Small-cell lung cancer - metastatic to the breast

Case contributed by Bruno Di Muzio

Presentation

Hemoptysis and bilateral breast lumps.

Patient Data

Age: 50 years
Gender: Female

CT Chest, Abdomen, and Pelvis

ct

There is a right hilar soft tissue mass encasing the branches of the pulmonary artery and bronchi to the right middle and lower lobes. It measures approximately 4.3 x 3.8 cm in its hilar/right upper lobe component, but it has no cleavage planes with the confluent mediastinal lymphadenopathy that extends through the subcarinal, paratracheal, and prevascular levels. Also, a para cardiac 1.5 cm node and bilateral supraclavicular enlarged lymph nodes measuring up to 2.2 x 1.6 cm. There are at least two other small mass lesions in the right lower lobe that are felt to represent tumor spread, and the associated patchy ground-glass opacities in this lobe are felt to represent partial atelectasis due to bronchial stenosis and mucus plugging. The lungs and pleural spaces are otherwise unremarkable. Bilateral breast masses are demonstrated, the largest ones measuring up to 2.6 x 2.4 cm in the right breast and 1.7 x 1.5 cm in the left breast.

The liver is enlarged and demonstrates multiple hypodense nodular lesions in keeping with metastatic disease involving all the segments. The portal vein is patent. There are periportal, portocaval, and retroperitoneal lymphadenopathy measuring up to 4 cm in diameter.  The right adrenal gland demonstrates a hypodense nodule which measures 2.6 x 2.2 cm, suspicious for metastasis, the left adrenal gland appears normal.  The pancreas and spleen are normal.  Both kidneys have normal size and enhancement, no hydronephrosis. There is a right adnexal mass. There has heterogeneous enhancement and is highly concerning for over metastatic disease in this clinical scenario.  The bowel has unremarkable appearances; there is no free gas or free fluid in the peritoneal cavity.  No suspicious bone lesions identified.  Anterior right upper quadrant anterior subcutaneous solid nodule measuring 1.8 cm is also suspicious for metastasis.

US-guided bilateral breast biopsies were performed. 

Bilateral breast core-biopsy: 

Microscopy: The tumor is composed of highly cellular sheets and solid nests of tumor cells, surrounded by a fibroblastic stromal response. Tumor cells have hyperchromatic, angulated nuclei with dispersed chromatin and scant cytoplasm. Mitotic figures and apoptotic bodies are very frequent. Nuclear molding and streaking are a feature. Very focally, there are regions comprising nests of tumor cells with more abundant eosinophilic cytoplasm, but these foci occupy represent <5% of the tumor. No lymphovascular or perineural invasion is identified. No in situ carcinoma is seen.

Immunoperoxidase stains: 

  • Positive: broad-spectrum cytokeratin (AE 1/3, paranuclear dot), synaptophysin, chromogranin
  • Negative: ER, PR, Her2
  • Ki67 shows a proliferative index of approximately 90%

Conclusion: Bilateral breast core biopsies: All specimens show poorly differentiated neuroendocrine carcinoma (small cell carcinoma).

Case Discussion

This case illustrated widespread metastatic disease due to a right pulmonary neoplasm confirmed to represent small-cell lung cancer. The disease was staged as T3 N3 M1c.

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