A carcinoma of unknown origin

EG, a 32-year-old female client, discovered a hard, fixed node at the Lt breast-axilla region. The lump was very small but, because it was not mobile and it was in an atypical position for a fibroadenoma, we decided for excision-biopsy.

The U/S confirmed the solid nature of the lump, while both breasts and armpits were negative for other growths or enlarged lymphnodes.

We have done the operation and we have realized that the mass was very attached to the surrounding fat tissue, a situation very unlikely in the case of a fibroadenoma.

Nevertheless the excision was successful and complete.

With surprise the biopsy report was: “invasive carcinoma, high grade. Impossible to state if the site of origin is breast or axillary sweat gland, or if it is a distant metastasis”.

We have therefore readmitted EG in order to find the original site of tumor, and in order to do a staging: EG has in fact declined our proposal to go to an oncologist at Kenyatta National Hospital, because of financial constraints.

The situation has become more and more complicated because EG is in perfect physical shape, she has no complaints, she feels in good health, and all our investigations have been completely negative: breast ultrasound and mammogram were both normal. Chest X-Ray has not found either lung metastasis or a primitive lung tumor. Gastroscopy and colonoscopy were both absolutely normal. At abdominal ultrasound all the examined organs were regular. The superficial ultrasound of neck (to rule out thyroid lumps or cervical lymphnodes) has been normal. The same applies for ultrasound of both armpits and groins: no enlarged lymphnodes. No abnormal findings.

Also the laboratory has not helped us; in fact all the tests were normal, including liver, kidney and pancreatic function tests.

Peripheral blood field was negative for blasts and, together with full haemogram, seems to exclude the possibility of leukemia.

We do not have the possibility of total body bone scintigraphy.

We have therefore decided that:

a)     So far the original tumour remains hidden

b)    We have removed completely the carcinoma and our operation was radical

c)     The biopsy result was wrong.

At the moment we have put EG under strict follow up and we will examine her monthly for possible signs of the hidden malignancy.

If there is any cancer specialist reading this post, I kindly ask him to give me some indication on the way forward, in case there is anything I have missed in my staging.

I thank in advance for any suggestion which may help me on EG.

EG in fact is young and she has small children… and really she deserves to survive.

Bro Dr Joseph Gaido