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A small axillary nodule—a therapeutic dilemma?

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Q1: What is the significance of an axillary nodule in an elderly patient?

In an elderly patient, an axillary nodule may be a metastatic deposit from a known or unknown primary tumour. Axillary lymph node metastasis other than breast cancer, especially in males, includes lung, thyroid, gastric, colorectal, and pancreatic malignancy; however, in females the commonest is ipsilateral breast cancer.1

Q2: What should be the diagnostic modality in a case of axillary nodule?

A suspicious nodule (particularly in an elderly person) should always have a histopathological diagnosis by FNAC and/or histopathology.

Q3: What is the treatment modality in a case of axillary nodule with occult metastasis?

Once diagnosed, routine haematological and biochemical investigations, chest radiography, ultrasonography of the abdomen, and bilateral mammography are undertaken. Additional investigation to locate the exact site of primary tumour is unrewarding.2In most of the series on this subject, the sensitivity of mammography in the identification of the occult lesion is as low as 33%.3 Magnetic resonance imaging (MRI) may be helpful; however, the absence of abnormality on mammography and MRI does not exclude the diagnosis of primary breast cancer. A bone scan may be done as a part of metastatic work up.

Total mastectomy and axillary clearance are practised by the majority of surgeons.4 Recently some surgeons have suggested conservative surgery with or without radiation therapy.5 Ellerbroek et altreated such patients with irradiation alone and showed a 17% five year actuarial risk for locoregional recurrence.6Advantages claimed are that the breast is preserved and survival is comparable to total mastectomy. The presence of extensive tumour burden and multifocality, even when the disease is clinically occult, may limit breast conservation therapy as it may not be feasible to excise the primary or deliver a boost dose of radiotherapy to the primary site. Moreover, in the absence of details of the primary tumour and lymph nodal status, it is not possible to evaluate tumour characteristics and prescribe adjuvant treatment.

Q4: What are the various histopathological considerations in such a case?

The pathologist should be alerted to the occult primary in the breast as more sections may be required to locate the tumour. A primary tumour is identified only in 64%–93% as reported in various series.6 Infiltrating duct carcinoma is the commonest tumour, while carcinoma in situ is seen in 8%–20% of cases.3 Rosen and Kimmel reported median tumour size of 1.5 cm (0.1–6.6 cm).7 Baron et al had noted 45% of their cases to be multifocal.3A study of hormone receptors may be helpful in confirming the diagnosis as it is positive in 50%–60% of the cases and a negative result does not exclude breast carcinoma.3 A positive result can also be seen in other malignancies like renal cell carcinoma, melanoma, and colorectal carcinoma.

Discussion

In 1907, William Steward Halsted first described two patients with extensive carcinomatous involvement of the axilla caused by occult breast cancer.8 The incidence of occult carcinoma with axillary nodal metastasis varies from 0.35% (35 out of 10 014 patients) at the Memorial Sloan-Kettering Cancer Center to 0.5% (60/12 000) at the National Cancer Institute in Milan.3

The commonest cause in females is ipsilateral breast cancer. No investigations can identify an occult primary lesion with accuracy. Total mastectomy and axillary clearance, conservative surgery with or without radiation, and primary radiation therapy are the various options available in elderly patients. Total mastectomy and axillary clearance are undertaken especially in patients where frequent follow up is not possible and the patient does not opt for breast conservation treatment. Since studies have shown significant survival advantage in patients with stage II breast cancer after adjuvant therapy, patients with occult carcinoma metastatic to the axilla should be treated as stage II disease and hence adjuvant systemic therapy instituted.

Learning points

  • A small axillary nodule in an elderly woman can be metastatic tumour.

  • A primary tumour is usually found in the breast; however, at times the primary tumour may be occult.

  • Total mastectomy and axillary clearance are undertaken in the case of an occult primary in the breast with lymph node metastasis where frequent follow up is not possible and the patient does not opt for breast conservation therapy.

  • At times, the primary site is not detected even on histopathological examination and such cases remain a therapeutic dilemma.

In an elderly postmenopausal patient only tamoxifen should be given as a treatment option especially in the case of an occult or small oestrogen receptor positive primary.

In our patient, no primary focus could be detected in the large number of sections that were studied, although it is not possible for us to completely rule out the presence of a small focus in the unexamined parts of the breast. The axillary metastasis was in the centre of the axilla in the subcutaneous tissue with no metastatic deposit found in the lymph nodes. It is difficult to predict whether the tumour was present in ectopic breast tissue or part of the axillary tail or it was an occult primary in the breast with metastasis to subcutaneous axillary tissue. Carcinoma has also been reported to arise primarily in the ectopic breast tissue inclusions present in an axillary lymph node.9 Our case demonstrated metastasis in the subcutaneous tissue, a rare event. This case gives an important message; however small a small nodule may be, especially in an elderly patient, it should not be ignored.

Final diagnosis

Metastatic axillary nodule with occult breast cancer.

References

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