|Year : 2012 | Volume
| Issue : 1 | Page : 129-131
Synchronous bilateral medullary carcinoma of breast: Is it metastasis or second primary?
Chandrika1, Harish S Permi1, HL Kishan Prasad1, Rajashekar Mohan2, K Jayaprakash Shetty1, Channappa Patil3
1 Department of Pathology, K S Hegde Medical Academy of Nitte University, Deralakatte, Mangalore, Karnataka, India
2 Department of General Surgery, K S Hegde Medical Academy of Nitte University, Deralakatte, Mangalore, Karnataka, India
3 Department of Oncology, K S Hegde Medical Academy of Nitte University, Deralakatte, Mangalore, Karnataka, India
|Date of Web Publication||19-Apr-2012|
Department of Pathology, K S Hegde Medical Academy of Nitte University, Mangalore, Karnataka
Bilateral breast cancer is a rare event accounting for 2-5% of all breast malignancies. A second tumor in contralateral breast may be either synchronous or metachronous lesion. Synchronous bilateral invasive ductal carcinoma is known but medullary carcinoma is rare. The etiology of bilateral breast cancer is uncertain and prognosis in these cases once thought to be poor but recent data suggest a similar survival compared to unilateral disease. We report a case of triple negative synchronous bilateral medullary carcinoma in a 38-year-old female who presented with lump in both the breasts for three months. Multidetector computed tomography breast scan revealed bilateral heterogeneously enhancing well-defined lesion in both the breasts. Fine needle aspiration cytology from both the breast lump was suggestive of malignancy. Patient underwent bilateral modified radical mastectomy with axillary clearance in a single sitting. Histopathology showed synchronous bilateral medullary carcinoma of breast with ER, PR and HER- 2/ neu negativity. Patient was treated with chemoradiation and she is on regular follow up for one year without any recurrence or metastasis.
Keywords: Bilateral, medullary carcinoma, synchronous, triple negative
|How to cite this article:|
Chandrika, Permi HS, Kishan Prasad H L, Mohan R, Shetty K J, Patil C. Synchronous bilateral medullary carcinoma of breast: Is it metastasis or second primary?. J Can Res Ther 2012;8:129-31
|How to cite this URL:|
Chandrika, Permi HS, Kishan Prasad H L, Mohan R, Shetty K J, Patil C. Synchronous bilateral medullary carcinoma of breast: Is it metastasis or second primary?. J Can Res Ther [serial online] 2012 [cited 2014 Sep 3];8:129-31. Available from: http://www.cancerjournal.net/text.asp?2012/8/1/129/95193
| > Introduction|| |
Bilateral invasive synchronous breast cancer is uncommon and reported incidence ranges between 0.3 and 12%. , Bilateral medullary carcinoma of breast is a rare event.  According to several studies, it has been the least common type of cancer occurring bilaterally in the breast.  In medical literature, distinction between synchronous and metachronous bilateral breast cancer is ambiguous. The interval between the two tumors ranges from one month to two years. However, most studies consider a tumor to be synchronous if it is diagnosed within six months after first tumor.  The contralateral breast lesion may be metastasis from ipsilateral breast or the second primary. The etiology of bilateral breast cancer is largely uncertain. We report a rare case of triple negative synchronous bilateral medullary carcinoma breast in a 38-year-old female who presented with lump in both the breasts for 3 months. Bilateral modified radical mastectomy was performed in single setting, which showed synchronous bilateral medullary carcinoma probably two separate primary lesions in both the breasts. After completion of post operative chemoradiation, patient is doing well in one year of follow up without any evidence of recurrence or metastasis. This case highlights the rare occurrence of synchronous bilateral separate primary medullary carcinoma, treated successfully with multimodality approach (surgery followed by chemoradiation).
| > Case Report|| |
A 38-year-old female presented with gradually increasing lump in both the breasts for three months. There was no family history of breast cancer. General physical examination and systemic examination was normal. Local examination showed a well-defined, firm to hard swelling in both the breasts located in lower outer quadrant and central region, measuring 7 × 5 cm and 4 × 3 cm in right and left breast respectively. Multidetector computed tomography breast scan revealed bilateral heterogeneously enhancing well-defined lesions with enlarged lymph nodes in both the breasts. Fine needle aspiration cytology was suggestive of bilateral breast carcinoma. She underwent bilateral modified radical mastectomy with axillary clearance in single sitting. Grossly both breasts showed well circumscribed partly cystic grey white, fleshy growth. [Figure 1] Histopathology from both the lesions showed tumor cells arranged in syncytial pattern with pushing margin admixed with diffuse lymphoplasmacytic infiltrate in the fibrous stroma. Tumor cells were large with abundant cytoplasm, vesicular nuclei and prominent nucleoli. [Figure 2]A and B Nipple areola, resected margins and lymph nodes were free from tumor deposits. Tumor cells were negative for estrogen, progesterone receptors and HER-2/neu. [Figure 3]A-C Final diagnosis of synchronous bilateral medullary carcinoma breast (Stage pT3pN0-IIB) was considered. In the absence of local lymphnode metastasis and distant spread even with identical histology, the possibility of synchronous bilateral separate primary medullary carcinoma was thought of. Patient received postoperative chemotherapy (four cycles of adriamycin with cyclophosphamide combination followed by paclitaxel) and six weeks of external beam irradiation to right breast. She is on regular follow up for one year without any evidence of recurrence or metastasis.
|Figure 1: Gross picture showing well circumscribed partly cystic grey white, fl eshy growth in both left and right breasts|
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|Figure 2: Histopathology of the tumor with pushing margin and syncytial arrangement with lymphocytic infi ltration in stroma (A and B)|
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|Figure 3: Tumor showing negativity for estrogen (A), progesterone (B) receptor and HER 2/ neu (C)|
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| > Discussion|| |
Bilateral breast cancer is a rare event accounting for 2-5% of all breast malignancies.  A second tumor in contralateral breast may be either synchronous or metachronous lesion. The prognosis in bilateral breast carcinoma is worse than unilateral disease; however, recent studies showed similar prognosis compared to unilateral disease.  The initial tumor is usually diagnosed by palpation, whereas contralateral tumor is often diagnosed by mammography, ultrasound or magnetic resonance imaging. In our case, both the tumors were diagnosed by palpation, which stresses the importance of self examination of breasts. This supports the role of careful screening of the contralateral breast and follow-up of all patients diagnosed with breast cancer.
The most common histologic subtype of breast cancer is infiltrating ductal carcinoma; however, infiltrating lobular carcinoma subtype is associated with bilaterality and multifocality.  Medullary carcinoma of the breast accounts for 1-6% of all breast carcinoma.  It has a better prognosis than infiltrating ductal carcinoma, inspite of high degree of epithelial atypia.  Several studies conclude that incidence of medullary carcinoma is increased in younger women (<40 years), the interval between last pregnancy and diagnosis of medullary carcinoma is significantly shorter than other cell types and majority of them give positive family history. However, there is no significant incidence of bilaterality or multifocality with this histologic type.  A tumor in contralateral breast may represent either a second primary tumor or metastasis from first tumor. Guidelines for determining whether the second tumor represents a separate primary or metastasis should be based on nuclear differentiation, the presence of contiguous in situ cancer, different histologic types and the presence of systemic metastases. , Generally in the absence of widespread systemic metastases, the vast majority of contralateral breast tumors are separate primary tumors.  In our case, in the absence of local lymph node metastasis and distant spread even with identical histology, the possibility of synchronous bilateral separate primary medullary carcinoma was thought of. The other factors to be associated with bilaterality in primary breast cancer include degree of ductal differentiation, nodal status, tumor size, intensity of lymphoid filtrate and menstrual status.  Histopathologically, several studies have shown synchronous bilateral breast tumor tend to be of lower histologic grade with higher rate of estrogen and progesterone receptor positivity.  Family history and early age of onset have reported to increase the risk of contralateral breast carcinoma. 
Unlike unilateral breast cancer, there are no clear treatment guidelines for bilateral breast cancer. There are several controversial issues regarding bilateral breast cancer pertaining to the diagnostic criteria, nomenclature and management policies. Optimal results can be obtained by using a logical multimodality treatment approach for bilateral breast cancer and in such cases treatment should be based on tumor with higher stage. In our case, patient was staged as IIB and treated with four cycles of adriamycin and cyclophosphamide followed by paclitaxel with external beam irradiation to the right breast. Several studies have shown that prognosis of patients with synchronous bilateral breast carcinoma is similar to unilateral disease and can safely be treated with bilateral breast conserving surgery.  Lower disease free survival and high rates of distant metastasis are recognized features of bilateral synchronous tumors and hence has worse overall survival compared to unilateral tumors. , In our case, patient has disease free survival at the end of one year.
| > References|| |
|1.||Branica BV, Jezek SS, Juros Z, Meniga IN, Krizanac S. Synchronous bilateral breast carcinoma with two different morphology subtypes: A case report. Coll Antropol 2010;34:701-4. |
|2.||Tousimis E. Synchronous bilateral invasive breast cancer. Breast Cancer Online 2005;8:??. |
|3.||Young JS, Sterchi MJ, Hopkins M. Asynchronous bilateral medullary carcinoma of the breast. South Med J 1997;90:423-5. |
|4.||Tuttle TM, Douglas Y. Bilateral Breast cancer. In: Singletary SE, Robb GL, Hortobagyi GN, editors. Advanced Therapy of Breast disease. 2nd ed. USA: B C Decker Inc; 2004. p. 629-30. |
|5.||Leis HP. Bilateral breast cancer. Surg Clin North Am 1978;5:833-41. |
|6.||Janschek E, Kandioler-Eckersberger D, Ludwig C, Kappel S, Wolf B, Taucher S, et al. Contralateral breast cancer: Molecular differentiation between metastasis and second primary breast cancer. Breast Cancer Res Treat 2001;67:1-8. |
|7.||Carmichael AR, Bendall S, Lockerbie L, Prescott R, Bates T. The long term outcome of synchronous bilateral breast cancer is worse than metachronous or unilateral tumors. Eur J Surg Oncol 2002;28:388-91. |
|8.||Gong SJ, Rha SY, Jeung HC, Roh JK, Yang WI, Chung HC. Bilateral breast cancer: Differential diagnosis using histological and biological parameters. Jpn J Clin Oncol 2007;37:487-92. |
[Figure 1], [Figure 2], [Figure 3]