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Gynaecology Case Reports 215 Fine-needle aspiration cytology is suggested as an initial, diagnostic procedure in cases of suspected umbilical metastasis. It is a simple and accurate method, which confirms the suspected diagnosis of the umbilical nodule (Handa et al. 2008). In our patient, umbilical metastasis was confirmed by cytological examination of the aspirated specimen. The presence of the Sister Mary Joseph’s nodule is an ominous sign, which suggests widespread metastases, with survival rates of 4–14 months from the time of diagnosis, despite combined aggressive medical and surgical interventions (Powell et al. 1984; Al-Marshat and Sibiany 2010). Management is controversial, with some authors favouring aggressive surgery, followed by adjuvant chemotherapy, while others suggesting only palliative therapy (Barrow 1966; Majmudar et al. 1991; Gabriele et al. 2005; Al-Marshat and Sibiany 2010). Recent data indicate that an aggressive surgical approach combined with chemotherapy may be beneficial for the patients to achieve longer overall survival compared with patients receiving no therapy or those treated with either surgery or chemotherapy alone (Barrow 1966; Majmudar et al. 1991; Gabriele et al. 2005). However, the fitness of the patient determines the type of treatment. Surgery should be considered only in solitary umbilical metastasis and should be avoided in cases with widespread disseminated disease. In such cases, effective palliation can be achieved only with chemotherapy. The primary malignancy and the organ affected determine the prognosis. Survival was improved in patients with umbilical metastasis, when the primary tumour site was of ovarian origin and especially serous cystadenocarcinomas vs other malignancies (Majmudar et al. 1991; Al-Marshat and Sibiany 2010). Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Al-Marshat F, Sibiany AM. 2010. Sister Mary Joseph’s nodule of the umbilicus: is it always of gastric origin? A review of eight cases at different sites of origin. Indian Journal of Cancer 47:65–69. Barrow MV. 1966. Metastatic tumors of the umbilicus. Journal of Chronic Diseases 19:1113–1117. Dubreuil A, Dompmartin A, Barjot P et al. 1998. Umbilical metastasis or Sister Mary Joseph’s nodule. International Journal of Dermatology 37:7–13. Gabriele R, Conte M, Egidi F et al. 2005. Umbilical metastases: current viewpoint. World Journal of Surgical Oncology 3:13. Handa U, Garg S, Mohan H. 2008. Fine-needle aspiration cytology of Sister Mary Joseph’s (paraumbilical) nodules. Diagnostic Cytopathology 36: 348–350. Majmudar B, Wiskind AK, Croft BN et al. 1991. The Sister (Mary) Joseph nodule: its significance in gynecology. Gynecologic Oncology 40:152–159. Panaro F, Andorno E, Di Domenico S et al. 2005. Sister Joseph’s nodule in a liver transplant recipient: Case report and mini-review of literature. World Journal of Surgical Oncology 3:4. Powell FC, Cooper AJ, Massa MC et al. 1984. Sister Joseph’s nodule: a clinical and histologic study. J Am Acad Derm 10:610–615. Steck WD, Helwig EB. 1965. Tumors of the umbilicus. Cancer 18:907–911. Tourand JP, Lentz N, Dutronc Y et al. 2000. Umbilical cutaneous metastasis (or Sister Mary Joseph’s nodule) disclosing an ovarian adenocarcinoma. Gynecologie, Obstetrique et Fertilite 28:719–721.
Case report A 70-year-old woman presented with a 3-day history of vaginal bleeding. On examination, two mobile masses were palpable in the adnexa. Blood tests showed aspartate transaminase (AST) 35 IU/l (normal ⬍ 30), lactate dehydrogenase (LDH) 692 IU/l (normal ⬍ 480) and CA125 458 IU/ml (normal ⬍ 35). Ultrasonography and computed tomography (CT) of the abdomen and pelvis showed well described ovarian masses and multiple retroperitoneal lymphadenopathy. At laparotomy, total hysterectomy, bilateral oophorectomy, appendicectomy, omentectomy and pelvic lymphadenectomy were performed. The pathology report described a poorly-differentiated bilateral papillary serous cystadenocarcinoma of the ovary (40 negative nodes). At 6 months after completing chemotherapy treatment, positron emission tomography (PET) and CT showed an increase of 11 mm in right inguinal adenopathy and a left axillary lymph node of 13 mm, but no retroperitoneal nodes. CA125 was within normal limits. A decision was made to continue observation. CT was repeated 3 months later and growth of the previously noted lymphadenopathy was visible (Figure 1). Fine-needle aspiration biopsy of both lymph nodes was carried out, demonstrating the presence of metastatic carcinoma of ovarian origin. The patient received 6 cycles (50 mg/m2 each cycle, each 4 weeks) of doxorubicin hydrochloride. The patient noted, 8 months later, the presence of two tumours, one in her left breast and another in her left axilla. On examination, a solid tumour of about 2 cm in the upper outer quadrant of the left breast was palpable, and ipsilateral axillary level 3 lymph nodes were palpable, the largest of 1.5 cm and two of 0.5 cm. The multidisciplinary review decided on palliative surgery, carrying out a lumpectomy and removal of the axillary adenopathic conglomerate. Currently, 3 months after surgery, the patient is undergoing chemotherapy with oral etoposide.
Discussion Metastases to the breast from extramammary malignancies are rare, representing between 0.2% and 1.3% of all malignant tumours diagnosed in the breast. Surprisingly, in up to 30% of cases of breast metastasis of extramammary malignant neoplasms, the metastasis to the breast or armpit is the initial presentation of the disease (Dursun et al. 2009; Gayathri et al. 2009). Metastasis from a tumour in the contralateral breast is the most common secondary tumour of the breast. Malignant melanoma, haematological malignancies and malignant lung tumours constitute the largest proportion of metastatic tumours in the breast (Hejmadi et al. 2003; Lee 2007). Metastatic tumours of the breast are more likely to appear as superficial lesions, without fixation to the skin or the surrounding tissue (Hejmadi et al. 2003; Lee 2007). Because treatment for ovarian cancer has improved, oncologists should provide for the possibility of a secondary cancer or recurrence of disease in unusual sites with optimal treatment for recurrences in these places. At present, the surgical treatment of breast metastases from a primary tumour in another location is considered diagnostic and palliative. Karam et al. (2009) reviewed all cases of patients with epithelial ovarian cancer that occurs in the axilla or breast at Memorial Sloan-Kettering Cancer Centre between 1990 and 2007.
Ovarian serous cystadenocarcinoma metastasising to the breast D. Abehsera, A. Hernández, J. Santisteban & F. J. de Santiago Department of Obstetrics and Gynecology, La Paz University Hospital, Madrid, Spain DOI: 10.3109/01443615.2012.740528 Correspondence: D. Abehsera, Department of Obstetrics and Gynecology, La Paz University Hospital, Paseo de la Castellana 261, 28047 Madrid, Spain. E-mail:
[email protected]
Figure 1. CT scan showing left axillary cluster, adenopathic.
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A total of 29 cases, of which 10 were due to metastases originating from a primary tumour of the ovary, and 19 are primary breast tumours, were found. The authors found statistically significant differences between the groups, so that in the group of metastatic breast ovarian described lower disease-free survival as well as reduced time interval between diagnoses of ovarian and breast tumour. The largest series was presented by Recine et al. (2004) who collected 18 cases of serous ovarian cancers metastasising to breast or armpit, over a period of 14 years.
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Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Dursun P, Yanik FB, Kuscu E et al. 2009. Bilateral breast metastasis of ovarian carcinoma. European Journal of Gynaecological Oncology 30:9–12. Gayathri S, Badve S, Matei D. Breast mass in a patient with ovarian cancer: a case report. 2009. Journal of Reproductive Medicine 54:639–644. Hejmadi RK, Day LJ, Young JA. 2003. Extramammary metastatic neoplasms in the breast: a cytomorphological study of 11 cases. Cytopathology 14:191–194. Karam AK, Stempel M, Barakat RR et al. 2009. Patients with a history of epithelial ovarian cancer presenting with a breast and/or axillary mass. Gynecologic Oncology 112:490–495. Lee AH. 2007. The histological diagnosis of metastases to the breast from extramammary malignancies. Journal of Clinical Pathology 60:1333–1341. Recine MA, Deavers MT, Middleton LP et al. 2004. Serous carcinoma of the ovary and peritoneum with metastases to the breast and axillary lymph nodes: a potential pitfall. American Journal Surgical Pathology 28:1646–1651.
