br Discussion Rarely a breast cancer patient has histologica

Discussion Rarely, a breast cancer patient has histologically proven breast cancer found outside the breast without a detectable primary breast tumor. Almost always the site of detected disease is an axillary lymph node. The incidence of axillary breast cancer with occult primary is relative low, with a peak incidence at the age of 55 years [1,2]. Malignant tumors from other sites like lung, thyroid, gastrointestinal tract, ovary etc. also can spread to axilla, however, the most common source of primary tumor is the ipsilateral breast, unless proven otherwise [2,3]. Diagnosis and treatment remain challenging in these patients. Relevant anamnesis to rule out other sites of malignancy and mastectomy with axillary clearance are usually recommended [2,3]. Historically, 20–30% with occult primary breast cancer have reported a family history of breast cancer, although this was not the case in our patient [4]. Diagnostic workup for an axillary metastasis must first rule out other primary sites of disease. Emi et al. [5] have reported that in a female patient in such situation, investigations other than related to breast cancer are unnecessary. A thorough history taking, physical examination, fine needle aspiration order zip of the palpable axillary lymph node, chest X-ray, ultrasound of the abdomen, screening blood work, mammogram and/or MRI of the breast are sufficient as the recommended diagnostic tools for locating potential sites of primary carcinoma [6]. Imaging of the breast for occult primary breast cancer includes breast ultrasound and MRI. MRI\'s high sensitivity for breast tumors may optimize diagnostic accuracy and, in turn, disease management [7]. Estrogen and progesterone receptor status with estimation of HER2/neu are very useful to classify the tumor with a molecular criterium that is useful for diagnosis and to plan the treatment [8]. Traditionally occult primary breast cancers were treated with mastectomy and axillary lymph node dissection; however, with the advent of breast MRI and improvement in radiation techniques, the management of this rare entity is changing [9]. If a primary site is identified, the patient should undergo appropriate surgical management with a lumpectomy or mastectomy with lymph node evaluation. Occult primary breast cancer has traditionally been treated with ipsilateral mastectomy and axillary lymph node (ALN) dissection [9,10]. In terms of definitive therapy for occult primary breast cancer, breast conserving therapy (BCT) or mastectomy with ALND provides equivalent survival and recurrence outcomes, and the practice of BCT is steadily increasing. Khandelwal and Garguilo [11] reported 50% recurrence rate when the axilla is treated only with radiotherapy in comparison to axillary dissection (<10%). ALN biopsy (without formal axillary dissection) followed by RT to axilla also showed higher recurrence (20–50%) as well. They concluded that ALN dissection as an essential component for better loco-regional control of disease for such patients. In case of fixed unresectable ALN, neoadjuvant chemotherapy and hormone therapy depending on hormone receptor status followed by ALN dissection could be a valid option [11–13]. We emphasize that aggressive approach and detail clinical history with thorough examination should be undertaken, in a woman with metastatic adenocarcinoma in the ALN.
Conflict of interests
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