WOMEN WITH AXILLARY LYMPH NODE METASTASES AND PERITONEAL CARCINOMATOSIS
Metastatic breast cancer should be suspected in women who have axillary lymph node involvement with adenocarcinoma, particularly when other metastatic sites are not evident. In these patients, pathologic evaluation of the initial lymph node biopsy should include staining for oestrogen and progesterone receptors and for HER-2 expression; elevated levels provide strong evidence for the diagnosis of breast cancer.
When no other metastases are identified, these women should be treated as if they had stage II breast cancer, which is potentially curable with appropriate therapy. Modified radical mastectomy identifies a breast primary site in 44% to 82% of women even when the breast examination and mammographic findings are normal. Axillary lymph node dissection followed by radiation therapy to the breast appears to give results similar to those of mastectomy, although these two options for primary therapy have not been compared directly. Adjuvant systemic therapy should follow standard guidelines for the treatment of women with stage II breast cancer.
WOMAN WITH PERITONEAL CARCINOMATOSIS
Adenocarcinoma involving the peritoneum in women usually originates from the ovary, although carcinomas arising in the GI tract or breast can occasionally produce this syndrome. However, diffuse peritoneal carcinomatosis occasionally occurs in women who have histologically normal ovaries or who have had a previous bilateral oophorectomy. The peritoneum is frequently the only site of tumour involvement, and serum CA-125 levels are usually elevated. When histologic features suggest ovarian cancer, this syndrome has been called peritoneal papillary serous carcinoma or primary extraovarian serous carcinoma.
Even when the histologic features are not typical, women with adenocarcinoma of unknown primary site involving the peritoneum often have cancers with biologic characteristics similar to those of ovarian cancer. Treatment of these patients should follow guidelines for stage III ovarian cancer. When feasible, a full laparotomy with maximal surgical cytoreduction should be performed followed by combination chemotherapy with a taxane/platinum–containing regimen. Measurement of serial serum CA-125 levels provides an accurate assessment of the efficacy of treatment. A few of these patients may have complete responses and long-term survival, particularly when initial surgical cytoreduction leaves minimal residual disease. A similar syndrome of peritoneal carcinomatosis that is responsive to chemotherapy for ovarian cancer has rarely been reported in men.