Axillary node metastases with occult primary breast cancer
- Virginia Kaklamani, MD, DSc
Virginia Kaklamani, MD, DSc
- Professor of Medicine
- Leader, Breast Oncology Program
- CTRC, University of Texas Health Science Center San Antonio
- William J Gradishar, MD
William J Gradishar, MD
- Professor of Medicine
- Feinberg School of Medicine
- Northwestern University
- Section Editors
- Daniel F Hayes, MD
Daniel F Hayes, MD
- Section Editor — Breast Cancer
- Professor of Medicine
- University of Michigan School of Medicine
- Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
- Section Editor — Breast Surgery
- Associate Professor, Department of Surgery
- Yale University School of Medicine
Cancer of unknown primary site (CUP), defined as the presence of metastatic cancer with an undetectable primary site at the time of presentation, is not a common clinical entity. Although the exact incidence is difficult to ascertain, CUP accounted for 2 percent of all cancer diagnoses in the Surveillance, Epidemiology and End Results (SEER) registries between 1973 and 1987 .
Within the category of CUP, tumors from many primary sites with varying biologic behavior are represented. Approximately 70 percent are adenocarcinomas, 15 to 20 percent are poorly differentiated carcinomas, and an additional 10 percent represent poorly differentiated adenocarcinomas. The remainder are squamous cell, neuroendocrine, or poorly differentiated neoplasms. (See "Overview of the classification and management of cancers of unknown primary site".)
The prognosis for most patients with CUP is poor. However, substantial improvements have been made in treating some subsets. The identification of specific subgroups of treatable patients has been made possible by the development of specialized immunohistologic techniques that can aid in tumor characterization (table 1) and by the recognition of several clinical syndromes that are predictive for a durable response to systemic therapy.
One such subgroup consists of women (rarely men) who have adenocarcinoma or poorly differentiated carcinoma in the axillary lymph nodes and who have no evident primary breast lesion or distant disease spread after completion of the routine staging evaluation. Such patients are potentially curable when managed according to standard guidelines for anatomic stage II breast cancer.
This topic review will focus on the treatment of women with adenocarcinoma or poorly differentiated carcinoma in axillary nodes who do not have an evident primary breast cancer. The identification and management of other subgroups of patients with CUP is discussed in detail elsewhere, as is the general approach to neoplasms of unknown primary site. (See "Adenocarcinoma of unknown primary site" and "Overview of the classification and management of cancers of unknown primary site".)
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- INCIDENCE AND DIFFERENTIAL DIAGNOSIS
- Differential diagnosis
- INITIAL DIAGNOSTIC WORKUP
- - Immunohistochemistry
- Breast examination and mammography
- Breast MRI
- MANAGEMENT OF PATIENTS WITH NORMAL IMAGING WORKUP
- Completion of the staging workup
- Locoregional treatment
- - Mastectomy
- - Radiation
- - Observation only
- Adjuvant systemic therapy
- Postmastectomy chest wall RT
- METASTATIC DISEASE
- SUMMARY AND RECOMMENDATIONS