天美传媒

A 24-year-old thin-built female with primary infertility presented to the outpatient department with a painless lump in the right breast for seven months and abdominal distension for two months. The patient had no family history of breast cancer and no history of previous breast pathology [1-3]. Clinical examination revealed a multi-lobulated 5 x 5 cm lump in the right breast not fixed to the skin with no palpable lymph nodes in the axilla (Figure 1). The patient had gross ascites and abdominopelvic examination revealed bilateral fixed adnexal masses- 6-8 cm on right and 8 cm on left. Breast sonography showed multilobulated mass predominantly occupying the upper outer quadrant of the right breast comprising of a grossly ectatic ductal element with anterior margin reaching sub-cutaneous level with sub- centimetric right axillary nodes. Contrast-enhanced computed tomography (CECT) of the abdomen showed a malignant bilateral ovarian mass with ascites and omento-peritoneal thickening (Figure 2).

Figure 1: The clinical picture of right breast lump (arrow).

Figure 2: CE-CT –axial view showing adnexal masses.

Tumour biopsy of breast lump showed features of adenocarcinoma and tumor cells showed PAX-8 positivity, ER 80 % positive, AR 80 % positive, Ki67 50 % positive and were negative for GCDFP15, PR, and HER-2 NEU. Further IHC on both pelvic and breast mass showed p16 and WT-1 positive and GATA-3 negative. The final treatment was planned based on primary ovarian malignancy with breast metastasis. The patient received 4 cycles of neo adjuvant chemotherapy (NACT) with paclitaxel 175 mg/m2 and carboplatin AUC-5. The patient and relatives were counselled regarding BRCA mutation testing, but they could not afford it. Fertility preservation was not an option in stage IV B disease. Post- NACT evaluation revealed a decrease in size of the breast lump. The biochemical response showed a fall in CA-125 from pre- NACT level of > 1000 IU/ml to post- NACT value of 548 IU/ml (Figure 3).

Figure 3: Histo-pathology of (A) Ovarian mass (B) Breast lump.

The patient underwent interval debunking surgery comprising of extra-peritoneal retro-grade total abdominal hysterectomy and bilateral salpingo-oophorectomy with supra-colic omentectomy, Para-colic peritonectomy, partial bladder peritonectomy, ascending colon growth wedge resection, and repair and removal of deposits on the bowel, bladder, POD and sigmoid mesentery and right simple mastectomy. The final histopathological report showed papillary serous carcinoma of the ovary with metastasis to the right breast. The patient has completed platinum-based adjuvant chemotherapy and is currently on follow-up.

The typical course of metastatic ovarian cancer is intra-abdominal spread manifesting as peritoneal carcinomatosis, whereas the most common sites of distant metastases are pleura, liver, lung, and lymph nodes. In a study of 4,051 breast cancer women, it was reported that the overall incidence of primary gynecologic tumor metastasis to the breast was 0.17%, and only 0.07% of metastatic disease was related to primary ovarian carcinoma. The diagnosis of MOCB is a clinical challenge as it presents with various clinical, radiological, and pathological findings and may be misdiagnosed as a primary breast tumour. Common Immuno-histochemical panels to distinguish mammary carcinoma (estrogen receptor, gross cystic fluid protein-15) from common metastases to the breast, including carcinoma of the lung (thyroid transcription factor-1), malignant melanoma (S100, HMB45, Melan-A), and ovarian serous papillary carcinoma (Wilms’ tumor 1) (Figure 4). In patients with ovarian tumor-associated with breast metastases, serous papillary carcinoma is the most common histological type [4], comprising 72% of such cases. It has been reported that the most common form of clinical presentation is a solitary mass, while only 4% of women have diffuse breast involvement [5]. Furthermore, the most frequent location is the upper outer quadrant in 62% of patients [6], as described in our case. Currently, surgical management for secondary breast cancer is considered diagnostic and reserved as a palliative measure, together with radiotherapy, for patients who are unresponsive to systemic chemotherapy agents. The prognosis is generally poor as secondary breast cancer from ovarian cancer suggests concomitant disseminated disease. The survival times after breast metastatic disease secondary to ovarian cancer ranged from 13 days to 3.5 years, with a 1-year survival rate of about 40%, as opposed to a 4-year survival rate of 75% for patients with primary breast cancer [7].

Figure 4: IHC on ovarian and breast tissue – WT-1, GATA-3, and P-16.

MOCB recognition and accurate distinction from primary breast cancer are of crucial importance for the patient management and prognosis, allowing in some instances to avoid unnecessary surgeries (e.g., mastectomy, lymphadenectomy) and choose appropriate systemic chemotherapy.

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