Axillary metastasis from occult breast cancer and synchronous contralateral breast cancer initially suspected to be cancer with contralateral axillary metastasis: a case report

Background Initial detection of axillary metastasis without known ipsilateral breast cancer could be a challenging diagnostic problem. Four options could be considered for the primary site of the malignancy: ipsilateral occult breast cancer, contralateral breast cancer, tumors in other distant organs, and primary axillary malignancy itself. Although breast cancer is known as the most common primary cancer of axillary metastasis, both occult breast cancer and breast cancer with contralateral axillary metastasis (CAM) are rare. Case presentation A 63-year-old woman presented with palpable right axillary metastasis, and a tiny contralateral breast cancer was detected by breast magnetic resonance imaging. No lesion was found in the ipsilateral right breast and contralateral left axillary region. Both right axillary metastasis and contralateral breast cancer were positive for estrogen receptor. The diagnostic issue was to determine whether the axillary metastasis was derived from the contralateral breast cancer or not. Right axillary dissection and left breast conserving surgery were performed. The final diagnosis was occult breast cancer that presented with axillary lymph node metastasis and early-stage synchronous contralateral breast cancer, based on clinical evidence and postoperative pathologic results. After surgery, systemic treatment and whole breast irradiation were administered. No recurrence or metastasis was observed 15 months postoperatively. Conclusion For accurate diagnosis of axillary metastasis without detectable ipsilateral breast cancer, multifaceted diagnostic approach considering clinical, radiological, and pathological evidences is required.

Dynamic Nomogram Predicts Overall Survival in Patients With Occult Breast Cancer: a Population-based Analysis

Background: Due the rarity of occult breast cancer (OBC), no precise prognostic instruments were available to assess the overall survival (OS) in patients with OBC. The aim of this study is to construct a nomogram for predicting the OS probability in patients with OBC. Methods: Patients who were enrolled in the Surveillance, Epidemiology, and End Results database between 2004 and 2015 were regarded as subjects and studied. We constructed a dynamic nomogram that can predict prognosis in patients with OBC based on crucial independent factors by using univariate and multivariate Cox regression analyses. C-index and calibration plots were chosen for validation. Net reclassification index (NRI), integrated discrimination improvement (IDI) and DCA (Ddecision Curve Analysis) were used to evaluate the nomogram’s clinical pragmatism. Results: Totally, 693 patients with OBC were included in this study. The nomogram integrated six independent prognostic factors through multivariate Cox regression analysis, such as surgical method, radiotherapy status, chemotherapy status, ER status, AJCC-stage and age. The prediction model exhibited robustness with the C-index 0.75 (95%CI: 0.72-0.77) in training cohort and 0.79 (95%CI: 0.76-0.82) in validation group. Moreover, the calibration curves presented favorably. The NRI values of 0.61 (95%CI: 0.28-0.99) for 5-year,0.53 (95%CI: 0.23-0.77) for 8-year OS prediction in the training cohort,0.75 (95%CI: 0.36-1.23) for 5-year and 0.6 (95%CI: 0.15-1.2) for 8-year OS prediction in the validation cohort,and the IDI values of 0.1 (95%CI: 0.04-0.17) for 5-year and 0.11 (95%CI: 0.03-0.19) for 8-year OS prediction in the training cohort, 0.21 (95%CI: 0.09-0.3) for 5-year and 0.22 (95%CI: 0.08-0.32) for 8-year OS prediction in the validation cohort,, indicated that the established nomogram performed significantly better than the AJCC stage system alone. Furthermore, DCA showed that the nomogram in our study was clinically useful and had better discriminative ability than the AJCC stage system. Conclusions: A nomogram was developed and validated to accurately predict the individualized probability OS for patients with occult breast cancer (OBC) and is expected to offer guidance for strategic decision.

EP.TH.531Occult breast cancer: Breast conservation or Mastectomy in terms of recurrence. A single center experience

Aim We sought to compare breast conservation therapy & mastectomy as treatment of occult breast cancer in terms of recurrence. Methods It is a retrospective cross sectional study conducted on patients diagnosed to have occult breast cancer and going for either breast conservation therapy or mastectomy at The Aga Khan University Hospital Karachi between January 200o to December 2018, patients will be divided into two groups, first group will be consisting of patients who underwent breast conservation therapy and 2nd one will be of patients who had mastectomy. Patients will be included by consecutive sampling technique. Hospital database will be used to identify patients and data collected on a self designed tool using files and electronic patient records. Patients in both groups will be followed to see local recurrence from date of diagnosis to 2 years post operatively in hospital data base and their files, and then their data will be compared with the reference studies reported in this article. Results Awaited as the study is ongoing. Conclusions Awaited as study is ongoing.

Clinicopathological Characteristics and Treatment Outcomes of Occult Breast Cancer: A Population-Based Study

Background Occult breast cancer (OBC) is a special type of breast cancer. It is defined as an axillary lymph node metastasis without ipsilateral breast malignancy according to mammogram and ultrasonography. Because of its rarity and no primary lesion, clinicopathological information is still insufficient, causing a controversial condition about its treatment recommendation. In this study, we aimed to clarify major clinicopathological information, treatment strategies and prognosis of OBC based on a large population. Methods We retrospectively collected adult female OBC population from Surveillance, Epidemiology, and End Results (SEER) database. We divided the whole OBC cohort into two groups based on surgical treatment. Descriptive analysis of 18 clinicopathological variables was conducted by Wilcoxin rank sum test, Chi-square and Fisher’s exact test. Survival analysis was performed in the whole cohort as well as based on different clinicopathological factors. Univariate and multivariate Cox regression analysis was performed to identify potential independent predictor for prognosis of OBC. Results 1189 OBC patients was included in final analysis. Elderly patients predominated with a mean age of nearly 60. Most of the OBC patients were diagnosed as an early-stage carcinoma and ductal carcinoma took up nearly 40% of all the histological types of OBC. Luminal A is the commonest subtypes of OBC. For in-breast treatment, number of patients received mastectomy was 4 times more than that of patients received breast-conserving surgery (BCS). More than 70% patients receiving BCS took radiotherapy, significantly more than the portion of patients receiving radiation in mastectomy group (50.9%, P < 0.001). Median follow-up period of all subjects was about 62 months. 5-year and 10-year overall survival (OS) of the complete OBC cohort was 81.6% and 68.8%, respectively. No significant difference in OS and breast-cancer specific survival (BCSS) was found between mastectomy and BCS. Older age and larger number of positive lymph nodes causes a worse prognosis whereas radiotherapy brought a better clinical outcome for OBC patients. Conclusion OBC is a rare breast malignancy with a generally good prognosis. Less-intensive surgical intervention does not negatively impact clinical outcomes of OBC while additional radiotherapy is totally beneficial to prolong OS and BCSS.

Axillary Nodal Metastases from Carcinoma of Unknown Primary (CUPAx): Role of Contrast-Enhanced Spectral Mammography (CESM) in Detecting Occult Breast Cancer

Axillary lymph node metastases of occult breast cancer (CUPAx) is an unusual condition that represents both a diagnostic and therapeutic challenge. The first steps in the diagnostic work-up of patients with CUPAx are the histological analysis of the lymph node metastasis and the execution of basic breast diagnostic imaging (mammography and ultrasound). In the case of occult breast cancer, breast Magnetic Resonance (MR) must be performed. Breast MR identifies a suspicious lesion in many patients and second-look ultrasound detects a corresponding ultrasound alteration in about half of cases, allowing the performance of a US-guided biopsy. In the case of an MR-only lesion, MR-guided biopsy is mandatory. We present a case of CUPAx in which contrast-enhanced spectral mammography (CESM) is used to help the detection of occult breast cancer and to guide stereotactic vacuum breast biopsy (VABB). CESM is a new breast imaging technique that is proving to have good performance in breast cancer detection and that is showing potential in the identification of occult breast cancer in a CUPAx setting. The use of an innovative and personalized breast imaging approach in breast cancer patients improves diagnostic possibilities and promises to become the focus in decision strategies.

Nomogram for Predicting the Overall Survival and Cancer-Specific Survival of Patients with Occult Breast Cancer: A Population-Based Study

Background: Occult breast cancer is a rare breast tumor, whose prognostic nomogram model has not been established. Thus, we aim to develop and validate a nomogram for evaluating the overall survival (OS) and cancer-specific survival (CSS) of patients with occult breast cancer. Methods: Between 2004 and 2015, 704 eligible occult breast cancer patients were screened from the Surveillance, Epidemiology, and End Results (SEER) database using specific inclusion and exclusion criteria and then included in the surveillance. They were randomly divided into a training cohort (n = 494) and a validation cohort (N = 210). Univariate and multivariate Cox analyses were performed to explore independent prognostic factors and establish two survival-related nomograms. Area under the curve (AUC), consistency index (C index), internal and external validation calibration curve, decision curve analysis (DCA), Kaplan-Meier analysis, and subgroup analysis were used to evaluate the nomogram. Results: A total of seven variables were considered to be independent prognostic factors for overall survival (OS) and cancer-specific survival (CSS): age, chemotherapy, radiotherapy, Progesterone receptor (PR) status, N stage, number of lymph node examinations, and number of positive lymph nodes. In the training cohort, the OS nomogram-predicted AUC for three, five, and ten years were 0.792, 0.775, and 0.783, respectively, while those of the CSS nomogram were 0.807, 0.817, and 0.812, respectively. The calibration chart showed excellent agreement between the actual and the nomogram-predicted survival rates in both the training and validation cohorts. The C-index values ​​of the OS nomogram in the training and validation cohorts were 0.762 and 0.782, respectively, while those ​​of the CSS nomogram were 0.786 and 0.816, respectively. DCA and subgroup analysis proved the usefulness of nomograms. Conclusion: The developed nomogram provided a comprehensive visual model of the risk of each prognostic factor. It can be conveniently used as a personalized prediction tool for the prognosis of occult breast cancer patients.

Occult breast cancer. Literature review and case series

Background. Currently, there are several forms of breast cancer (BC): nodular, diffuse, edematous-infiltrative, mastitis-like form, as well as Paget’s cancer. A special form of BC is the hidden or occult form. Taking into account the analysis of methods for the diagnosis and treatment of occult BC, it is important that this form of the disease is detected at a later stage. It includes axillary lymphadenopathy and histologically appears to be a metastatic lesion of the lymph nodes from undetectable invasive BC.Materials and methods. We conducted a thorough analysis of domestic and foreign literature and described two clinical examples with authentic documentation of the results of the examination and treatment. The article describes in detail the schemes of drug treatment and descriptions of the results of morphological examination of the surgical material.Results. Given the complexity of the diagnostic stage, the clinical form of the course of diseases, the described clinical examples can be attributed specifically to the occult form of BC. An important and determining factor in treatment is the diagnostic stage using all possible methods, including positron emission tomography–computed tomography, breast magnetic resonance imaging and trepan-biopsy of regional lymph nodes, followed by the determination of the molecular biological subtype of the tumor.Conclusions. In this article, the presented data confirm the general statement about the uniqueness of this disease, which requires a more detailed and multidisciplinary approach at the stage of diagnosis and determination of treatment tactics.