Neoadjuvant Chemotherapy in Occult Breast Cancer: A Case Report

Yıl 2023, Cilt: 2 Sayı: 2, 105 - 109, 19.06.2023

Cem Karaali , Hüseyin Esin , Emel Ebru Pala , Enver İlhan

https://doi.org/10.57221/izmirtip.1212817

Öz

Aim: Occult breast cancer is a clinical condition that is detected by metastasis of breast cancer to the axilla (rarely to distant organs) without a detectable tumor in the breast. Modified radical mastectomy is the most common treatment for patients with occult breast cancer. Neoadjuvant chemotherapy was started as the initial treatment in order to avoid mastectomy and axillary dissection due to the patient's young age and the patient's preference. For this reason, we aim to discuss the diagnosis, treatment and follow-up options of occult breast cancers in the current literature. Case: In the physical examination of a 38-year-old female patient who noticed a mass in the right armpit and admitted to the outpatient clinic, a firm and non-fixed mass of approximately 2 cm was found in the right axillary region of the patient. On ultrasound, two pathological lymphadenopathies with a size of 14x11 mm and 10x7 mm in the right axilla without fatty hilum were observed. Pathological examination revealed 'carcinoma metastasis' in the lymph node. Magnetic resonance imaging of the breast was performed to cross out occult breast cancer diagnosis. Magnetic resonance imaging report revealed two lesions with suspicious primary focus in the right breast, but multiple metastatic lymphadenopathy in the right axilla, although they were not typically malignant. The patient was discussed at the multidisciplinary breast cancer council and neoadjuvant chemotherapy was started. Axillary lymph node dissection was performed after neoadjuvant chemotherapy. Radiotherapy was used for the right breast and axillary region in the postoperative period. Conclusion: In order to exclude the diagnosis of occult breast cancer , breast magnetic resonance imaging methods should be applied in addition to classical imaging methods such as ultrasound and mammography . These patients should be evaluated in multidisciplinary councils. In addition, it should be kept in mind that patients diagnosed with ocult breast cancer may be told that, apart from modified radical mastectomy, there are more conservative treatments that protect the breast and axilla with the application of neoadjuvant chemotherapy beforehand, and it may be an appropriate approach to include the patient in the choice of treatment.

Anahtar Kelimeler

Breast cancer, axilla, neoadjuvant chemotherapy

Okult Meme Kanserinde Neoadjuvan Kemoterapi: Bir Olgu Sunumu

Öz

Amaç
Okult meme kanseri, memede saptanabilen bir tümör olmaksızın meme kanserinin aksillaya (nadiren de uzak organlara) metastazı ile saptanan klinik bir durumdur. Okult meme kanserli hastalara en sık uygulanan tedavi modifiye radikal mastektomidir. Hastanın yaşının genç olması ve hastanın da tercih nedeni ile hastamıza mastektomi ve aksiller disseksiyondan kaçınabilmek için başlangıç tedavisi olarak neoadjuvan kemoterapi başlandı. Bu nedenle sunduğumuz olguda güncel literatür eşliğinde okult meme kanserlerinin tanı, tedavi ve takip seçeneklerini tartışmayı amaçlıyoruz. Olgu: 38 yaşında sağ koltuk altında kitle fark ederek polikliniğe başvuran kadın hastanın yapılan fizik muayenesinde hastanın sağ aksiller bölgesinde yaklaşık 2 cm.’lik sert, fikse olmayan bir kitle saptandı. Ultrasonda sağ aksillada 14x11 mm ve 10x7 mm boyutlarında yağlı hilusu gözlenmeyen patolojik görünümlü iki adet lenfadenopati izlendi. Patolojik inceleme lenf nodunda, ‘karsinom metastazı’ olduğunu ortaya koydu. Okult meme kanserini dışlayabilmek için memeye manyetik rezonans görüntüleme yapıldı. Manyetik rezonans görüntüleme raporunda tipik malign nitelikte olmamakla beraber sağ memede primer odak kuşkulu iki adet lezyon ve sağ aksillada multipl metastatik lenfadenopati saptandı. Hasta multidispliner meme kanseri konseyinde görüşülerek neoadjuvan kemoterapi başlandı. Neoadjuvan kemoterapi sonrası aksiller lenf nodu diseksiyonu uygulandı. Postoperatif dönemde sağ meme ve aksiller bölgeye radyoterapi verildi. Sonuçlar:Okult meme kanseri tanısının dışlanabilmesi için hastalara ultrason ve mammografi gibi klasik görüntüleme yöntemlerine ek olarak mutlaka meme manyetik rezonans görüntüleme eklenmelidir. Bu hastaların multidisipliner konseylerde değerlendirilmesi gerekmektedir. Ek olarak okult meme kanseri tanısı konan hastalara modifiye radikal mastektomi dışında, öncesinde neoadjuvan kemoterapinin uygulanması ile meme ve aksillanın korunduğu daha konservatif tedavilerin de olduğu anlatılarak tedavi seçimine hastanın da dahil edilmesi uygun bir yaklaşım olabilir.

Anahtar Kelimeler

Meme kanseri, aksilla, neoadjuvan kemoterapi.

Kaynakça

• Referans1. Zhang Y, Di Wu BZ, Tian X-L, Yao T-C, Li F, Liu W-F et al. Application of neoadjuvant chemotherapy combined with anlotinib in occult breast cancer: a case report and review of literature. World J Clin Cases. 2021;9:919.
• Referans2. Kebudi A. Occult breast cancer. J Breast Health. 2013;9:118-24.
• Referans3. Cohen BL, Collier AL, Kelly KN, Goel N, Kesmodel SB, Yakoub D et al. Surgical management of the axilla in patients with occult breast cancer (cT0 N+) after neoadjuvant chemotherapy. Ann Surg Oncol. 2020;27:1830-41.
• Referans4. Rueth NM, Black DM, Limmer AR, Gabriel E, Huo L, Fornage BD et al. Breast conservation in the setting of contemporary multimodality treatment provides excellent outcomes for patients with occult primary breast cancer. Ann Surg Oncol. 2015;22:90-5.
• Referans5. Gradishar WJ, Moran MS, Abraham J, Aft R, Agnese D, Allison KH et al. Breast Cancer, Version 3.2022, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw. 2022;20:691-722.
• Referans6. Ofri A, Moore K. Occult breast cancer: Where are we at? Breast J. 2020;54:211-5.
• Referans7. Brill KL, Brenin DR. Occult breast cancer and axillary mass. Curr Treat Options Oncol. 2001;2:149-55.
• Referans8. Kemeny MM, Rivera DE, Terz JJ, Benfield JR. Occult primary adenocarcinoma with axillary metastases. Am J Surg. 1986;152:43-7.
• Referans9. De Bresser J, De Vos B, Van der Ent F, Hulsewe K. Breast MRI in clinically and mammographically occult breast cancer presenting with an axillary metastasis: a systematic review. Eur J Surg Oncol. 2010;36:114-9.
• Referans10. Haupt HM, Rosen PP, Kinne DW. Breast carcinoma presenting with axillary lymph node metastases. An analysis of specific histopathologic features. Am J Surg Pathol. 1985;9:165-75.
• Referans11. Grundfest S, Steiger E, Sebek B. Metastatic axillary adenopathy: use of estrogen receptor protein as an aid in diagnosis. Arch Surg. 1978;113:1108-9.
• Referans12. Macedo FIB, Eid JJ, Flynn J, Jacobs MJ, Mittal VK. Optimal surgical management for occult breast carcinoma: a meta-analysis. Ann Surg Oncol. 2016;23:1838-44.