AJR 2004; 182:745-747
© American Roentgen Ray Society
Unusual Soft-Tissue Metastasis of an Invasive Lobular Carcinoma Mimicking Fasciitis
M. El Khoury1,
P. Cherel1,
V. Becette2,
C. De Maulmont1,
V. Costes1,
V. Talma1 and
C. Hagay1
1 Department of Radiology, Centre René Huguenin, 35 Rue Dailly, Saint
Cloud 92210, France.
2 Department of Pathology, Centre René Huguenin, Saint Cloud 92210,
France.
Received June 9, 2003;
accepted after revision August 12, 2003.
Address correspondence to M. El Khoury.
Introduction
Invasive lobular carcinoma accounts for 5–15% of all breast cancer
[1]. It differs from invasive
ductal carcinoma, the most common histologic subtype of breast cancer, not
only by histologic and mammographic characteristics, but also by a different
pattern of metastatic spread
[2]. We report a case of tumor
infiltration of the fasciae of the anterior muscular compartment of the thigh
presenting as edema of the lower extremity 10 years after treatment of an
invasive lobular carcinoma of the breast.
Case Report
A 50-year-old woman presented to our hospital with edema of her lower left
extremity that appeared 2 months earlier. Ten years previously, she had
undergone a right total mastectomy and axillary dissection because of a right
breast carcinoma. Pathologic examination revealed a 3 x 1 cm
infiltrating lobular carcinoma of histopathologic grade II, using the
Scarff-Bloom-Richardson tumor grading system. Results for all the 13 resected
lymph nodes were negative. The tumor was positive for estrogen but not for
progesterone receptors. Adjuvant chemotherapy was given. At admission, neither
clinical nor mammographic anomalies of the breast were noted. Laboratory test
results were pertinent for an isolated increase of the serum tumor marker most
often used in the detection of breast cancer, the circulating CA 15.3 antigen,
to 158 U/mL (normal, < 30 U/mL).
Doppler sonographic examination of the lower extremities showed no evidence
of venous thrombosis. Findings from CT examination of the thorax, abdomen, and
pelvis and radionuclide bone scans were negative for distant metastases. No
significantly enlarged pelvic or inguinal lymph nodes were found. Unenhanced
and enhanced helical CT (Somatom Plus Power, Siemens, Erlangen, Germany) using
120 mL of iodinated contrast medium (ioversol, Optiject 300, Guerbet, France)
and MRI examinations on a 1.5-T scanner (Signa, General Electric Medical
Systems, Milwaukee, WI) with gadoterate dimeglumine (Dotarem, Guerbet) of the
thigh were performed. They showed diffuse infiltration and thickening of the
fasciae surrounding the muscles of the femoral triangle and encasing the
femoral sheath (Figs. 1A,
1B,
1C,
1D). Edematous congestion of
the subcutaneous tissue was noted with no evidence of cutaneous or
subcutaneous tumoral extension. The negative result of CT-guided fine-needle
aspiration prompted surgical biopsy. Histopathologic examination revealed
infiltration with malignant cells of an undifferentiated carcinoma
(Fig. 1E). No non-neoplastic
breast tissue was identified. Review of the specimen of the primary breast
lesion and immunohistochemical staining for estrogen and progesterone
receptors showed similar results to the lesion with the same infiltrative
pattern (Fig. 1F). The
diagnosis of a soft-tissue metastatic infiltration of the breast carcinoma was
retained. The patient is undergoing chemotherapy with, until now, slow
regression of the edema but significant decrease of the circulating CA 15.3
antigen to 24 U/mL.
View larger version (78K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A. —50-year-old woman with soft-tissue metastasis of invasive
lobular carcinoma of breast. Axial CT scan obtained before iodinated contrast
medium administration reveals absence of nodular masses.
|
|
View larger version (92K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B. —50-year-old woman with soft-tissue metastasis of invasive
lobular carcinoma of breast. Axial CT scan obtained at same level as A,
after iodinated contrast medium administration, shows enhancement of thickened
fascia (arrow) surrounding muscles of anterior compartment of
thigh.
|
|
View larger version (137K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1C. —50-year-old woman with soft-tissue metastasis of invasive
lobular carcinoma of breast. Contrast-enhanced coronal (C) and sagittal
(D) T1-weighted spin-echo MR images with fat suppression show extension
of tumor along thickened fasciae (arrow).
|
|
View larger version (148K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1D. —50-year-old woman with soft-tissue metastasis of invasive
lobular carcinoma of breast. Contrast-enhanced coronal (C) and sagittal
(D) T1-weighted spin-echo MR images with fat suppression show extension
of tumor along thickened fasciae (arrow).
|
|
View larger version (205K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1E. —50-year-old woman with soft-tissue metastasis of invasive
lobular carcinoma of breast. Photomicrograph of histologic specimen from
muscle biopsy of groin shows isolated cells and small cords of cells in
"Indian file" pattern (arrow) that is characteristic of
lobular carcinoma and diffusely infiltrating skeletal muscle fibers
(arrowhead). (H and E, x200)
|
|
View larger version (230K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1F. —50-year-old woman with soft-tissue metastasis of invasive
lobular carcinoma of breast. Photomicrograph of histologic specimen from
primary breast invasive lobular carcinoma shows same pattern of small cells
infiltration (arrow). Note normal ductule (arrowhead). (H
and E, x200)
|
|
Discussion
The specific pattern of metastatic spread of invasive lobular carcinoma is
well known and has been described in several case reports and studies
[1,
3], some of which compare the
behavior of lobular carcinoma with that of its counterpart, the invasive
ductal carcinoma [4,
5].
This peculiar behavior has been noted in the distribution of metastases and
in their gross appearance and microscopic appearance. Although invasive
lobular carcinoma may spread with the same frequency as invasive ductal
carcinoma to the lung, pleura, liver, and lymph nodes, it has a propensity to
metastasize to atypical sites such as to the peritoneum and retroperitoneum
and to the gastrointestinal and urogenital tracts
[1,
2,
4,
5]. Its tumor deposits, unlike
those of invasive ductal carcinoma, do not organize into nodular masses but
present as confluent tiny nodules infiltrating and thickening the
leptomeninges, the serosal membranes, and the visceral walls
[3,
5]. The reason for this
discrepancy is unclear but has been suggested by the loss of expression of the
cell–cell adhesion molecule E-cadherin in invasive lobular carcinoma
[1]. This may explain the
single files of regular noncohesive tumor cells infiltrating preexistent
structures rather than invading and destroying them
[5]. This pattern of
infiltration and the absence of nodules were found in our patient. To our best
knowledge, no previous cases of distant soft-tissue localization from invasive
lobular carcinoma, except chest wall recurrence, have been reported. Although
isolated lymphatic spread limited to the femoral triangle may be considered,
the absence of significant inguinal or deep pelvic adenopathy is unusual. The
other hypothesis would be metachronous involvement of a supernumerary breast
in the groin, because breast tissue may be located anywhere along the mammary
ridge, which extends from the axilla to the groin
[6]. Ectopic breast is known to
remain silent unless it undergoes clinical or pathologic change
[7,
8]. However, its location below
the umbilicus is unusual and has been seldom reported in the vulva, and never
in the groin. Because no nonneoplastic breast tissue was identified in the
biopsy specimen, that hypothesis was excluded. Therefore, the diagnosis of a
soft-tissue metastasis from the primary invasive lobular carcinoma,
compromising lymphatic drainage, was retained.
In conclusion, we have described an atypical case of soft-tissue metastasis
of an invasive lobular carcinoma of the breast that involved the proximal part
of the thigh and mimicked fasciitis.
Radiologists should be aware of the particular pattern of dissemination of
invasive lobular carcinoma of the breast. The absence of nodular masses does
not exclude the possibility of malignant infiltration. Pathologic proof is
warranted for any infiltrative lesion detected, especially if a strong
clinical suspicion of metastatic disease is present.
References
- Sastre-Garau X, Jouve M, Asselain B, 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
–120[Medline]
- Winston CB, Hadar O, Teitcher JB, et al. Metastatic lobular
carcinoma of the breast: patterns of spread in the chest, abdomen, and pelvis
on CT. AJR2000; 175:795
–800[Abstract/Free Full Text]
- Kidney DD, Cohen AJ, Butler J. Abdominal metastases of infiltrating
lobular breast carcinoma: CT and fluoroscopic imaging findings.
Abdom Imaging1997; 22:156
–159[Medline]
- Borst MJ, Ingold JA. Metastatic patterns of invasive lobular versus
invasive ductal carcinoma of the breast. Surgery1993; 114:637
–642[Medline]
- Lamovec J, Bracko M. Metastatic pattern of infiltrating lobular
carcinoma of the breast: an autopsy study. J Surg
Oncol 1991;48:28
–33[Medline]
- Moore KL, Persaud TVN. Development of mammary glands. In: Moore KL,
Persaud TVN, eds. The developing human: clinically oriented
embryology, 6th ed. Philadelphia, PA: Saunders,1998
: 520–522
- Bailey CL, Sankey HZ, Donovan JT, et al. Primary breast cancer of
the vulva. Gynecol Oncol1993; 50:379
–383[Medline]
- Marshall MB, Moynihan JJ, Frost A, et al. Ectopic breast cancer:
case report and literature review. Surg Oncol1994; 3:295
–304[Medline]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Top
Introduction
Case Report
