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An Uncommon Breast Odyssey: A Rare Case of Carcinoma Breast with Mesenteric Metastasis
Address for correspondence: Dr. Prakash Singh, Department of Nuclear Medicine, King George Medical University, Lucknow, Uttar Pradesh, India. E-mail: dr.singhprakash1@gmail.com
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Received: ,
Accepted: ,
This article was originally published by Wolters Kluwer - Medknow and was migrated to Scientific Scholar after the change of Publisher.
Abstract
We present an unusual case of invasive ductal breast carcinoma in a postmenopausal female with a clinically node-negative disease that was incidentally found to have mesenteric metastatic deposits on 18F-fluorodeoxyglucose positron emission tomography/computed tomography scan. Mesenteric metastasis from invasive breast carcinoma is rare, with <1% cases reported worldwide and limited availability of diagnostic and therapeutic protocols for carcinoma breast with mesenteric metastasis, this proved to be a challenging and intriguing case. To further accentuate the complexity, the primary tumor of this mesenteric metastasis was found to be invasive ductal carcinoma, which is even more infrequent, and <0.5% of cases have been reported till date.
Keywords
18F-fluorodeoxyglucose positron emission tomography/computed tomography scan
advanced breast cancer
invasive ductal carcinoma
invasive lobular carcinoma
mesenteric deposits
mammogram
peritoneal metastasis
Case Summary
A 62-year-old, postmenopausal female presented with a painless lump in the upper outer quadrant of her right breast for 8 months. Examination of the right breast revealed a peau d’orange appearance. The local temperature was mildly raised, but there was no induration or discharge. The lump was palpated and measured 5 cm × 3 cm with ill-defined margins, irregular surface, and firm consistency. It was not fixed to the chest wall. The nipple–areola complex was normal. No lymphadenopathy was clinically present. The contralateral breast revealed no abnormality on examination.
Mammography of bilateral breasts was performed, and it showed a dense irregular spiculated mass of size 19 mm × 17 mm in the upper outer quadrant of the right breast with architectural distortion and skin thickening. A prominent right axillary node of 19 mm × 16 mm was also seen. It was reported as Breast Imaging-Reporting and Data Systems 4B.
A true-cut biopsy of the lump was performed, and it was reported as invasive ductal carcinoma (IDC) grade 1 not infiltrating into adjacent structures. Immunohistochemistry was suggestive of estrogen receptor (−), progesterone receptor (−), and Her2/neu (+). The patient was staged T4bN1aMx and for metastatic workup, a whole-body 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) was performed [Figure 1A], which revealed an FDG-avid lesion in the upper outer quadrant of the right breast measuring 1.7 cm × 1.5 cm (standardized uptake value [SUV]max – 14.4) [Figure 1C; a,b], a single ipsilateral axillary lymph node measuring around 2.1 cm × 1.8 cm (SUVmax −9.0) [Figure 1B; a,b], and surprisingly, few (2 in number) FDG-avid (SUVmax –4.5) centimetric-sized mesenteric deposits [Figure 1D; a,b]. An ultrasound-guided fine-needle aspiration cytology of the mesenteric deposits was performed, and they turned out to be metastatic IDC, thus upstaging the patient to stage IV disease. The patient, however, had no significant gastrointestinal (GI) complaints apart from mild anorexia, which could be attributed to the primary disease as well.
![(A) Maximum intensity projection image demonstrated hypermetabolic lesions in the right breast, axillae, and abdomen, (B [a and b]) Axial fused positron emission tomography-computed tomography (PET-CT) and CT images showing metabolically active enlarged level I axillary lymphadenopathy, (C [a and b]) Axial fused PET-CT and CT images showing metabolically active lesion in the right breast with cutaneous thickening, (D [a and b]) Axial fused PET-CT and CT images showing metabolically active enlarged mesenteric deposits, Blue arrow represents FDG avid lesion in MIP image and white arrow depicts lesion in fused PET-CT and CT axial images](/content/210/2024/39/6/img/IJNM-39-463-g001.png)
Discussion
Breast cancer is an extensively dominant cancer in India, accounting for 13.5% of all cancer cases (26.3% in females) and 10.6% of all cancer-related mortalities with a cumulative risk of 2.81.[1] Up to 30% of patients develop metastatic disease during disease progression or follow-up.[2] It is known to frequently metastasize to bone, liver, lungs, and brain. However, mesenteric metastasis from breast cancer is extremely rare, and very limited literature is available for analysis in this regard as till date <1% of invasive breast cancer cases are reported to have mesenteric metastasis. The route of spread and molecular basis of lung, bone, liver, and brain metastasis has been well established, but the mechanism of metastasis to the peritoneum remains a conundrum.[34] The majority of available studies have reported a statistically significant difference between metastatic patterns from invasive lobular carcinoma (ILC) and IDC.[5] Compared to 4.5% from ILC, only 0.2% of IDC metastasizes to the peritoneum or GI system.[6]
Borst and Ingold reported that out of 2605 cases of invasive breast cancer studied, only 17 cases (<1%) had peritoneal or GI metastasis.[6] According to published literature, mesenteric deposits in lobular breast carcinoma were relatively common as compared to ductal carcinoma.[78] While ductal carcinoma by and large metastasizes in the liver, lungs, and brain; lobular carcinoma has a stronger propensity to spread to the GI system, gynecological organs, and the peritoneum.[5] Although ascites is thought to be the most typical peritoneal carcinomatosis presenting symptom, the patient described here was inadvertently diagnosed with mesenteric deposits since she had no symptoms of GI involvement.[9] This patient was worked up with imaging and histopathology, both of which proved to be consistent with IDC of the right upper quadrant of the breast with axillary and mesenteric metastasis. 18F-FDG PET/CT exhibits superior sensitivity and specificity compared to conventional imaging modalities in discerning distant metastases of breast cancer. The discernment of distant metastases showcased remarkable sensitivity and specificity with PET/CT, standing at 97.4% and 91.2%, respectively, surpassing conventional imaging modalities, which yielded 85.9% sensitivity and 67.3% specificity.[1011] This case proved to be interesting as diagnosis of this entity is challenging as it can masquerade as a primary disease process in lieu of a secondary one, furthermore confounding treatment protocols for breast carcinoma with mesenteric metastasis. The patient was referred to the medical oncology department for further management, as primary surgery for such an advanced disease would not be feasible.[12]
This case emphasizes the fact that in Stage IIIB, 18F-FDG PET/CT is instrumental in elucidating the clinical intricacies of breast carcinoma, offering a nuanced assessment of the disease extent and defining the total burden of the disease. It substantiates that the absence of clinical suspicion should not exclude the possibility of metastatic disease. The detection and diagnosis of this unusual metastatic spread using 18F-FDG PET/CT underscores the importance of precise imaging techniques in uncovering diverse manifestations of malignancy, aiding tailored therapeutic strategies for optimal patient management.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Conflicts of interest
There are no conflicts of interest.
Nil.
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