|Year : 2012 | Volume
| Issue : 4 | Page : 630-632
Squamous cell carcinoma of lung metastasizinig in breast
Sarbani Chattopadhyay1, Ranen Kanti Aich2, Amitava Sengupta3, Poonam Kumari1
1 Department of Pathology, N.R.S. Medical College, Kolkata, West Bengal, India
2 Department of Radiotherapy, N.R.S. Medical College, Kolkata, West Bengal, India
3 Department of Chest Medicine, N.R.S. Medical College, Kolkata, West Bengal, India
|Date of Web Publication||29-Jan-2013|
Ranen Kanti Aich
Department of Radiotherapy, N R S Medical College & Hospital, Kolkata - 700 014, West Bengal
Source of Support: None, Conflict of Interest: None
Metastasis in breast from extra-mammary malignancy is rare and lung is the third most common primary site when such a metastasis occurs. Small cell carcinoma and adenocarcinoma are two histological varieties of lung carcinoma that may metastasize to breast and squamous cell type is very rare. Here we report a case of squamous cell carcinoma of lung that metastasized in the breast and mimicked primary breast carcinoma.
Keywords: Metastatic breast, lung carcinoma, squamous cell carcinoma
|How to cite this article:|
Chattopadhyay S, Aich RK, Sengupta A, Kumari P. Squamous cell carcinoma of lung metastasizinig in breast. J Can Res Ther 2012;8:630-2
| > Introduction|| |
Metastasis in breast from extra-mammary malignancies is rare compared with primary breast carcinoma. If an unusual type of malignancy is encountered in the breast, clinicians should try to find out a preexisting malignancy elsewhere in the body to rule out a metastatic spread. Metastasis spreading to breast commonly occurs from malignant melanoma, lymphoma, lung and ovarian carcinomas, soft tissue sarcoma, gastro-intestinal and genitor-urinary malignancies in order of decreasing frequencies. 
Most lung primaries metastasizing to breast represent adenocarcinoma or small cell carcinoma. Squamous cell carcinoma of lung metastasizing to breast is very rare. Here we report a case of squamous cell carcinoma of lung metastasizing in breast mimicking a primary breast carcinoma.
| > Case Report|| |
A 55-year-old lady presented herself with the history of a right breast lump of 2 months duration, a persistent cough for past 1 month, and hemoptysis on two occasions. Though she claimed herself as a nonsmoker, after intensive questioning she admitted that she was an occasional smoker in her early twenties and has quit smoking for about last 30 years. On palpation, a hard mass of about 6 cm diameter was felt in upper and outer quadrant of right breast, without any palpable lymphadenopathy in axillary, supraclavicular, or cervical regions. X-ray of chest showed an irregular mass near hilum of right lung along with upper lobe collapse. The initial clinical impression was a breast malignancy spreading to lung. Fine needle aspiration cytology (FNAC) from the breast mass showed dyscohesive malignant epithelial cells with definite squamoid appearance mostly lying in scattered formation, some in loose clusters [Figure 1]. Bronchoscopic biopsy showed a moderately differentiated squamous cell carcinoma with dysplastic changes in the epithelial lining [Figure 2]. Histology of the 'tru-cut biopsy' from the breast mass showed a poorly differentiated squamous cell carcinoma with areas of extensive necrosis [Figure 3] which was estrogen (ER) and progesterone (PR) negative on immunohistochemical analysis. Ultrasonography of whole abdomen, routine blood examination, liver, and kidney function tests were within normal limits. Computerized tomography (CT) scan of chest showed a rounded mass near hilum of right lung with hilar, mediastinal, and para tracheal lymph node enlargement along with collapse-consolidation of right upper lobe. Positron emission tomography PET scan was suggested but the patient could not afford it. With the diagnosis of lung carcinoma metastasizing to breast, chemotherapy with injection gemcitabine (1200 mg/M 2 on day 1 and 8) and injection cisplatin (80 mg/M 2 on day 1) started and the patient showed gradual improvement. However, the patient did not turn up for third cycle of chemotherapy and on enquiry over telephone, we came to know that she expired at her residence with symptoms suggesting of superior vena caval obstruction.
|Figure 1: Microscopic picture of FNAC from the breast mass showing dyscohesive malignant epithelial cells mostly lying scattered, some in loose clusters, with definite squamoid appearance|
Click here to view
|Figure 2: Bronchoscopic biopsy showing a moderately differentiated squamous cell carcinoma with dysplastic changes in the epithelial lining|
Click here to view
|Figure 3: Tru-cut biopsy from the breast mass showing poorly differentiated squamous cell carcinoma with extensive necrosis|
Click here to view
| > Discussion|| |
Metastatic spread of extra-mammary malignancy to breast is rare with an incidence of 0.5-3%.  Breast metastasis as the initial presentation is more infrequent and can simulate a primary malignancy clinically and radiologically. Recognition of metastatic spread to the breast is important to avoid unnecessary extensive surgery and for appropriate treatment.  In the present patient, the breast lesion appeared to be the primary with metastasis to the lung, but actually it was the reverse.
The importance of FNAC in management of a breast lump cannot be overemphasized. If it shows duct carcinoma then the management will include surgery, chemotherapy, and/or radiotherapy. But if the smear proves otherwise, then the differential diagnoses should include metastatic deposit from some extra-mammary site. If there is a known primary site elsewhere, then diagnosis becomes easier, but if the patient presents with the breast lump only, then the diagnosis becomes confusing. In the present case, the patient presented with a single, hard mass in the breast and respiratory symptoms, and the clinical impression was that of a breast malignancy metastasizing to lung. But demonstration of malignant squamous cells on FNAC from breast suggested that it could be a metastasis from the lung carcinoma. Bronchoscopic biopsy showed that the lung lesion was also of same histology accompanied by dysplastic changes in the lining epithelium above the malignant tumor. Islands of malignant cells amidst areas of extensive necrosis were found on histological examination of the tru-cut biopsy from the breast mass. There was no evidence of squamous metaplasia or in situ component to suggest that breast mass could be a primary one. Thus a primary squamous cell lung carcinoma spreading to the breast was the reasonable diagnosis. Though, sometimes, FNAC or histology does not provide adequate evidence and a panel of immunohistochemical tests are required, and that too, may not be conclusive in certain situations. The breast mass of the present patient was ER and PR negative, and so a lot of breast cancer patients are ER and PR negative depending upon the age and menopausal status. Similarly, almost all the lung cancers are also ER and PR negative. Squamous cell carcinomas from all sites show similar Immunohistochemistry (IHC) features (positivity for low and high molecular weight keratins, involucrin, etc.) and there is no way to establish a pulmonary pathology. Thyroid Transcription Factor - 1 (TTF-1) is a useful marker to establish pulmonary primary but it is positive for adenocarcinomas of lung and usually negative in squamous cell carcinomas of lung.
Lung cancer may spread to adrenals, bone, brain, and liver apart from the lymph nodes; breast being a very uncommon site for metastatic involvement. Wood et al. reviewed 32 cases of extra-mammary malignancies having metastasis to breast. There were previous history of extra-mammary malignancy in 26 patients, while the breast mass was the initial presentation in the remaining 6 patients. Lung was the primary site in only 8 of these 26 patients. If it has metastasized, the lung primary is more commonly an adenocarcinoma or small cell type. Shukla et al.,  recorded 15 metastatic breast lesions of which breast lump was the initial presentation in 4 patients and the lung primary was of small cell type only. In this case, the lung primary was a moderately differentiated squamous cell carcinoma, whereas the breast metastasis showed much poorer differentiation. Sauer  study of metastatic involvement of breast by extra-mammary primaries recorded 36 cases over a long period of 18 years, of which 15 were from lung primaries. But the tumors were small cell carcinoma, adenocarcinoma, and poorly differentiated nonsmall cell carcinoma and there was not a single case of squamous cell carcinoma of lung among them. Similarly, Domanski,  reported six cases and Smymiotis et al. reported seven patients all of whom had metastasis to breast from extra-mammary sites, but none of them was from squamous cell carcinoma of lung. In his article, Lee  reported only 1 case of squamous cell carcinoma of lung metastasizing to breast out of his 18 patients.
| > Conclusion|| |
Metastatic involvement of breast from an extra-mammary primary is uncommon, but may occur. Management of metastatic involvement of breast is entirely different from a primary breast malignancy. Hence awareness of such possibility and prompt and correct histo/cyto diagnosis is essential to avoid mistreatment.
| > References|| |
|1.||Liu W, Palma-Diaz F, Alasio TM. Primary small cell carcinoma of the lung initially presenting as a breast mass: A fine-needle aspiration diagnosis. Diagn Cytopathol 2009;37:208-12. |
|2.||Hsu W, Sheen-Chen SM, Wang JL, Huang CC, Ko SF. Squamous cell lung carcinoma metastatic to the breast. Anticancer Res. 2008;28:1299-301. |
|3.||Fulciniti F, Losito S, Botti G, Di Mattia D, La Mura A, Pisano C, et al. Metastases to the breast: Role of fine needle cytology samples. Our experience with nine cases in 2 years. Ann Oncol 2008;19:682-7. |
|4.||Wood B, Sterrett G, Frost F, Swarbrick N. Diagnosis of extramammary malignancy metastatic to the breast by fine needle biopsy. Pathology 2008;40:345-51. |
|5.||Shukla R, Pooja B, Radhika S, Nijhawan R, Rajwanshi A. Fine-needle aspiration cytology of extramammary neoplasms metastatic to the breast. Diagn Cytopathol 2005;32:193-7. |
|6.||Sauer T. Fine-needle aspiration cytology of extra mammary metastatic lesions in the breast: A retrospective study of 36 cases diagnosed during 18 years. Cytojournal 2010;7:10-18. |
|7.||Domanski H A. Metastasis to the breast from extramammary neoplasms. A report of six cases with diagnosis by fine needle aspiration cytology. ActaCytol. 1996;40(6):1293-300. |
|8.||Smymiotis V, Theodosopoulos T, Marinis A, Goula K, Psychogios J, Kondi-Pafiti A. Metastatic disease in the breast from nonmammary neoplasms. Eur J Gynaecol Oncol 2005;26:547-50. |
|9.||Lee AH. The histological diagnosis of metastases to the breast from extramammary malignancies. J Clin Pathol 2007;60:1333-41. |
[Figure 1], [Figure 2], [Figure 3]