Metastases
to the Breast
Erlinda
S. McCrea1
Curtis Phillip
Johnston2 J. Haney1
Metastases to the breast are uncommon, with about 250 cases reported from clinical and autopsy series. The mammographic findings In 1 6 new cases revealed a spectrum of changes that Included solitary or multiple lesions, well demarcated or poorly marginated masses, and diffuse involvement of skin or parenchyma or both. Diffuse disease was seen more frequently in this series (4/ 1 6), at times simulating Inflammatory breast cancer. Although diagnosis of a primary malignancy usually preceded detection of the breast lesion, 40% (6/16) had no history of malignancy. Prognosis remains poor; however, it has improved in the lymphoma-leukemla group due to Improved Immunotherapeutic and chemotherapeutic regimens. The clinical, radlologic, and pathologic features are discussed. Some of the lesions encountered can be confused with a primary breast malignancy or a benign lesion, necessitating prompt and accurate biopsy to preclude unnecessary major surgery and to improve survival In cancers amenable to current therapy.
Diagnosis and management of metastases to the breast is an uncommon clinical problem but one that can present difficulties to the radiologist and oncologist. We undertook a retrospective review of patients with documented breast metastases to evaluate the findings on mammography and to assess their significance with regard to prognosis and patient management.
Materials
Review disclosed
and
of
Methods
records from our and mammograms with patients from pathologic January or no history clinical 1 975 to proof August of 1982
clinical
1 6 patients
institution
metastatic
disease
University
to the
breast.
Ten
Cancer
patients
Center.
were
Six
known
cancer
had
patients
being
treated
disease
in the
and
of Maryland
of malignant
the breast abnormality was the first presentation of an extramammary malignancy. All 1 6 patients had xeromammograms, with craniocaudad, contact lateral, and optional axillary views. Pathologic proof was obtained by biopsy in nine patients, autopsy in five patients, biopsy of associated skin nodules in one patient, and clinical remission of the breast abnormality after local radiotherapy in one patient.
Results The
Received
revision June
primary acute
were: acute
four
lymphomas myelocytic),
(two three
four oat
November
7, 1983.
29,
1 982;
accepted
after
(two
Department of Diagnostic Radiology, University of Maryland Hospital, 22 S. Greene St., Baltimore. MD 21201. Address reprint requests to E.
one cholangiocellular carcinoma of the of the left tonsil, one malignant mesothelioma adenocarcinoma, and one highly anaplastic
S. McCrea.
2Department land Hospital, of Pathology. Baltimore, University of MaryMD 21201.
AJR 141:685-690,
adenocarcinoma (origin from lung, cervix, or breast). The metastases appeared on the average 1 .9 years after diagnosis of the primary malignancy. There were 15 women and one man. Metastatic disease was present elsewhere in 14 patients when the breast lesions were discovered. Six of these 14 patients had no history of malignancy.
686
McCREA
ET
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AJR:141,
October
1983
Fig.
1 .-Xeromammogram.
Large
.-:
area of asymmetry occupying 40% of left breast from proven oat cell carcinoma of lung.
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Signs
and
symptoms
included
pain,
tenderness,
inflam-
breasts of pain
fort, especially those with diffuse involvement. Ten patients had painless masses that were usually solitary and either well limited or poorly marginated clinically. Axillary adenopathy was present in seven patients; six patients had supraclavicular adenopathy. Two of these seven patients had both axillary and supraclavicular adenopathy. The left breast was involved in seven patients was noted lymphoma, was positive and the right breast in five. Bilateral involvement leukemia, one with noma of the lung. Mammography patients discerned in four patients, two with and one with adenocarciin 1 3 patients. The three not be post-
None demonstrated any calcifications or spiculations. Asymmetry of breast architecture was noted in one patient with metastatic oat cell carcinoma, with the abnormality occupying 40% of one breast (fig. 1 ). Two young patients (20 and 26 years) had poorly marginated masses in one breast, one due to Hodgkin disease and the other leukemia. One patient had right axillary and upper increased density. Biopsy revealed Hodgkin outer quadrant disease.
One patient had diffuse increased parenchymal density of the breast (prior contralateral mastectomy for malignant melanoma) secondary to diffuse histiocytic lymphoma. Eleven patients died within 1 2 months or less with dissemmated metastases. Three patients died within 1 3 months or less, due to diffuse hemorrhage in a patient with acute myelocytic leukemia, adriamycin-induced congestive heart failure in a patient with pergillosis in a patient None of the last Two three had at autopsy. patients, diffuse lymphoma, and with acute lymphocytic evidence with of their primary and Hodgkin leukemia diffuse asleukemia. disease dis6 years malignancy.
partum (one). Their diagnoses were kemia, diffuse histiocytic lymphoma, leukemia, respectively. Four similar thought diagnoses patients had to inflammatory clinically were diffuse skin carcinoma cell
lymphocytic leuacute myelocytic of one breast breast and were cancer. tonsil The and of the
to have squamous
inflammatory carcinomas
breast
ease, are currently well and after discovery of their primary Four patients in this report
of the lung, and pancreatic and mas. A fifth patient demonstrated thickening cinoma patients mammary There ing benign responsible
anaplastic localized
in one breast, from proven cholangiocellular carof the liver. The breast lesion in the last three was the first manifestation of an unknown extraprimary. were four nodular lesions in three patients simulatdisease. Mesothelioma for solitary nodules. and leukemia were The other two nodules each were
Two patients had a history of cervical cancer several years earlier; one with stage I disease developed highly anaplastic adenocarcinoma, oped squamous diffuse metastases with cholangiocellular lungs, thyroid and liver follicular and the other cell carcinoma involving the carcinoma at autopsy, carcinoma. with stage II disease develof the lung. Both died with breasts. The third metastatic to the patient, breasts,
AJR:141,
October
1983
METASTASES
TO
THE
BREAST
687
of carcinoma.
B. Photomicrograph
(H
and
E,
of mammary
ductules.
Fig.
3.-Case
2. A, Xeromammogram.
Diffuse
permeation
by poorly
differentiated
squamous
breast
carcinoma.
B, Photomicrograph
(H and E. x490).
Lymphatic
histiocytic
lymphoma,
stage
IVA,
with
three
recurrences
Lymphoma
recurred
in the
mediastinum
with
over a 31/3-year period. During the second recurrence, a left breast mole was discovered and diagnosed as malignant melanoma, Clarks level Ill, necessitating mastectomy and
into the right breast. She also developed central system metastases from melanoma and eventually
688
McCREA
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AJR:141,
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1983
Representative Case 1
Case
Reports
lesion. Biopsy disclosed metastatic mesothelioma (fig. rence in the left chest and in the same breast occurred patient died 1 year after diagnosis of the breast mass.
without any known exposure
A 51-year-old
woman,
a nonsmoker
to asbestos, had left chest pain and dyspnea on exertion. Chest radiographs revealed left pleural effusion, and thoracentesis disclosed malignant mesothelioma. Appropriate therapy produced an apparently good response. A year later a freely movable, nontender left breast lump was noted. The mammogram suggested a benign
Case 2 A 60-year-old
carcinoma of the
woman
left
was diagnosed
stage
as having
poorly
squamous
differentiated,
cell
tonsil,
IV T2N3,
with metastases to the left neck and left axilla. Partial remission was obtained with two chemotherapeutic regimens and radiotherapy
over a 9-month period. She then complained of firmness and
tenderness in her left breast. Clinical and mammographic suggested inflammatory breast cancer (fig. 3). Chest were normal. Biopsy revealed metastatic disease. months later despite aggressive chemotherapy. Case 3
#{128}:
A 55-year-old woman noted nontender lumps in both breasts and axillae for 3 months. Biopsy of the right axilla revealed Hodgkin disease, stage IV, of mixed cellularity. Mammograms obtained 3 days after axillary biopsy revealed increased density in the upper outer quadrant and axilla. The second rib had a lytic lesion (fig. 4). Aadionuclide bone scan was positive in the rib, right breast, and
axilla. Two chemotherapeutic regimens produced a good response;
the patient
p5L
is currently
in clinical
remission
6 years
later.
1.
Case 4 A 26-year-old
cytic leukemia,
woman
and
was diagnosed
as having
acute
lymphowas insti-
intravenous
methotrexate
therapy
I, #{149}r
tuted. Four months later, she incurred trauma to her right breast with a resultant lump developing. She had not noted a lump before the trauma. Right axillary nodes were palpable. Mammography revealed a large, poorly marginated mass deep within the breast
(fig. 5). The differential management considerations were hematoma and leu-
4.-Case
3. Xeromammogram.
Increased
and axilla
of right
breast.
residual
Lytic
lesion
of second
arrowheads).
density
kemic
Further
infiltrate.
An absence produced
of clinical
prompted
change
biopsy,
2 weeks
disclosing
later under
a chloroma.
conservative
Postbiopsy
air (small
Biopsy
revealed
Hodgkin
clinical
remission
Fig. 5.-Case 4. Xeromammogram. Large, asymmetric, poorly marginated mass deep within right breast (arrowheads). Biopsy revealed acute lymphocytic leukemic infiltrate.
AJR:141,
October
1983
METASTASES
TO
THE
BREAST
689
Discussion
had
no
history
of malignancy.
All
patients
died
within
12
months or less after discovery ofthe breast lesion, indicating the lethal nature of blood-borne metastases. This is conBreast plasms from from clinical 1 .2% involvement is distinctly by unusual, extramammary with about 250 malignant cases neoreported firmed The by other final type series [1 -4, 10-12]. is hematologic, myeloma systemic comprising [5, 8, 9]. The first process, although Mambo of the breast of metastasis and rarely of a diffuse
Iymphoma, leukemia, two are usually part infrequently et al. [8] breast tumors Tumor actuarial range reported malignant they reported
or exclusion of the leukemiaseries and the increased mciseries. Because of the rarity
occur as a primary breast tumor. 1 4 cases of primary lymphoma representing 0.12% of all malignant at M. 0. Anderson 5-year survival rate, 1 4 patients to 1 2 years. lymphoma breast. more Hodgkin rare [5,
in 1977
and unusual clinicopathologic characteristics of these metastases, it can be difficult to make adequate diagnoses clinically and histologically [1 , 4]. This is particularly true if the breast abnormality is the first presentation of an unknown extramammary Cancers metastatic sharply limited, solitary
,
in a 32-year period Institute. The total methods, of survival five breast cases lymphoma primarily for was
1 3 of the 3 months
in 1 2 patients
breast with
are
often
a predilection
ing the
Multiple lesions, bilateral are less common. Pain, usually of 51 complained absent, cases, of although stated pain that and in the is encan
Eight patients They included phoma younger the age (two), age
in our series had Hodgkin disease and group, leukemia mostly of lymphoma (four). in the
hematologic malignancies. (two), non-Hodgkin lymThe fourth patients decade, Six were in a reflecting patients
discharge
],
in a report patients
incidence
and
leukemia.
changes often
died within 1 1 months or less. Three of these had disseminated disease, one believed secondary to noncompliance with therapy other three evidence for nodular sclerosing Hodgkin disease. The died of complications related to therapy without primary disease. The final two patients are
be more difficult
nosis usually can
breast
cancer.
Diagbiopsy
of their
frozen-section
examination, although infrequently it may be necessary to perform detailed examination of the entire excisional biopsy material to arrive at a correct diagnosis [1 , 7]. Histologically, one noma looks and/or for tumor periductal cells lobular to make and/or in the carcinoma a histologically perilobular absence in situ distribution carcitype-speto avoid to the therbeen [1 ]. It is of utmost and of malignant importance of intraductal correct
alive and well 6 years later. The radiographic appearance varied greatly, including a solitary nodule, poorly marginated masses in one breast, and diffuse parenchymal involvement. Three young patients had no detectable abnormality, two of whom were pregnant and known to one immediately to cause diffuse glandular postpartum. increased proliferation in very of these
Both that
conditions tends
excessive
cific identification of the primary unnecessary major surgery and extramammary apy then can established. Metastasis (metastatic Hematologic blood-borne neoplasm be initiated can occur
entire breast, resulting graphically [1 3]. One chymal normal pregnancy involvement architecture changes
cifications secondary to metastatic ovarian cancer, ing psammoma bodies [5, 1 4, 1 5]. The presence nizable calcifications in a mass on a mammogram excludes metastatic also distinctly absent of metastatic desmoplasia Four of Mcintosh cancers associated our et al. patients [1 6], disease to the breast. from the mammographic to the breast, since with these lesions. had more than of 4,1 47 one in a report
source
of blood-
of frequency. gastrointestinal
malignancy. primary
metastases radiographic
treated
finding
diffuse skin thickening (four). This is in contradiction other series, which describe nodular lesions as more mon [1-6]. The histologic type of primary malignancy series may account cells permeating the in diffuse involvement, nodules, one case one case of focal for this discrepancy, lymphatics and blood particularly dermal. of breast Three thickening.
breast tumors, found that 57 patients had a previous extramammary malignancy, and 1 26 patients subsequently developed a second primary malignancy other than in the breast. This suggested that the presence of two primary tumors is not uncommon when one primary tumor metastasizes to the breast [5, 1 5]. The reason for this is unclear. The small number and variety of the malignancies involved in our Future series makes observations any evaluation difficult at may elucidate this association. this time.
with the tumor vessels resulting There were three architecture of these and patients
of asymmetry skin
690
McCREA
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