685

Metastases

to the Breast

Erlinda

S. McCrea1

Curtis Phillip

Johnston2 J. Haney1

Metastases to the breast are uncommon, with about 250 cases reported from clinical and autopsy series. The mammographic findings In 1 6 new cases revealed a spectrum of changes that Included solitary or multiple lesions, well demarcated or poorly marginated masses, and diffuse involvement of skin or parenchyma or both. Diffuse disease was seen more frequently in this series (4/ 1 6), at times simulating Inflammatory breast cancer. Although diagnosis of a primary malignancy usually preceded detection of the breast lesion, 40% (6/16) had no history of malignancy. Prognosis remains poor; however, it has improved in the lymphoma-leukemla group due to Improved Immunotherapeutic and chemotherapeutic regimens. The clinical, radlologic, and pathologic features are discussed. Some of the lesions encountered can be confused with a primary breast malignancy or a benign lesion, necessitating prompt and accurate biopsy to preclude unnecessary major surgery and to improve survival In cancers amenable to current therapy.

Diagnosis and management of metastases to the breast is an uncommon clinical problem but one that can present difficulties to the radiologist and oncologist. We undertook a retrospective review of patients with documented breast metastases to evaluate the findings on mammography and to assess their significance with regard to prognosis and patient management.

Materials
Review disclosed

and
of

Methods
records from our and mammograms with patients from pathologic January or no history clinical 1 975 to proof August of 1982

clinical

1 6 patients

institution

metastatic

disease
University

to the

breast.

Ten
Cancer

patients
Center.

were
Six

known

cancer
had

patients

being

treated
disease

in the
and

of Maryland

of malignant

the breast abnormality was the first presentation of an extramammary malignancy. All 1 6 patients had xeromammograms, with craniocaudad, contact lateral, and optional axillary views. Pathologic proof was obtained by biopsy in nine patients, autopsy in five patients, biopsy of associated skin nodules in one patient, and clinical remission of the breast abnormality after local radiotherapy in one patient.

Results The
Received
revision June

primary acute

malignancies lymphocytic, two

were: acute

four

lymphomas myelocytic),

(two three

Hodgkin), lung (one

four oat

leukemias cell, one

November
7, 1983.

29,

1 982;

accepted

after

(two

Department of Diagnostic Radiology, University of Maryland Hospital, 22 S. Greene St., Baltimore. MD 21201. Address reprint requests to E.

squamous liver, one of the left

cell, one adenocarcinoma), squamous cell carcinoma pleura, one pancreatic

one cholangiocellular carcinoma of the of the left tonsil, one malignant mesothelioma adenocarcinoma, and one highly anaplastic

S. McCrea.
2Department land Hospital, of Pathology. Baltimore, University of MaryMD 21201.

AJR 141:685-690,

October1983 0361 -8o3x/83/1 414-0685 American Roentgen Ray Society

adenocarcinoma (origin from lung, cervix, or breast). The metastases appeared on the average 1 .9 years after diagnosis of the primary malignancy. There were 15 women and one man. Metastatic disease was present elsewhere in 14 patients when the breast lesions were discovered. Six of these 14 patients had no history of malignancy.

686

McCREA

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AJR:141,

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1983

Fig.

1 .-Xeromammogram.

Large

.-:

area of asymmetry occupying 40% of left breast from proven oat cell carcinoma of lung.

SS.)#{149}.

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:...:
.:I.:X

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--.

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.

.:

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Signs

and

symptoms

included

pain,

tenderness,

inflam-

mation, and palpable Six patients complained

masses within the of some degree

breasts of pain

and axillae. and discom-

single lesions in each metastatic skin nodules

breast of the same due to adenocarcinoma

patient, proven of the lung.

fort, especially those with diffuse involvement. Ten patients had painless masses that were usually solitary and either well limited or poorly marginated clinically. Axillary adenopathy was present in seven patients; six patients had supraclavicular adenopathy. Two of these seven patients had both axillary and supraclavicular adenopathy. The left breast was involved in seven patients was noted lymphoma, was positive and the right breast in five. Bilateral involvement leukemia, one with noma of the lung. Mammography patients discerned in four patients, two with and one with adenocarciin 1 3 patients. The three not be post-

None demonstrated any calcifications or spiculations. Asymmetry of breast architecture was noted in one patient with metastatic oat cell carcinoma, with the abnormality occupying 40% of one breast (fig. 1 ). Two young patients (20 and 26 years) had poorly marginated masses in one breast, one due to Hodgkin disease and the other leukemia. One patient had right axillary and upper increased density. Biopsy revealed Hodgkin outer quadrant disease.

One patient had diffuse increased parenchymal density of the breast (prior contralateral mastectomy for malignant melanoma) secondary to diffuse histiocytic lymphoma. Eleven patients died within 1 2 months or less with dissemmated metastases. Three patients died within 1 3 months or less, due to diffuse hemorrhage in a patient with acute myelocytic leukemia, adriamycin-induced congestive heart failure in a patient with pergillosis in a patient None of the last Two three had at autopsy. patients, diffuse lymphoma, and with acute lymphocytic evidence with of their primary and Hodgkin leukemia diffuse asleukemia. disease dis6 years malignancy.

in whom a radiographic were either pregnant

abnormality could (two) or immediately acute and thickening of the

partum (one). Their diagnoses were kemia, diffuse histiocytic lymphoma, leukemia, respectively. Four similar thought diagnoses patients had to inflammatory clinically were diffuse skin carcinoma cell

lymphocytic leuacute myelocytic of one breast breast and were cancer. tonsil The and of the

to have squamous

inflammatory carcinomas

breast

ease, are currently well and after discovery of their primary Four patients in this report

in clinical remission malignancy. had more than one

of the lung, and pancreatic and mas. A fifth patient demonstrated thickening cinoma patients mammary There ing benign responsible

anaplastic localized

adenocarcinoouter lateral skin

in one breast, from proven cholangiocellular carof the liver. The breast lesion in the last three was the first manifestation of an unknown extraprimary. were four nodular lesions in three patients simulatdisease. Mesothelioma for solitary nodules. and leukemia were The other two nodules each were

Two patients had a history of cervical cancer several years earlier; one with stage I disease developed highly anaplastic adenocarcinoma, oped squamous diffuse metastases with cholangiocellular lungs, thyroid and liver follicular and the other cell carcinoma involving the carcinoma at autopsy, carcinoma. with stage II disease develof the lung. Both died with breasts. The third metastatic to the patient, breasts,

also had a locally invasive The fourth patient had diffuse

AJR:141,

October

1983

METASTASES

TO

THE

BREAST

687

Fig. 2.-Case x490). Anaplastic

1. A, Xeromammogram. malignant cells, similar

Solitary nodule to mesothelioma

interpreted as benign of left pleura, infiltrate

lesion or circumscribed form stroma between two clusters

of carcinoma.

B. Photomicrograph

(H

and

E,

of mammary

ductules.

Fig.

3.-Case

2. A, Xeromammogram.

Diffuse

permeation

by poorly

differentiated

squamous

skin thickening cell carcinoma,

suggestive of inflammatory in section of breast tissue.

breast

carcinoma.

B, Photomicrograph

(H and E. x490).

Lymphatic

histiocytic

lymphoma,

stage

IVA,

with

three

recurrences

radiotherapy. extension nervous died.

Lymphoma

recurred

in the

mediastinum

with

over a 31/3-year period. During the second recurrence, a left breast mole was discovered and diagnosed as malignant melanoma, Clarks level Ill, necessitating mastectomy and

into the right breast. She also developed central system metastases from melanoma and eventually

688

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Representative Case 1

Case

Reports

lesion. Biopsy disclosed metastatic mesothelioma (fig. rence in the left chest and in the same breast occurred patient died 1 year after diagnosis of the breast mass.
without any known exposure

2). Recurlater; the

A 51-year-old

woman,

a nonsmoker

to asbestos, had left chest pain and dyspnea on exertion. Chest radiographs revealed left pleural effusion, and thoracentesis disclosed malignant mesothelioma. Appropriate therapy produced an apparently good response. A year later a freely movable, nontender left breast lump was noted. The mammogram suggested a benign

Case 2 A 60-year-old
carcinoma of the

woman
left

was diagnosed
stage

as having
poorly

squamous
differentiated,

cell

tonsil,

IV T2N3,

with metastases to the left neck and left axilla. Partial remission was obtained with two chemotherapeutic regimens and radiotherapy
over a 9-month period. She then complained of firmness and

tenderness in her left breast. Clinical and mammographic suggested inflammatory breast cancer (fig. 3). Chest were normal. Biopsy revealed metastatic disease. months later despite aggressive chemotherapy. Case 3

evaluation radiographs She died 3

#{128}:

A 55-year-old woman noted nontender lumps in both breasts and axillae for 3 months. Biopsy of the right axilla revealed Hodgkin disease, stage IV, of mixed cellularity. Mammograms obtained 3 days after axillary biopsy revealed increased density in the upper outer quadrant and axilla. The second rib had a lytic lesion (fig. 4). Aadionuclide bone scan was positive in the rib, right breast, and
axilla. Two chemotherapeutic regimens produced a good response;

the patient
p5L

is currently

in clinical

remission

6 years

later.

1.

Case 4 A 26-year-old
cytic leukemia,

woman
and

was diagnosed

as having

acute

lymphowas insti-

intravenous

methotrexate

therapy

I, #{149}r

tuted. Four months later, she incurred trauma to her right breast with a resultant lump developing. She had not noted a lump before the trauma. Right axillary nodes were palpable. Mammography revealed a large, poorly marginated mass deep within the breast
(fig. 5). The differential management considerations were hematoma and leu-

Fig. heads). disease.

4.-Case

3. Xeromammogram.

Increased

and axilla

of right

breast.
residual

Lytic

lesion

of second
arrowheads).

in upper quadrant rib anteriorly (large arrow-

density

kemic
Further

infiltrate.

An absence produced

of clinical
prompted

change
biopsy,

2 weeks
disclosing

later under
a chloroma.

conservative

Postbiopsy

air (small

Biopsy

revealed

Hodgkin

treatment well for 6 years.

clinical

remission

and she has remained

Fig. 5.-Case 4. Xeromammogram. Large, asymmetric, poorly marginated mass deep within right breast (arrowheads). Biopsy revealed acute lymphocytic leukemic infiltrate.

AJR:141,

October

1983

METASTASES

TO

THE

BREAST

689

Discussion

had

no

history

of malignancy.

All

patients

died

within

12

months or less after discovery ofthe breast lesion, indicating the lethal nature of blood-borne metastases. This is conBreast plasms from from clinical 1 .2% involvement is distinctly by unusual, extramammary with about 250 malignant cases neoreported firmed The by other final type series [1 -4, 10-12]. is hematologic, myeloma systemic comprising [5, 8, 9]. The first process, although Mambo of the breast of metastasis and rarely of a diffuse

and autopsy series. to 6.6% of all breast

Reported incidence varies malignancies [1 -3]. The

Iymphoma, leukemia, two are usually part infrequently et al. [8] breast tumors Tumor actuarial range reported malignant they reported

variation lymphoma dence

is due to the inclusion group in different in autopsy vs. clinical

or exclusion of the leukemiaseries and the increased mciseries. Because of the rarity

occur as a primary breast tumor. 1 4 cases of primary lymphoma representing 0.12% of all malignant at M. 0. Anderson 5-year survival rate, 1 4 patients to 1 2 years. lymphoma breast. more Hodgkin rare [5,

in 1977

and unusual clinicopathologic characteristics of these metastases, it can be difficult to make adequate diagnoses clinically and histologically [1 , 4]. This is particularly true if the breast abnormality is the first presentation of an unknown extramammary Cancers metastatic sharply limited, solitary
,

in a 32-year period Institute. The total methods, of survival five breast cases lymphoma primarily for was

Hospital and by standard 49%. The with involvet al. [9]

1 3 of the 3 months

was Meyer disease 8, 9].

primary. to the masses

of primary of the is even

in 1 2 patients

breast with

are

often

superficial, for the

a predilection

ing the

upper outer involvement, tenderness, Hajdu more and than

quadrant [1 and diffuse and/or Urban half [2-4]. usually of [1

2, 4-6]. disease are

Multiple lesions, bilateral are less common. Pain, usually of 51 complained absent, cases, of although stated pain that and in the is encan

Eight patients They included phoma younger the age (two), age

in our series had Hodgkin disease and group, leukemia mostly of lymphoma (four). in the

hematologic malignancies. (two), non-Hodgkin lymThe fourth patients decade, Six were in a reflecting patients

discharge
],

in a report patients

their Adherence absent.

incidence

and

leukemia.

discomfort nipple are

to the skin and Axillary involvement

,

changes often

died within 1 1 months or less. Three of these had disseminated disease, one believed secondary to noncompliance with therapy other three evidence for nodular sclerosing Hodgkin disease. The died of complications related to therapy without primary disease. The final two patients are

countered, particularly in lymphoma [1 The histologic diagnosis of metastasis

2, 4, 6-8]. to the breast

be more difficult
nosis usually can

than that of primary

be made on routine

breast

cancer.

Diagbiopsy

of their

frozen-section

examination, although infrequently it may be necessary to perform detailed examination of the entire excisional biopsy material to arrive at a correct diagnosis [1 , 7]. Histologically, one noma looks and/or for tumor periductal cells lobular to make and/or in the carcinoma a histologically perilobular absence in situ distribution carcitype-speto avoid to the therbeen [1 ]. It is of utmost and of malignant importance of intraductal correct

alive and well 6 years later. The radiographic appearance varied greatly, including a solitary nodule, poorly marginated masses in one breast, and diffuse parenchymal involvement. Three young patients had no detectable abnormality, two of whom were pregnant and known to one immediately to cause diffuse glandular postpartum. increased proliferation in very of these

Both that

conditions tends

are density to fill

well due the

parenchymal dense patients as the and

excessive

cific identification of the primary unnecessary major surgery and extramammary apy then can established. Metastasis (metastatic Hematologic blood-borne neoplasm be initiated can occur

tumor in order to direct attention

entire breast, resulting graphically [1 3]. One chymal normal pregnancy involvement architecture changes

breasts mammohad diffuse parenbreasts resolution regained of the

[1 ]. Prompt once extent through two

and appropriate of disease has routes: cross-lymphatic

in retrospect, after treatment in the breasts.

from contralateral malignancies metastases [5].

breast) account A review

and blood-borne for a subtype of the literature

[5]. under mdinext can-

None of the lesions demonstrated three cases have been reported

any calcifications: only to demonstrate microcalcontainof recogvirtually is little

cifications secondary to metastatic ovarian cancer, ing psammoma bodies [5, 1 4, 1 5]. The presence nizable calcifications in a mass on a mammogram excludes metastatic also distinctly absent of metastatic desmoplasia Four of Mcintosh cancers associated our et al. patients [1 6], disease to the breast. from the mammographic to the breast, since with these lesions. had more than of 4,1 47 one in a report

cates that melanoma

borne metastases most common are cer in decreasing from sites such

is the most common

source

of blood-

to the breast lung cancer, as order the

[2, 3, 5, 1 0, 1 1 ]. The sarcomas, and ovarian Fewer and

Spiculation appearance there is

of frequency. gastrointestinal

lesions arise genitourinary had abnormal was to comin our

tracts[i-6, 12]. All patients with mammograms. The

malignancy. primary

blood-borne most common

metastases radiographic

treated

finding

diffuse skin thickening (four). This is in contradiction other series, which describe nodular lesions as more mon [1-6]. The histologic type of primary malignancy series may account cells permeating the in diffuse involvement, nodules, one case one case of focal for this discrepancy, lymphatics and blood particularly dermal. of breast Three thickening.

breast tumors, found that 57 patients had a previous extramammary malignancy, and 1 26 patients subsequently developed a second primary malignancy other than in the breast. This suggested that the presence of two primary tumors is not uncommon when one primary tumor metastasizes to the breast [5, 1 5]. The reason for this is unclear. The small number and variety of the malignancies involved in our Future series makes observations any evaluation difficult at may elucidate this association. this time.

with the tumor vessels resulting There were three architecture of these and patients

of asymmetry skin

690

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REFERENCES 9.
1 . Hajdu

2.

3. 4. 5. 6.

7.

8.

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of the breast. Cancer 1977;39 : 2033-2040 Meyer JE, Kopans DB, Long JC. Mammographic appearance of malignant lymphoma of the breast. Radiology 1980;
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