Final Diagnosis -- Widely Metastatic Infiltrating Ductal Carcinoma



Contributor's Note:

During the patient's admission, an open lung biopsy and a breast biopsy were performed. Nodules found on her diaphragm were also biopsied. The breast mass demonstrated an infiltrating ductal carcinoma with mucinous differentiation. The other biopsies were histologically similar. Her additional work-up also revealed a posterior choroidal mass involving one orbit.

At least 25% of breast carcinomas metastasize to distant sites. When this occurs, 95% of the patients so affected die of metastatic disease. Breast carcinoma metastasizes to distant sites by way of the angiolymphatic system. The first lymph nodes to be seeded with tumor cells are the axillary nodes, followed by the supraclavicular nodes and the mammary nodes. Distant sites of metastases include the skeletal system, lungs and pleurae, liver, ovaries, adrenal glands, and central nervous system including the leptomeninges and eyes.

Breast carcinoma may be undiagnosed at the time that a patient presents with masses involving various body sites. Such cases require thorough physical examination and complete work-up for proper diagnosis. This case points out some of the varied presentations of advanced breast carcinoma.

This patient's malignancy presented as an atypical pneumonia. The decline of her pulmonary status with antibiotic treatment, as demonstrated by increasing bilateral pulmonary infiltrates, was significant. This patient demonstrated numerous lung metastases, as well as widely disseminated metastases. Other patients, however, may present with pulmonary metastases after diagnosis, and treatment of, breast carcinoma. Complete resection of a solitary pulmonary metastasis may result in complete remission with prolongation of survival time. A study by Salat and others found that patients who underwent complete resection of isolated lung metastases had a mean survival time of 79 months, while those who underwent incomplete resection, or had no surgical intervention, had mean survival times of 15.5 and 9 months, respectively. There was no statistical significance between the last two groups. It is now currently accepted that such surgical intervention carries a low morbidity rate and prolongs survival time.

Secondly, the occurrence of ocular metastases secondary to breast carcinoma has been documented and is more common than previously suspected. Patients may present with what clinically appears to be a diffuse, infiltrative, inflammatory syndrome. In 20% of these cases, there is bilateral involvement of the eyes. Again, such cases warrant a thorough medical history and complete physical examination. Close ophthalmologic monitoring is necessary for patients previously diagnosed with breast carcinoma. As the eyes are actually an embryologic outpouching of the rudimentary brain, they exhibit the brain's propensity for seeding by breast carcinoma cells. Visual disturbances are a warning clue to these ocular metastases. Eyeball enucleation to resect such metastases may result in increased survival time.

Finally, this patient's primary breast carcinoma developed in the subareolar region, an area more difficult to image with mammography. This case, therefore, points to the importance of breast self-exam and regular complete physical examinations. At the time of presentation, this patient, unfortunately, had never practiced breast self-examination.


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Contributed by Debra L. Callahan, MD


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