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CORRESPONDENCE
Year : 2019  |  Volume : 15  |  Issue : 5  |  Page : 1170-1172

Occult breast cancer in a female with benign lesions


1 Department of Radiology, University of Foggia, Foggia, Italy
2 Center of Diagnostic and Interventional Breast Imaging, Department of Simple Facility, Scientific Institute Hospital “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, FG, Italy
3 Department of Radiology, Scientific Institute Hospital “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, FG, Italy
4 Department of Radiology, University of Foggia, Foggia; Department of Radiology, Scientific Institute Hospital “Casa Sollievo della Sofferenza,” San Giovanni Rotondo, FG, Italy

Date of Web Publication4-Oct-2019

Correspondence Address:
Francesca Di Chio
Department of Radiology, University of Foggia, Viale Luigi Pinto 1, 71100 Foggia
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_329_17

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 > Abstract 


Occult breast cancer is a carcinoma discovered by the presence of axillary lymph node metastases without the detection of the primary breast tumor. The incidence of this very rare pathology is 0.3%–1.0%. The limited number of these cases does not allow for the precise management of this rare pathology and often, the breast cancer manifestation can take many years to become obvious. We report the case of a 35-year-old woman who presented to our department for annual breast screening examination, without any symptoms. At the time of visit, there were two right and one left tumefactions; unfixed and palpable. Ultrasonography examination confirmed the lesions to be benign. One year later, a palpable hypoechoic axillary left lesion appeared: a lymph node with doubtful morphology. On cytological examination, a biopsy was performed for the axillary left mass which showed irregular masses of large malignant cells with pleomorphism and mitotic figures that suggested a carcinoma. The management of this case is suggestive for cancer of unknown primary syndrome.

Keywords: Axillary mass, fibroadenomas, mammography, metastases, occult breast cancer


How to cite this article:
Di Chio F, Santangelo G, Fiorentino F, Simeone A, Guglielmi G. Occult breast cancer in a female with benign lesions. J Can Res Ther 2019;15:1170-2

How to cite this URL:
Di Chio F, Santangelo G, Fiorentino F, Simeone A, Guglielmi G. Occult breast cancer in a female with benign lesions. J Can Res Ther [serial online] 2019 [cited 2019 Nov 22];15:1170-2. Available from: http://www.cancerjournal.net/text.asp?2019/15/5/1170/244455




 > Introduction Top


Occult breast cancer is a carcinoma discovered by the presence of axillary lymph node metastases without the detection of the primary breast tumor. The incidence of this very rare pathology is 0.3%–1.0%.[1]

Differential diagnosis of this carcinoma is very difficult because it includes adenocarcinoma of the breast, ovary, uterus, thyroid, lung, kidney, and gastrointestinal tract; but in many cases, the primary site of the adenocarcinoma is the ipsilateral breast.[2],[3]

The limited number of these cases does not allow for the precise management of this rare pathology and often, the breast cancer manifestation can take many years to become obvious. In 1950, Klopp and, in 1956, Haagensen reported, respectively, a period of 4 and 5 years before the breast manifestations appeared.[4]

Previously, mastectomy and lymph node dissection was the suggested treatment.[5]

Today, this approach is not performed if there is no clear lesion in the breast; in fact, it has been demonstrated that the locoregional axillary and breast treatment, when possible, produces the same results, with less discomfort for the patient.[6]


 > Case Report Top


A 35-year-old woman presented to our department for annual breast screening examination, without any symptoms. There were no abnormal findings in previous years with normal screening of mammography and ultrasonography (US). The patient had no family history and did not take hormonal drugs.

At the time of visit, there were two right and one left tumefactions: unfixed and palpable.

Complete examination showed bilateral breast new opacity at mammography examination, in particular two lesions in the right breast: one in the upper outer quadrant and one in the equatorial inner quadrant and one in the left breast at the equatorial inner quadrant [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d.
Figure 1: (a-d) Right CC-left CC and right LM-left LM mammography images of the first presentation of the nodules. Two in the right breast and one in the left breast. They appear like benign nodules confirmed at the ultrasonography examination

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US examination confirmed the lesions to be benign, but since the lesions were seen for the first time, a cytological examination was ordered and the results showed no abnormalities.

A follow-up visit was scheduled after 6 months where the situation was unchanged, with no difference in the lesions and the diagnosis was stable. For this reason, the patient was scheduled for another checkup after 6 months at which time the US examination did not demonstrate differences.

After 2 years, the patient underwent another checkup where one new lesion in the left breast, upper internal quadrant, was observed. A follow-up visit was scheduled after 6 months.

One year later, a palpable hypoechoic axillary left lesion appeared: a lymph node with doubtful morphology; therefore, enhanced magnetic resonance imaging (MRI) was performed which showed that the axillary left mass and the known bilateral nodules appeared like benign lesions, most likely fibroadenomas [Figure 2]a and [Figure 2]b.
Figure 2: (a and b) Left mediolateral oblique mammography image and magnetic resonance imaging with Dotarem® that show palpable axillary left lesion: A lymph node with doubtful morphology

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A biopsy for the cytological exam was performed for the axillary left mass which showed irregular masses of large malignant cells with pleomorphism and mitotic figures that suggested a carcinoma. Considering the age of the patient and the absence of palpable masses in the breast, a mastectomy was excluded, but removal of the left axillary lymph node was the best option. The histological examination of the axillary lymph node was suggestive of breast cancer.

The patient underwent chemotherapy and was kept under observation.

At follow-up, two inhomogeneous hypoechoic lesions in the upper outer and the lower inner quadrants of the left breast were evident and hence a biopsy was performed. The result of the biopsy demonstrated fibroadenomas.

A whole-body search included total-body computed tomography (CT) scan with contrast medium to evaluate the situation and make a diagnosis but it was negative. The CT showed only the enlarged right axillary lymph nodes. Staging positron-emission tomography (PET) scan was performed which confirmed 18 F-FDG avidity in two bilateral breast lumps. (One in the upper inner quadrant of the right breast and one in the lower inner quadrant of the left breast.)

At the next checkup, 1 year later, the situation was compared to the previous findings. Mammography confirmed different scattered nodules, with benign properties. The patient underwent MRI with contrast medium that confirmed different nodules with contrast enhancement, the most remarkable at the upper outer quadrant of the right breast and at the lower inner quadrant of the left breast.

After 10 days, a biopsy was carried out on two different nodules, the first at the lower inner quadrant on the left breast and the second at the upper inner quadrant on the right breast, but the results showed fibroadenomas with no evidence of neoplastic cells.

This patient, after 7 years, continues with annual checkups at the breast unit and continues to stay under observation.


 > Discussion Top


Occult breast carcinoma presenting with axillary mass is rare. For the first time, it was described by Halstead in 1907[7] and the conventional treatment was total mastectomy and axillary lymph node dissection.[8] In the past, without the modern imaging techniques, the incidence of this cancer was overestimated. In particular, in 1954, it was 0.3%, but today, it is not so clear because it is a rare condition.[9] In 1995, Rosen, at the 12th Annual International Breast Cancer Conference, confirmed that fewer than 1% of patients with occult breast cancer presented at clinical observation with axillary tumefaction. It was demonstrated that occult carcinoma becomes palpable in cases not immediately treated.[4]

To evaluate the origin of the axillary metastasis, today we have some instruments. The patient should undergo the following examinations: chest X-ray, total-body CT, total-body PET scan, and the specific study of the breast that includes mammography, ultrasound, and MRI with contrast agent. MRI is very helpful in the management of the disease and makes preservation of the breast possible. In fact, today, mastectomy is not necessary and, breast conservation, if possible, is preferred. In this case, 7 years have passed since the first checkup, the patient is currently under observation and is doing well.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Vlastos G, Jean ME, Mirza AN, Mirza NQ, Kuerer HM, Ames FC, et al. Feasibility of breast preservation in the treatment of occult primary carcinoma presenting with axillary metastases. Ann Surg Oncol 2001;8:425-31.  Back to cited text no. 1
    
2.
Abbruzzese JL, Abbruzzese MC, Hess KR, Raber MN, Lenzi R, Frost P, et al. Unknown primary carcinoma: Natural history and prognostic factors in 657 consecutive patients. J Clin Oncol 1994;12:1272-80.  Back to cited text no. 2
    
3.
Hainsworth JD, Greco FA. Treatment of patients with cancer of an unknown primary site. N Engl J Med 1993;329:257-63.  Back to cited text no. 3
    
4.
Smith GM. Occult carcinoma of the breast. Br Med J 1971;4:598-9.  Back to cited text no. 4
    
5.
Cameron HC. An address entitled some clinical facts regarding mammary cancer. Br Med J 1909;1:577-82.  Back to cited text no. 5
    
6.
Visconti G, Eltahir Y, Van Ginkel RJ, Bart J, Werker PM. Approach and management of primary ectopic breast carcinoma in the axilla: Where are we? A comprehensive historical literature review. J Plast Reconstr Aesthet Surg 2011;64:e1-11.  Back to cited text no. 6
    
7.
Varadarajan R, Edge SB, Yu J, Watroba N, Janarthanan BR. Prognosis of occult breast carcinoma presenting as isolated axillary nodal metastasis. Oncology 2006;71:456-9.  Back to cited text no. 7
    
8.
Fortunato L, Sorrento JJ, Golub RA, Cantu R. Occult breast cancer. A case report and review of the literature. N Y State J Med 1992;92:555-7.  Back to cited text no. 8
    
9.
Owen HW, Dockerty MB, Gray HK. Occult carcinoma of the breast. Surg Gynecol Obstet 1954;98:302-8.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

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