whole-breast (WB; n = 11), regional lymph node (RLN; n = 2), and WB plus RLN (n = 35).

Results

The median follow-up time was 85 months. Recurrence was found in four patients: two in the breast, one in RLN, and one in the breast and RLN. The 5-year and 7-year disease-free survival (DFS) rates were 96.1% and 93.5%, respectively. Molecular subtype and receipt of breast radiotherapy were significantly associated with DFS. Patients with estrogen receptor negative, progesterone receptor negative, and human epidermal growth factor receptor 2 negative (ER-/PR-/HER2-) subtype had significantly lower 7-year DFS than those with non-ER-/PR-/HER2- tumor (76.9% vs. 100.0%; p = 0.03). Whole breast irradiation (WBI) was significantly associated with a higher 7-year DFS rate (94.7% for WBI group vs. 83.3% for non-WBI group; p = 0.01). Other factors including patient’s age, number of +LNs, taxane chemotherapy, and RLN irradiation were not associated with DFS.

Conclusion

Patients with OBC achieved favorable outcome after ALND and breast-targeting treatment. Molecular subtype and receipt of WBI was significant factors for DFS.

Application of neoadjuvant chemotherapy combined with anlotinib in occult breast cancer: A case report and review of literature

BACKGROUND

Occult breast cancer (OBC) is a special type of breast cancer presenting as axillary lymph node metastasis with undetectable primary lesions in the breast. Due to its low incidence and unique clinical manifestations, there is a lack of consensus on the diagnosis and treatment of OBC. We report a case of OBC treated with neoadjuvant chemotherapy combined with anlotinib. The treatment was well tolerated, and the patient achieved a pathologic complete response.

CASE SUMMARY

A 53-year-old woman presented with a lump in her right axillary area with no primary lesions in the breast. Pathological biopsy confirmed right axillary metastatic carcinoma. Immunohistochemical staining results were positive for progesterone receptor, cytokeratin 7, specific breast markers GATA3 and gross cystic disease fluid protein-15. Tumor cells were negative for estrogen receptor, human epidermal growth factor receptor-2, cytokeratin 5/6, cytokeratin 20, and villin. The patient was diagnosed with OBC, and she underwent neoadjuvant chemotherapy combined with anlotinib. Mastectomy plus axillary lymph node dissection was performed. The patient achieved pathologic complete response with no residual invasive tumor cells in the breast or axillary lymph nodes. Postoperatively, she received adjuvant radiotherapy and endocrine therapy.

CONCLUSION

Neoadjuvant chemotherapy and anlotinib had good efficacy and safety in the treatment of OBC and may be a new therapeutic option.

Outcome of breast-conserving treatment for axillary lymph node metastasis from occult breast cancer with negative breast MRI

Purpose

We conducted this study to investigate the prognosis and failure pattern after breast-conserving treatment (BCT) in patients with occult breast cancer (OBC) with negative breast magnetic resonance imaging (MRI) (MRI-OBC).

Materials and methods

Survival rates and failure patterns in 66 patients who received axillary lymph node dissection (ALND) and BCT for MRI-OBC between 2001 and 2013 at seven hospitals were analyzed. OBC was defined as adenocarcinoma in the axillary lymph node (ALN) +/− supraclavicular (SCN) or internal mammary lymph node (IMN) with a negative breast MRI.

Results

Fifty-four patients had only ALN metastasis (ALN only), and 12 patients had ALN metastasis along with SCN or IMN metastasis (ALN + SCN/IMN). Median follow-up was 82 months. The 5-year overall, disease-free, and breast cancer-free survival rates were 93.4%, 92.1%, and 96.8%, respectively. Nine patients experienced recurrence: breast (n = 4), regional lymph nodes (RLN, n = 1), distant metastases (DM, n = 2), breast/RLN (n = 1), and breast/RLN/DM (n = 1). Five-year disease-free survival was significantly higher in ALN only patients compared to ALN + SCN/IMN patients (96.1% vs. 75.0%; p = 0.02).

Conclusions

Patients with MRI-OBC were successfully treated with BCT. There was a small risk of ipsilateral breast cancer recurrence. Failure patterns depended on the extent of initial disease.

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Occult breast cancer (OBC) presenting with axillary metastases is a rare disease.

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This study reports on the outcome of OBC with negative breast MRI (MRI-OBC).

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Patients with MRI-OBC were successfully treated with breast-conserving treatment.

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Very few breast recurrences occurred when whole breast radiotherapy was used.

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Failure patterns of MRI-OBC depended on the initial extent of nodal involvement.

Clinicopathologic characteristics of malignant non-hematopoietic tumors first presented as an axillary mass with emphasis on occult breast carcinoma

BACKGROUND

Non-hematopoietic malignancies first presented as an axillary mass constitute a unique clinical presentation. We investigated the incidence of various types of malignancies and aimed to define clinicopathologic variables that may assist in the diagnosis, with focus on occult breast carcinoma (OBC).

DESIGN

We reviewed the pathology reports of cases with non-hematopoietic malignancies of the axillary region in our institution between 2000 and 2016. We included patients who presented first with axillary mass and with the absence of a known primary. We recorded patients' age and gender, tumor characteristics including size, histologic type, number of positive lymph nodes, and the clinical management. Then we focused on BC which were divided into OBC or primary BC (PBC).

RESULTS

There were 100 cases that met our criteria (28 melanoma, 7 sarcoma and 65 carcinoma). For carcinoma cases, there were 42 BC (19 OBC, 17 PBC, and 6 possible OBC), 17 non-BC, and 6 carcinoma of unknown primary (CUP). Tumors found incidentally were more likely to be of breast primary (p = 0.01). Larger tumor size (in mm) favored melanoma or sarcoma over BC, non-BC carcinoma or CUP with median and range 61 (15, 180), 60 (23, 80), 30 (15, 75), 31 (17, 90), 26 (20, 55), respectively (p < 0.001). There were no differences in the histopathologic findings or clinical presentation.

CONCLUSIONS

More than half of the patients with axillary malignancy have a tumor of non-breast origin. Therefore, clinical and pathologic studies are warranted to identify the primary site.

Clinicopathological characteristics and treatment outcomes of occult breast cancer: a SEER population-based study

Background

Occult breast cancer (OBC) is a rare type of breast cancer that has not been well studied. The clinicopathological characteristics and treatment recommendations for OBC are based on a limited number of retrospective studies and thus remain controversial.

Patients and methods

We identified 479 OBC patients and 115,739 non-OBC patients from 2004 to 2014 in and the Surveillance, Epidemiology, and End Results (SEER) database. The clinicopathological characteristics and survival outcomes were compared between OBC and non-OBC patients. We used the propensity score 1:1 matching analysis to evaluate OBC vs non-OBC comparison using balanced groups with respect to the observed covariates. We further divided the OBC population into four groups based on different treatment strategies. Univariable and multivariable analyses were used to calculate and compare the four treatment outcomes within the OBC population.

Results

OBC patients were older, exhibited a more advanced stage, a higher rate of negative estrogen receptor and progesterone receptor status, a higher rate of HER2-positive status, and a higher rate of ≥10 positive lymph nodes, and were less likely to undergo surgical treatment than non-OBC patients. After adjustments for clinicopathological factors, the OBC patients exhibited a significantly better survival than the non-OBC patients (P<0.001). This result was confirmed in a 1:1 matched case–control analysis. Within the four OBC treatment groups, we observed no difference in survival among the mastectomy group, the breast-conserving surgery (BCS) group, and the axillary lymph node dissection (ALND)-only group. The multivariable analysis revealed that the sentinel lymph node dissection-only group had the worst prognosis (P<0.001). Conclusion: OBC has unique clinicopathological characteristics and a favorable prognosis compared with non-OBC. BCS plus ALND and radiotherapy showed a survival benefit that was similar to that of mastectomy for OBC patients.

Comparable Survival between Additional Radiotherapy and Local Surgery in Occult Breast Cancer after Axillary Lymph Node Dissection: A Population-based Analysis

Purpose: To investigate the clinical value of additional local treatment strategies in occult breast cancer (OBC) after axillary lymph node dissection (ALND). Methods: Patients diagnosed with OBC between 1990 and 2013 were included from the Surveillance, Epidemiology, and End Results registry database. The significant risk factors of cause-specific survival (CSS) and overall survival (OS) were identified using univariate and multivariate Cox regression analyses. Results: We identified 980 patients, including 219 (22.3%), 252 (25.7%), 263 (26.8%), and 246 (25.1%) of patients underwent ALND, ALND + radiotherapy (RT), ALND + surgery (S) (mastectomy or breast-conserving surgery), and ALND + S + RT, respectively. Patients with younger age, diagnosed before 2000, advanced nodal stage, ER-negative disease, and PR-negative disease were more likely to undergo additional local treatment compared with ALND only. The 10-year rate CSS of the ALND only group was 57.2%, while that of the ALND + RT, ALND + S, and ALND + S + RT groups was 78.0%, 81.0%, and 71.5%, respectively (p < 0.001). The 10-year OS rate in the ALND only, ALND + RT, ALND + S, and ALND + S + RT groups was 46.0%, 69.5%, 66.1%, and 67.0%, respectively (p < 0.001). Multivariate analysis indicated that older age, advanced nodal stage, and ALND only were independent risk factors for decreased CSS and OS. CSS and OS among the groups including ALND + RT, ALND + S, and ALND + S + RT were not significantly different. Conclusions: Additional local treatment (local surgery or RT) improves survival outcomes compared with ALND only in OBC after ALND. ALND + RT may be the optimal local treatment for OBC due to no different in survival outcomes and cosmesis is better.

Oncologic Outcomes After Treatment for MRI Occult Breast Cancer (pT0N+)

BACKGROUND

Studies assessing outcomes in occult breast cancer have often included women treated before the routine use of magnetic resonance imaging (MRI). This study examined outcomes for patients presenting with axillary adenopathy and no primary breast tumor detectable by MRI or other imaging methods.

METHODS

All patients with axillary nodal metastases consistent with breast carcinoma and no breast primary tumor detectable by physical exam, mammography, or MRI treated between 1 January 1996 and 30 June 2011 were identified from an institutional database. Data were collected on local, regional, and distant recurrences.

RESULTS

For the study, 38 patients were identified. Modified radical mastectomy (MRM) was performed for 13 of the patients, whereas 25 of the patients underwent axillary dissection (ALND) and whole-breast radiotherapy (WBRT). Most of the women had pathologic N1 disease [median number of positive nodes, 2 (MRM cohort) and 3 (ALND + WBRT cohort); p = 0.38]. All the patients received chemotherapy, and 30 (79%) of the 38 patients received an anthracycline and taxane. Regional nodal radiation was used for 60% of those with ALND + WBRT and for all 46% of the MRM patients who received chest wall radiotherapy. During a median follow-up period of 7 years, there were no nodal recurrences. Two patients treated with ALND + WBRT had in-breast recurrences, whereas none in the MRM group experienced a local recurrence. The proportion that experienced distant disease was similar between the MRM cohort (1 of 13) and the ALND + WBRT cohort (2 of 25).

CONCLUSION

Breast cancer presenting as axillary adenopathy with no detectable primary tumor is rare. Breast conservation with WBRT is a viable option for patients with a diagnosis of occult breast cancer and a negative preoperative MRI.

Evaluation of the Benefit of Radiotherapy in Patients with Occult Breast Cancer: A Population-Based Analysis of the SEER Database

Purpose

Few studies for occult breast cancer (OBC) have evaluated the effect of radiotherapy (RT) after mastectomy or axillary lymph node dissection (ALND) with/without breast surgery. Therefore, we investigated clinicopathologic factors of OBC with the impact of postoperative RT to determine its prognostic significance using large population-based data.

Materials and Methods

We performed a retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER) database from 1983 to 2013. A total of 1,045 eligible patients with OBC were identified. We compared overall survival (OS) using Cox proportional hazards regression with propensity score matching after verifying an imbalance of prognosticators between RT group (n=518) and non-RT group (n=479).

Results

Patients with age < 70 (p=0.033), married marital status (p < 0.001), undergoing ALND (p < 0.001), more examined lymph nodes (LNs) (p < 0.001), and more metastatic LNs (p < 0.001) were more likely to receive RT. Multivariate analysis after propensity score matching (n=798) showed that patients treated with RT survived significantly longer than those without RT (5-year OS, 81.5% vs. 78.3%; p=0.014). A significantly prolonged OS was observed when RT was given to patients treated with mastectomy (p=0.033), those treated with ALND (p=0.036), or those with more than seven metastatic LNs (p=0.016).

Conclusion

RT may offer survival benefit in OBC even after mastectomy or ALND, especially in patients with more than seven metastatic LNs. Further prospective studies are needed to validate these findings.

Postradiation Extraskeletal Osteosarcoma Masquerading as an Axillary Artery Pseudoaneurysm

BACKGROUND

A 68-year-old woman with a thoracoabdominal aortic aneurysm recently status after first-stage elephant trunk procedure with right brachiocephalic artery endarterectomy and reimplantation of the innominate and left carotid using a 14 × 10-mm branch graft presented to clinic with increasing pain in her right arm and shoulder for 2 weeks. She also had a remote history of radiation to the right axilla for breast cancer. On physical examination, she had a tender mass under her clavicle, numbness in shoulder and right hand weakness. Computed tomography scan revealed a 5.3 × 4.3-cm coarsely rim calcified lesion in the right axillary region reported as a pseudoaneurysm.

METHODS

She was taken to the operating room for exploration. After obtaining proximal and distal control, the mass revealed to be a solid tumor. The mass was removed, taking care to avoid the axillary artery and medial and lateral cords of the brachial plexus.

RESULTS

Pathology revealed an extraskeletal osteosarcoma.

CONCLUSIONS

Extraskeletal osteosarcoma is an extremely rare primary bone cancer, making up <1% of all osteosarcomas. Less than 350 cases are described in the literature. Of the cases described in the literature, less than 5% involve the upper extremity and/or thorax. They are aggressive tumors located in the soft tissue and not an extension of bone. Treatment involves multimodality therapy with surgical resection and adjuvant chemoradiation.

A unique presentation of occult primary breast cancer with a review of the literature

We are reporting a case of a 34-year-old woman with occult primary breast cancer discovered after initially presenting with neurological symptoms. She was successfully treated with neoadjuvant chemotherapy followed by definitive axillary lymph node dissection and ipsilateral whole breast radiotherapy. The case presented is unique due to the rarity of occult primary breast cancer, especially in light of her initial confounding neurological signs and symptoms, which highlights the importance of careful staging.

Invasive mucinous carcinoma arising in ectopic axillary breast tissue: a case report and literature review

BACKGROUND

Invasive mucinous carcinoma arising in ectopic axillary breast tissue is an uncommon diagnosis. While some published medical literature makes recommendations regarding the management of ectopic primaries, many of these recommendations are outdated. We therefore hope to provide general guidance with the management of this rare entity.

CASE REPORT

We report a case of a 70-year-old woman with primary invasive mucinous carcinoma of ectopic breast tissue. A literature study was performed on primary ectopic breast carcinoma. This case report with review of the literature was performed to provide rationales for a more conservative treatment based upon current data and treatment paradigms. Although the diagnosis of primary ectopic breast carcinoma is uncommon, the presence of a suspicious nodule along the mammary ridge should alert the clinician to consider the possibility of this diagnosis. A mammogram and ultrasound of the nodule were performed and the suspicious nodule was biopsied, confirming the diagnosis. Breast conservation was performed with standard nodal evaluation.

CONCLUSIONS

The management of primary ectopic breast carcinoma should be based upon current breast conservation techniques of orthotopic breast cancer. Current data suggest that standard treatment paradigms remain applicable to this rare clinical entity.

Treatment and survival of patients with occult breast cancer with axillary lymph node metastasis: a nationwide retrospective study

BACKGROUND AND OBJECTIVES

Occult breast cancer (OBC) accounts for 0.3-1.0% of all breast cancers and is a rare presentation of the disease. The present retrospective study examined the overall survival and prognostic factors associated with OBC in Korea.

METHOD

The study included 142 OBC patients identified from the Korean Breast Cancer Society cancer registry from January 1990 to December 2009. All patients had pathologically positive axillary lymph nodes (N1-N3) and pathologically and radiologically negative in-breast lesions (T0/Tx) based on a retrospective review of the database.

RESULTS

No statistically significant differences in overall survival were observed between patients undergoing axillary lymph node dissection (ALND) only (80.8%), breast conserving surgery (BCS) with ALND (98.0%), and mastectomy with ALND (92.5%) with P-value of 0.061. Nodal status was a significant prognostic factor (P = 0.004) on univariate analysis. When compared with T1 patients group, T0/TxN1 patients showed better survival than T1N1 patients (hazard ratio [HR] 0.253; 95% confidence interval, 0.104-0.618; P = 0.003), but T0/TxN2, T0/TxN3 patients showed similar survival to T1N2, T1N3 patients.

CONCLUSIONS

OBC patients treated with ALND only showed comparable outcomes to those undergoing ALND combined with BCS or mastectomy. Nodal status may be an independent predictor of poor outcome in OBC patients.

Survival outcomes of different treatment methods for the ipsilateral breast of occult breast cancer patients with axillary lymph node metastasis: a single center experience

Purpose

This study compared the survival outcomes of different treatment methods for the ipsilateral breast of occult breast cancer (OBC) patients with axillary lymph node metastasis.

Methods

A retrospective study was conducted in which forty OBC patients with axillary lymph node metastasis were identified out of 15,029 patients who had been diagnosed with a primary breast cancer at between 1992 and 2010. The patients were categorized into three treatment groups based on ipsilateral breast management: breast-conserving surgery (BCS) (n=17), mastectomy (n=12), and nonsurgical intervention with or without radiation therapy (No surgery with or without radiation therapy [No Op±RT]) (n=11). All patients underwent axillary lymph node dissection. Cases were evaluated based on treatment and potential prognostic factors with respect to overall survival (OS) and disease-free survival (DFS).

Results

During the follow-up period (median follow-up of 71.5 months), the overall OS and DFS were 76.9% and 74.9%, respectively. The 5-year treatment-specific OS was 72.0% for the BCS group, 74.0% for the mastectomy group, and 87.5% for the No Op±RT group (log-rank p=0.49). The 5-year DFS was 70.6% for the BCS group, 66.7% for the mastectomy group, and 90.9% for the No Op±RT group (log-rank p=0.36). Recurrence rates for the BCS and No Op±RT groups were 5.9% and 18.2%, respectively. Histologic grade and lymph node status were inversely correlated with DFS (log-rank p=0.04 and p<0.01, respectively).

Conclusion

There was no difference in survival outcomes between the three treatment methods for the ipsilateral breast (mastectomy, BCS, and No Op±RT) of OBC patients with axillary lymph node metastasis. A large-scale multicenter study is needed to validate the results from this small retrospective study.

[Radiotherapeutic concepts in cancer of unknown primary site]

BACKGROUND

The term cancer of unknown primary (CUP) encompasses a group of entities which differ to a great extent regarding etiology, prognosis and therapeutic management.

OBJECTIVES

The aim of the study was an elaboration of the role of radiotherapy in CUP syndrome.

MATERIAL AND METHODS

Systematic literature search and specification of the available treatment options.

RESULTS

Radiotherapy is an integral part of interdisciplinary management approaches for patients with CUP in both curative and palliative situations. Radio-oncological techniques, such as intensity-modulated radiotherapy and stereotactic body radiotherapy increase the therapeutic window. Modern diagnostic modalities from radiology and nuclear medicine are the cornerstone of radiotherapeutic interventions, especially in terms of target volume definition and pretherapeutic staging. In the interdisciplinary setting radiation oncology offers the possibility of curative and often organ preserving approaches in patients with axillary and cervical CUP. In addition, improvement and preservation of quality of life can be achieved in patients with metastatic disease.

CONCLUSION

Radiation oncology is a crucial component of the interdisciplinary management of patients with CUP. Therapeutic decisions in patients with CUP should be made in an interdisciplinary setting.

Geographic and temporal trends in the management of occult primary breast cancer: a systematic review and meta-analysis

BACKGROUND

Management of occult primary breast cancer (OPBC), including the role of magnetic resonance imaging (MRI), is controversial. We conducted a pooled analysis of OPBC patients and a meta-analysis of MRI accuracy in OPBC in order to elucidate current practices.

METHODS

A literature search yielded 201 studies. Patient-level data for clinically/mammographically OPBC from studies published after 1993 and from our institution were pooled; logistic regression examined associations between patient/study data and outcomes, including treatments and recurrence. We report adjusted odds ratios (OR) and 95 % confidence intervals (95 % CI) significant at 2-tailed p < 0.05. Meta-analysis included data for patients who received MRIs for workup of clinically/mammographically OPBC. We report pooled sensitivity and specificity with 95 % CIs.

RESULTS

The pooled analysis included 92 patients (15 studies [n = 85] plus our institution [n = 7]). Patients from Asia were more likely to receive breast surgery (OR = 5.98, 95 % CI = 2.02-17.65) but not chemotherapy (OR = 0.32, 95 % CI = 0.13-0.82); patients from the United States were more likely to receive chemotherapy (OR = 13.08, 95 % CI = 2.64-64.78). Patients from studies published after 2003 were more likely to receive radiotherapy (OR = 3.86, 95 % CI = 1.41-10.55). Chemotherapy recipients were more likely to have distant recurrence (OR = 9.77, 95 % CI = 1.10-87.21). More patients with positive MRIs received chemotherapy than patients with negative MRIs (10 of 12 [83.3 %] vs 5 of 13 [38.5 %]; p = 0.0414). In the MRI-accuracy meta-analysis (10 studies, n = 262), pooled sensitivity and specificity were 96 % (95 % CI = 91-98 %) and 63 % (95 % CI = 42-81 %), respectively.

CONCLUSIONS

OPBC management varied geographically and over time. We recommend establishing an international OPBC patient registry to facilitate longitudinal study and develop global treatment standards.

Occult primary breast cancer at a comprehensive cancer center

BACKGROUND

Management of occult primary breast cancer (OPBC), that is, breast cancer that first presents through regional nodal or distant disease without clinical or mammographic evidence of disease in the breast, has been controversial and inconsistent. Here, we review OPBC patients treated at our institution.

METHODS

We conducted a retrospective review of women diagnosed with a first primary breast cancer between March 1999 and September 2010 to identify patients who presented with isolated axillary lymphadenopathy proven to be histologically consistent with primary breast malignancy but had no evidence of a breast mass on physical examination, mammography, or ultrasound. Descriptions of treatments received, recurrence, morbidity, and mortality as of October 2012 are reported.

RESULTS

Of 5533 patients reviewed, seven (0.1%) patients were identified. The median age was 65 y old (range, 40-72), and the median length of follow-up was 86 mo (range, 42-124). Four patients underwent modified radical mastectomy, one patient had a lumpectomy and axillary lymph node dissection, and two patients had axillary lymph node dissection without breast surgery. Four patients received adjuvant radiation therapy. All seven patients received chemotherapy. Three patients received endocrine therapy, and two patients received anti-HER2 therapy. At the last follow-up, all seven patients were alive with no evidence of disease.

CONCLUSIONS

Although there was some variation in the management of OPBC at our institution, our patients had excellent outcomes after multimodal treatment. Our results support a curative intent approach to the treatment of OPBC and illustrate the need for individualized treatment algorithms based on tumor biology and extent of the disease at diagnosis.

Treatment outcomes and unfavorable prognostic factors in patients with occult breast cancer

AIMS

The purpose of this study was to evaluate the treatment outcomes and prognostic factors in patients with occult breast cancer (OBC).

METHODS

We retrospectively analyzed 95 patients with OBC who were treated at our facility between January 1998 and June 2010. Of the 95 patients, 64 underwent mastectomy plus axillary lymph node dissection (ALND) with or without post-mastectomy radiation (Mast + ALND group), 13 underwent ALND followed by ipsilateral breast radiotherapy (BR + ALND group) and the remaining 18 were treated with ALND (ALND group).

RESULTS

Patients who underwent Mast + ALND or BR + ALND had significantly improved rates of locoregional recurrence-free survival (LRFS) and recurrence/metastasis-free survival (RFS) than patients who only underwent ALND (p < 0.05). There were no significant differences in the LRFS (p = 0.718), RFS (p = 0.935) and breast cancer-specific survival (BCSS) (p = 0.991) rates between the patients who underwent Mast + ALND compared with those who received BR + ALND. Multivariate analysis revealed that patients with four or more involved lymph nodes had significantly worse outcomes (p = 0.042, HR = 4.63, 95% CI = 1.66-32.47 for BCSS and p = 0.038, HR = 3.62, 95% CI = 1.08-20.77 for RFS).

CONCLUSIONS

Patients with OBC who received ALND and subsequent breast radiotherapy had similar outcomes to patients who underwent mastectomy. The presence of four or more involved lymph nodes may independently predict poor outcomes of OBC.