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Radiology - Diagnostic
Resident PGY 5
Henry Ford Hospital
Case Summary: This is a case of a 74-year-old post-menopausal female who presents for vaginal bleeding for several months. Endometrial curettage and subsequent histopathology arrived at the diagnosis of endometrial serous carcinoma. Subsequently, the patient developed a lump in her right breast. Mammogram of the palpable abnormality revealed a suspicious mass that was biopsied and revealed metastatic endometrial carcinoma.ImagingImaging will be reviewed including CT of the abdomen and pelvis as well as mammographic images and breast ultrasound. Histopathologic findings will also be reviewed. Discussion: Endometrial carcinoma is a common gynecologic malignancy that typically affects post-menopausal women during their 6th or 7th decade of life. Clinical presentation of endometrial cancer may consist of abnormal vaginal bleeding, pelvic pain, and involuntary weight loss. Definitive diagnosis involves dilatation and curettage or endometrial biopsy.Endometrial carcinoma may spread locally by direct invasion as well as systemically via lymphatic or hematogenous routes. Endometrial cancer is staged via surgicopathologic findings. Pre-operative imaging offer the benefit of identifying distal metastases. Typical metastatic sites include local pelvic recurrence, abdominal lymph nodes, peritoneum, and lungs. Rare metastatic targets include extra-abdominal lymph nodes, liver, adrenal glands, brain, bones, and soft tissues.The breast is a rare target of extramammary metastases, with the most common primary tumors being melanomas, leukemias, or lymphomas. Endometrial metastases to the breast are even more rare. To our best knowledge, there is only one other documented account of metastatic endometrial serous carcinoma to the breast.Metastatic disease to the breast may mimic primary breast cancer on imaging studies. Sonographically, extramammary metastases may appear differently when the cancer seeds the breast through hematogenous versus lymphatic routes. Hematogenous metastases tend to colonize richly vascularized areas of the breast. Typical US presentation includes single or multiple circumscribed hypoechoic oval masses involving only one breast. Features common to primary breast cancer such as spiculations, calcification, parenchymal distortion, acoustic shadowing, secondary skin or nipple changes are typically not observed with hematogenous metastases to the breast. Sonographic appearance of lymphatic metastases may mimic inflammatory primary breast cancer by demonstrating heterogeneous echogenicity, coarse trabecular pattern, skin thickening and lymphedema. On mammography, the morphology of metastases to the breast is that of an oval circumscribed mass with no associated microcalcifications and no desmoplastic features.Diagnosis of metastases to the breast can be confirmed using comparative histopathology of the mammary lesion and the primary cancer. For primary endometrial serous carcinoma, common histological features from the endometrial biopsy include papillae containing highly pleomorphic tumor cells with glandular structure. Myometrial invasion and high mitotic activity are also frequently observed due to the cancer’s aggressive nature. Psammoma bodies may be present, but they are not distinguishing features of endometrial serous carcinoma.ConclusionMetastatic disease to the breast is an uncommon occurence with the most primaries being melanomas and hematopoietic malignancies. Conversely, metastatic endometrial carcinoma to the breast is especially unique. Breast metastases may resemble primary breast cancer under mammogram and ultrasound. However, they usually lack the microcalcifications and spiculations characteristic of primary breast cancer. Tissue biopsies of the suspicious breast lesion are crucial for the correct diagnosis that will subsequently guide disease management and treatment.
Lin, David S.; Lin, Tayson; Zhang, Ziying; and Shah, Biren, "Metastatic Endometrial Serous Carcinoma to the Breast" (2019). Case Reports. 82.