Breast Cancer in Special Situations.

MRI is negative? Is the management of axillary lymph node metastases in women with CUP the same as for patients with breast cancer? Finally, one has to ask about the systemic treatment. Alwin Krämer and colleagues tried to give answers to all these questions about CUP in general and in specific situations, such as unilateral axillary lymph node involvement [8]. The next review by Sibylle Loibl deals with the increasing problem of breast cancer in pregnancy [9]. With an increase in average age of pregnant women, the coincidence of a breast cancer diagnosis with the patient also being pregnant or nursing has become more frequent. This fact urgently needs to be acknowledged by physicians since the diagnosis of breast cancer is frequently delayed in pregnancy. As a consequence, it is not only recommended that pregnant or nursing women should examine their breast on a regular basis but also that clinical examination of breasts and loco-regional lymph nodes should be part of a routine medical care during pregnancy and nursing period. Moreover, S. Loibl states that also in pregnancy or the nursing period breast imaging (breast ultrasound, mammography) and biopsy should be performed as in nonpregnant patients. Regarding therapy recommendations for pregnant women, Loibl points out some important exceptions, for example, chemotherapy is only possible after the 12th week of pregnancy, therapeutic radiation during pregnancy is contraindicated, and there should be a three-week interval between the last chemotherapy cycle and delivery, since the risk of maternal delivery-associated complications is increased and the newborn may not be able to metabolize potential chemotherapy remainders [2]. It is estimated that worldwide nearly one third of breast cancer patients are older than 65 years. In more developed countries this proportion even rises to more than 40% [10]. The average age of women and along with that the number of breast cancer cases will further increase. For example, in Germany the life expectancy is estimated to rise from currently 81 to 88 Diagnosis and therapy of breast cancer in women are based on randomized clinical trials and determined by consensus conferences, and in recommendations and guidelines [1–4]. However, special situations like breast cancer during pregnancy, in elderly patients, in male patients and carcinomas of unknown primary with first manifestation in the axillary lymph nodes as well as rare histological types of breast tumors are infrequent and mostly excluded in guidelines. Common to all of these ‘special situations’ is that: – each of us will see only very few cases during their professional life, – these rare diseases are frequently not considered in differential diagnosis, – diagnosis and treatment are not standardized, – there are no randomized clinical trials and none will be available in the near future, – although we believe to do the best for our patients, underor overtreatment are very frequent. The focus in this issue of BREAST CARE contains review articles dealing with ‘special situations’ in the diagnosis and treatment of breast malignancies. The current knowledge of carcinomas of unknown primary (CUP) leaves many open questions. For example, which diagnostic procedures are indicated in metastatic involvement of axillary lymph nodes with negative mammography and ultrasound? Magnetic resonance imaging (MRI) of the breast enables identification of an occult breast primary tumor in up to 80% of women who display adenocarcinoma in the axillary lymph nodes [5, 6]. Moreover, is MRI the standard or should one better start with positron emission tomography (PET) scan today [7]? Which primary tumor locations are possible and which perioperative staging examinations are necessary? Also, the appropriate treatment of the breast after an axillary presentation of CUP continues to be a controversial issue. Furthermore, is there an indication for mastectomy and/or mammary irradiation if mammary Breast Cancer in Special Situations