Metastatic uterine leiomyosarcoma presenting as a breast lump
- First Online:
- Cite this article as:
- Sibartie, S., Larkin, J.O., Lee, G. et al. Ir J Med Sci (2011) 180: 889. doi:10.1007/s11845-009-0286-8
- 130 Downloads
It is uncommon to encounter a breast metastasis from an extramammary malignancy and even rarer from a uterine leiomyosarcoma.
We describe the third case report in the medical literature of a breast metastasis from a uterine leiomyosarcoma.
We report the management of a 56-year-old patient who presented with a breast lump 3 years after hysterectomy for a fibroid uterus. We conducted a literature review of breast leiomyosarcomas.
The excision of the breast mass revealed a low-grade leiomyosarcoma. Radiographic examinations demonstrated metastases to the lung, liver, pelvis and bone. Retrospective pathology review of her uterus identified a small focus of leiomyosarcoma. She received chemotherapy and palliative radiotherapy but passed away within few months.
Metastasis to the breast from a non-breast primary is generally a sign of disseminated disease and; thus, a poor prognostic indicator.
KeywordsBreast Leiomyosarcoma Uterine Metastasis
A 56-year-old woman presented to the breast clinic with a painless left breast lump that had increased considerably in size over 10 days. She was otherwise asymptomatic. Three years previously, she had presented with anaemia and menorrhagia, and underwent total abdominal hysterectomy for fibroid uterus with conservation of the ovaries. Her postoperative course was uneventful. In the intervening time, she had been entirely well. She was on no medication, had never been pregnant and smoked 10 cigarettes a day. She had no personal or family history of breast disease.
Retrospective pathology review of the uterus showed several large fibroids. A single section of the largest of these, which was not grossly suspicious, showed an area of pauci-cellular smooth muscle with little or no pleomorphism and a few cellular foci containing mitotic figures with very rare pleomorphic nuclei. One area of central tumour-type coagulative necrosis was identified, and thus this was considered to represent a sarcoma arising in a benign fibroid. Magnetic resonance imaging and computed tomography revealed masses in the lung, mediastinum, liver and pelvis and a pathological fracture of the inferior pubic ramus.
A diagnosis of uterine leiomyosarcoma metastatic to the breast, lung, liver and bone was made. Our patient was willing to be treated with adjuvant chemotherapy and based on her young age and the absence of medical co-morbidities; she received six cycles of chemotherapy with adriamycin and ifosfamide. The disease remained clinically and radiologically stable for 4 months. She died subsequently from progressive disease and renal failure.
Metastasis to the breast is rare and represents less than 2% of all breast malignancies . Metastasis to the breast from a uterine leiomyosarcoma is even rarer. The first case of uterine leiomyosarcoma metastatic to the breast was reported in 2003 when a 44-year-old patient presented 12 years after a right salpingo-oophorectomy and hysterectomy for leiomyosarcoma . There was no local recurrence but lung, liver, gastrointestinal and gluteal involvement were present. She was healthy and symptom-free during the 12-month postoperative follow-up. A second case published the same year describes a 60-year-old patient presenting 10 years after a hysterectomy for leiomyosarcoma . Diagnosis was made on ultrasound-guided fine-needle aspiration cytology.
Distant metastases often occur several years after hysterectomy for uterine leiomyosarcoma. The most common sites of distant metastasis after hysterectomy for uterine leiomyosarcoma are the lungs and the liver. Rare metastases to the kidney, brain, bones, heart, thyroid, parotid gland and the oral cavity have also been reported .
Primary leiomyosarcoma rarely arises from the breast—about 20 cases have been described, including three cases in males, which would suggest the lack of endocrine influence. Simple mastectomy without axillary dissection is considered the most appropriate intervention as no axillary lymphatic involvement has been reported. Leiomyosarcomas of the breast have a better prognosis than other breast neoplasms, although information on long-term follow-up in the literature is relatively sparse. Leiomyosarcoma of the breast, whether metastatic or primary, is often initially misdiagnosed as Phyllodes tumour.
The rarity of metastases to the breast may be due to the predominance of relatively avascular fibrous tissue found in the breast. Nonetheless, nearly all cancers have been reported to metastasize to the breast. Very occasionally, the first sign of an occult primary lesion is a breast metastasis, most commonly small cell carcinoma of the lung . Breast metastases are often noted to be firm, painless, well-circumscribed nodules . These tumours are usually located superficially but with no skin involvement as in the case described herein . The most common primary sites are the contralateral breast, malignant melanoma, lymphoma, lung (particularly small cell), ovary, thyroid and in men, the prostate. Metastasis to the breast has been described up to 9 years after a known non-breast malignancy .
In uterine leiomyosarcomas mitotic activity is the single most important risk factor associated with prognosis as these tumours are at high risk for distant metastasis and recurrence. Cases of advanced or recurrent disease have a poor prognosis with limited treatment options. Adjuvant radiation therapy has not shown any survival advantage, and the use of single agent and combination chemotherapy in the systemic treatment of these cancers has shown mixed results. Doxorubicin (adriamycin) still remain to be the most highly active single agent in these cancers with a response rate of approximately 25%. Several chemotherapy regimens have been tried but a survival advantage has not been demonstrated and new targeted therapies are under investigation .
Metastasis to the breast is rare and usually indicates disseminated disease and is thus a poor prognostic indicator. It should be considered in anyone presenting with a breast lump with a history of previous surgery on tumours elsewhere.