1991, The British Journal of Radiology, 64, 277-278 Case reports Acknowledgments We would like to thank Sophie Kalifatidis and Patricia Murnane for typing the manuscript.
diagnosis of transitional cell carcinoma of the kidney. Journal of Urology, 127, 876-887. GOLDMAN, S. M.,
BOHLMAN, M. E. & GATEWOOD, O. M.
B.,
1987. Neoplasms in the renal collecting system. Seminars in Roentgenology, 22, 284-291. GOLDMAN,
References DAVIDSON, A. J., 1985. Radiology of the Kidney (W. B. Saunders, Philadelphia, PA), pp. 453-468. GATEWOOD, O. M. B., GOLDMAN, S. M., MARSHALL, F. F. &
SIEGELMAN, S. S., 1982. Computed tomography in the
S.
M.,
MENG,
C,
WHITE,
R.
I.
et
al,
1977.
Transitional cell tumour of the kidney. How diagnostic is the angiogram? American Journal of Roentgenology, 129, 99-105. LOWE, P. P. & ROYLANCE, J., 1976. Transitional cell carcinoma of the kidney. Clinical Radiology, 27, 503-512.
Metastatic carcinoma to the male breast By Lalitha Ramamurthy, MD and *tRichard A. Cooper, MD Department of Radiology, Hines VA Hospital, Fifth Avenue and Roosevelt Road, Hines, Illinois 60141 and tDepartment of Radiology, Loyola University Medical Center, Foster G. McGaw Hospital, 2160 South First Avenue, Maywood, Illinois 60153, USA {Received May 1990 and in revised form September 1990) Keywords: Male breast carcinoma, Mammography
Metastatic carcinoma to the breast is relatively rare. In autopsy studies, metastatic tumours to the breast accounted for 1.7-6.6% of breast tumours (Abrams et al, 1950; Sandison, 1950). The clinically reported incidence of metastatic tumours to the breast ranges from 0.5-2% (Toombs & Kalisher, 1977; Egan, 1988a). Of primary breast cancers, 0.15-0.9% cancers occur in males (Kapdi & Parekh, 1983; Egan, 1988b). Metastatic tumours to the male breast are even rarer and this is the first such case reported in the literature. In this article, we report the clinical, radiographic and pathologic features of a case of metastatic prostate cancer to the male breast. Case report A 64-year-old black man had a 2-year history of Stage II prostate carcinoma. Histology showed infiltrating, moderate to poorly differentiated adenocarcinoma. The patient had radiation therapy and was continually treated with stilbesterol. His initial metastatic work-up was unremarkable. A bone scan 1 year prior to admission was positive in the axial skeleton. A repeat bone scan on the last admission showed progression of the disease. The patient presented with bilateral, painful gynecomastia secondary to oestrogen therapy which did not respond to radiation therapy. The right breast demonstrated a firm, palpable mass on clinical examination. Mammography (Fig. 1) revealed bilateral gynecomastia and multiple moderately well circumscribed, non-calcified masses in the lateral aspect of each breast. Fine needle aspiration biopsy (Fig. 2) of the right breast mass showed moderately well differentiated * Author for reprint requests. Vol. 64, No. 759
Figure 1. Bilateral gynecomastia with multiple well circumscribed masses. The largest mass (*) measured 1.75 cm in diameter and corresponded to the palpable mass. It was this mass that was biopsied.
277
Case reports
as well as Hajdu (1972) point to the absence of malignant cells within the ductal system as a sign of metastasis. Instead, in metastatic disease, there is a periductal distribution of tumour cells. Also, Charache (1953) noted that metastatic lesions are less fixed to the breast tissue and more likely to be encapsulated in subcutaneous fat. Azzopardi (1979) stresses not only the absence of ductal involvement but also the absence of elastosis as a salient feature of metastatic carcinoma to the breast. Specific diagnosis of metastatic prostate carcinoma has been obtained using immunochemical studies for prostate specific antigen (Nadgi et al, 1981). Summary Figure 2. Fine needle aspiration biopsy smear demonstrating adenocarcinoma consistent with prostatic primary. Note the small acinar structures at the centre of the slide. Each nucleus contains a single prominent nucleolus characteristic of prostatic carcinoma. (Alcohol fixed Papanicolaou stained smear, x 92). metastatic adenocarcinoma consistent with the primary prostatic lesion. Immunochemistry revealed tumour positivity for prostate specific antigen. The patient did not receive treatment and died 4 months after discovery of the breast metastasis.
A case of metastasis to the male breast from prostate carcinoma is reported. For proper treatment, it is important to differentiate primary from metastatic tumours. Prostate-specific antigen screening should be strongly considered in all breast masses seen in patients with known prostatic carcinoma. One cannot assume that breast enlargement in these patients is solely due to oestrogen-induced gynecomastia. References ABRAMS, H. L., SPIRO, R. & GOLDSTEIN, N., 1950. Metastases
Discussion
Metastatic tumours to the male breast are extremely rare. The frequency of prostatic metastasis to the breast has been studied. Toombs & Kalisher (1977) reported nine prostate primaries out of 152 metastatic lesions to the breast. Salyer & Salyer (1973) examined histologically breast in 46 patients who died of metastatic prostate carcinoma. Metastases were found in 26% of these patients, none of whom had clinical evidence of breast metastasis. Earlier, many cases of metastatic carcinoma to the breast were wrongly diagnosed as primary carcinoma attributable to oestrogen therapy (Azzopardi, 1979). Salyer & Salyer (1973) found no increased incidence of primary breast cancer in their series of patients who died from metastatic prostate carcinoma. All their patients received oestrogen therapy and 95% had gynecomastia. Bland et al (1980) states that oestrogen causes proliferative changes in the breast with development of both ducts and periductal stroma. This may provide a more suitable environment for metastatic cancer. Mostofi and Price (1973) reported prostate cancer metastatic to the breast in patients without prior oestrogen therapy. Yet Toombs and Kalisher (1977) reported that oestrogen therapy was administered to eight out of nine patients with breast metastasis from adenocarcinoma of the prostate. The prognosis after discovery of metastasis to the breast is poor. Our patient lived only 4 months after diagnosis. Although one cannot always reliably differentiate metastatic lesions from primary breast cancer, Lo (1978)
278
in carcinoma. Cancer, 3, 74-84. AZZOPARDI, J. G., 1979. Problems in Breast Pathology (W. B. Saunders, Philadelphia), p. 311-314. BLAND, K. I., BUCHANAN, J. B., WISEBERG, B. F., HAGAN,
T. A. & GRAY, L. A., 1980. The effects of exogenous estrogen replacement therapy of the breast: Breast cancer risk and mammographic parenchymal patterns. Cancer, 45, 3027-3033. CHARACHE, H., 1953. Metastatic tumors to the breast. Surgery, 3, 385-390. EGAN, R., 1988a. Breast Imaging (W. B. Saunders, Philadelphia), p. 288. 1988b. Breast Imaging (W. B. Saunders, Philadelphia), p. 295. HAJDU, S. I. & URBAN, J. A., 1972. Cancer metastatic to the
breast. Cancer, 29, 1691-1696. KAPDI, C. C. & PAREKH, N. J., 1983. The male breast.
Radiological Clinics of North America, 21, 137-148. Lo, M. C , CHOMET, B. & RUBINSTONE, A., 1978. Metastatic
prostatic adenocarcinoma of the male breast. Urology, 11, 641-646. MOSTOFI, F. K. & PRICE, E. B., 1973. Tumors of the Male
Genital System (Armed Forces Institute of Pathology, Washington DC), p. 239. NADJGI, M., TABEI, S., CASTRO, A., C H U , T. M. & MORALES,
A. R., 1980. Prostatic origins of tumours. An immunohistochemical study. American Journal of Clinical Pathology, 73, 735-739. SALYER, W. R. & SALYER, D. C , 1973. Metastases of prostatic
carcinoma to the breast. Journal of Urology, 109, 671-675. SANDISON, A. T., 1950. Metastatic tumours in the breast. British Journal of. Surgery, 47, 54-58. TOOMBS, B. D. & KALISHER, L., 1977. Metastatic disease to the
breast: Clinical, pathologic and radiographic features. American Journal of Roentgenology, 129, 673-676.
The British Journal of Radiology, March 1991
diagnosis of transitional cell carcinoma of the kidney. Journal of Urology, 127, 876-887. GOLDMAN, S. M.,
BOHLMAN, M. E. & GATEWOOD, O. M.
B.,
1987. Neoplasms in the renal collecting system. Seminars in Roentgenology, 22, 284-291. GOLDMAN,
References DAVIDSON, A. J., 1985. Radiology of the Kidney (W. B. Saunders, Philadelphia, PA), pp. 453-468. GATEWOOD, O. M. B., GOLDMAN, S. M., MARSHALL, F. F. &
SIEGELMAN, S. S., 1982. Computed tomography in the
S.
M.,
MENG,
C,
WHITE,
R.
I.
et
al,
1977.
Transitional cell tumour of the kidney. How diagnostic is the angiogram? American Journal of Roentgenology, 129, 99-105. LOWE, P. P. & ROYLANCE, J., 1976. Transitional cell carcinoma of the kidney. Clinical Radiology, 27, 503-512.
Metastatic carcinoma to the male breast By Lalitha Ramamurthy, MD and *tRichard A. Cooper, MD Department of Radiology, Hines VA Hospital, Fifth Avenue and Roosevelt Road, Hines, Illinois 60141 and tDepartment of Radiology, Loyola University Medical Center, Foster G. McGaw Hospital, 2160 South First Avenue, Maywood, Illinois 60153, USA {Received May 1990 and in revised form September 1990) Keywords: Male breast carcinoma, Mammography
Metastatic carcinoma to the breast is relatively rare. In autopsy studies, metastatic tumours to the breast accounted for 1.7-6.6% of breast tumours (Abrams et al, 1950; Sandison, 1950). The clinically reported incidence of metastatic tumours to the breast ranges from 0.5-2% (Toombs & Kalisher, 1977; Egan, 1988a). Of primary breast cancers, 0.15-0.9% cancers occur in males (Kapdi & Parekh, 1983; Egan, 1988b). Metastatic tumours to the male breast are even rarer and this is the first such case reported in the literature. In this article, we report the clinical, radiographic and pathologic features of a case of metastatic prostate cancer to the male breast. Case report A 64-year-old black man had a 2-year history of Stage II prostate carcinoma. Histology showed infiltrating, moderate to poorly differentiated adenocarcinoma. The patient had radiation therapy and was continually treated with stilbesterol. His initial metastatic work-up was unremarkable. A bone scan 1 year prior to admission was positive in the axial skeleton. A repeat bone scan on the last admission showed progression of the disease. The patient presented with bilateral, painful gynecomastia secondary to oestrogen therapy which did not respond to radiation therapy. The right breast demonstrated a firm, palpable mass on clinical examination. Mammography (Fig. 1) revealed bilateral gynecomastia and multiple moderately well circumscribed, non-calcified masses in the lateral aspect of each breast. Fine needle aspiration biopsy (Fig. 2) of the right breast mass showed moderately well differentiated * Author for reprint requests. Vol. 64, No. 759
Figure 1. Bilateral gynecomastia with multiple well circumscribed masses. The largest mass (*) measured 1.75 cm in diameter and corresponded to the palpable mass. It was this mass that was biopsied.
277
Case reports
as well as Hajdu (1972) point to the absence of malignant cells within the ductal system as a sign of metastasis. Instead, in metastatic disease, there is a periductal distribution of tumour cells. Also, Charache (1953) noted that metastatic lesions are less fixed to the breast tissue and more likely to be encapsulated in subcutaneous fat. Azzopardi (1979) stresses not only the absence of ductal involvement but also the absence of elastosis as a salient feature of metastatic carcinoma to the breast. Specific diagnosis of metastatic prostate carcinoma has been obtained using immunochemical studies for prostate specific antigen (Nadgi et al, 1981). Summary Figure 2. Fine needle aspiration biopsy smear demonstrating adenocarcinoma consistent with prostatic primary. Note the small acinar structures at the centre of the slide. Each nucleus contains a single prominent nucleolus characteristic of prostatic carcinoma. (Alcohol fixed Papanicolaou stained smear, x 92). metastatic adenocarcinoma consistent with the primary prostatic lesion. Immunochemistry revealed tumour positivity for prostate specific antigen. The patient did not receive treatment and died 4 months after discovery of the breast metastasis.
A case of metastasis to the male breast from prostate carcinoma is reported. For proper treatment, it is important to differentiate primary from metastatic tumours. Prostate-specific antigen screening should be strongly considered in all breast masses seen in patients with known prostatic carcinoma. One cannot assume that breast enlargement in these patients is solely due to oestrogen-induced gynecomastia. References ABRAMS, H. L., SPIRO, R. & GOLDSTEIN, N., 1950. Metastases
Discussion
Metastatic tumours to the male breast are extremely rare. The frequency of prostatic metastasis to the breast has been studied. Toombs & Kalisher (1977) reported nine prostate primaries out of 152 metastatic lesions to the breast. Salyer & Salyer (1973) examined histologically breast in 46 patients who died of metastatic prostate carcinoma. Metastases were found in 26% of these patients, none of whom had clinical evidence of breast metastasis. Earlier, many cases of metastatic carcinoma to the breast were wrongly diagnosed as primary carcinoma attributable to oestrogen therapy (Azzopardi, 1979). Salyer & Salyer (1973) found no increased incidence of primary breast cancer in their series of patients who died from metastatic prostate carcinoma. All their patients received oestrogen therapy and 95% had gynecomastia. Bland et al (1980) states that oestrogen causes proliferative changes in the breast with development of both ducts and periductal stroma. This may provide a more suitable environment for metastatic cancer. Mostofi and Price (1973) reported prostate cancer metastatic to the breast in patients without prior oestrogen therapy. Yet Toombs and Kalisher (1977) reported that oestrogen therapy was administered to eight out of nine patients with breast metastasis from adenocarcinoma of the prostate. The prognosis after discovery of metastasis to the breast is poor. Our patient lived only 4 months after diagnosis. Although one cannot always reliably differentiate metastatic lesions from primary breast cancer, Lo (1978)
278
in carcinoma. Cancer, 3, 74-84. AZZOPARDI, J. G., 1979. Problems in Breast Pathology (W. B. Saunders, Philadelphia), p. 311-314. BLAND, K. I., BUCHANAN, J. B., WISEBERG, B. F., HAGAN,
T. A. & GRAY, L. A., 1980. The effects of exogenous estrogen replacement therapy of the breast: Breast cancer risk and mammographic parenchymal patterns. Cancer, 45, 3027-3033. CHARACHE, H., 1953. Metastatic tumors to the breast. Surgery, 3, 385-390. EGAN, R., 1988a. Breast Imaging (W. B. Saunders, Philadelphia), p. 288. 1988b. Breast Imaging (W. B. Saunders, Philadelphia), p. 295. HAJDU, S. I. & URBAN, J. A., 1972. Cancer metastatic to the
breast. Cancer, 29, 1691-1696. KAPDI, C. C. & PAREKH, N. J., 1983. The male breast.
Radiological Clinics of North America, 21, 137-148. Lo, M. C , CHOMET, B. & RUBINSTONE, A., 1978. Metastatic
prostatic adenocarcinoma of the male breast. Urology, 11, 641-646. MOSTOFI, F. K. & PRICE, E. B., 1973. Tumors of the Male
Genital System (Armed Forces Institute of Pathology, Washington DC), p. 239. NADJGI, M., TABEI, S., CASTRO, A., C H U , T. M. & MORALES,
A. R., 1980. Prostatic origins of tumours. An immunohistochemical study. American Journal of Clinical Pathology, 73, 735-739. SALYER, W. R. & SALYER, D. C , 1973. Metastases of prostatic
carcinoma to the breast. Journal of Urology, 109, 671-675. SANDISON, A. T., 1950. Metastatic tumours in the breast. British Journal of. Surgery, 47, 54-58. TOOMBS, B. D. & KALISHER, L., 1977. Metastatic disease to the
breast: Clinical, pathologic and radiographic features. American Journal of Roentgenology, 129, 673-676.
The British Journal of Radiology, March 1991
