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[1–4] [INVALID Stage]
Journal of
Oncology Pharmacy Practice
Case Report
Bilateral synchronous adrenal metastasis of invasive ductal carcinoma treated with multimodality therapy including adrenalectomy and oophorectomy
J Oncol Pharm Practice 0(0) 1–4 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1078155214551314 opp.sagepub.com
Orhan Onder Eren1, Cetin Ordu2, Nalan A Selcuk3, ¨ zkan6, Cengiz Akosman4, Mehmet Akif Ozturk5, Ferda O 7 1 ¨ zcan Gokce and Basak Oyan O
Abstract A 38-year-old woman presented with a mass in the left breast. Biopsy of the lesion revealed invasive ductal carcinoma. Bilateral adrenal metastasis was detected in whole body positron emission tomography scanning. Needle biopsy of the left adrenal lesion proved infiltration of malignant cells from breast carcinoma. After eight cycles of neoadjuvant (preoperative) chemotherapy, mastectomy, bilateral adrenalectomy, and bilateral oopherectomy were performed. No further hormonal treatment was recommended due to the resection of both adrenal glands and ovaries. The patient is still followed without any sign of progression. To our knowledge, this is the first case representing multimodality approach to breast cancer with bilateral synchronous adrenal metastasis. Patients with oligometastatic disease may benefit from aggressive treatment including local therapies.
Keywords Synchronous, adrenal metastasis, ductal carcinoma
Introduction Patients with metastatic breast cancer (MBC) usually have a poor prognosis.1 Although great progress has been made in chemotherapy, hormonal therapy and targeted therapies, cure is still impossible in most of the patients.2,3 Less than 10% of the patients may survive beyond five years, but there is increasing evidence showing that long-term survival can be achieved in a subset of patients with limited metastasis, the so-called oligometastatic disease.4,5 Invasive ductal carcinoma is the most common histologic type of invasive breast carcinomas. The usual sites of metastasis of invasive ductal carcinoma are bones, lung, liver, and brain.6 Adrenal gland metastasis due to invasive breast carcinoma is rarely encountered in routine daily practice.7,8 Synchronous bilateral adrenal metastasis due to breast carcinoma treated with metastasectomy has not been reported in English literature. Most of the reported cases are from autopsy series and frequently associated with invasive lobular
carcinoma of breast rather than invasive ductal carcinoma.9–11 Herein we present a case of invasive ductal carcinoma presenting with bilateral adrenal gland metastasis
1 Department of Medical Oncology, Faculty of Medicine, Yeditepe University, Istanbul, Turkey 2 Department of Medical Oncology, Faculty of Medicine, Bilim University, Istanbul, Turkey 3 Department of Nuclear Medicine, Faculty of Medicine, Yeditepe University, Istanbul, Turkey 4 Department of Medical Oncology, Medical Park Hospital, Ordu, Turkey 5 Department of Internal Medicine, Faculty of Medicine, Yeditepe University, Istanbul, Turkey 6 Department of Pathology, Faculty of Medicine, Yeditepe University, Istanbul, Turkey 7 Department of General Surgery, Faculty of Medicine, Yeditepe University, Istanbul, Turkey
Corresponding author: Mehmet Akif Ozturk, Yeditepe University Hospital, Devlet Yolu, Ankara Caddesi, No:102–104, Istanbul, Turkey. Email: [email protected]
Downloaded from opp.sagepub.com at UCSF LIBRARY & CKM on January 27, 2015
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A 38-year-old woman presented with a breast mass measuring 7 cm in diameter. Tru cut biopsy of the lesion revealed grade II invasive ductal carcinoma. The tumor cells were strongly positive for estrogen and progesteron receptors but negative for C-erb B2 in immunohistochemistry. Bone scintigraphy and chest X-ray revealed no distant metastasis. Contrast enhanced computed tomography (CT) of abdomen showed right adrenal mass with a diameter of 4 4 cm and a left adrenal mass of 4.5 4.5 cm. Both lesions were solid, and contrast enhancement pattern was suspicious for malignant infiltration. A diagnostic whole body positron emission tomography (PET) CT scanning showed fludeoxyglucose (FDG) uptake in the left breast with a maximum standardized uptake value (SUV) of 3.85. Both the adrenal glands showed uptake of FDG with a maximum SUV 4.64 on the right and 5.74 on the left (Figure 1). No FDG uptake was detected in the left axillary region and any other part of the body. Needle aspiration biopsy of the left adrenal lesion revealed malignant epithelial cells (Figure 2) staining positive for epithelial membrane antigen and pancytokeratin, negative for vimentin, cytokeratin 7, and chromogranin A. The biopsy findings were compatible with
metastasis of invasive breast carcinoma. The patient was diagnosed with stage IV invasive ductal carcinoma with limited metastases. Upon discussion of the patient in tumor board, evaluation for surgery after preoperative chemotherapy was planned. The patient received four cycles of FEC 100 every three weeks (cyclophosphamide 500 mg/m2, epirubicin 100 mg/m2, 5 fluorouracil 500 mg/m2), followed by four cycles of docetaxel (100 mg/m2) every three weeks. After completion of preoperative chemotherapy, a partial response was observed in the breast lump upon physical examination. Contrast enhanced tomography of abdomen revealed partial regression of the lesions in the both adrenal glands. A whole body PET scanning revealed no FDG uptake in the breast lump and adrenal lesions (Figure 1). In January 2007, a left modified radical mastectomy with axillary lymph node dissection was conducted. There was a 6.5 1.5 1.5 cm residual tumor in the breast but 70% of the mass was necrotic. Three of the 16 lymph nodes dissected were positive for invasive ductal carcinoma metastasis. Residual tumor cells were stained strongly positive for both estrogen and progesteron receptors but were negative for C-erb B2. In February 2007, bilateral adrenalectomy for metastatic disease was conducted. During the same session, bilateral salpingooopherectomy was performed for medical castration. Pathologic examination revealed carcinoma infiltration in both adrenal glands. These metastatic cells were also strongly positive for pancytokeratin, estrogen, and progesteron receptors. These pathologic and immunohistochemical findings again suggested the breast as the primary focus of the metastatic carcinoma. Following surgery, adjuvant radiotherapy was performed for left breast. After completion of radiotherapy, the patient received six cycles
Figure 1. (a and b) Bilateral adrenal metastasis in PET and CT scans, (c and d) absence of FDG uptake and mass after chemotherapy ET and CT scans.
Figure 2. Atypical epithelial cells in glandular arrangement with high N/C ratio and showing hyperchromasia (PAP 400). N/C: nucleus/cytoplasmic ratio; PAP: papanicolau stain.
and achieving long-term survival with aggressive chemotherapy and surgical intervention.
Case report
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of postoperative treatment with capecitabine at a dose of 2500 mg/m2. After completion of the therapy, the patient was followed without any hormonal manipulation due to the absence of both adrenal glands and ovaries. As of November 2013, the patient had no sign of recurrence.
Discussion Despite improvements in early detection and systemic therapy for the disease, MBC is still accepted as an incurable disease by most of the physicians. However, long-term survival or even cure may be obtained in a few patients with metastatic breast cancer.12,13 It has been suggested that up to 10% of patients with MBC can enjoy a long survival (five years or more), whereas a minority (as few as 2% to 3%) may be considered cured.12–14 The term oligometastatic state has been proposed by Hellman and Weichselbaum.15 It implies that there is a limited number of sites and metastases. The concept stresses the importance of aggressive systemic and local treatment in prolonging survival in some patients with MBC.15,16 Patients with bone and soft tissue metastasis, limited visceral metastases with a relatively long disease-free interval may benefit from aggressive local and systemic treatment.4,15–17 Our patient had bilateral synchronous adrenal metastasis at the time of diagnosis. There was partial response to induction therapy. Less than pathologic complete response is suggested to be an adverse prognostic factor for long-term survival in locally advanced breast cancer.18 However, it is well known that complete pathologic response to induction chemotherapy is rare in hormone receptor– positive breast cancer.19 Despite the presence of these negative prognostic and predictive factors, the patient is still alive without signs of recurrence six years after multimodality therapy. After surgery, the patient received adjuvant radiotherapy. We recommended six cycles of capecitabine as preoperative chemotherapy after surgery. At this point, there is no standard chemotherapy option after the preoperative use of antracyclines and taxanes in the preoperative setting.20 Some sort of postoperative chemotherapy may be feasible in this clinical scenario. Adrenal glands are a frequent site of metastasis due to the rich blood supply.7,8 Adrenal metastases are usually asymptomatic but sometimes may cause symptoms due to mass effect, hemorrhage or rarely adrenal insufficiency.21 Solitary adrenal metastases is a rare finding in autopsy series of patients with metastatic cancer.10 In case series, less than 4% of all adrenal metastases are from primary breast carcinomas.10,11 When it occurs, it is usually accompanied by invasive lobular carcinoma.11 Adrenal metastasis is usually bilateral and
metachronous.10,11 Our patient is the first case reported with bilateral adrenal synchronous metastases from invasive ductal carcinoma of the breast treated in a multidisciplinary fashion. There are cases with adrenal metastases from lung, kidney, melanoma, or hepatocellular carcinoma which enjoy long-term survival after adrenalectomy.22 Resection of primary tumor in the presence of metastatic disease is a controversial issue in breast carcinoma.17 Although there is no prospective randomized trial, retrospective analyses of case series suggest that there may be a gain of survival from resecting primary in MBC.17 Aggressive local treatment may be effective in patients with predominant bone and soft tissue disease.16,17 Some patients with limited visceral disease may also be candidates for aggressive treatment. Adjuvant radiotherapy, as a local treatment option may also be useful due to the curative intent treatment. Hormonal therapy is an important component of both adjuvant and palliative treatment of breast cancer. The selective estrogen receptor modulators exert their activity by competitively inhibiting estrogen receptors.23 Another group of agents, aromatase inhibitors, block conversion of androgenic precursors to estrone and estradiol.24 As the main source of estrogen precursors are adrenal glands and ovaries,25 we did not apply adjuvant hormonal therapy due to the removal of all sources of estrogenic precursor production. Surgical adrenalectomy combined or followed by bilateral oopherectomy was a popular form of palliative hormonal treatment in advanced breast cancer in 60s and 70s.26 These modalities are rarely applied in the era of modern chemotherapy and hormonal therapy. Five years of disease-free interval after surgery justified this surgical approach for this patient. Potential side effects of selective estrogen receptor modu¨lato¨rs and aromatase inhibitors have been avoided this way. This strategy also seems cost effective. In conclusion, we present a case of breast carcinoma with solitary bilateral adrenal metastases who benefited from multimodal treatment. Patients with newly diagnosed stage IV MBC should be evaluated carefully. The opportunity to gain a significant survival in a minority of patients should not be missed. Patients with oligometastatic breast carcinoma should be evaluated by a multidisciplinary team. Aggressive local and systemic treatment modalities may aid in prolonging survival. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest None declared.
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References 1. Tait CR, Waterworth A, Loncaster J, et al. The oligometastatic state in breast cancer: hypothesis or reality. Breast 2005; 14: 87–93. 2. Greenberg PA, Hortobagyi GN, Smith TL, et al. Longterm follow-up of patients with complete remission following combination chemotherapy for metastatic breast cancer. J Clin Oncol 1996; 14: 2197–2205. 3. Andre F, Slimane K, Bachelot T, et al. Breast cancer with synchronous metastases: trends in survival during a 14-year period. J Clin Oncol 2004; 22: 3302–3308. 4. Ly BH, Nguyen NP, Vinh-Hung V, et al. Locoregional treatment in metastatic breast cancer patients: is there a survival benefit. Breast Cancer Res Treat 2010; 119: 537–545. 5. Corbin KS, Hellman S and Weichselbaum RR. Extracranial oligometastases: a subset of metastases curable with stereotactic radiotherapy. J Clin Oncol 2013; 31: 1384–1390. 6. Viadana E, Cotter R, Pickren JW, et al. An autopsy study of metastatic sites of breast cancer. Cancer Res 1973; 33: 179–181. 7. Demirci U, Buyukberber S, Cakir T, et al. Isolated mucinous adrenal metastasis in a breast cancer patient. J Oncol Pharm Pract 2011; 17: 444–447. 8. Liu XJ, Shen P, Wang XF, et al. Solitary adrenal metastasis from invasive ductal breast cancer: an uncommon finding. World J Surg Oncol 2010; 8: 7. 9. Borst MJ and Ingold JA. Metastatic patterns of invasive lobular versus invasive ductal carcinoma of the breast. Surgery 1993; 114: 637–641. (discussion 641–642). 10. Lam KY and Lo CY. Metastatic tumours of the adrenal glands: a 30-year experience in a teaching hospital. Clin Endocrinol (Oxf) 2002; 56: 95–101. 11. Bumpers HL, Hassett JM Jr, Penetrante RB, et al. Endocrine organ metastases in subjects with lobular carcinoma of the breast. Arch Surg 1993; 128: 1344–1347. 12. Hortobagyi GN. Can we cure limited metastatic breast cancer? J Clin Oncol 2002; 20–620–623. 13. Sledge GW Jr. Should we dream the impossible dream? The meaning of long-term survival in metastatic breast cancer. J Clin Oncol 1996; 14: 2191–2193. 14. Iwata H. Future treatment strategies for metastatic breast cancer: curable or incurable? Breast Cancer 2012; 19: 200–205.
15. Hellman S and Weichselbaum RR. Oligometastases. J Clin Oncol 1995; 13: 8–10. 16. Friedel G, Pastorino U, Ginsberg RJ, et al. Results of lung metastasectomy from breast cancer: prognostic criteria on the basis of 467 cases of the International Registry of Lung Metastases. Eur J Cardiothorac Surg 2002; 22: 335–344. 17. Rapiti E, Verkooijen HM, Vlastos G, et al. Complete excision of primary breast tumor improves survival of patients with metastatic breast cancer at diagnosis. J Clin Oncol 2006; 24: 2743–2749. 18. Von Minckwitz G, Untch M, Blohmer JU, et al. Definition and impact of pathologic complete response on prognosis after neoadjuvant chemotherapy in various intrinsic breast cancer subtypes. J Clin Oncol 2012; 30: 1796–1804. 19. Guarneri V, Broglio K, Kau SW, et al. Prognostic value of pathologic complete response after primary chemotherapy in relation to hormone receptor status and other factors. J Clin Oncol 2006; 24: 1037–1044. 20. Thomas E, Holmes FA, Smith TL, et al. The use of alternate, non-cross-resistant adjuvant chemotherapy on the basis of pathologic response to a neoadjuvant doxorubicin-based regimen in women with operable breast cancer: long-term results from a prospective randomized trial. J Clin Oncol 2004; 22: 2294–2302. 21. Bausewein C, Ku¨hnbach R and Haberland B. Adrenal insufficiency caused by bilateral adrenal metastases, a rare treatable cause for recurrent nausea and vomiting in metastatic breast cancer. Onkologie 2006; 29: 203–205. 22. Zheng QY, Zhang GH, Zhang Y, et al. Adrenalectomy may increase survival of patients with adrenal metastases. Oncol Lett 2012; 3: 917–920. 23. Mac Gregor JI and Jordan VC. Basic guide to the mechanisms of antiestrogen action. Pharmacol Rev 1998; 50: 151–196. 24. Smith IE and Dowsett M. Aromatase inhibitors in breast cancer. N Engl J Med 2003; 348: 2431–2442. 25. Buzdar A and Howell A. Advances in aromatase inhibition: clinical efficacy and tolerability in the treatment of breast cancer. Clin Cancer Res 2001; 7: 2620–2635. 26. Horsley JS 3rd, Alrich EM, Sears HF, et al. Adrenalectomy for metastatic mammary cancer. Ann Surg 1971; 173: 906–912.
Downloaded from opp.sagepub.com at UCSF LIBRARY & CKM on January 27, 2015
(OPP)
[1–4] [INVALID Stage]
Journal of
Oncology Pharmacy Practice
Case Report
Bilateral synchronous adrenal metastasis of invasive ductal carcinoma treated with multimodality therapy including adrenalectomy and oophorectomy
J Oncol Pharm Practice 0(0) 1–4 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1078155214551314 opp.sagepub.com
Orhan Onder Eren1, Cetin Ordu2, Nalan A Selcuk3, ¨ zkan6, Cengiz Akosman4, Mehmet Akif Ozturk5, Ferda O 7 1 ¨ zcan Gokce and Basak Oyan O
Abstract A 38-year-old woman presented with a mass in the left breast. Biopsy of the lesion revealed invasive ductal carcinoma. Bilateral adrenal metastasis was detected in whole body positron emission tomography scanning. Needle biopsy of the left adrenal lesion proved infiltration of malignant cells from breast carcinoma. After eight cycles of neoadjuvant (preoperative) chemotherapy, mastectomy, bilateral adrenalectomy, and bilateral oopherectomy were performed. No further hormonal treatment was recommended due to the resection of both adrenal glands and ovaries. The patient is still followed without any sign of progression. To our knowledge, this is the first case representing multimodality approach to breast cancer with bilateral synchronous adrenal metastasis. Patients with oligometastatic disease may benefit from aggressive treatment including local therapies.
Keywords Synchronous, adrenal metastasis, ductal carcinoma
Introduction Patients with metastatic breast cancer (MBC) usually have a poor prognosis.1 Although great progress has been made in chemotherapy, hormonal therapy and targeted therapies, cure is still impossible in most of the patients.2,3 Less than 10% of the patients may survive beyond five years, but there is increasing evidence showing that long-term survival can be achieved in a subset of patients with limited metastasis, the so-called oligometastatic disease.4,5 Invasive ductal carcinoma is the most common histologic type of invasive breast carcinomas. The usual sites of metastasis of invasive ductal carcinoma are bones, lung, liver, and brain.6 Adrenal gland metastasis due to invasive breast carcinoma is rarely encountered in routine daily practice.7,8 Synchronous bilateral adrenal metastasis due to breast carcinoma treated with metastasectomy has not been reported in English literature. Most of the reported cases are from autopsy series and frequently associated with invasive lobular
carcinoma of breast rather than invasive ductal carcinoma.9–11 Herein we present a case of invasive ductal carcinoma presenting with bilateral adrenal gland metastasis
1 Department of Medical Oncology, Faculty of Medicine, Yeditepe University, Istanbul, Turkey 2 Department of Medical Oncology, Faculty of Medicine, Bilim University, Istanbul, Turkey 3 Department of Nuclear Medicine, Faculty of Medicine, Yeditepe University, Istanbul, Turkey 4 Department of Medical Oncology, Medical Park Hospital, Ordu, Turkey 5 Department of Internal Medicine, Faculty of Medicine, Yeditepe University, Istanbul, Turkey 6 Department of Pathology, Faculty of Medicine, Yeditepe University, Istanbul, Turkey 7 Department of General Surgery, Faculty of Medicine, Yeditepe University, Istanbul, Turkey
Corresponding author: Mehmet Akif Ozturk, Yeditepe University Hospital, Devlet Yolu, Ankara Caddesi, No:102–104, Istanbul, Turkey. Email: [email protected]
Downloaded from opp.sagepub.com at UCSF LIBRARY & CKM on January 27, 2015
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A 38-year-old woman presented with a breast mass measuring 7 cm in diameter. Tru cut biopsy of the lesion revealed grade II invasive ductal carcinoma. The tumor cells were strongly positive for estrogen and progesteron receptors but negative for C-erb B2 in immunohistochemistry. Bone scintigraphy and chest X-ray revealed no distant metastasis. Contrast enhanced computed tomography (CT) of abdomen showed right adrenal mass with a diameter of 4 4 cm and a left adrenal mass of 4.5 4.5 cm. Both lesions were solid, and contrast enhancement pattern was suspicious for malignant infiltration. A diagnostic whole body positron emission tomography (PET) CT scanning showed fludeoxyglucose (FDG) uptake in the left breast with a maximum standardized uptake value (SUV) of 3.85. Both the adrenal glands showed uptake of FDG with a maximum SUV 4.64 on the right and 5.74 on the left (Figure 1). No FDG uptake was detected in the left axillary region and any other part of the body. Needle aspiration biopsy of the left adrenal lesion revealed malignant epithelial cells (Figure 2) staining positive for epithelial membrane antigen and pancytokeratin, negative for vimentin, cytokeratin 7, and chromogranin A. The biopsy findings were compatible with
metastasis of invasive breast carcinoma. The patient was diagnosed with stage IV invasive ductal carcinoma with limited metastases. Upon discussion of the patient in tumor board, evaluation for surgery after preoperative chemotherapy was planned. The patient received four cycles of FEC 100 every three weeks (cyclophosphamide 500 mg/m2, epirubicin 100 mg/m2, 5 fluorouracil 500 mg/m2), followed by four cycles of docetaxel (100 mg/m2) every three weeks. After completion of preoperative chemotherapy, a partial response was observed in the breast lump upon physical examination. Contrast enhanced tomography of abdomen revealed partial regression of the lesions in the both adrenal glands. A whole body PET scanning revealed no FDG uptake in the breast lump and adrenal lesions (Figure 1). In January 2007, a left modified radical mastectomy with axillary lymph node dissection was conducted. There was a 6.5 1.5 1.5 cm residual tumor in the breast but 70% of the mass was necrotic. Three of the 16 lymph nodes dissected were positive for invasive ductal carcinoma metastasis. Residual tumor cells were stained strongly positive for both estrogen and progesteron receptors but were negative for C-erb B2. In February 2007, bilateral adrenalectomy for metastatic disease was conducted. During the same session, bilateral salpingooopherectomy was performed for medical castration. Pathologic examination revealed carcinoma infiltration in both adrenal glands. These metastatic cells were also strongly positive for pancytokeratin, estrogen, and progesteron receptors. These pathologic and immunohistochemical findings again suggested the breast as the primary focus of the metastatic carcinoma. Following surgery, adjuvant radiotherapy was performed for left breast. After completion of radiotherapy, the patient received six cycles
Figure 1. (a and b) Bilateral adrenal metastasis in PET and CT scans, (c and d) absence of FDG uptake and mass after chemotherapy ET and CT scans.
Figure 2. Atypical epithelial cells in glandular arrangement with high N/C ratio and showing hyperchromasia (PAP 400). N/C: nucleus/cytoplasmic ratio; PAP: papanicolau stain.
and achieving long-term survival with aggressive chemotherapy and surgical intervention.
Case report
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of postoperative treatment with capecitabine at a dose of 2500 mg/m2. After completion of the therapy, the patient was followed without any hormonal manipulation due to the absence of both adrenal glands and ovaries. As of November 2013, the patient had no sign of recurrence.
Discussion Despite improvements in early detection and systemic therapy for the disease, MBC is still accepted as an incurable disease by most of the physicians. However, long-term survival or even cure may be obtained in a few patients with metastatic breast cancer.12,13 It has been suggested that up to 10% of patients with MBC can enjoy a long survival (five years or more), whereas a minority (as few as 2% to 3%) may be considered cured.12–14 The term oligometastatic state has been proposed by Hellman and Weichselbaum.15 It implies that there is a limited number of sites and metastases. The concept stresses the importance of aggressive systemic and local treatment in prolonging survival in some patients with MBC.15,16 Patients with bone and soft tissue metastasis, limited visceral metastases with a relatively long disease-free interval may benefit from aggressive local and systemic treatment.4,15–17 Our patient had bilateral synchronous adrenal metastasis at the time of diagnosis. There was partial response to induction therapy. Less than pathologic complete response is suggested to be an adverse prognostic factor for long-term survival in locally advanced breast cancer.18 However, it is well known that complete pathologic response to induction chemotherapy is rare in hormone receptor– positive breast cancer.19 Despite the presence of these negative prognostic and predictive factors, the patient is still alive without signs of recurrence six years after multimodality therapy. After surgery, the patient received adjuvant radiotherapy. We recommended six cycles of capecitabine as preoperative chemotherapy after surgery. At this point, there is no standard chemotherapy option after the preoperative use of antracyclines and taxanes in the preoperative setting.20 Some sort of postoperative chemotherapy may be feasible in this clinical scenario. Adrenal glands are a frequent site of metastasis due to the rich blood supply.7,8 Adrenal metastases are usually asymptomatic but sometimes may cause symptoms due to mass effect, hemorrhage or rarely adrenal insufficiency.21 Solitary adrenal metastases is a rare finding in autopsy series of patients with metastatic cancer.10 In case series, less than 4% of all adrenal metastases are from primary breast carcinomas.10,11 When it occurs, it is usually accompanied by invasive lobular carcinoma.11 Adrenal metastasis is usually bilateral and
metachronous.10,11 Our patient is the first case reported with bilateral adrenal synchronous metastases from invasive ductal carcinoma of the breast treated in a multidisciplinary fashion. There are cases with adrenal metastases from lung, kidney, melanoma, or hepatocellular carcinoma which enjoy long-term survival after adrenalectomy.22 Resection of primary tumor in the presence of metastatic disease is a controversial issue in breast carcinoma.17 Although there is no prospective randomized trial, retrospective analyses of case series suggest that there may be a gain of survival from resecting primary in MBC.17 Aggressive local treatment may be effective in patients with predominant bone and soft tissue disease.16,17 Some patients with limited visceral disease may also be candidates for aggressive treatment. Adjuvant radiotherapy, as a local treatment option may also be useful due to the curative intent treatment. Hormonal therapy is an important component of both adjuvant and palliative treatment of breast cancer. The selective estrogen receptor modulators exert their activity by competitively inhibiting estrogen receptors.23 Another group of agents, aromatase inhibitors, block conversion of androgenic precursors to estrone and estradiol.24 As the main source of estrogen precursors are adrenal glands and ovaries,25 we did not apply adjuvant hormonal therapy due to the removal of all sources of estrogenic precursor production. Surgical adrenalectomy combined or followed by bilateral oopherectomy was a popular form of palliative hormonal treatment in advanced breast cancer in 60s and 70s.26 These modalities are rarely applied in the era of modern chemotherapy and hormonal therapy. Five years of disease-free interval after surgery justified this surgical approach for this patient. Potential side effects of selective estrogen receptor modu¨lato¨rs and aromatase inhibitors have been avoided this way. This strategy also seems cost effective. In conclusion, we present a case of breast carcinoma with solitary bilateral adrenal metastases who benefited from multimodal treatment. Patients with newly diagnosed stage IV MBC should be evaluated carefully. The opportunity to gain a significant survival in a minority of patients should not be missed. Patients with oligometastatic breast carcinoma should be evaluated by a multidisciplinary team. Aggressive local and systemic treatment modalities may aid in prolonging survival. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interest None declared.
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References 1. Tait CR, Waterworth A, Loncaster J, et al. The oligometastatic state in breast cancer: hypothesis or reality. Breast 2005; 14: 87–93. 2. Greenberg PA, Hortobagyi GN, Smith TL, et al. Longterm follow-up of patients with complete remission following combination chemotherapy for metastatic breast cancer. J Clin Oncol 1996; 14: 2197–2205. 3. Andre F, Slimane K, Bachelot T, et al. Breast cancer with synchronous metastases: trends in survival during a 14-year period. J Clin Oncol 2004; 22: 3302–3308. 4. Ly BH, Nguyen NP, Vinh-Hung V, et al. Locoregional treatment in metastatic breast cancer patients: is there a survival benefit. Breast Cancer Res Treat 2010; 119: 537–545. 5. Corbin KS, Hellman S and Weichselbaum RR. Extracranial oligometastases: a subset of metastases curable with stereotactic radiotherapy. J Clin Oncol 2013; 31: 1384–1390. 6. Viadana E, Cotter R, Pickren JW, et al. An autopsy study of metastatic sites of breast cancer. Cancer Res 1973; 33: 179–181. 7. Demirci U, Buyukberber S, Cakir T, et al. Isolated mucinous adrenal metastasis in a breast cancer patient. J Oncol Pharm Pract 2011; 17: 444–447. 8. Liu XJ, Shen P, Wang XF, et al. Solitary adrenal metastasis from invasive ductal breast cancer: an uncommon finding. World J Surg Oncol 2010; 8: 7. 9. Borst MJ and Ingold JA. Metastatic patterns of invasive lobular versus invasive ductal carcinoma of the breast. Surgery 1993; 114: 637–641. (discussion 641–642). 10. Lam KY and Lo CY. Metastatic tumours of the adrenal glands: a 30-year experience in a teaching hospital. Clin Endocrinol (Oxf) 2002; 56: 95–101. 11. Bumpers HL, Hassett JM Jr, Penetrante RB, et al. Endocrine organ metastases in subjects with lobular carcinoma of the breast. Arch Surg 1993; 128: 1344–1347. 12. Hortobagyi GN. Can we cure limited metastatic breast cancer? J Clin Oncol 2002; 20–620–623. 13. Sledge GW Jr. Should we dream the impossible dream? The meaning of long-term survival in metastatic breast cancer. J Clin Oncol 1996; 14: 2191–2193. 14. Iwata H. Future treatment strategies for metastatic breast cancer: curable or incurable? Breast Cancer 2012; 19: 200–205.
15. Hellman S and Weichselbaum RR. Oligometastases. J Clin Oncol 1995; 13: 8–10. 16. Friedel G, Pastorino U, Ginsberg RJ, et al. Results of lung metastasectomy from breast cancer: prognostic criteria on the basis of 467 cases of the International Registry of Lung Metastases. Eur J Cardiothorac Surg 2002; 22: 335–344. 17. Rapiti E, Verkooijen HM, Vlastos G, et al. Complete excision of primary breast tumor improves survival of patients with metastatic breast cancer at diagnosis. J Clin Oncol 2006; 24: 2743–2749. 18. Von Minckwitz G, Untch M, Blohmer JU, et al. Definition and impact of pathologic complete response on prognosis after neoadjuvant chemotherapy in various intrinsic breast cancer subtypes. J Clin Oncol 2012; 30: 1796–1804. 19. Guarneri V, Broglio K, Kau SW, et al. Prognostic value of pathologic complete response after primary chemotherapy in relation to hormone receptor status and other factors. J Clin Oncol 2006; 24: 1037–1044. 20. Thomas E, Holmes FA, Smith TL, et al. The use of alternate, non-cross-resistant adjuvant chemotherapy on the basis of pathologic response to a neoadjuvant doxorubicin-based regimen in women with operable breast cancer: long-term results from a prospective randomized trial. J Clin Oncol 2004; 22: 2294–2302. 21. Bausewein C, Ku¨hnbach R and Haberland B. Adrenal insufficiency caused by bilateral adrenal metastases, a rare treatable cause for recurrent nausea and vomiting in metastatic breast cancer. Onkologie 2006; 29: 203–205. 22. Zheng QY, Zhang GH, Zhang Y, et al. Adrenalectomy may increase survival of patients with adrenal metastases. Oncol Lett 2012; 3: 917–920. 23. Mac Gregor JI and Jordan VC. Basic guide to the mechanisms of antiestrogen action. Pharmacol Rev 1998; 50: 151–196. 24. Smith IE and Dowsett M. Aromatase inhibitors in breast cancer. N Engl J Med 2003; 348: 2431–2442. 25. Buzdar A and Howell A. Advances in aromatase inhibition: clinical efficacy and tolerability in the treatment of breast cancer. Clin Cancer Res 2001; 7: 2620–2635. 26. Horsley JS 3rd, Alrich EM, Sears HF, et al. Adrenalectomy for metastatic mammary cancer. Ann Surg 1971; 173: 906–912.
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