CASE REPORT
Endometrioid carcinoma of the ovary presenting as primary carcinoma of the breast A case report and review of the literature ILAN-GILRON,' MOSHEINBAR,'MARISAHALPERN~ AND SAMARIO CHAITCHIK' From the 'Department of Oncology, lchilov Hospital, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, and *Department of Pathology, Hasharon Hospital, Golda Medical Center, Petach Tikva, Israel
Acta Ohstet gynecol Scand 1992; 71: 81-83
A case is presented of endometrioid carcinoma of the ovary, metastasizing to the breast in a 63-year old woman. Differentiation of metastatic cancer to the breast for primary breast carcinoma and discovering the primary tumor site are rather important for treatment and prognosis. Lumpectomy, followed by panhysterectorny, was performed and six courses of cisplatinum and cyclophosphamide were given. No signs of recurrence or metastasis are apparent 16 months after the discovery of the breast lesion. Key words: endometrioid carcinoma; carcinoma of the ovary; metastic cancer to breast
Submitted April 4, I991 Accepted Septemher 23, 1991
Single metastatic carcinoma to the breast is generally uncommon, particularly from ovarian carcinoma, and only 27 cases have been published. The present case is the first report of metastatic endometrioid carcinoma of the ovary to the breast. The breast metastasis was the presenting feature of the ovarian carcinoma.
the ovary (Fig. 1). The axillary lymph nodes were tumor-free. T h e patient underwent a full gynecological evaluation. Vaginal examination was normal. Vaginal ultrasound examination revealed ascites and
Case report In October 1989, a 63-year-old white female of European origin presented with a lump in the left breast. Examination revealed a well-defined 2.5 x 2.5 cm mass in the upper inner quadrant. There was no nipple discharge or skin retraction. Axillary lymph nodes could not be palpated. Physical examination was unremarkable. A mammogram showed an irregular, ill-defined mass. Lumpectomy and axillary node sampling were performed. The histopathological picture was consistent with metastatic endometrioid carcinoma of 6'
Fig. 1 , Endometrioid carcinoma of ovary metastasizing in breast tissue (H & E, ~ 6 3 ) . Acta Obstet Gynecol Scarid 71 (1992)
82
I . 4 . Ron et ul.
Fig, 2. High magnification from an area of endometrioid carcinoma of ovary with extensive necrosis and foci of squamous metaplasia in breast (H & E, ~ 4 0 0 ) .
an enlarged semi-solid ovarian tumor mass. Computerized tomographic examination of the chest and abdomen disclosed small bilateral pleural effusions and a minimal quantity of ascites. Pleural and abdominal fluid was aspirated but did not reveal any malignant cells. The patient subsequently underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy and peritoneal biopsies. Residual ovarian disease > 2 cm remained at the completion of surgery. Histopathology demonstrated endometrioid carcinoma of the ovary, Grade I1 (Fig. 2) consistent with the previous metastatic endometrioid carcinoma excised from the breast. The disease was staged as F I G 0 stage IV, Grade I1 ovarian carcinoma and referred f o r chemotherapy. Three weeks after the surgical procedure, and just before initiation of chemotherapy, her serum CA-125 levels were 317 U/ml (normal levels < 35 U/ml). After the second course of intravenous cisplatinum and cyclophosphamide, the patient achieved complete remission of the malignancy according to CA-125 levels, which fell to 21 U/ml. Four more courses of cisplatinum and cyclophosphamide were administered. Her condition, 9 months off-treatment, and 16 months after discovery of her breast lesion, is excellent, with normal CA-125 levels, abdominopelvic C T scan and mammography.
Discussion The breast is an uncommon site for metastasis from extra-mammary malignancies. Nevertheless, among cancers that metastasize to the breast, malignant melanoma, lung, ovary and stomach predominate ( 1 ) . The clinically observed rate of metastasis to the Acru Ohste, Gvtiecol Scund 71 (1992)
breast varies between 0.5 and 1.3% (2, 3), although the actual incidence is unknown. Analysis based on clinical and autopsy material is inaccurate, as the breasts are not often extensively examined (4, 5 ) . In the literature, there are 27 reported cases of ovarian neoplasms metastatic to the breast (1-3, 617). Breast metastases appear approximately 2 years after discovery of the primary lesion, most commonly as solitary discrete lesions (15, 18). Serous cystadenocarcinoma is the malignancy most often seen in breast lesions metastatic from the ovary (17). The patient under discussion presented with a breast lesion but no other symptoms or signs. Microscopic examination of the resected breast tumor demonstrated endometrioid carcinoma. The histopathology findings prompted further investigation of the ovarian origin. The average survival for these patients is less than one year after discovery of the breast metastases. In 10 out of 15 patients for whom survival data were available, the average survival was only 8.1 months. The other 5 patients are still alive, with an average timelapse of 2.0 years from discovery of the breast lesion. Unfortunately, there does not seem to be any single therapeutic regimen affording relatively prolonged life (17). Although rare, it is important that metastatic cancer to the breast be differentiated from primary breast carcinoma, as both treatment and prognosis differ significantly. A metastatic breast tumor presenting initially in a patient ostensibly free of malignant disease, where cytology or histology indicates that the malignancy is not of mammary origin, requires immunohistochemical staining with specific antigens to determine possible primary site(s). Compared with breast metastases of ovarian carcinoma reviewed in the literature, the presentation of the our patient was unusual and appears to be the first reported case of metastatic endometrioid carcinoma to the breast.
References 1. lbach J R . Carcinoma of the ovary metastatic to breast. Arch Surg 1964; 88: 41&14. 2. McIntosh IH, Hooper A A , Millis R R , Greening WP. Metastatic carcinoma within the breast. Clin Oncol 1976; 2: 393-401. 3 . Hughes J D , Hynes H E , Lin JJ. Ovarian carcinoma metastatic to breast. South Med J 1983; 76: 667-9. 4. Abrams HL, Spiro R , Goldstein N. Metastases in carcinoma: Analysis of 1000 autopsies cases. Cancer 1950; 3: 7 4 8 5 . 5 . Turksoy N . Ovarian metastasis of breast carcinoma. A surgical surprise. Obstet Gynecol 1960; 15: S73. 6. Brown JB, O’Keefe C D . Sarcoma of the ovary with unusual oral metastascs. Ann Surg 1928; 87: 467-71.
Metastatic endometrioid carcinoma in breast 7. Charache H. Metastatic tumors in the breast. Surgery 1953; 33: 385-90. 8. Harwood TR. Metastatic carcinoma to the breast. J Am Med Assoc 1973; 218: 97. 9 . Hajdu SI, Urban JA. Cancers metastatic to the breast. Cancer 1972; 29: 1691-6. 10. Moncada R, Cooper RA, Carces M, Badrinath K. Calcified metastases from malignant ovarian neoplasm. Radiology 1974; 113: 31-35. 11. Royen PM, Ziter FMH. Ovarian carcinoma metastatic to the breast. Br J Radio1 1974; 47: 345-57. 12. Kirshman EV. Phillips AK, Randell A, Taylor B, Garp SK. Bilateral metastatic inflammatory carcinoma in the breast from primary ovarian cancer. Obstet Gynecol 1980; 55: 94s-96s. 13. Paulus DD, Libshitz HI. Metastasis to the breast. Radial Clin North Am 1982; 20: 561-8. 14. Scotto V , Masci P, Sbiroli C. Breast metastasisof ovarian cancer during cisplatinum therapy. Eur J Gynaecol Oncol 1985; 6: 62-65. 15. Laifer S, Bruscema J , Parmley TH, Rosenshein NB.
83
Ovarian cancer metastatic to the breast. Gynecol Oncol 1986; 24: 97-102. 16. Matseoane SL. Ovarian carcinoma metastasis to the breast: A literature review and report of two cases. Obstet Gynecol Surv 1988; 43: 645-54. 17. Loredo DS, Powell JL, Reed WP, Rosenbaum JM. Ovarian carcinoma metastatic to breast: A case report and review of the literature. Gynecol Oncol 1990; 37: 432-6. 18. Toombs BD, Kalisher L. Metastatic disease to the breast: Clinical, pathological and radiographic features. Am J Roentgenol 1977; 129: 6734.
Address for correspondence: I. G. Ron, M.D. Department of Oncology Ichilov Hospital 6 Weizman Street Tel-Aviv 64239 Israel
Acta Ohsrer Gyner.o/ Scand 71 (1992)
Endometrioid carcinoma of the ovary presenting as primary carcinoma of the breast A case report and review of the literature ILAN-GILRON,' MOSHEINBAR,'MARISAHALPERN~ AND SAMARIO CHAITCHIK' From the 'Department of Oncology, lchilov Hospital, Tel-Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, and *Department of Pathology, Hasharon Hospital, Golda Medical Center, Petach Tikva, Israel
Acta Ohstet gynecol Scand 1992; 71: 81-83
A case is presented of endometrioid carcinoma of the ovary, metastasizing to the breast in a 63-year old woman. Differentiation of metastatic cancer to the breast for primary breast carcinoma and discovering the primary tumor site are rather important for treatment and prognosis. Lumpectomy, followed by panhysterectorny, was performed and six courses of cisplatinum and cyclophosphamide were given. No signs of recurrence or metastasis are apparent 16 months after the discovery of the breast lesion. Key words: endometrioid carcinoma; carcinoma of the ovary; metastic cancer to breast
Submitted April 4, I991 Accepted Septemher 23, 1991
Single metastatic carcinoma to the breast is generally uncommon, particularly from ovarian carcinoma, and only 27 cases have been published. The present case is the first report of metastatic endometrioid carcinoma of the ovary to the breast. The breast metastasis was the presenting feature of the ovarian carcinoma.
the ovary (Fig. 1). The axillary lymph nodes were tumor-free. T h e patient underwent a full gynecological evaluation. Vaginal examination was normal. Vaginal ultrasound examination revealed ascites and
Case report In October 1989, a 63-year-old white female of European origin presented with a lump in the left breast. Examination revealed a well-defined 2.5 x 2.5 cm mass in the upper inner quadrant. There was no nipple discharge or skin retraction. Axillary lymph nodes could not be palpated. Physical examination was unremarkable. A mammogram showed an irregular, ill-defined mass. Lumpectomy and axillary node sampling were performed. The histopathological picture was consistent with metastatic endometrioid carcinoma of 6'
Fig. 1 , Endometrioid carcinoma of ovary metastasizing in breast tissue (H & E, ~ 6 3 ) . Acta Obstet Gynecol Scarid 71 (1992)
82
I . 4 . Ron et ul.
Fig, 2. High magnification from an area of endometrioid carcinoma of ovary with extensive necrosis and foci of squamous metaplasia in breast (H & E, ~ 4 0 0 ) .
an enlarged semi-solid ovarian tumor mass. Computerized tomographic examination of the chest and abdomen disclosed small bilateral pleural effusions and a minimal quantity of ascites. Pleural and abdominal fluid was aspirated but did not reveal any malignant cells. The patient subsequently underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy and peritoneal biopsies. Residual ovarian disease > 2 cm remained at the completion of surgery. Histopathology demonstrated endometrioid carcinoma of the ovary, Grade I1 (Fig. 2) consistent with the previous metastatic endometrioid carcinoma excised from the breast. The disease was staged as F I G 0 stage IV, Grade I1 ovarian carcinoma and referred f o r chemotherapy. Three weeks after the surgical procedure, and just before initiation of chemotherapy, her serum CA-125 levels were 317 U/ml (normal levels < 35 U/ml). After the second course of intravenous cisplatinum and cyclophosphamide, the patient achieved complete remission of the malignancy according to CA-125 levels, which fell to 21 U/ml. Four more courses of cisplatinum and cyclophosphamide were administered. Her condition, 9 months off-treatment, and 16 months after discovery of her breast lesion, is excellent, with normal CA-125 levels, abdominopelvic C T scan and mammography.
Discussion The breast is an uncommon site for metastasis from extra-mammary malignancies. Nevertheless, among cancers that metastasize to the breast, malignant melanoma, lung, ovary and stomach predominate ( 1 ) . The clinically observed rate of metastasis to the Acru Ohste, Gvtiecol Scund 71 (1992)
breast varies between 0.5 and 1.3% (2, 3), although the actual incidence is unknown. Analysis based on clinical and autopsy material is inaccurate, as the breasts are not often extensively examined (4, 5 ) . In the literature, there are 27 reported cases of ovarian neoplasms metastatic to the breast (1-3, 617). Breast metastases appear approximately 2 years after discovery of the primary lesion, most commonly as solitary discrete lesions (15, 18). Serous cystadenocarcinoma is the malignancy most often seen in breast lesions metastatic from the ovary (17). The patient under discussion presented with a breast lesion but no other symptoms or signs. Microscopic examination of the resected breast tumor demonstrated endometrioid carcinoma. The histopathology findings prompted further investigation of the ovarian origin. The average survival for these patients is less than one year after discovery of the breast metastases. In 10 out of 15 patients for whom survival data were available, the average survival was only 8.1 months. The other 5 patients are still alive, with an average timelapse of 2.0 years from discovery of the breast lesion. Unfortunately, there does not seem to be any single therapeutic regimen affording relatively prolonged life (17). Although rare, it is important that metastatic cancer to the breast be differentiated from primary breast carcinoma, as both treatment and prognosis differ significantly. A metastatic breast tumor presenting initially in a patient ostensibly free of malignant disease, where cytology or histology indicates that the malignancy is not of mammary origin, requires immunohistochemical staining with specific antigens to determine possible primary site(s). Compared with breast metastases of ovarian carcinoma reviewed in the literature, the presentation of the our patient was unusual and appears to be the first reported case of metastatic endometrioid carcinoma to the breast.
References 1. lbach J R . Carcinoma of the ovary metastatic to breast. Arch Surg 1964; 88: 41&14. 2. McIntosh IH, Hooper A A , Millis R R , Greening WP. Metastatic carcinoma within the breast. Clin Oncol 1976; 2: 393-401. 3 . Hughes J D , Hynes H E , Lin JJ. Ovarian carcinoma metastatic to breast. South Med J 1983; 76: 667-9. 4. Abrams HL, Spiro R , Goldstein N. Metastases in carcinoma: Analysis of 1000 autopsies cases. Cancer 1950; 3: 7 4 8 5 . 5 . Turksoy N . Ovarian metastasis of breast carcinoma. A surgical surprise. Obstet Gynecol 1960; 15: S73. 6. Brown JB, O’Keefe C D . Sarcoma of the ovary with unusual oral metastascs. Ann Surg 1928; 87: 467-71.
Metastatic endometrioid carcinoma in breast 7. Charache H. Metastatic tumors in the breast. Surgery 1953; 33: 385-90. 8. Harwood TR. Metastatic carcinoma to the breast. J Am Med Assoc 1973; 218: 97. 9 . Hajdu SI, Urban JA. Cancers metastatic to the breast. Cancer 1972; 29: 1691-6. 10. Moncada R, Cooper RA, Carces M, Badrinath K. Calcified metastases from malignant ovarian neoplasm. Radiology 1974; 113: 31-35. 11. Royen PM, Ziter FMH. Ovarian carcinoma metastatic to the breast. Br J Radio1 1974; 47: 345-57. 12. Kirshman EV. Phillips AK, Randell A, Taylor B, Garp SK. Bilateral metastatic inflammatory carcinoma in the breast from primary ovarian cancer. Obstet Gynecol 1980; 55: 94s-96s. 13. Paulus DD, Libshitz HI. Metastasis to the breast. Radial Clin North Am 1982; 20: 561-8. 14. Scotto V , Masci P, Sbiroli C. Breast metastasisof ovarian cancer during cisplatinum therapy. Eur J Gynaecol Oncol 1985; 6: 62-65. 15. Laifer S, Bruscema J , Parmley TH, Rosenshein NB.
83
Ovarian cancer metastatic to the breast. Gynecol Oncol 1986; 24: 97-102. 16. Matseoane SL. Ovarian carcinoma metastasis to the breast: A literature review and report of two cases. Obstet Gynecol Surv 1988; 43: 645-54. 17. Loredo DS, Powell JL, Reed WP, Rosenbaum JM. Ovarian carcinoma metastatic to breast: A case report and review of the literature. Gynecol Oncol 1990; 37: 432-6. 18. Toombs BD, Kalisher L. Metastatic disease to the breast: Clinical, pathological and radiographic features. Am J Roentgenol 1977; 129: 6734.
Address for correspondence: I. G. Ron, M.D. Department of Oncology Ichilov Hospital 6 Weizman Street Tel-Aviv 64239 Israel
Acta Ohsrer Gyner.o/ Scand 71 (1992)
