Breast cancer is a common malignancy among women. Due to the improvement of social awareness and advances in imaging technologies, significant achievements are obtained at its diagnosis and treatment each passing day. A 54-year-old, multiparous and postmenopausal woman, who presented with a palpable lymph node in the right supraclavicular region and a right adnexal mass but had no findings from the breast examination, is reported in this article. Following advanced assessment, metastatic carcinoma was identified in the lymph node biopsy and the adnexal mass. During the exploration for the primary origin, microinvasive breast cancer was diagnosed following mammographic imaging and an excisional biopsy from the right breast. Microinvasive breast cancer, which did present itself with clinical findings with metastases despite the lack of local findings, was discussed with the review of the literature.
In the United States, one in every eight women has the risk to experience breast cancer in her lifetime. Breast cancer is one of the most common cancers and it is often stated as the second cause of cancer related deaths among women[
In this article, we present a case of microinvasive breast cancer that presented clinical findings with supraclavicular lymph node involvement and ovarian metastasis without any findings from breast examination. We found it to be interesting, due to the rarity of such cases.
A 54-year-old patient (Gravida 4, parity 3, 3 years since menopause, gave birth to her last child 20 years ago) was visited due to the complaint of a palpable lymph node at the right supraclavicular region. Due to the finding of a metastatic carcinoma at the lymph node after thin needle aspiration biopsy, she was investigated with imaging and systemic examination in order to find the primary focus. Systemic examination only demonstrated a palpable lymph node, which was 2 cm × 3 cm in size, at the right supraclavicular region. No other abnormal clinical finding was detected. A solid, mobile mass was found at the right adnexal region during gynecologic examination. The mass was 6 cm × 7 cm in size. Pelvic ultrasonography of the left adnexa and the uterus was normal regarding the patient’s age. The lesion, which seemed to be originating from the right ovary was measured to be 65 mm × 72 mm in size. No free abdominal fluid was present. Ultrasonography of the upper abdomen and the physical examination of the breast was normal. Cervical smear, endometrial sampling, endoscopy of the gastrointestinal system, routine biochemical tests and complete blood count resulted in the normal range.
Apart from elevated CA15-3 concentration (157 IU/mL) and erythrocyte sedimentation rate (72 mm per 30 min); no abnormal blood parameters were present. Bilateral mammography was reviewed as Breast Imaging Reporting and Data System - 4B for the right breast (possible malignant findings), and therefore excisional biopsy (surgical margin clear of disease) was performed. Following radiological examinations showed no residual lesions. Pathological examination resulted as: microinvasive breast carcinoma, nuclear grade II. Immunohistochemistry results were as follows: p63 (+) at myoepithelial cells, estrogen receptor (ER) (+) for about 5%-10% of the cells at the ductal carcinoma
Positron emission tomography-computerized tomography (PET-CT) showed increased F-18 fluorodeoxyglucose (FDG) uptake at both supraclavicular lymph nodes, especially more prominent on the right cervical level. In addition, increased uptake of FDG was also present at the lymph nodes in thorax and abdomen. The mass lesion, whose margins were not distinguishable from the uterus, was located in the right adnexal region and showed increased F-18 FDG uptake. These radiological findings in the right adnexal region supported the diagnosis of primary gynecological malignancy.
The case was reviewed in the gynecological oncology council of our institution. The decision was to perform diagnostic laparotomy in order to confirm the primary focus. The patient underwent surgery. A firm, solid mass with lobulated margins and 6 cm × 7 cm in size was observed during laparotomy (
Macroscopic image of the tumor located in the right ovary
The paraffin sections of the removed mass were examined by our pathology department and the diagnosis of metastatic carcinoma at the right ovary was confirmed (
Microscopic image of the tumor H&E × 100
At the present day, more patients are diagnosed with microinvasive breast cancer due to the broad usage of mammography. Most of the microinvasive breast cancer cases (80%) do not have palpable masses in the breast and are diagnosed with mammography[
In spite of the advancements in its diagnosis and treatment, breast cancer continues to be fatal. Because of the fact that it can spread both locally and distantly simultaneously, breast cancer is considered to be a systemic disease from the beginning.
Three point five to ten percent of the breast cancer cases present findings with distant metastasis at the moment of diagnosis[
Debulking surgery has a role in patients with metastatic ovarian tumors that originate from non-genital organs, however it is not established that which patients are going to benefit from this technique of surgery[
Concerning the diagnosis and management of primary ovarian tumors, serum CA 125 levels are among important markers. Still, it is difficult to tell the same for metastatic tumors[
As patient history, laboratory findings and physical examination, radiological examination is also an important means while detecting the primary focus of the tumor. In addition to ultrasonography, mammography, magnetic resonance imaging and CT; PET-CT is also very helpful. Especially during the postmenopausal period, when the ovaries are non-functional, the diagnostic power of PET-CT is higher[
Distant organ metastasis is beyond expectation at the moment of diagnosis for microinvasive breast cancers. Nevertheless, ovarian metastasis should be kept in mind provided there is involvement of regional lymph nodes and the tumor is histologically lobular type[
Microinvasive breast cancers constitute a rare subgroup of invasive breast cancers. Since their histological features are better acknowledged and imaging technologies are more enhanced, more patients are diagnosed with the disease in recent years. While it presents a fair survival expectation, systemic spread and metastases may occur in very early phases of microinvasive breast cancers, when it is accompanied with regional lymph node involvement and poor prognostic immunohistochemical factors. Hence, testing for immunohistochemical and molecular markers may provide more information regarding the biology and behavior of this tumor[
Wrote the manuscript: Kurt S, Timur HT
Provided data regarding the patient’s treatment in the department of Obstetrics and Gynecology: Kurt S, Timur HT, Saatli HB
Provided information about the patient’s treatment in the department of General Surgery: Sevinc AI
Provided the pathological findings and other information from the department of Pathology: Ulukus EÇ
Not applicable.
None.
All authors declared that there are no conflicts of interest.
The consent form was signed by the patient herself. We foresee no ethical issues regarding the publication of this case report.
The consent form was signed by the patient herself.
© The Author(s) 2019.