Gastrointest Radiol 16:80-82 (1991)
Gastrointestinal
Radiology 9 Springer-VerlagNewYorkInc.1991
Pseudomyxoma Peritonei from Metastatic Colloid Carcinoma of the Breast Donald Hawes, 1 Robert Robinson, 2 and Raymund Wira 1 Departments of 1Radiology and 2 Pathology, The University of Iowa College of Medicine, Iowa City, Iowa, USA
Abstract. Cystic lesions involving the peritoneum and/or mesentery are uncommon. We present a case of metastatic mucinous adenocarcinoma of the breast to the peritoneum, a new entity to be added to the list of diagnoses that may present with this appearance. Key words: Pseudomyxoma peritonei, breast - Colloid carcinoma.
The increasing use of computed tomography (CT), ultrasound (US), and magnetic resonance in abdominal imaging has led to the more frequent premortem identification of cystic lesions involving the peritoneum and/or mesentery. Differential considerations are many [1] but can be somewhat focused by the imaging appearance and clinical presentation. We present an unusual entity with this cystic appearance: peritoneal metastasis from a primary breast malignancy. Case Report A 72-year-old woman presented for control of diabetes mellitis. She denied problems related to the abdomen but was noted to be somewhat stoic. Physical examination revealed a hard, 3-cm mass in the left breast just deep to the nipple. Abdominal examination revealed a poorly defined midabdominal mass, normal bowel sounds, and no organomegaly. Pelvic examination indicated a right adnexal mass. Under local anesthesia an excisional biopsy of the left breast mass was performed revealing a colloid carcinoma (Fig. 1 A). On the edges of the invasive, mucinous component w e r e a r e a s of ductal carcinoma in situ composed of cribriform glands. Except for the extensive mucin production, the cribriAddress offprint requests to : Donald Hawes, M.D., Department of Radiology, The University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
form spaces appeared identical to ordinary cribriform intraductal carcinoma. Abdominal US showed cholelithiasis, ascites (Fig. 2A), and a cystic right adnexal mass (Fig. 2 B). An abdominal CT study showed the midabdominal fluid collection (Fig. 3 A) to be a distinct mass with a different density than that of the adnexal mass (Fig. 3 B). No ascites was found, and there was no evidence of adenopathy or other indications of metastatic disease. A CT-guided aspirate of the midabdominal mass was mucoid with cellular characteristics (Fig. 1 B), virtually identical to the breast lesion. The patient underwent pelvic exploration, and the adnexal mass was removed. Pathologic evaluation revealed a serous cystadenocarcinoma of the ovary with distinctly different cellular characteristics (Fig. 4) from the breast and midabdominal lesions (i.e., there was no evidence of signet ring cells or mucin production). The ovarian tumor was classified as borderline, since there was no invasion into the stroma. Pelvic exploration revealed no other ovarian lesions, and adnexal biopsies showed no evidence of mucinous neoplasm.
Discussion Mucinous carcinomas constitute 1-6% of primary breast malignancies [2, 3]. The presence of distant metastases at the time of original diagnosis is rare, but more common in the advanced age group of our patient. The clinical presentation and initial imaging studies in our patient suggested separate primary malignancies of the breast and ovary, with pseudomyxoma peritonei as a result of metastasis from the ovarian tumor. The surgical specimens and peritoneal aspirate demonstrated the following: that the cystic lesion in the ovary was unrelated to the peritoneal lesion, that the cellularity of the breast and peritoneal lesions was identical, and that the breast lesion represented a primary malignancy. Spread of mucinous breast carcinoma is usually by direct extension or via lymphangitic pathways; hematogenous spread has been rarely reported. We are unaware of any report of peritoneal or mesenteric metastasis [2-4]. Reports of metastasis to the
D. Hawes et al. : Metastatic Colloid Carcinoma of the Breast
Fig. 1. A Photomicrograph of the breast tumor. Note mucin (M) between the carcinoma cells. Original magnification, x 400. B Photomicrograph of the aspirate from the peritoneal lesion. Note the clusters of adenocarcinoma cells with mucin vacuoles (arrows). The nucleus is distorted and pushed to one side by the large vacuoles of mucinous material. Original magnification, x 460. Fig. 2. A Real-time sector scan reveals a large, midabdominal anechoic mass with a well-defined posterior wall and good through-transmission. No abnormal bowel can be seen. B Realtime sector scan in the pelvis shows a 5.5 x 7.5 em hypoechoic mass with excellent sound transmission and a clear posterior wall. Both were thought to be cystic.
81
Fig. 3. A Contrast CT shows the midabdominal mass, which is irregular in shape and contiguous with the bowel, without obvious invasion. The mass appears to have a thin enhancing rim suggestive of a neoplastic or inflammatory capsule. The density of the internal material (18 HU) is less than that of the pelvic mass. There is no evidence of bowel obstruction, adenopathy, or other intraabdominal fatty infiltrates. B In the pelvis, a well-defined, 6-cm, water-density (36 HU) mass with a thin enhancing rim is shown (arrow). Fig. 4. Photomicrograph of the cystic pelvic mass. Note the papillary structure (P) covered by a single layer of cytologically bland cuboidal to columnar serous-type epithelial cells. Psammorea bodies are present (arrows). Original magnification, x 360.
82
breast from an ovarian primary are rare and do not include a case of mucinous cell type [5, 6]. CT characteristics of the midabdominal lesion indicated a cystic mass enveloping but not obstructing the bowel. This appearance is most commonly seen with pseudomyxoma peritonei secondary to mucin-producing malignancies of the appendix, ovary, and endometrium, or rarely pancreas, bowel, or urachus. Other lesions of the peritoneum that may present with a cystic appearance on abdominal imaging, include cystic peritoneal mesothelioma, endometrioma, mesenteric cysts, duplication cysts of the bowel, pancreatic pseudocysts, plexiform neurofibromatosis [7], intraabdominal panniculitis, loculated benign or malignant ascites, posttraumatic seromas, intraabdominal desmoid tumors, and abscesses [1, 8, 9]. Clinical presentation and imaging characteristics will help focus these differential considerations. Diagnosis, however, often requires aspiration and/or biopsy.
D. Hawes et al. : Metastatic Colloid Carcinoma of the Breast Gastrointestinal Tract: Including the Peritoneal Cavity and Mesentery. New York: Springer-Verlag, 1986, pp 139-220 2. Clayton F: Pure mucinous carcinomas of breast: Morphologic features and prognostic correlates. Hum Pathol 17:34--38, 1986 3, Komaki K, Sakamoto G, Sugano H, Morimoto T, Monden Y: Mucinous carcinoma of the breast in Japan. Cancer 61:989-996, 1988 4. Royen PM, Ziter FMH: Ovarian carcinoma metastatic to the breast. Br J Radio147: 356-357, 1986 5. Paulus DD, Libshitz HI: Metastasis to the breast. Radiol Clin North Am 20: 561-568, 1982 6. Toombs BD, Kalisher L: Metastatic disease to the breast: Clinical, pathologic, and radiographic features. A JR 129: 673-676, 1977 7. Mirich DR, Gray RR, Grosman: Abdominal plexiform neurofibromatosis simulating pseudomyxoma peritonei on computed tomography. J Comput Assist Tomogr 13:709-711, 1989 8. Seshul MB, Coulam CM: Pseudomyxoma peritonei: Computed tomography and sonography. A JR 136: 803-806, 1981 9. Yeh H, Shafir MK, Slater G, Meyer RJ, Cohen BA, Geller SA: Ultrasonography and computed tomography in pseudomyxoma peritonei. Radiology 153:507-510, 1984
References 1. Whitley NO : Mesenterie disease. Intraperitoneal fluid collections. In Meyers MA (ed): Computed Tomography of the
Received: February 12, 1990; accepted: February 27, 1990
Gastrointestinal
Radiology 9 Springer-VerlagNewYorkInc.1991
Pseudomyxoma Peritonei from Metastatic Colloid Carcinoma of the Breast Donald Hawes, 1 Robert Robinson, 2 and Raymund Wira 1 Departments of 1Radiology and 2 Pathology, The University of Iowa College of Medicine, Iowa City, Iowa, USA
Abstract. Cystic lesions involving the peritoneum and/or mesentery are uncommon. We present a case of metastatic mucinous adenocarcinoma of the breast to the peritoneum, a new entity to be added to the list of diagnoses that may present with this appearance. Key words: Pseudomyxoma peritonei, breast - Colloid carcinoma.
The increasing use of computed tomography (CT), ultrasound (US), and magnetic resonance in abdominal imaging has led to the more frequent premortem identification of cystic lesions involving the peritoneum and/or mesentery. Differential considerations are many [1] but can be somewhat focused by the imaging appearance and clinical presentation. We present an unusual entity with this cystic appearance: peritoneal metastasis from a primary breast malignancy. Case Report A 72-year-old woman presented for control of diabetes mellitis. She denied problems related to the abdomen but was noted to be somewhat stoic. Physical examination revealed a hard, 3-cm mass in the left breast just deep to the nipple. Abdominal examination revealed a poorly defined midabdominal mass, normal bowel sounds, and no organomegaly. Pelvic examination indicated a right adnexal mass. Under local anesthesia an excisional biopsy of the left breast mass was performed revealing a colloid carcinoma (Fig. 1 A). On the edges of the invasive, mucinous component w e r e a r e a s of ductal carcinoma in situ composed of cribriform glands. Except for the extensive mucin production, the cribriAddress offprint requests to : Donald Hawes, M.D., Department of Radiology, The University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
form spaces appeared identical to ordinary cribriform intraductal carcinoma. Abdominal US showed cholelithiasis, ascites (Fig. 2A), and a cystic right adnexal mass (Fig. 2 B). An abdominal CT study showed the midabdominal fluid collection (Fig. 3 A) to be a distinct mass with a different density than that of the adnexal mass (Fig. 3 B). No ascites was found, and there was no evidence of adenopathy or other indications of metastatic disease. A CT-guided aspirate of the midabdominal mass was mucoid with cellular characteristics (Fig. 1 B), virtually identical to the breast lesion. The patient underwent pelvic exploration, and the adnexal mass was removed. Pathologic evaluation revealed a serous cystadenocarcinoma of the ovary with distinctly different cellular characteristics (Fig. 4) from the breast and midabdominal lesions (i.e., there was no evidence of signet ring cells or mucin production). The ovarian tumor was classified as borderline, since there was no invasion into the stroma. Pelvic exploration revealed no other ovarian lesions, and adnexal biopsies showed no evidence of mucinous neoplasm.
Discussion Mucinous carcinomas constitute 1-6% of primary breast malignancies [2, 3]. The presence of distant metastases at the time of original diagnosis is rare, but more common in the advanced age group of our patient. The clinical presentation and initial imaging studies in our patient suggested separate primary malignancies of the breast and ovary, with pseudomyxoma peritonei as a result of metastasis from the ovarian tumor. The surgical specimens and peritoneal aspirate demonstrated the following: that the cystic lesion in the ovary was unrelated to the peritoneal lesion, that the cellularity of the breast and peritoneal lesions was identical, and that the breast lesion represented a primary malignancy. Spread of mucinous breast carcinoma is usually by direct extension or via lymphangitic pathways; hematogenous spread has been rarely reported. We are unaware of any report of peritoneal or mesenteric metastasis [2-4]. Reports of metastasis to the
D. Hawes et al. : Metastatic Colloid Carcinoma of the Breast
Fig. 1. A Photomicrograph of the breast tumor. Note mucin (M) between the carcinoma cells. Original magnification, x 400. B Photomicrograph of the aspirate from the peritoneal lesion. Note the clusters of adenocarcinoma cells with mucin vacuoles (arrows). The nucleus is distorted and pushed to one side by the large vacuoles of mucinous material. Original magnification, x 460. Fig. 2. A Real-time sector scan reveals a large, midabdominal anechoic mass with a well-defined posterior wall and good through-transmission. No abnormal bowel can be seen. B Realtime sector scan in the pelvis shows a 5.5 x 7.5 em hypoechoic mass with excellent sound transmission and a clear posterior wall. Both were thought to be cystic.
81
Fig. 3. A Contrast CT shows the midabdominal mass, which is irregular in shape and contiguous with the bowel, without obvious invasion. The mass appears to have a thin enhancing rim suggestive of a neoplastic or inflammatory capsule. The density of the internal material (18 HU) is less than that of the pelvic mass. There is no evidence of bowel obstruction, adenopathy, or other intraabdominal fatty infiltrates. B In the pelvis, a well-defined, 6-cm, water-density (36 HU) mass with a thin enhancing rim is shown (arrow). Fig. 4. Photomicrograph of the cystic pelvic mass. Note the papillary structure (P) covered by a single layer of cytologically bland cuboidal to columnar serous-type epithelial cells. Psammorea bodies are present (arrows). Original magnification, x 360.
82
breast from an ovarian primary are rare and do not include a case of mucinous cell type [5, 6]. CT characteristics of the midabdominal lesion indicated a cystic mass enveloping but not obstructing the bowel. This appearance is most commonly seen with pseudomyxoma peritonei secondary to mucin-producing malignancies of the appendix, ovary, and endometrium, or rarely pancreas, bowel, or urachus. Other lesions of the peritoneum that may present with a cystic appearance on abdominal imaging, include cystic peritoneal mesothelioma, endometrioma, mesenteric cysts, duplication cysts of the bowel, pancreatic pseudocysts, plexiform neurofibromatosis [7], intraabdominal panniculitis, loculated benign or malignant ascites, posttraumatic seromas, intraabdominal desmoid tumors, and abscesses [1, 8, 9]. Clinical presentation and imaging characteristics will help focus these differential considerations. Diagnosis, however, often requires aspiration and/or biopsy.
D. Hawes et al. : Metastatic Colloid Carcinoma of the Breast Gastrointestinal Tract: Including the Peritoneal Cavity and Mesentery. New York: Springer-Verlag, 1986, pp 139-220 2. Clayton F: Pure mucinous carcinomas of breast: Morphologic features and prognostic correlates. Hum Pathol 17:34--38, 1986 3, Komaki K, Sakamoto G, Sugano H, Morimoto T, Monden Y: Mucinous carcinoma of the breast in Japan. Cancer 61:989-996, 1988 4. Royen PM, Ziter FMH: Ovarian carcinoma metastatic to the breast. Br J Radio147: 356-357, 1986 5. Paulus DD, Libshitz HI: Metastasis to the breast. Radiol Clin North Am 20: 561-568, 1982 6. Toombs BD, Kalisher L: Metastatic disease to the breast: Clinical, pathologic, and radiographic features. A JR 129: 673-676, 1977 7. Mirich DR, Gray RR, Grosman: Abdominal plexiform neurofibromatosis simulating pseudomyxoma peritonei on computed tomography. J Comput Assist Tomogr 13:709-711, 1989 8. Seshul MB, Coulam CM: Pseudomyxoma peritonei: Computed tomography and sonography. A JR 136: 803-806, 1981 9. Yeh H, Shafir MK, Slater G, Meyer RJ, Cohen BA, Geller SA: Ultrasonography and computed tomography in pseudomyxoma peritonei. Radiology 153:507-510, 1984
References 1. Whitley NO : Mesenterie disease. Intraperitoneal fluid collections. In Meyers MA (ed): Computed Tomography of the
Received: February 12, 1990; accepted: February 27, 1990
