Metastatic breast cancer presenting as an ovarian cyst: diagnosis by fine needle aspiration cytology K. R. P A T E L A N D A. P. BOON Departnients qf Histopathology and Cytopathology, St James’s University Hospital, Leeds, U K Accepted for publication 25 March 1992
PATEL K. R. AND BOON A. P.
(1992) Cytopathology 3,191-195
Metastatic breast cancer presenting as an ovarian cyst: diagnosis by fine needle aspiration cytology
A fifty-year-old woman with a history of breast cancer presented with a clinically benign ovarian cyst. Laparoscopic aspiration of cyst fluid was performed and the cytology was suspicious of epithelial neoplasia. At subsequent hysterectomy and bilateral salpingooopherectomy, the specimen showed extensive metastatic breast carcinoma. Although the cytological examination of fluid from ovarian cysts is often unrewarding, this case shows that metastatic carcinoma may occasionally be diagnosed in this fashion. Keywords: fine needle aspiration cytology, ovarian cysts, metastatic carcinoma, laparoscopic diagnosis
INTRODUCTION Although the diagnosis of ovarian cysts by aspiration cytology remains controversial, there is an increasing tendency to manage small cysts by laparoscopic aspiration’. We report an unusual, and possibly unique case of metastatic breast carcinoma discovered in this manner. CASE R E P O R T
A 50-year-old woman presented to the accident and emergency department complaining of severe pain and tenderness in the right iliac fossa. Significant past medical history included an extended left mastectomy for breast cancer 9 months previously and an appendicectomy at the age of 25. Vaginal examination revealed a mass in the right adnexa. Ultrasound examination showed a 3.8cm diameter cyst in her right ovary. The left ovary and the uterus appeared normal. Subsequent laparoscopic examination confirmed these findings and fluid was aspirated peroperatively and submitted for cytology. Correspondence: Dr A. P. Boon, Departments of Histopathology and Cytopathology. St James’s University Hospital, Beckett Street, Leeds LS9 7TF, UK.
192 K . R.Pate1 & A . P.Boon
Figure 1. FFJA of ovarian cyst. Papanicolaou stain. Original magnification x 400.
CYTOLOGY Eight ml of fluid including clot were received. The clot was fixed in 0.9% formalin for 12 h, embedded in paraffin wax and stained using haematoxylin and eosin. The remaining fluid was centrifuged (Cytospin 2 (Shandon Scientific) 1250 rev/min, 15Og, for 10 min) and slides prepared for staining by a Romanowsky technique and the Papanicolaou method. The clot contained degenerate cells, that were not suspicious of malignancy. Material from the cytospin preparations included loosely cohesive groups of cells, with some forming small round clusters (Figures 1 and 2). There was a background of erythrocytes. The nuclei were hyperchromatic but showed little pleomorphism. Mitotic figures and necrotic debris were not evident. The specimen was reported as suspicious of an epithelial malignancy. HISTOLOGY On the basis of these findings, the patient underwent a total hysterectomy and bilateral salpingo-oopherectomy. The gross specimen consisted of a fibroid uterus with normal appearing ovaries and fallopian tubes. Microscopy showed multifocal poorly differentiated adenocarcinoma diffusely infiltrating the cervix, myometrium and both ovaries. The walk of simple cysts were involved, with the pattern of infiltration showing a single file arrangement in places (Figure 3). Review of sections from the original mastectomy specimen showed a primary grade 3 ductal carcinoma with ipsilateral axillary lymph node involvement. Focally, the pattern
FNA cytology diagnosis of metastatic breast cancer
193
Figure 2. FNA of ovarian cyst. Haema-Gurr stain. Original magnification x 400.
resembled infiltrating lobular carcinoma with a prominent single file arrangement of tumour cells, virtually identical to that seen in the ovaries. DISCUSSION
Metastases to the ovary are not uncommon and are said to occur in 2 4 4 0 % of cases of disseminated breast carcinoma*. These tumours are usually incidental findings and rarely give rise to clinical problems. Involvement is usually bilateral with the ovaries containing multiple nodules of white tissue or completely replaced by a solid mass. Very infrequently the metastatic neoplasm is predominantly cystic. The use of fine needle aspiration cytology in the diagnosis and management of ovarian tumours remains controversial. Most authors agree that clinically benign cysts may be assessed and treated in this manner'*3.The high incidence of false negatives and the possibility of spillage of tumour into the peritoneal cavity generally precludes the use of this technique in the initial diagnosis of clinically malignant tumours3. There are relatively few large series reporting FNA of the ovaries in the English scientific literature"". We have identified two reports which mention cases of metastases to the ovary encountered during FNA cytology, although the possibility of this occurring is alluded to by most authors. Ramzy et al.' found two cases of metastaticcancer to the ovary out of a series of 77 ovarian tumour aspirates. One of these was a metastasis from a primary small cell carcinoma of the
194 K . R.Pate1 & A . P.Boon
Figure 3. Histology of the ovary showing strands of malignant cells resembling those in mastectomy specimen. Original magnification x 400.
lung whilst the other was a secondary deposit from a poorly differentiated adenocarcinoma of the breast. Angstrom6 mentions one Krukenberg tumour in his series of 155 cases. This case was one of six in which FNA produced blood or cyst fluid that was not diagnostic. This unusual presentation of metastasis to the ovary illustrates the importance of considering this diagnosis, when reporting on FNA of ovarian cysts. ACKNOWLEDGEMENT We wish to thank Mrs Eileen Hewer FIMLS for her technical assistance.
REFERENCES I Buckley CH. Is needle aspiration of ovarian cysts adequate for diagnosis? Br J Obst Gynaecol 1989; 96 1021-3. 2 Fox H. Metastatic tumours of the ovary. In: Fox H, ed. Haines and Taylor obstetrical and gynaecological pathology, 3rd edn. London: Churchill Livingstone, 1987: 714-23. 3 Nunez C. Cytopathology and fine-needle aspiration in ovarian tumours: its utility in diagnosis
and management. Curr Top Pathol 1989; 78: 69-83. 4 Ramzy I, Delaney M. Fine needle aspiration of ovarian masses. I. Correlative cytological and histological study of celomic epithelial neoplasms. Acta Cytol1979; 23: 97-104. 5 Ramzy I, Delaney M, Rose P. Fine needle aspiration of ovarian masses 11. Correlative cytological and histological study of non neoplastic cysts and non celomic epithelial neoplasms. Acta Cyrol 1979; 2 3 185-93.
FNA cytology diagnosis of metastatic breust cancer 6 Angstrom T. Fine needle aspiration biopsy in diagnosis and classification of ovarian tumours. In: DeWatterville H, ed. Diagnosis and treatment of ovarian neoplastic alterations. Basel: Excerpta Medica, 1975: 67-72. 7 Geier G, Kraus H, Schuhmann R. Fine needle aspiration biopsy in ovarian tumours. In: DeWatterville H, ed. Diagnosis and Treatment of Ovarian Neoplastic Alterations. Basel: Excerpta Medica, 1975: 73-6. 8 Kjellgren 0,Angstrom T, Bergman F, Wiklund D. Fine needle aspiration biopsy in diagnosis and
195
classification of ovarian carcinoma. Cancer 1971; 28: 967-76. 9 Kjellgren 0,Angstrom T. Transvaginal and transrectal aspiration biopsies in diagnosis and classification of ovarian carcinoma. In: Zajicek J, ed. Aspiration Biopsy Cytology. Part 2. Cytology of Infradiaphragmatic Organs. Basel: S Karger, 1979: 80-103. 10 Kjellgren 0, Angstrom T. Aspiration biopsy cytology of ovarian tumours. In: Blaustein A, ed. Pathology of the Female Genital Tract, 2nd edn. New York: Springer Verlag, 1982: 741-51.
PATEL K. R. AND BOON A. P.
(1992) Cytopathology 3,191-195
Metastatic breast cancer presenting as an ovarian cyst: diagnosis by fine needle aspiration cytology
A fifty-year-old woman with a history of breast cancer presented with a clinically benign ovarian cyst. Laparoscopic aspiration of cyst fluid was performed and the cytology was suspicious of epithelial neoplasia. At subsequent hysterectomy and bilateral salpingooopherectomy, the specimen showed extensive metastatic breast carcinoma. Although the cytological examination of fluid from ovarian cysts is often unrewarding, this case shows that metastatic carcinoma may occasionally be diagnosed in this fashion. Keywords: fine needle aspiration cytology, ovarian cysts, metastatic carcinoma, laparoscopic diagnosis
INTRODUCTION Although the diagnosis of ovarian cysts by aspiration cytology remains controversial, there is an increasing tendency to manage small cysts by laparoscopic aspiration’. We report an unusual, and possibly unique case of metastatic breast carcinoma discovered in this manner. CASE R E P O R T
A 50-year-old woman presented to the accident and emergency department complaining of severe pain and tenderness in the right iliac fossa. Significant past medical history included an extended left mastectomy for breast cancer 9 months previously and an appendicectomy at the age of 25. Vaginal examination revealed a mass in the right adnexa. Ultrasound examination showed a 3.8cm diameter cyst in her right ovary. The left ovary and the uterus appeared normal. Subsequent laparoscopic examination confirmed these findings and fluid was aspirated peroperatively and submitted for cytology. Correspondence: Dr A. P. Boon, Departments of Histopathology and Cytopathology. St James’s University Hospital, Beckett Street, Leeds LS9 7TF, UK.
192 K . R.Pate1 & A . P.Boon
Figure 1. FFJA of ovarian cyst. Papanicolaou stain. Original magnification x 400.
CYTOLOGY Eight ml of fluid including clot were received. The clot was fixed in 0.9% formalin for 12 h, embedded in paraffin wax and stained using haematoxylin and eosin. The remaining fluid was centrifuged (Cytospin 2 (Shandon Scientific) 1250 rev/min, 15Og, for 10 min) and slides prepared for staining by a Romanowsky technique and the Papanicolaou method. The clot contained degenerate cells, that were not suspicious of malignancy. Material from the cytospin preparations included loosely cohesive groups of cells, with some forming small round clusters (Figures 1 and 2). There was a background of erythrocytes. The nuclei were hyperchromatic but showed little pleomorphism. Mitotic figures and necrotic debris were not evident. The specimen was reported as suspicious of an epithelial malignancy. HISTOLOGY On the basis of these findings, the patient underwent a total hysterectomy and bilateral salpingo-oopherectomy. The gross specimen consisted of a fibroid uterus with normal appearing ovaries and fallopian tubes. Microscopy showed multifocal poorly differentiated adenocarcinoma diffusely infiltrating the cervix, myometrium and both ovaries. The walk of simple cysts were involved, with the pattern of infiltration showing a single file arrangement in places (Figure 3). Review of sections from the original mastectomy specimen showed a primary grade 3 ductal carcinoma with ipsilateral axillary lymph node involvement. Focally, the pattern
FNA cytology diagnosis of metastatic breast cancer
193
Figure 2. FNA of ovarian cyst. Haema-Gurr stain. Original magnification x 400.
resembled infiltrating lobular carcinoma with a prominent single file arrangement of tumour cells, virtually identical to that seen in the ovaries. DISCUSSION
Metastases to the ovary are not uncommon and are said to occur in 2 4 4 0 % of cases of disseminated breast carcinoma*. These tumours are usually incidental findings and rarely give rise to clinical problems. Involvement is usually bilateral with the ovaries containing multiple nodules of white tissue or completely replaced by a solid mass. Very infrequently the metastatic neoplasm is predominantly cystic. The use of fine needle aspiration cytology in the diagnosis and management of ovarian tumours remains controversial. Most authors agree that clinically benign cysts may be assessed and treated in this manner'*3.The high incidence of false negatives and the possibility of spillage of tumour into the peritoneal cavity generally precludes the use of this technique in the initial diagnosis of clinically malignant tumours3. There are relatively few large series reporting FNA of the ovaries in the English scientific literature"". We have identified two reports which mention cases of metastases to the ovary encountered during FNA cytology, although the possibility of this occurring is alluded to by most authors. Ramzy et al.' found two cases of metastaticcancer to the ovary out of a series of 77 ovarian tumour aspirates. One of these was a metastasis from a primary small cell carcinoma of the
194 K . R.Pate1 & A . P.Boon
Figure 3. Histology of the ovary showing strands of malignant cells resembling those in mastectomy specimen. Original magnification x 400.
lung whilst the other was a secondary deposit from a poorly differentiated adenocarcinoma of the breast. Angstrom6 mentions one Krukenberg tumour in his series of 155 cases. This case was one of six in which FNA produced blood or cyst fluid that was not diagnostic. This unusual presentation of metastasis to the ovary illustrates the importance of considering this diagnosis, when reporting on FNA of ovarian cysts. ACKNOWLEDGEMENT We wish to thank Mrs Eileen Hewer FIMLS for her technical assistance.
REFERENCES I Buckley CH. Is needle aspiration of ovarian cysts adequate for diagnosis? Br J Obst Gynaecol 1989; 96 1021-3. 2 Fox H. Metastatic tumours of the ovary. In: Fox H, ed. Haines and Taylor obstetrical and gynaecological pathology, 3rd edn. London: Churchill Livingstone, 1987: 714-23. 3 Nunez C. Cytopathology and fine-needle aspiration in ovarian tumours: its utility in diagnosis
and management. Curr Top Pathol 1989; 78: 69-83. 4 Ramzy I, Delaney M. Fine needle aspiration of ovarian masses. I. Correlative cytological and histological study of celomic epithelial neoplasms. Acta Cytol1979; 23: 97-104. 5 Ramzy I, Delaney M, Rose P. Fine needle aspiration of ovarian masses 11. Correlative cytological and histological study of non neoplastic cysts and non celomic epithelial neoplasms. Acta Cyrol 1979; 2 3 185-93.
FNA cytology diagnosis of metastatic breust cancer 6 Angstrom T. Fine needle aspiration biopsy in diagnosis and classification of ovarian tumours. In: DeWatterville H, ed. Diagnosis and treatment of ovarian neoplastic alterations. Basel: Excerpta Medica, 1975: 67-72. 7 Geier G, Kraus H, Schuhmann R. Fine needle aspiration biopsy in ovarian tumours. In: DeWatterville H, ed. Diagnosis and Treatment of Ovarian Neoplastic Alterations. Basel: Excerpta Medica, 1975: 73-6. 8 Kjellgren 0,Angstrom T, Bergman F, Wiklund D. Fine needle aspiration biopsy in diagnosis and
195
classification of ovarian carcinoma. Cancer 1971; 28: 967-76. 9 Kjellgren 0,Angstrom T. Transvaginal and transrectal aspiration biopsies in diagnosis and classification of ovarian carcinoma. In: Zajicek J, ed. Aspiration Biopsy Cytology. Part 2. Cytology of Infradiaphragmatic Organs. Basel: S Karger, 1979: 80-103. 10 Kjellgren 0, Angstrom T. Aspiration biopsy cytology of ovarian tumours. In: Blaustein A, ed. Pathology of the Female Genital Tract, 2nd edn. New York: Springer Verlag, 1982: 741-51.
