Metastases to the Breast: The Diagnosis and Management of Extramammary Tumors Metastatic to the Breast

Authors:

Carol EH Scott-Conner, M.D., Ph.D.
Professor
Department of Surgery

Beverly Chaignaud,* M.D.
Department of Surgery

The University of Iowa

Peer Review Status: Externally Peer Reviewed
Creation Date: May 1997
Last Revision Date: May 1997

Table of Contents

With better therapy for cancer, clinicians are encountering more patients who have survived or are undergoing treatment for malignancy. When such a patient develops a breast mass, the dilemma of differentiating primary breast cancer from metastatic disease in the breast may prove difficult. Therapy is quite different, and must be based upon an accurate diagnosis. This article describes the presentation, diagnosis, and management of extramammary tumors metastatic to the breast, and is designed to provide a resource to the clinician encountering such a patient.

In the patient with known extramammary cancer, the differential diagnosis of a breast mass should be expanded to include metastasis of that primary tumor to the breast. In the female patient, the most common primary site is contralateral breast, and in this case it may be difficult to differentiate this from a second primary lesion. Other common sites include melanoma, lymphoma (and leukemia), lung, and ovary.

Image 1

Virtually all malignancies have been reported to metastasize to breast. A partial list is given below.

Image 2

In male patients, prostate is the commonest primary site of metastases to breast and nipple. This is somewhat more frequent in men on estrogen therapy for advanced malignancy. Most breast metastases in males are subareolar (corresponding to the distribution of glandular breast tissue in the male).

Presentation:
Most patients are known to have extramammary cancer at the time of presentation, but occasionally a breast metastasis is the first manifestation of a previously-occult primary lesion located elsewhere in the body. A palpable mass is the usual symptom. About half are painful or tender. The mass is generally mobile, firm, and may feel suspicious for malignancy on physical examination. Many of these lesions are quite superficial, possibly in the subcutaneous fat rather than breast per se. Unless the mass is quite large, skin changes are absent. Rarely, a large rapidly growing metastasis may simulate inflammatory carcinoma of the breast. Metastatic lesions within the breast may grow rapidly, be associated with Mondor's disease, or with clinically positive axillary lymph nodes.

Occasionally metastatic disease to the breast is the first presentation of an extramammary malignancy. Similarly, sometimes the first indication of these metastases is an abnormal screening mammogram. Specific mammographic characteristics aid in identification.

Mammographic findings:
The classic mammographic appearance of one or more rounded, well-circumscribed masses without architectural distortion, microcalcification, or skin thickening is often seen. Multiple lesions may be seen, simulating cysts or fibroadenomas. These multiple metastatic lesions are apt to all be of similar size and mammographic density. On spot compression or magnification views, however, the margins are apt to be less distinct than those noted with benign lesions.

Image 3

Sometimes a diffuse increase in parenchymal density with associated skin changes may simulate inflammatory carcinoma of the breast.

Image 4

And sometimes the mammogram may be unremarkable other than a subtle increase in parenchymal density.

Image 5

Architectural distortion, spiculation, and microcalcifications are rare (with the exception of ovarian carcinoma, in which case calcified Psammoma bodies may be prominent). The mammographic size of a palpable metastatic lesion corresponds closely with the size on physical examination. In contrast, in primary breast cancer, the palpable mass often feels larger than the mammographic size, due to surrounding tissue reaction.

It is extremely important that the mammographer be given the prior history of malignancy in order for an accurate diagnosis to be rendered.

Fine Needle Aspiration Cytology:
FNAC is a useful way to confirm the diagnosis without surgery and is often confirmatory. Special stains, immunohistochemistry, and/or electron microscopy may assist. Occasionally open biopsy is needed.

Histology:
It is crucial that the pathologist be informed of the prior malignancy and given access to slides from the prior diagnosis for purposes of comparison. Generally the metastatic nature of the lesion is readily apparent. In contrast to primary breast cancer, metastatic tumors are well demarcated and appear to displace mammary ducts rather than to arise from them.

Image 6

Precursor lesions such as ductal carcinoma in situ or atypical hyperplasia are not seen adjacent to the lesion, which appears against a background of normal breast parenchyma. Necrosis, calcifications, and elastosis are generally absent.

Image 7

Special stains and immunohistochemistry may assist, particularly when the primary site has unique histochemical properties (such as argentaffin or argyrophil staining, neeurone-specific enolase, CA-125, cytokeratin, PSA, or calcitonin). Similarly, if serum tumor markers are being followed, elevation of beta-HCG or CA-125 may provide a clue to the presence of metastatic disease. Electron microscopy may provide additional information by demonstrating dense core granules, neurosecretory granules, or melanosomes.

These adjunctive techniques become especially important when the tumor is extremely poorly differentiated or when it appears to grow within the ducts and lobules, simulating in situ or intraductal carcinoma.

When the suspected primary site is contralateral breast, clonal analysis may help differentiate a breast metastasis from a second primary tumor.

Treatment:
The therapy should be aimed at the underlying malignancy and surgical management of the breast lesion(s) should be as conservative as possible. Excisional biopsy, with or without radiation therapy, is generally adequate for local control. Deep, painful, or bulky disease may require mastectomy, but generally this should be avoided.

Metastatic disease in the breast is generally a sign of disseminated disease and rapid spread. In most series, one-year survival after diagnosis is 20% or less. Lymphoma, choriocarcinoma, ovarian carcinoma and other malignancies for which effective chemotherapy exists and tumors such as carcinoid (which are noted for an indolent course) may be associated with prolonged survival.

In summary:
When non-mammary tumors metastasize to the breast, there is likely to be associated widespread metastatic disease and the prognosis is poor. Mammography may be confusing and it is crucial that the radiologist (and pathologist) be informed of the prior history. Clinical judgment, careful attention to prior history, and assessment of histopathologic features are needed to avoid confusion with primary breast cancer and unnecessary radical surgery. Conversely, appropriate treatment for primary breast cancer should not be denied the patient with a history of prior malignancy, once breast metastases are ruled out.

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