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CASE REPORT
Year : 2022  |  Volume : 18  |  Issue : 3  |  Page : 831-833

Carcinoma male breast with tracheal and endobronchial metastasis, masquerading as nonsmall-cell lung cancer, presenting with superior vena cava obstruction - A rare case report


1 Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
2 Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
3 Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
4 Department of Pulmonary Medicine, All India Institute of Medical Sciences, New Delhi, India

Date of Submission01-Jul-2020
Date of Decision07-Oct-2020
Date of Acceptance15-Feb-2021
Date of Web Publication25-Jul-2022

Correspondence Address:
Astha Srivastava
Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_894_20

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 > Abstract 


Cancer male breast is not very common. It comprises <1% of all breast cancers. Primary sites of metastasis are bone, brain, lung, and liver. Endobronchial and tracheal metastasis is very rare. To the best of our information, this is the first case of male breast carcinoma with upfront tracheal and endobronchial metastasis which presented as Superior vena cava obstruction (SVCO), initially evaluated on the lines of metastatic nonsmall-cell lung cancer. A 60-year-old gentleman presented with shortness of breath and features of SVCO. On primary evaluation, he was thought to be a case of nonsmall-cell lung cancer. Later on, it was confirmed to be carcinoma male breast with endobronchial and tracheal metastasis, which was reconfirmed with biopsy. The case we came across had symptoms associated with endobronchial metastases from primary extrapulmonary tumor and which was later found out to be breast. Treatment options are very different from lung primary and thus, we should be aware of the unusual disease presentation.

Keywords: Endobronchial metastasis, male breast cancer, tracheal metastasis


How to cite this article:
Srivastava A, Pandey R, Anjali V R, Nambirajan A, Angamuthu M, Mohan A. Carcinoma male breast with tracheal and endobronchial metastasis, masquerading as nonsmall-cell lung cancer, presenting with superior vena cava obstruction - A rare case report. J Can Res Ther 2022;18:831-3

How to cite this URL:
Srivastava A, Pandey R, Anjali V R, Nambirajan A, Angamuthu M, Mohan A. Carcinoma male breast with tracheal and endobronchial metastasis, masquerading as nonsmall-cell lung cancer, presenting with superior vena cava obstruction - A rare case report. J Can Res Ther [serial online] 2022 [cited 2022 Aug 10];18:831-3. Available from: https://www.cancerjournal.net/text.asp?2022/18/3/831/348233




 > Introduction Top


Male breast cancer is rare, it comprises <1% of all cancers in men and <1% of all breast cancers.[1] Carcinoma breast primarily metastasizes to bone, brain, lung, and liver via hematogeneous route. Endobronchial metastasis from breast cancer is rare. Neoplasm detected during endobronchial biopsies is usually regarded as evidence of lung cancer. It is important to distinguish endobronchial metastases from primary lung cancer, as the treatment approach is entirely different. Endobronchial metastasis from extrapulmonary malignancies is rare and accounts for approximately 1.1% of total endobronchial tumors.[2] Usually, the time between the detection of the primary tumor and presentation of endobronchial metastasis is about 9 months–5 years.[3],[4] It is arduous to diagnose endobronchial metastasis from primary bronchogenic carcinoma without the preceding history of extrapulmonary malignancy because clinical, radiological, and bronchoscopic findings cannot differentiate these two entities.[5] To the best of our knowledge, this is the first case of carcinoma male breast with upfront tracheal and endobronchial metastasis presenting with superior vena cava obstruction (SVCO). Seeing the rarity of the case with a very rare initial presentation we aim to report it.


 > Case Report Top


A 62-year-old gentleman presented with complaints of cough and progressive shortness of breath on exertion for 6 months. No other co-morbidities. No history of any addictions. high resolution computed tomography showed a mass in the trachea at the level of the carina. Bone scan was suggestive of metastases to the sternum, right pubis, and right femur. In flexible bronchoscopy [Figure 1] there was a growth seen in the lower tracheal region which was extending into the right upper lobe bronchus and it was causing about 50% occlusion of the tracheal lumen. An endobronchial biopsy from the right upper lobe of the lung showed a nonsmall-cell carcinoma. His positron emission tomography-computed tomography (PET-CT) report was awaited. He presented with stridor, edema over face and upper trunk, and engorged veins in our outpatient department, referred from Pulmonary Medicine. The patient was in severe respiratory distress. Considering his general condition and poor performance status and unwillingness for any invasive procedure, he was urgently planned for palliative radiotherapy for SVCO, with a dose of 12 Gy in 3 fractions followed by an assessment for the response. After 3 fractions, he had a good subjective response. Meanwhile, his 18F-fluorodeoxyglucose (FDG) whole-body PET-CT [Figure 2] report came which was suggestive of metabolically active soft-tissue mass in right hilar and lower paratracheal region 5 cm × 3 cm encasing superior vena cava with complete occlusion. There was another FDG avid mass 2.9 cm × 4.3 cm in the right breast involving overlying skin, nipple-areolar complex, involving underlying pectoralis major muscle. Hypermetabolic right axillary, internal mammary, mediastinal and right supraclavicular lymph nodes, largest 3 cm × 2.8 cm, were noted. FDG avid mixed lytic sclerotic lesions were noted in manubrium, sternum, and right pubic bone. There was a strong suspicion of the synchronous second primary breast. A biopsy from the right breast lump was taken which was estrogen receptor strongly positive, progesterone receptor strongly positive, Her 2-neu negative. Hence, the previous biopsy was reviewed which showed similar tumor, suggestive of metastasis from breast lesion . This has to include [Figure 3] as follows-Hence, the previous biopsy [Figure 3] was reviewed which showed similar tumor, suggestive of metastasis from breast lesion . He was started on Tamoxifen 20 mg once daily followed by which response assessment was done by PET-CT which showed stable disease. He was then started on weekly Paclitaxel at 80 mg/m2 for 3 months, after which an assessment PET-CT was done which showed partial response.
Figure 1: Bronchoscopy image showing the growth

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Figure 2: Fluorodeoxyglucose positron emission tomography showing metabolically active endobronchial metastasis, tracheal metastasis, axillary nodes, and primary in the breast

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Figure 3: (a) Endobronchial biopsy shows a carcinoma infiltrating in the subepithelium and ulcerating the overlying metaplastic bronchial mucosa (arrows). (b) The tumor is arranged in variable-sized nests separated by delicate vasculature. (c) Tumor cells show diffuse nuclear staining for anti-estrogen receptor antibody. (d) Tumor cells do not stain for the anti-thyroid transcription factor antibody. (e) Tumor cells show diffuse staining for GATA3 which was performed later after the discovery of a primary breast mass

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 > Discussion Top


Endobronchial metastases are more frequently reported in patients with cancer of the female breast, kidney, colon, or rectum. Endobronchial metastases from extrapulmonary primary tumors are a rare disease presentation. They constitute about 1.1% of endobronchial tumors. The latency period between the primary malignancy and endobronchial metastasis may vary from 9 months to 5 years. The most common symptoms are cough, hemoptysis, dyspnea, and wheezing.[6],[7],[8] For patients presenting with tumors that most commonly cause endobronchial metastasis, the systematic use of chest CT scans and bronchoscopy could be useful. Endobronchial findings commonly suggest an exophytic growth partially or completely occluding the lumen of the bronchus. Chest radiological findings depend on the site and extent of metastasis, which includes atelectasis, visible tumors with hilar masses followed by multiple pulmonary nodules, mediastinal or hilar lymphadenopathy, lung mass, collapse, and consolidation. Management of endobronchial metastasis is decided by the histopathology, anatomic location, metastatic lesions elsewhere in the body, presenting symptoms, performance status of the patient, and life expectancy.[9] If the tumor is surgically resectable, resection is the standard treatment of choice. Breast cancer is quite uncommon in men. The most common presentations are painless palpable mass, skin ulceration, and nipple retraction or discharge. Male breast cancer is diagnosed in the elderly at locally advanced stage age than the female counterpart. Male breast cancer shows a higher estrogen and progesterone receptor expression. HER-2/neu expression is lower in men. The overall 5-year survival rate is around 40%–65%. Its common histopathological type is infiltrating carcinoma, not otherwise specified. Metastasis is identified at diagnosis in approximately 5%–15% of cases. Because of the low incidence of male breast cancer, there are no randomized trials to guide the treatment. The response rate of the Hormone receptor-positive tumors to hormone therapy is about 25%–58%. Tamoxifen is used as a treatment of choice in such tumors even in metastatic settings.[10] Chemotherapy is recommended if the tumor is not responsive to hormonal therapy. The role of aromatase inhibitors such as anastrozole and letrozole in metastatic breast cancers has not been fully established.

It is difficult to differentiate endobronchial metastasis from primary bronchogenic carcinoma without previous history of the extrapulmonary tumor because clinical, radiological, and bronchoscopic findings cannot distinguish these two entities. The case we came across had symptoms associated with endobronchial metastases from primary extrapulmonary tumor and which was later found out to be breast. The subsequent bronchoscopy with a positive histologic finding led to the conclusion that it is primary lung cancer, which was by far the most likely diagnosis and the clinical picture drawn was misleading due to the SVCO features, which is considered as an emergency. It was a technically challenging case.


 > Conclusion Top


Cancer male breast is a relatively rare entity, with the incidence being <1%. We came across an unusual case of carcinoma male breast with upfront tracheal and endobronchial metastasis which was mimicking lung primary. There have been a few case reports and case series for endobronchial metastasis with a history of malignancy in other solid organs including lungs, colo-rectum, and breast. Endobronchial metastasis and tracheal metastasis from cancer male breast is a rare disease manifestation. The therapeutic strategies are very different from those of primary lung cancer. It is necessary to be aware of the disease presentation. Our case had the rarest site of metastasis at the presentation which made it diagnostically challenging.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Oana Cristina V, Monica Mihaela C, Daniel I, Maria S, Adrian Vasile D, Oana Mari P, et al. Histology of male breast lesions. Series of cases and literature review. Maedica (Bucur) 2018;13:196-201.  Back to cited text no. 1
    
2.
Baumgartner WA, Mark JB. Metastatic malignancies from distant sites to the tracheobronchial tree. J Thorac Cardiovasc Surg 1980;79:499-503.  Back to cited text no. 2
    
3.
Ayub II, Thangaswamy D, Joseph LD, Meenakshisundaram M. Lung parenchymal and endobronchial metastases from ovarian carcinoma. J Bronchology Interv Pulmonol 2018;25:235-8.  Back to cited text no. 3
    
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Katsimbri PP, Bamias AT, Froudarakis ME, Peponis IA, Constantopoulos SH, Pavlidis NA. Endobronchial metastases secondary to solid tumors: Report of eight cases and review of the literature. Lung Cancer 2000;28:163-70.  Back to cited text no. 4
    
5.
Breta M, Arava S, Madan K, Singh A, Jain D, Guleria R. Endobronchial metastasis from extrathoracic malignancies: A clinicopathological study of 11 cases. Lung India 2019;36:212-5.  Back to cited text no. 5
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Chrysikos S, Karampitsakos T, Tzouvelekis A, Dimakou K. Endobronchial metastasis from renal cell carcinoma as a reason for recurrent pulmonary infections. Adv Respir Med 2018;86:245-8.  Back to cited text no. 6
    
7.
Fournel C, Bertoletti L, Nguyen B, Vergnon JM. Endobronchial metastases from colorectal cancers: Natural history and role of interventional bronchoscopy. Respiration 2009;77:63-9.  Back to cited text no. 7
    
8.
Çoşğun İG, Kaçan T, Erten G. Late endobronchial pulmonary metastasis in a patient with breast cancer. Turk Thorac J 2018;19:97-9.  Back to cited text no. 8
    
9.
Sørensen JB. Endobronchial metastases from extrapulmonary solid tumors. Acta Oncol 2004;43:73-9.  Back to cited text no. 9
    
10.
Yildirim E, Berberoğlu U. Male breast cancer: A 22-year experience. Eur J Surg Oncol 1998;24:548-52.  Back to cited text no. 10
    


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