GYNECOLOGIC
ONCOLOGY
43, 291-294
(1991)
CASE REPORT Cervical Cancer Metastatic to the Breast: A Rare Presentation of Tumor Dissemination JOSEPH Departments
L.
KELLEY,
of *Obstetrics
III,*,’
AMAL
and Gynecology,
KANBOUR-SHAKIR,?
SCOTT
TPathology, and SSurgery, Magee Forbes at Halket Street, Pittsburgh,
L.
WILLIAMS,+
AND
WAYNE A. CHRISTOPHERSON*
Womens Hospital, University Pennsylvania 15213
of Pittsburgh
School
of Medicine,
Received February 28, 1991
Metastatic diseasepresentingin the mammary gland from gynecologicmalignanciesis a rare occurrence.A caseof metastatic adenosquamous carcinomaof the cervix presentingas an inflammatory breast lesion is reported. Metastaseswithin the breast have distinct clinical, radiographic, and histologicfeaturesand shouldbe suspectedin a patient with a breastmassand a known extramammaryprimary. As with other distant metastases of cervical cancer, mammary gland involvement portendsa poor prognosis. 0 1991 Academic Press, Inc. INTRODUCTION
Cervical carcinoma can metastasize to virtually any part of the body. Many routes of spread are possible but the progression of disease usually proceeds in an orderly, predictable fashion. Initially, there is direct extension to the vaginal and paracervical tissues and lymphatic spread to the parametrial and pelvic nodes. Subsequently, paraaortic nodal and distant metastasis may occur. Hematogenous and intraperitoneal mechanisms of spread have been reported. Genital tract malignancies metastasizing to the breast are rare events. We treated a patient who developed metastatic adenosquamous cervical cancer presenting as an inflammatory lesion within the mammary gland. CASE REPORT
A 32-year-old gravida 1, para 1 was referred to the oncology service at Magee Womens Hospital with a 2month history of irregular vaginal bleeding, low back ’ To whom reprint requests should be addressed at 3358 Fifth Avenue, Pittsburgh, PA 15213. Fax: (412) 621-7432.
pain, and an abnormal-appearing cervix. She had a 3.5 cm friable cervix with a biopsy revealing adenosquamous carcinoma (Fig. 1). Intravenous pyelography, chest X ray, and cytoscopy were normal. She was assigned to International Federation of Gynecologists and Obstetricians (FIGO) stage IB and underwent exploratory celiotomy for protocol surgical staging and possible radical hysterectomy. Para-aortic lymph node biopsies revealed metastatic disease and the hysterectomy was abandoned. Bilateral salpingo-oophorectomy, appendectomy, and scalene lymph node biopsies were performed and were negative for metastatic disease. Gross disease remained in the para-aortic and pelvic lymph nodes. Postoperatively she was to receive external-beam therapy to pelvic and para-aortic fields, but 3 weeks into treatment (after 3000 cGy) she sought alternate therapy in a foreign country. Two months later she returned and a 6-cm left breast mass and enlarged, matted axillary nodes were noted. A fine-needle aspiration biopsy and a limited incisional biopsy demonstrated what appeared to be infiltrating ductal carcinoma. Liver/spleen and bone scans were normal. American Joint Committee staging was IIIA (T3, N2, MO). Estrogen and progesterone receptors assays were negative. The patient refused operative therapy. Adjustments in her therapy included cessation of para-aortic irradiation and conclusion of pelvic treatment with additional external-beam therapy (total dose, 5100 cGy) and a single brachytherapy application (6000 cGy surface dose, 3500 cGy point A, 920 cGy point B) with excellent control of her pelvic pain and bleeding. Her presumed breast carcinoma was treated with cyclophosphamide (100 mg/m2 Days l-14), methotrexate (40 mg/m*, Days 1 and 8), and 5fluorouracil (600 mg/m2, Days 1 and 8) for two courses
291
0090-8258191$1.50 Copyright 0 1991 by Academic Press, Inc. All rights of reproduction in any form reserved.
292
KELLEY
ET AL.
FI G. 1. Cervical biopsy with sheets and nests of invasive, poorly differentiated cytoplasm to be mucoukecreting neoplastic cells (H + E, x50).
with concomitant external-beam radiation to the left breast and chest wall in an attempt to achieve palliation. Subsequently, skin changes consistent with an inflammatory breast carcinoma occurred and a modified radical mastectomy with extensive skin excision and a limited axillary node dissection was performed. The specimen demonstrated metastatic adenosquamous cell carcinoma of the cervix in the breast and axillary nodes (Fig. 2). One month later the patient had mediastinal and contralateral axillary adenopathy and large pleural effusions. Palliative measures were undertaken and the patient succumbed to her disease within 9 months after her initial diagnosis.
DISCUSSION It is unusual for the breast to be a site of metastatic disease. In 1863, Virchow observed that organs that had a propensity for primary malignancy were rarely involved by metastatic disease [l]. Hadju and Urban, in reviewing a lo-year period at Memorial Hospital, found 51 cases of nonprimary metastatic mammary cancer compared to
carcinoma. Mucicarmine
stain revealed cells with basoph lilic
4000 primary breast carcinomas [2]. The most common sources of metastatic disease are the opposite breast, lymphoma, melanoma, and epithelial carcinoma, notably bronchogenic carcinoma [2,3]. The autopsy incidence of metastasis to the breast from extramammary primaries ranged from 1.4 to 6.1% [4-61 as compared to a clinically observed rate of 1.2% [2]. Genital tract malignancies rarely metastasize to the breast. Ovarian carcinoma has been reported to occur most frequently [5-71 with isolated reports of metastatic disease from endometrial [3], vulvar [8], and cervical carcinoma [2,4,9-121. Speert and Greely reported the first case of a squamous cell carcinoma of the cervix metastasizing to the breast in a patient with a breast mass and supraclavicular adenopathy [9]. Ward and associates recently reported a recurrence of an adenocarcinoma of the endocervix presenting with widespread venous thromboses and an inflammatory breast lesion [lo]. Of the known cases, onehalf have been diagnosed at autopsy (Table 1). Clinical presentation of these patients was a palpable mass in all cases. The most common histology was squamous carcinoma with adenocarcinoma and anaplastic carcinoma also
CASE REPORT
293
Fl G. 2. Mastectomy specimen demonstrated multiple tumor nodules similar in morphology to Fig. 1. There are nests of neoplastic It). The breast glands are seen on the left (arrow) and the stroma contains many inflammatory cells (H + E, x 125).
(righ
reported. Our patient presented with an adenosquamous carcinoma. This histologic type has been associated with an aggressive clinical course with early development of distant metastases [13]. Paulus and Libshitz state that metastatic disease in the breast occurs by a variety of mechanisms including crosslymphatic spread in the thorax, hematogenous dissemination, and in hematologic malignancies as a result of a unicentric or multicentric process [8]. In our patient, metastatic dissemination may have occurred by either a hematogenous or a lymphatic route. Lymphatic metastasis to the breast may occur by several routes and is dependent upon retrograde flow. One route would be via the subclavian lymph node chain with subsequent backflow to the axillary lymph node groups (lateral, pectoral, subscapular, central, and apical) and then to the subareolar and circumareoloar plexuses with final termination within the perilobular and interlobular plexuses within the breast. An alternate route would involve retrograde flow from the anterior sternal lymph nodes to the medial aspect of the breast. Metastatic lesions should be considered in a patient
with a known extrammamary primary. Hematogenously disseminated lesions are superficial, multiple, well circumscribed, and rapidly growing [2,8,14,15]. The lesions tend to involve the upper outer quadrant [2,14,15]. Hadju and Urban noted that one-half of the cases involved the skin, underlying subcutaneous tissue, and immediately adjacent breast tissue [2]. Mammographic evaluation correlates well with clinical measurements because of minimal proliferation of fibrous tissue surrounding the mass [ 141. Calcifications and spiculations are absent [2,8,14]. The presence of calcifications on mammography virtually excludes an extramammary primary except for some serous ovarian tumors with psammoma bodies [7,8]. Histologic diagnosis depends on periductal and/or perilobular distribution of tumor cells in the absence of intraductal carcinoma or lobular carcinoma in situ. The diagnosis is more difficult than that in the case of a primary malignancy and interpretation of frozen section or limited biopsy specimens can be misleading [2]. Metastatic carcinoma of the cervix carries a grave prognosis. Survival with metastatic disease to the breast was less than 6 months in our patient. Several of the reported
294
KELLEY
ET AL.
TABLE 1 Patients with Cervical Cancer Metastatic to Breast No. of patients
Author DeAlvarez
[ 121
Histology
Stage
Treatment
Method of diagnosis
Breast findings
Coexisting sites
1
Squamous
Not stated Not stated
Autopsy
Speert and Greely [9]
1
Squamous
Not stated XRT
Clinical
Badib ef al. [4]
4
Not stated
Not stated 3 XRT; 1 surgery Autopsy
Hadju and Urban [2]
3
Squamous
Not stated Not stated
Clinical
Nayar et al [ll]
1
Anaplastic
IVB
None
Clinical
Bilateral masses
Not stated
Ward et al. [lo]
1
Adenocarcinoma
IIB
XRT
Clinical
Inflammatory lesion
Cervical/axillary adenopathy
Kelley et al.
1
Adenosquamous carcinoma
IB
XRT
Clinical
Palpable mass Axillary adenopathy
Autopsy
Widespread dissemination Palpable mass Supraclavicular node; skull Autopsy Widespread dissemination Palpable mass Not stated
Comments DOD DOD 4 DOD 2 DOD 1 Unknown Presentation of cervical cancer was breast mass; DOD Nodal spread noted 6 months prior to breast metastasis; DOD DOD
Note. DOD, Dead of disease; XRT, radiotherapy.
patients had concomitant distant metastases or developed them shortly after the diagnosis was established [9,11]. The importance of correct diagnosis is underscored to prevent unnecessary surgery as well as to direct appropriate therapy to the primary malignancy. Cervical cancer metastatic to the breast is an unusual event but deserves consideration in patients with advanced disease. An adequate excisional biopsy and mammographic findings of well-circumscribed lesions with the absence of calcifications may aid in the diagnosis. Mastectomy may have a palliative benefit in some patients with large lesions, inflammation, and necrosis.
8. 9. 10.
11.
REFERENCES 1. Virchow, R. Die Krankhaften Geschwulste, Hirschwald, Berlin, Vol. 1, p. 69 (1863). 2. Hajdu, S. I., and Urban, J. A. Cancers metastatic to the breast, Cancer 29, 1691-1696 (1972). 3. McIntosh, I. H., Hooper, A. A., Millis, R. R., and Greening, W. P. Metastatic carcinoma within the breast, Clin. Oncol. 2, 393401 (1976). 4. Badib, A. O., Kurohara, S. S., Webster, J. H., and Pickren, J. W. Metastasis to organs in carcinoma of the uterine cervix. Influence of treatment on incidence and distribution, Cancer 21, 434-439 (1968).
12. 13.
14.
15.
Sandison, A. T. Metastatic tumours in the breast, Br. J. Surg. 47, 54-58 (1959). Abrahms, H. L., Spiro, R., and Goldstein, N. Metastases in carcinoma. Analysis of 1000 autopsied cases, Cancer 3, 74-85 (1950). Laifer, S., Buscema, J., Parmley, T. H., and Rosenshein, N. B. Ovarian cancer metastatic to the breast, Gynecol. Oncol. 24, 97102 (1986). Paulus, D. D., and Libshitz, H. 1. Metastasis to the breast, Radio{. Clin. North Am. 20, 561-567 (1982). Speert, H, and Greeley, A. V. Cervical cancer with metastasis to the breast, Am. J. Obstet. Gynecol. 55, 894-896 (1948). Ward, R., Conner, G., Delprado, W., and Dalley, D. Case report: Metastatic adenocarcinoma of the cervix presenting as an inflammatory breast lesion, Gynecol. Oncol. 35, 399-405 (1989). Nayar, M., Chandro, M., Aggarwal, R., and Chander, S. Carcinoma cervix presenting as primary breast malignancy, Indian J. Pathol. Microbial. 30, 283-286 (1987). DeAlvarez, R. R. The causes of death in cancer of the cervix uteri, Am. J. Obstet. Gynecol. 54, 91-96 (1947). Gallup, D. G., Harper, R. H., and Stock, R. J. Poor prognosis in patients with adenosquamous cell carcinoma of the cervix, Obstet. Gynecol. 65, 416-422 (1985). Bohman, L. G., Bassett, L. W., Gold, R. H., and Voet, R. Breast metastases from extramammary malignancies, Radiology 144,309312 (1982). Toombs, B. D., and Kahsher, L. Metastatic disease to the breast: Clinical, pathologic, and radiographic features, Am. J. Roentgenol. 129, 673-676 (1977).
ONCOLOGY
43, 291-294
(1991)
CASE REPORT Cervical Cancer Metastatic to the Breast: A Rare Presentation of Tumor Dissemination JOSEPH Departments
L.
KELLEY,
of *Obstetrics
III,*,’
AMAL
and Gynecology,
KANBOUR-SHAKIR,?
SCOTT
TPathology, and SSurgery, Magee Forbes at Halket Street, Pittsburgh,
L.
WILLIAMS,+
AND
WAYNE A. CHRISTOPHERSON*
Womens Hospital, University Pennsylvania 15213
of Pittsburgh
School
of Medicine,
Received February 28, 1991
Metastatic diseasepresentingin the mammary gland from gynecologicmalignanciesis a rare occurrence.A caseof metastatic adenosquamous carcinomaof the cervix presentingas an inflammatory breast lesion is reported. Metastaseswithin the breast have distinct clinical, radiographic, and histologicfeaturesand shouldbe suspectedin a patient with a breastmassand a known extramammaryprimary. As with other distant metastases of cervical cancer, mammary gland involvement portendsa poor prognosis. 0 1991 Academic Press, Inc. INTRODUCTION
Cervical carcinoma can metastasize to virtually any part of the body. Many routes of spread are possible but the progression of disease usually proceeds in an orderly, predictable fashion. Initially, there is direct extension to the vaginal and paracervical tissues and lymphatic spread to the parametrial and pelvic nodes. Subsequently, paraaortic nodal and distant metastasis may occur. Hematogenous and intraperitoneal mechanisms of spread have been reported. Genital tract malignancies metastasizing to the breast are rare events. We treated a patient who developed metastatic adenosquamous cervical cancer presenting as an inflammatory lesion within the mammary gland. CASE REPORT
A 32-year-old gravida 1, para 1 was referred to the oncology service at Magee Womens Hospital with a 2month history of irregular vaginal bleeding, low back ’ To whom reprint requests should be addressed at 3358 Fifth Avenue, Pittsburgh, PA 15213. Fax: (412) 621-7432.
pain, and an abnormal-appearing cervix. She had a 3.5 cm friable cervix with a biopsy revealing adenosquamous carcinoma (Fig. 1). Intravenous pyelography, chest X ray, and cytoscopy were normal. She was assigned to International Federation of Gynecologists and Obstetricians (FIGO) stage IB and underwent exploratory celiotomy for protocol surgical staging and possible radical hysterectomy. Para-aortic lymph node biopsies revealed metastatic disease and the hysterectomy was abandoned. Bilateral salpingo-oophorectomy, appendectomy, and scalene lymph node biopsies were performed and were negative for metastatic disease. Gross disease remained in the para-aortic and pelvic lymph nodes. Postoperatively she was to receive external-beam therapy to pelvic and para-aortic fields, but 3 weeks into treatment (after 3000 cGy) she sought alternate therapy in a foreign country. Two months later she returned and a 6-cm left breast mass and enlarged, matted axillary nodes were noted. A fine-needle aspiration biopsy and a limited incisional biopsy demonstrated what appeared to be infiltrating ductal carcinoma. Liver/spleen and bone scans were normal. American Joint Committee staging was IIIA (T3, N2, MO). Estrogen and progesterone receptors assays were negative. The patient refused operative therapy. Adjustments in her therapy included cessation of para-aortic irradiation and conclusion of pelvic treatment with additional external-beam therapy (total dose, 5100 cGy) and a single brachytherapy application (6000 cGy surface dose, 3500 cGy point A, 920 cGy point B) with excellent control of her pelvic pain and bleeding. Her presumed breast carcinoma was treated with cyclophosphamide (100 mg/m2 Days l-14), methotrexate (40 mg/m*, Days 1 and 8), and 5fluorouracil (600 mg/m2, Days 1 and 8) for two courses
291
0090-8258191$1.50 Copyright 0 1991 by Academic Press, Inc. All rights of reproduction in any form reserved.
292
KELLEY
ET AL.
FI G. 1. Cervical biopsy with sheets and nests of invasive, poorly differentiated cytoplasm to be mucoukecreting neoplastic cells (H + E, x50).
with concomitant external-beam radiation to the left breast and chest wall in an attempt to achieve palliation. Subsequently, skin changes consistent with an inflammatory breast carcinoma occurred and a modified radical mastectomy with extensive skin excision and a limited axillary node dissection was performed. The specimen demonstrated metastatic adenosquamous cell carcinoma of the cervix in the breast and axillary nodes (Fig. 2). One month later the patient had mediastinal and contralateral axillary adenopathy and large pleural effusions. Palliative measures were undertaken and the patient succumbed to her disease within 9 months after her initial diagnosis.
DISCUSSION It is unusual for the breast to be a site of metastatic disease. In 1863, Virchow observed that organs that had a propensity for primary malignancy were rarely involved by metastatic disease [l]. Hadju and Urban, in reviewing a lo-year period at Memorial Hospital, found 51 cases of nonprimary metastatic mammary cancer compared to
carcinoma. Mucicarmine
stain revealed cells with basoph lilic
4000 primary breast carcinomas [2]. The most common sources of metastatic disease are the opposite breast, lymphoma, melanoma, and epithelial carcinoma, notably bronchogenic carcinoma [2,3]. The autopsy incidence of metastasis to the breast from extramammary primaries ranged from 1.4 to 6.1% [4-61 as compared to a clinically observed rate of 1.2% [2]. Genital tract malignancies rarely metastasize to the breast. Ovarian carcinoma has been reported to occur most frequently [5-71 with isolated reports of metastatic disease from endometrial [3], vulvar [8], and cervical carcinoma [2,4,9-121. Speert and Greely reported the first case of a squamous cell carcinoma of the cervix metastasizing to the breast in a patient with a breast mass and supraclavicular adenopathy [9]. Ward and associates recently reported a recurrence of an adenocarcinoma of the endocervix presenting with widespread venous thromboses and an inflammatory breast lesion [lo]. Of the known cases, onehalf have been diagnosed at autopsy (Table 1). Clinical presentation of these patients was a palpable mass in all cases. The most common histology was squamous carcinoma with adenocarcinoma and anaplastic carcinoma also
CASE REPORT
293
Fl G. 2. Mastectomy specimen demonstrated multiple tumor nodules similar in morphology to Fig. 1. There are nests of neoplastic It). The breast glands are seen on the left (arrow) and the stroma contains many inflammatory cells (H + E, x 125).
(righ
reported. Our patient presented with an adenosquamous carcinoma. This histologic type has been associated with an aggressive clinical course with early development of distant metastases [13]. Paulus and Libshitz state that metastatic disease in the breast occurs by a variety of mechanisms including crosslymphatic spread in the thorax, hematogenous dissemination, and in hematologic malignancies as a result of a unicentric or multicentric process [8]. In our patient, metastatic dissemination may have occurred by either a hematogenous or a lymphatic route. Lymphatic metastasis to the breast may occur by several routes and is dependent upon retrograde flow. One route would be via the subclavian lymph node chain with subsequent backflow to the axillary lymph node groups (lateral, pectoral, subscapular, central, and apical) and then to the subareolar and circumareoloar plexuses with final termination within the perilobular and interlobular plexuses within the breast. An alternate route would involve retrograde flow from the anterior sternal lymph nodes to the medial aspect of the breast. Metastatic lesions should be considered in a patient
with a known extrammamary primary. Hematogenously disseminated lesions are superficial, multiple, well circumscribed, and rapidly growing [2,8,14,15]. The lesions tend to involve the upper outer quadrant [2,14,15]. Hadju and Urban noted that one-half of the cases involved the skin, underlying subcutaneous tissue, and immediately adjacent breast tissue [2]. Mammographic evaluation correlates well with clinical measurements because of minimal proliferation of fibrous tissue surrounding the mass [ 141. Calcifications and spiculations are absent [2,8,14]. The presence of calcifications on mammography virtually excludes an extramammary primary except for some serous ovarian tumors with psammoma bodies [7,8]. Histologic diagnosis depends on periductal and/or perilobular distribution of tumor cells in the absence of intraductal carcinoma or lobular carcinoma in situ. The diagnosis is more difficult than that in the case of a primary malignancy and interpretation of frozen section or limited biopsy specimens can be misleading [2]. Metastatic carcinoma of the cervix carries a grave prognosis. Survival with metastatic disease to the breast was less than 6 months in our patient. Several of the reported
294
KELLEY
ET AL.
TABLE 1 Patients with Cervical Cancer Metastatic to Breast No. of patients
Author DeAlvarez
[ 121
Histology
Stage
Treatment
Method of diagnosis
Breast findings
Coexisting sites
1
Squamous
Not stated Not stated
Autopsy
Speert and Greely [9]
1
Squamous
Not stated XRT
Clinical
Badib ef al. [4]
4
Not stated
Not stated 3 XRT; 1 surgery Autopsy
Hadju and Urban [2]
3
Squamous
Not stated Not stated
Clinical
Nayar et al [ll]
1
Anaplastic
IVB
None
Clinical
Bilateral masses
Not stated
Ward et al. [lo]
1
Adenocarcinoma
IIB
XRT
Clinical
Inflammatory lesion
Cervical/axillary adenopathy
Kelley et al.
1
Adenosquamous carcinoma
IB
XRT
Clinical
Palpable mass Axillary adenopathy
Autopsy
Widespread dissemination Palpable mass Supraclavicular node; skull Autopsy Widespread dissemination Palpable mass Not stated
Comments DOD DOD 4 DOD 2 DOD 1 Unknown Presentation of cervical cancer was breast mass; DOD Nodal spread noted 6 months prior to breast metastasis; DOD DOD
Note. DOD, Dead of disease; XRT, radiotherapy.
patients had concomitant distant metastases or developed them shortly after the diagnosis was established [9,11]. The importance of correct diagnosis is underscored to prevent unnecessary surgery as well as to direct appropriate therapy to the primary malignancy. Cervical cancer metastatic to the breast is an unusual event but deserves consideration in patients with advanced disease. An adequate excisional biopsy and mammographic findings of well-circumscribed lesions with the absence of calcifications may aid in the diagnosis. Mastectomy may have a palliative benefit in some patients with large lesions, inflammation, and necrosis.
8. 9. 10.
11.
REFERENCES 1. Virchow, R. Die Krankhaften Geschwulste, Hirschwald, Berlin, Vol. 1, p. 69 (1863). 2. Hajdu, S. I., and Urban, J. A. Cancers metastatic to the breast, Cancer 29, 1691-1696 (1972). 3. McIntosh, I. H., Hooper, A. A., Millis, R. R., and Greening, W. P. Metastatic carcinoma within the breast, Clin. Oncol. 2, 393401 (1976). 4. Badib, A. O., Kurohara, S. S., Webster, J. H., and Pickren, J. W. Metastasis to organs in carcinoma of the uterine cervix. Influence of treatment on incidence and distribution, Cancer 21, 434-439 (1968).
12. 13.
14.
15.
Sandison, A. T. Metastatic tumours in the breast, Br. J. Surg. 47, 54-58 (1959). Abrahms, H. L., Spiro, R., and Goldstein, N. Metastases in carcinoma. Analysis of 1000 autopsied cases, Cancer 3, 74-85 (1950). Laifer, S., Buscema, J., Parmley, T. H., and Rosenshein, N. B. Ovarian cancer metastatic to the breast, Gynecol. Oncol. 24, 97102 (1986). Paulus, D. D., and Libshitz, H. 1. Metastasis to the breast, Radio{. Clin. North Am. 20, 561-567 (1982). Speert, H, and Greeley, A. V. Cervical cancer with metastasis to the breast, Am. J. Obstet. Gynecol. 55, 894-896 (1948). Ward, R., Conner, G., Delprado, W., and Dalley, D. Case report: Metastatic adenocarcinoma of the cervix presenting as an inflammatory breast lesion, Gynecol. Oncol. 35, 399-405 (1989). Nayar, M., Chandro, M., Aggarwal, R., and Chander, S. Carcinoma cervix presenting as primary breast malignancy, Indian J. Pathol. Microbial. 30, 283-286 (1987). DeAlvarez, R. R. The causes of death in cancer of the cervix uteri, Am. J. Obstet. Gynecol. 54, 91-96 (1947). Gallup, D. G., Harper, R. H., and Stock, R. J. Poor prognosis in patients with adenosquamous cell carcinoma of the cervix, Obstet. Gynecol. 65, 416-422 (1985). Bohman, L. G., Bassett, L. W., Gold, R. H., and Voet, R. Breast metastases from extramammary malignancies, Radiology 144,309312 (1982). Toombs, B. D., and Kahsher, L. Metastatic disease to the breast: Clinical, pathologic, and radiographic features, Am. J. Roentgenol. 129, 673-676 (1977).
