|Year : 2009 | Volume
| Issue : 3 | Page : 203-205
Epitrochlear lymph node metastases from invasive ductal breast cancer
Pavan Kumar1, Shalini Singh1, NR Datta2, Ashwani Tandon3
1 Department of Radiotherapy, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow - 226 014, India
2 Department of Radiation Oncology, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
3 Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow - 226 014, India
|Date of Web Publication||16-Oct-2009|
Department of Radiotherapy, Regional Cancer Centre, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow - 226 014
Source of Support: None, Conflict of Interest: None
Metastasis to an epitrochlear lymph node from a primary invasive breast cancer has not been reported earlier. We report a case of epitrochlear lymph node metastasis that presented 10 years after the primary breast malignancy had been treated with radiotherapy, chemotherapy, and hormonal therapy. The patient was successfully treated and continues to remain asymptomatic more than 2 years after she presented with the metastasis.
Keywords: Epitrochlear lymph node, invasive breast carcinoma, metastases
|How to cite this article:|
Kumar P, Singh S, Datta N R, Tandon A. Epitrochlear lymph node metastases from invasive ductal breast cancer. J Can Res Ther 2009;5:203-5
| > Introduction|| |
Breast cancer most frequently metastasizes to bone, lung, liver, brain, and skin. Dissemination to other sites like spleen,  gall bladder,  eye,  urinary bladder,  and submaxillary gland,  have also been reported but are unusual. We report a case of invasive ductal breast cancer with metastasis to an unusual site: the epitrochlear lymph node. This patient presented 10 years after treatment of the primary tumor. To the best of our knowledge such a case has not been reported earlier in the literature.
| > Case Report|| |
A 51-year-old postmenopausal lady presented in November 1995 as a case of cancer right breast, which was staged pT 1 N 1 M 0 after modified radical mastectomy. Histopathology showed invasive ductal carcinoma, with three out of the six dissected axillary lymph nodes having metastatic disease along with evidence of vascular emboli. Her metastatic workup, which included skiagram of the chest and bone and liver scans, was normal. She had a past history of subtotal thyroidectomy in 1993 and was on thyroxin replacement therapy. She received postoperative locoregional radiotherapy to a total dose of 50 Gy in 25 fractions delivered over 5 weeks. Radiotherapy was completed in January 1996. This was followed by six cycles of adjuvant chemotherapy, consisting of cyclophosphomide (500 mg/m 2 ), methotrexate (50 mg/m 2 ), and 5-fluorouracil (500 mg/m 2 ), administered parenterally on days 1 and 8 of a 4-weekly cycle. Chemotherapy was completed in June 1996. She was thereafter put on hormonal therapy (tamoxifen 10 mg twice daily) for 5 years till August 2001.
The patient was on regular follow-up. She had yearly metastatic workup and was asymptomatic till October 2005, when she complained of a swelling in the right elbow region. On examination, there was a mobile 3.0 Χ 1.5 cm nodal swelling in the medial side of the right elbow in the epitrochlear region. There was no past history of any skin lesion, and no pigmented cutaneous lesion or ulceration of the skin was seen on clinical examination. Inspection of the entire skin and mucosal surfaces, as well as detailed examination of the area drained by the affected lymphatic basin, was within normal limits. Fine needle aspiration cytology showed paucicellular smears, mainly composed of scattered single and loosely cohesive neoplastic cells, with occasional acinar structures. The cells were large, with a high nuclear-cytoplasmic ratio, hyperchromatic nuclei, and scant to moderate cytoplasm, and were seen against a hemorrhagic background with sparse lymphoid cells. Against the background of the patient's past history of carcinoma of the breast, these features were suggestive of metastatic ductal carcinoma deposits in an epitrochlear lymph node [Figure 1]. The metastatic workup was otherwise normal.
She refused surgical excision of the node and was therefore treated with palliative radiotherapy to the right epitrochlear region to a total dose of 36 Gy delivered in 12 fractions. There was complete regression of the epitrochlear node following completion of radiotherapy in December 2005. She was resumed on tamoxifen 10 mg twice daily for 2 years, which was changed to letrozole 2.5 mg once daily from February 2008 onwards. On follow-up, the metastatic workup has been normal and the patient continues to be asymptomatic.
| > Discussion|| |
Metastases from invasive ductal carcinoma of the breast usually involve bone, liver, lung, and brain. To the best of our knowledge, and according to the literature, involvement of epitrochlear node has never been reported. This is perhaps the first case report of epitrochlear lymph node metastasis from a neoplastic lesion of the breast.
Benign lymphadenopathy of the epitrochlear lymph node has been suggested to result from minor trauma and infection caused by the fungus Sporothrix schenckii in gardeners or by the bacterium Bartonella henselae in cat-scratch disease.  Malignant etiology includes mainly lymphoma and chronic lymphocytic leukemia, but these malignancies are likely to cause generalized lymphadenopathy.
Ratanatharathorn et al. reported a series of 32 patients with primary carcinoma of the breast and metastasis to the eye. The time interval from diagnosis of the primary lesion to detection of the metastasis ranged from 2 to 107 months, with a median interval of 56 months.  Smet et al. reported a case in which metastases to the index metacarpal was seen 11 years after mastectomy had been done for the primary breast tumor. The metastasis appeared late and progressed slowly; the patient survived for 4 years after the metastasis was diagnosed. 
Chambers and her colleagues observed that most cancer cells that enter the circulation generally stop at the first tangle of capillaries they encounter, apparently because the vessels simply become too small for the cells to pass through. The cancer cells either die or fail to grow in their new locations. An ability of these cells to lie dormant may explain why some breast cancer metastases show up as late as two decades after surgery and/or other treatment has been carried out to eradicate the primary neoplasm. Of the cells that do grow, few divide often enough to produce clinically relevant metastases. 
Once individual tumor cells arrive at the secondary site, they may experience one of three fates: they may proliferate to form micrometastases, they may die, or they may remain viable but dormant. These dormant solitary cells are defined by a prolonged state of G 0 , where there is an absence of either proliferation or apoptosis. This quiescence is likely to afford protection from many conventional cytotoxic drugs, which only target actively cycling cells. If these solitary cancer cells do begin to proliferate and go on to form micrometastases, they may again experience one of three fates at this next stage: they may continue to proliferate to form vascularized macrometastases, they may die, or they may persist as 'dormant' micrometastases. Dormancy at this stage would mean a balance between cell proliferation and apoptosis within the cell population, such that there is no net increase in the size of the micrometastases. 
In the present case, right epitrochlear lymph node metastases occurred 10 years after treatment of the primary right breast cancer. The theory outlined above can very well explain this long time gap since the primary histopathology report had mentioned the presence of vascular emboli.
Smith et al. reported epitrochlear lymph node metastases in 18% (7/39) of patients with cutaneous melanoma of the forearm and hand when the lesion was within 5 cm of the elbow or was on the ulnar aspect.  Armando et al. have reported that 5.6% of cases of metastatic malignant melanoma to lymph nodes show no obvious detectable primary. However, the most commonly accepted explanation for an unknown primary in metastatic melanoma is spontaneous regression of the primary cutaneous lesion.  This possibility was also ruled out in our patient since she had no past history of a skin lesion.
The prolonged survival achieved after her salvage treatment consisting of radiation therapy indicates that radiotherapy can give quick and effective disease control at this site. This patient continues to be on close follow-up so that any new metastases can be identified as early as possible.
To summarize, in this case report, we describe a novel metastatic site in cancer breast that has not been reported so far and also describe its successful control.
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