Rare abdominal metastases from occult lobular breast cancer: report of two cases

Intra-abdominal metastases from breast carcinomas are rarely reported in the literature. Least are those originating from occult breast primary. We report, one case of pancreatic metastasis and one case of metastatic infiltration of the colonic wall, both by occult lobular breast carcinoma. The first patient underwent pancreaticoduodenectomy for obstructive jaundice, with unexpected histological finding of infiltration of distal bile duct, pancreatic gland, portal vein and retroperitoneal soft tissue by lobular carcinoma of the breast. The second patient complained of diffuse abdominal pain associated with constipation and rectal bleeding and underwent endoscopic biopsy of three intestinal strictures, revealing metastatic lobular carcinoma with signet-ring cell morphology. In both cases, a subsequent complete diagnostic work-up demonstrated asymptomatic multiple breast nodules, diagnosed as lobular carcinoma by fine needle aspiration cytology.     

Pancreatic cancer presenting with hematemesis from directly invading the duodenum: report of an unusual manifestation and review

Pancreatic cancer is a rare cause of gastrointestinal bleeding, and it is extremely rare for hematemesis to be the initial manifestation of invasive pancreatic cancer. We report the case of a 67-year-old man with hematemesis who was found to have invasive pancreatic cancer with a bleeding duodenal ulcer. The patient was not icteric, but repeated sudden hematemesis. An urgent pancreatoduodenectomy was performed with a favorable outcome. Microscopic examination revealed that an adenocarcinoma originating from the pancreatic head extended to the muscularis propria of the duodenum. Furthermore, an exposed vessel and narrow fistula were found. The diagnosis, pathological findings, preoperative events, and postoperative outcome in this unusual case are reviewed.     

The Development of New, Primary, Noninvasive Carcinoma of the Breast 29 Years after Bilateral Radical Mastectomy

Abstract: We present the case of a patient with a new, primary noninvasive breast carcinoma arising in residual breast tissue 29 years after radical mastectomy. The patient, a 75-year-old black woman with no family history of breast or ovarian cancer, had undergone left radical mastectomy in 1956 (age 35) and right radical mastectomy in 1965 (age 44). Examination revealed a 3-mm nodule in the right anterior axillary line. On excision, the lesion was a 1.5-mm intracystic papillary ductal carcinoma in situ arising in a background of atypical ductal hyperplasia (representing residual breast tissue). The patient has not agreed to testing for BRCA1 or BRCA2 mutations. The theoretical risk of new primary breast cancers arising in residual breast tissue has been suggested as a reason why prophylactic mastectomy may not be completely effective. This case suggests that even after what appeared to be aggressive radical mastectomy, enough breast tissue remained so that the patient was at risk for recurrent breast cancer.     

The solitary pulmonary nodule in the patient with breast cancer

A solitary pulmonary nodule appearing in a patient with breast cancer, either past or present, is most likely to be a second primary cancer originating in the lung rather than a metastasis from the breast cancer. Between 1970 and 1983 there were at this institution 1416 patients with breast cancer and 579 patients with bronchogenic cancer, 198 of whom were women. Among the patients with breast cancer, 42 (or 3% of all of the patients with breast cancer) had a solitary pulmonary nodule either at the time of presentation of their breast cancer or during the follow-up period. Fifty-two percent of the solitary pulmonary nodules proved to be a primary lung tumor, 5% proved to be benign lesions, and only 43% proved to be metastatic breast cancer. Patients with breast cancer with solitary pulmonary nodules should have a diagnostic workup appropriate for lung cancer. Since adenocarcinoma has become the most common lung cancer cell type, the usual diagnostic tests may not allow a firm differentiation between primary lung and secondary breast cancer. Therefore if malignancy is proved or suspected, thoracotomy with appropriate resection is the treatment of choice in most patients with breast cancer, even at the initial appearance of the breast cancer.     

Rectal cancer metastasis to the head of the pancreas treated with pancreaticoduodenectomy

We report a case of a 50-year-old man who developed metastatic pancreatic cancer from a primary rectal cancer that had been curatively removed 3 years previously. The patient presented with a tumor that occupied the head of the pancreas, associated with obstructive jaundice, but the main pancreatic duct was not dilated. The patient was initially diagnosed as having primary pancreatic cancer. Cytological examination of the bile was conclusive for the presence of adenocarcinoma. The patient refused surgical treatment and chose to have gemcitabine therapy (1000 mg/body), which was given 27 times over 10 months. For 1 year, local disease progression was slow and no distant metastases developed; therefore, the initial diagnosis of pancreatic cancer was questioned. At that time, the patient asked for the tumor to be removed, and pancreaticoduodenectomy was performed. On histology, including immunohistochemical staining for cytokeratin 20 (positive) and cytokeratin 7 (negative), the tumor was shown to be a metastatic pancreatic carcinoma that had originated from the original rectal cancer.     

Metastatic breast cancer spread to peripancreatic lymph nodes causing biliary obstruction

Metastases to the pancreas and peripancreatic lymph nodes (PPLN) are unusual. Metastatic involvement of the PPLN without biliary obstruction, from a primary breast cancer has been published in only a single case in literature. We report the first metastatic breast cancer patient with PPLN deposit, presenting with obstructive jaundice.     

Primary Peritoneal Serous Carcinoma Presenting as Inflammatory Breast Cancer

Abstract:  Metastasis to the breast from extramammary malignancies is rare. Nevertheless, its recognition is important because the prognosis and treatment differ from that of primary breast cancer. We report a unique case of primary peritoneal serous carcinoma that initially presented as inflammatory breast cancer. The patient received neoadjuvant chemotherapy for breast cancer and subsequently underwent bilateral total mastectomy and bilateral sentinel lymph node biopsy. She was found to have extensive intralymphatic carcinoma in both breasts, with only focal minimal breast parenchymal involvement, and residual metastatic carcinoma in bilateral sentinel lymph nodes. Further work-up revealed pelvic ascites and omental nodularities. The patient underwent laparoscopic bilateral salpingo-oophorectomy, which revealed high-grade serous carcinoma involving both ovaries and fallopian tubes. Molecular testing of tumor from the ovary and axillary lymph node showed an identical pattern of allelic loss, confirming a common origin for both tumors. To our knowledge, this is the first reported case of an extramammary primary malignancy that not only presented as inflammatory breast cancer but also was diagnosed and initially treated as such.     

Primary tuberculosis of the breast: a rare cause of a breast lump

Primary tuberculosis (TB) of the breast is a very rare condition. We present a 50-year-old patient who presented with primary TB of the breast. The significance of the radiological findings, the importance of histological diagnosis and treatment, and the possibility of co-existence with breast cancer are discussed.     

Skin Angiosarcoma Arising in an Irradiated Breast: Case-Report and Literature Review

BACKGROUND: Angiosarcoma (AS) is a rare, invasive malignancy originating from endothelial cells caused by many different clinical situations. AS following radiotherapy for breast cancer after conservative surgery is a rare but well-known association. OBJECTIVE: The aim of this article is to describe a case of AS after breast conserving surgery and to review the literature to date. RESULTS: We report the case of an 84-year-old woman who developed AS four years after she was subjected to quadrantectomy for invasive ductal cancer, followed by 30 tangent field radiotherapy sessions. She presented with a one-month history or red papular skin eruptions on the operated breast. Skin lesions were submitted for biopsy, and they were positive for AS. The patients was subjected to surgical excision of the remaining breast including all AS lesions. She is alive with no evidence of disease after 10 months follow-up. CONCLUSION: Post-radiotherapy AS is rare neoplasm, but it should be considered in the case of patients with red lesions after breast conserving surgery and adjuvant radiotherapy.     

Brain metastases from asymptomatic adenocarcinoma of the pancreas: an autopsy case report

BACKGROUND: Brain metastasis from pancreatic cancer is extremely rare. Because pancreatic cancer usually has a rapidly progressive nature, the majority of affected patients die from primary lesions before exhibiting clinical signs suggestive of brain metastases. CASE DESCRIPTION: The patient was a 62-year-old man who developed generalized convulsion followed by right hemiparesis accompanied by decreased consciousness level. Computed tomography (CT) scan revealed multiple brain tumors with ring-like contrast enhancement. Stereotactic biopsy disclosed mucinous adenocarcinoma. A marked increase in the serum CA19-9 level was noted, but the patient did not exhibit any other signs of pancreatic disease. Repeated whole body CT scan and ultrasonography demonstrated no primary lesions. The patient died of multi-organ failure during chemotherapy combined with radiation for metastatic brain tumors. Autopsy revealed well-differentiated papillary adenocarcinoma in the pancreatic head and systemic metastases associated with tumor emboli were widely distributed in various organs. CONCLUSION: This patient initially presented only with symptoms of neurologic disorder and no pancreatic symptoms. Moreover, repeated radiologic examinations did not reveal the primary lesion. We considered that the unusual clinical course in our patient may be partly explained by the autopsy findings: diffuse sclerotic changes of the pancreas without swelling. The present report suggests that undetected pancreatic cancer may have been the primary lesion classified as "unknown origin" in some cases of metastatic brain tumors.     

Metastatic breast cancer to the bladder: A case report

The authors describe a rarely occurring case of extensive infiltration of the bladder wall by primary metastatic adenocarcinoma originating from breast cancer, and give a review of the pertaining literature.     

Patient and Tumor Characteristics Associated with Primary Tumor Resection in Women with Stage IV Breast Cancer: Analysis of 1988–2003 SEER Data

Abstract: Surgery is the cornerstone of treatment for women with nonmetastatic breast cancer. In contrast, standard treatment for patients with Stage IV disease includes chemotherapy and radiation, with surgery usually reserved for local tumor‐related complications. Little is known about the predictive factors associated with primary tumor resection for Stage IV breast cancer. We conducted a retrospective, population‐based, case–control study using the 1988–2003 Surveillance Epidemiology and End Results (SEER) data. Using multiple logistic regression, we identified patient and tumor characteristics from among SEER region, age at diagnosis, year of diagnosis, marital status, race, Hispanic ethnicity, tumor grade, and size that were associated with surgical resection of the primary breast tumor (compared with no surgical resection) among women with stage IV breast cancer. Adjusted odds ratios and 95% confidence intervals are reported. Of 10,017 patients, 4,836 (48%) underwent surgical resection of the primary breast tumor. Patients in the Northeast and Midwest and patients presenting with two or more primary breast tumors were more likely to have surgical resection. Patients who were older, diagnosed after 1992, unmarried, black, and whose tumors were >5 cm, inflammatory, of unknown size, indeterminate grade, or unknown progesterone status were less likely to have had surgical resection of the primary tumor. Several patient and tumor characteristics were significantly associated with surgical resection of the primary breast tumor in Stage IV disease. Further study of the surgery decision‐making process is recommended.     

Pulmonary Metastasis From Breast Cancer With an 18-Year Disease-Free Interval: Implication of the Role of Surgery

The appearance of pulmonary metastasis more than 15 years after primary treatment for breast cancer is rare. We herein report the case of a breast cancer patient with solitary pulmonary metastasis, after an 18-year disease-free period, treated with resection. A 66-year-old Japanese woman was found to exhibit an abnormal shadow on a chest X-ray. She had undergone a left mastectomy for breast cancer 18 years previously. The nodule was suspected to be either metastatic or primary lung cancer, and thus thoracoscopic surgery was performed. The histologic diagnosis was metastasis from breast cancer. Pulmonary resection in breast cancer recurrence is an important diagnostic tool that allows for a differential diagnosis with primary lung cancer. The clinical implication of surgery for a solitary pulmonary metastasis from breast cancer is discussed in this report.     

Defining social support systems for women with breast cancer

BACKGROUND: Providers often assume that a patient relies on the same person for primary support (PS), as emergency contact, and as health care proxy. We questioned how often this is not the case in women with breast cancer. METHODS: We questioned women who were in treatment or follow-up evaluation after a cancer diagnosis who they would name as primary support, emergency contact, and health care proxy. RESULTS: One hundred thirty-five women with breast cancer participated and 75% were married or partnered. More than 40% of women did not name the same person to these distinct roles. Even for women in relationships, almost 50% did not name their partner to all 3 support roles. CONCLUSIONS: A large proportion of breast cancer patients named different persons to these distinct support roles. By further defining the roles that social support networks play, we can identify strategies for including these support providers in the care models for women living with cancer.     

Incidence of additional primary cancers in patients with invasive intraductal papillary mucinous neoplasms and sporadic pancreatic adenocarcinomas

BACKGROUND: Recent small studies have reported an incidence of 23% to 39% for additional primary cancers in patients with intraductal papillary mucinous neoplasms (IPMN) of the pancreas. There have been no population-based studies evaluating this incidence rate. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) database (1983 to 1991), we identified all patients with primary pancreatic cancers (sporadic and adenocarcinomas arising in IPMNs). We determined the incidence of additional primary cancers that developed either before or after the diagnosis of invasive IPMN and compared it to the incidence of additional primary cancers in patients with sporadic pancreatic adenocarcinoma. RESULTS: Nineteen thousand six hundred forty-seven patients were reported with pancreatic cancer. Ninety-five percent of cancers were sporadic and 5.0% were invasive IPMNs. Ten point three percent had one or more extra-pancreatic primary cancers in addition to their pancreatic primary (10.3% in patients with sporadic adenocarcinoma and 10.1% in patients with invasive IPMNs, p = NS). The most common sites of additional primary cancers were colorectal (20.1%), breast (19.9%), prostate (16.6%), urinary system (11.1%), and lung (9.8%). In the 2,017 patients with additional primary cancer, 86% occurred before the diagnosis of pancreatic cancer and 14% occurred after the diagnosis of pancreatic cancer. CONCLUSIONS: Our population-based analysis shows that the incidence of additional primary malignancies in patients with invasive IPMNs is 10%. Although not as high as previously reported in smaller studies, the incidence is significant and comparable to the incidence seen in patients with adenocarcinoma. Surveillance for other common malignancies in patients with IPMNs and pancreatic adenocarcinomas should be performed.     

A case report of small bowel obstruction from previously undiagnosed lobular breast carcinoma: First in Australian literature

IntroductionThis case report is the first in the Australian literature of a patient, without prior diagnosis, presenting with a bowel obstruction secondary to lobular breast cancer. This highlights a relatively rare cause of bowel obstruction, but also the importance of breast self-examination as a compliment to the current BreastScreen Australia program.Presentation of caseA 67-year-old female presented to the Emergency Department with a 48-h history of sharp, constant epigastric pain, vomiting and constipation. The patient proceeded to emergency laparotomy for presumed large bowel obstruction, which revealed a stricture in the distal terminal ileum causing a distal small bowel obstruction. A right hemicolectomy was performed. Histopathology revealed the terminal ileum stricture to be metastatic lobular breast carcinoma. Clinical examination of the patient’s right breast revealed a lesion suggestive of the primary malignancy despite a normal ultrasound and mammogram in 2014. After failing to progress, a CT scan was performed which revealed progressive small and large bowel distension. A repeat laparotomy was performed revealing dilated large bowel without obstructing pathology and an intact anastomosis. A loop ileostomy was performed. Following a further febrile episode, the patient decided to withdraw care and the patient passed away three weeks into her admission from suspected intra-abdominal sepsis.DiscussionBreast cancer is becoming the third most common cancer amongst Australian women with a significant burden of disease and mortality.ConclusionDespite the rare presentation, this case reminds the medical community and general population of the importance of breast self-examination and the BreastScreen Australia program.     

Primary breast lymphoma in a male patient

Primary lymphoma of the male breast is extremely rare. We report a case of a diffuse large B-cell lymphoma in a male patient. A 67-year-old man presented with a palpable mass in the right breast and ipsilateral axillary lymphadenopathy. At operation a 6 x 5 x 4-cm mass was excised, and a frozen section demonstrated malignancy. A modified radical mastectomy was then performed, together with axillary lymph node clearance. Histological examination established the diagnosis of a primary non-Hodgkin's lymphoma of the breast. The patient was referred for chemotherapy and died a year later from systemic disease involving the adrenals. The importance of early diagnosis is emphasized; this should be based on an excisional biopsy or aspiration cytology. As patients with primary breast lymphoma (PBL) have a better prognosis than those with carcinoma of the breast or patients with extranodal lymphomas, a multidisciplinary approach including surgery, radiotherapy, and chemotherapy when needed would result in a more favorable outcome.     

A case of 19th year pulmonary metastasis after radical mastectomy for breast cancer

A 72-year-old woman was admitted to our hospital for further evaluation of a abnormal shadow in left middle lung field. The patient had undergone right mastectomy for infiltrating ductal carcinoma 19 years ago. She had no symptom, but had a time of mass X-ray screening this year. Chest CT finding showed a nodule 2 cm in diameter with slight irregular margin in S6 of left lung. We couldn't determine preoperatively that this tumor was a metastatic lesion or a primary lung cancer. And first, tumor was taken out for intraoperative frozen section diagnosis. Pathologist didn't diagnose whether this tumor was a metastatic or primary. So, we performed left lower lobectomy and mediastinal lymphadenectomy. On postoperative histopathologic finding lung cancer resembled well previous breast cancer. In immunohistochemical study cancer cells from lung and breast of the patient were respectively positive for anti Estrogen Receptor (ER) and anti Gross Cystic Disease Fluid Protein-15 (GCDFP-15). In conclusion lung cancer was diagnosed as a metastatic lesion from breast cancer 19 years ago. The patient has been well 2 years postoperatively without recurrence. In this case immunohistochemical examination was very useful for differentiation metastatic lesion and primary one.     

Diaphragma sellae metastasis from colon carcinoma mimicking a meningioma. A case report.

We describe a rare case of metastatic intra-suprasellar adenocarcinoma from colonic cancer mimicking a meningioma of the "diaphragma sellae". Autopsy studies indicate breast and lung carcinoma to be the most frequent primary tumor metastasizing this site, particularly in patients with systemic spread. While diabetes insipidus is reported to be one of the commonest symptoms in these cases, the only clinical manifestation of the tumor in our patient was a bitemporal hemianopia, while the primary tumor remained asymptomatic. In the available literature are reported only two pituitary metastasis from operated colon carcinoma. In both cases the diagnosis of the colon cancer preceded the pituitary operation. The clinico-pathological and neuroradiological aspects of this unusual lesion are analyzed in the light of the relevant literature on the topic focusing on recent MRI acquisitions.     

Brain and skull metastases of hepatic or pancreatic cancer--report of six cases.

Brain and skull metastases from primary hepatic or pancreatic cancer are very rare. The authors describe six cases of metastatic tumors. These are skull (three cases) and brain (one) metastasis of hepatic cancer and brain metastasis (two) of pancreatic cancer. In three hepatic cancer patients, the metastatic lesions were diagnosed before the diagnosis of primary cancer. In these patients, plain skull x-ray showed osteolytic lesions and vascular enlargement. A postcontrast computed tomographic (CT) scan showed an enhanced high-density epidural mass. Angiograms showed a tumor stain fed by abnormal vessels from the external carotid artery. In one patient with a metastatic brain tumor from hepatic cancer, a CT scan showed a high-density mass with hematoma. In one of the brain metastases from pancreatic cancer, a CT scan revealed a cystic, ring-like enhanced lesion in the thalamus. In the other case, a CT scan showed an isodensity mass in the vermis and hydrocephalus. Metastatic tumors from primary hepatic cancer were soft and hemorrhagic, but they were clearly demarcated from the surrounding tissue. In the case of thalamic metastasis, the cyst content was aspirated and an anticancer agent was administered into the cystic cavity. In the other cases, the tumors were totally removed. The outcome was very poor in all cases.