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Year : 2018  |  Volume : 14  |  Issue : 5  |  Page : 1135-1137

Lobular breast cancer metastasis to uterus during adjuvant tamoxifen treatment: A case report and review of the literature


1 Department of Internal Medicine, Division of Medical Oncology, Faculty of Medicine, Gazi University, Ankara, Turkey
2 Department of Pathology, Faculty of Medicine, Gazi University, Ankara, Turkey

Date of Web Publication7-Sep-2018

Correspondence Address:
Aydin Aytekin
Department of Medical Oncology, Hospital of Gazi University, Faculty of Medicine, E Block, 6th Floor, Konyayolu Street, Bahçelievler, Ankara
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.187235

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 > Abstract 


Tamoxifen plays a critical role in the treatment of hormone receptor-positive breast cancer. Despite these great benefits against breast cancer, tamoxifen increases the risk of endometrial pathologies such as endometrial hyperplasia, polyp, and neoplasms because of agonistic effect on endometrial tissues. Therefore, gynecologic follow-up should be carried out during tamoxifen treatment. Uterine tumors are frequently detected as the result of presentation with abnormal uterine bleeding. In addition, genital tract's metastases from distant primary tumors can present with abnormal uterine bleeding. Therefore, it is important to determine whether the uterine mass is metastatic or primary because different treatment modalities are used for them. In this context, breast carcinomas are the most frequent metastatic tumors, particularly invasive lobular carcinoma. Here, we report an invasive lobular carcinoma case that presented with abnormal uterine bleeding while receiving tamoxifen therapy and has metastasize in the uterus.

Keywords: Adjuvant treatment, breast cancer, lobular carcinoma, tamoxifen, uterine metastasis


How to cite this article:
Aytekin A, Bilgetekin I, Ciltas A, Ogut B, Coskun U, Benekli M. Lobular breast cancer metastasis to uterus during adjuvant tamoxifen treatment: A case report and review of the literature. J Can Res Ther 2018;14:1135-7

How to cite this URL:
Aytekin A, Bilgetekin I, Ciltas A, Ogut B, Coskun U, Benekli M. Lobular breast cancer metastasis to uterus during adjuvant tamoxifen treatment: A case report and review of the literature. J Can Res Ther [serial online] 2018 [cited 2019 Apr 19];14:1135-7. Available from: http://www.cancerjournal.net/text.asp?2018/14/5/1135/187235




 > Introduction Top


Tamoxifen plays a critical role in the treatment of hormone receptor-positive breast cancer. Tamoxifen has agonistic effect on endometrial tissues and increases the risk of endometrial pathologies such as endometrial hyperplasia, polyp, and neoplasms. Therefore, gynecologic follow-up should be performed during tamoxifen treatment. Uterine tumors are frequently detected as the result of presentation with abnormal uterine bleeding.[1] The genital tract metastases from distant primary tumors occur rarely. In this context, breast carcinomas and gastrointestinal carcinomas are the most common metastatic tumors. Ovaries are the most common metastatic region, whereas uterine metastasis rarely occurs and accounts for approximately 10% of all female genital tract metastases. Metastases often depend on extended primary disease and the most common sign is abnormal uterine bleeding.[2]

It is known that breast cancer can have multi-organ metastasis. The most common metastatic regions are bone, lung, and liver. Uterine metastases rarely occur and have been reported in autopsy series.[3] Among the extragenital cancers, breast cancer is the most frequent cancer that metastasizes to uterine regions and particularly invasive lobular cancers show more often tendency to metastasize to gynecologic organs.[4]

Although breast cancer rarely metastasizes to uterus, when endometrial pathology is detected, it is important to determine whether the uterine mass is metastatic or primary because different treatment modalities are used for them. We report a case of invasive lobular carcinoma (ILC) patient who presented with abnormal uterine bleeding while receiving tamoxifen therapy and has metastasize in the uterus.


 > Case Report Top


A 38-year-old woman referred with a mass called Breast Imaging, Reporting and Data System 5 (BI-RADS 5) in the left breast and mass BIRADS 4A in the right breast, thereon tru-cut biopsy was carried out and mixed type breast cancer (invasive ductal carcinoma [IDC] and ILC) was reported in the left breast by pathology. Modified radical mastectomy was performed in the left breast and simple mastectomy in the right side. Pathology result obtained from the left side was mixed type carcinoma (IDC and ILC), which was estrogen and progesterone receptor-positive and negative human epidermal growth factor receptor 2 expression. No pathological results were identified in the right mastectomy side.

As a result, the patient was diagnosed with T2 N3 MO stage breast cancer. Adjuvant chemotherapy (four cycles of adriamycin plus cyclophosphamide and then weekly paclitaxel during 12 weeks) and radiotherapy were administered. Afterward, tamoxifen and luteinizing hormone-releasing hormone analog were initiated. After about 10 months, the patient presented with vaginal bleeding. Endometrial curettage was performed and pathology reported the result as metastasis of breast lobular carcinoma. Subsequently, total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed and the pathology turned out to be the metastasis of lobular breast carcinoma and also diffuse infiltration to uterine wall, bilateral ovaries, vaginal cuff, and cervix [Figure 1]a, [Figure 1]b, [Figure 1]c. While screening for the findings of primary cancer, any other focus could not be found. We started a chemotherapy protocol to the patient as metastatic breast cancer first line setting. In follow-up evaluation 4 months later, liver metastasis and signs consistent with peritoneal metastasis were detected and another course of chemotherapy was administered. Two months later, the patient presented with gastrointestinal bleeding, massive acid and hepatic encephalopathy, and died.
Figure 1: (a) The close view of tumor cells that shows single infiltration with small oval cores between endometrial glands (H and E, ×200). (b) E-cadherin negativity in tumor cells (×100). (c) Diffuse positivity with keratin 7 in tumor cells (×100)

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 > Discussion Top


Among extragenital cancers, breast cancer is the most common metastasizing neoplasm to uterus and ILC is the most frequent histological type that does so. In a trial, it was reported that ovaries are the most affected metastatic organs account for about 75.8% of all patients followed by vagina 13.4%, uterine 4.7%, cervix 3.4%, vulva 2%, and salpinx 0.7%. Despite this trend in the distribution of metastases, all parts of female genitalia system are at a risk of metastases. In our case, myometrium, endometrium, cervix, bilateral ovaries, and vajinal cuff were involved by tumor infiltration. IDC is responsible for 75% of all breast cancer cases as compared with ILC that accounts for 5–20%. Although ILC has a low incidence in all types of breast cancer, it is the histological type that most frequently metastasizes to female genital tract which corresponds to more than 80% of the cases.[5] It is not clear that why there is a difference between IDC and ILC. It has been suggested that the reason is the loss of expression of E-cadherin called cell-to-cell adhesion molecule in ILC.[6] In addition, ILC has a tendency to diffusely metastasize to myometrium, endometrium, cervix, ureters, stomach, and to infiltrate peritoneal and retroperitoneal surfaces.[7] For this reason, our patient presented with acid. Otherwise, the most common symptom is abnormal uterine bleeding.[8] Therefore, it is difficult to determine whether uterine mass is primary or metastatic. Both clinicians and pathologists are compelled to identify the metastasis of breast cancer. Immunohistochemistry often helps to detect the primary site of tumor. Gross cystic disease fluid protein is known as a marker that has high sensitivity and specificity in the differential diagnosis of breast cancer. This marker is negative in endometrial pathologies. Since mammoglobin used for breast cancer diagnosis belongs to uteroglobin/clara cell protein family, it is positively expressed in female genital tract and its neoplasms are highly expressed in endometrium and normal endocervical epithelium. CK-7 is also an important marker that supports the diagnosis of breast cancer.[9] To date, there have been a few publications related to prognosis of metastatic uterine tumor from breast cancer. It is known that all patients have poor prognosis.[10] Similarly, our case died within a short time.


 > Conclusion Top


It should be kept in mind that breast cancer patients who use tamoxifen have not only primary endometrial cancers, but also sometimes develop uterine metastasis. Therefore, routine gynecological examination is recommended for patients with breast cancer.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Ismail SM. Gynaecological effects of tamoxifen. J Clin Pathol 1999;52:83-8.  Back to cited text no. 1
    
2.
Kumar NB, Hart WR. Metastases to the uterine corpus from extragenital cancers. A clinicopathologic study of 63 cases. Cancer 1982;50:2163-9.  Back to cited text no. 2
    
3.
Di Bonito L, Patriarca S, Alberico S. Breast carcinoma metastasizing to the uterus. Eur J Gynaecol Oncol 1985;6:211-7.  Back to cited text no. 3
    
4.
Lamovec J, Bracko M. Metastatic pattern of infiltrating lobular carcinoma of the breast: An autopsy study. J Surg Oncol 1991;48:28-33.  Back to cited text no. 4
    
5.
Ustaalioglu BB, Bilici A, Seker M, Salman T, Gumus M, Barisik NO, et al. Metastasis of lobular breast carcinoma to the uterus in a patient under anastrozole therapy. Oncol Res Treat 2009;32:424 6.  Back to cited text no. 5
    
6.
Sastre-Garau X, Jouve M, Asselain B, Vincent-Salomon A, Beuzeboc P, Dorval T, et al. Infiltrating lobular carcinoma of the breast. Clinicopathologic analysis of 975 cases with reference to data on conservative therapy and metastatic patterns. Cancer 1996;77:113-20.  Back to cited text no. 6
    
7.
Sobinsky JD, Willson TD, Podbielski FJ, Connolly MM. Unusual metastatic patterns of invasive lobular carcinoma of the breast. Case Rep Oncol Med 2013;2013:986517.  Back to cited text no. 7
    
8.
Piura B, Yanai-Inbar I, Rabinovich A, Zalmanov S, Goldstein J. Abnormal uterine bleeding as a presenting sign of metastases to the uterine corpus, cervix and vagina in a breast cancer patient on tamoxifen therapy. Eur J Obstet Gynecol Reprod Biol 1999;83:57-61.  Back to cited text no. 8
    
9.
Onuma K, Dabbs DJ, Bhargava R. Mammaglobin expression in the female genital tract: Immunohistochemical analysis in benign and neoplastic endocervix and endometrium. Int J Gynecol Pathol 2008;27:418-25.  Back to cited text no. 9
    
10.
Mazur MT, Hsueh S, Gersell DJ. Metastases to the female genital tract. Analysis of 325 cases. Cancer 1984;53:1978-84.  Back to cited text no. 10
    


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