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Original Report |
1
Department of Radiology, Columbia University, College of Physicians and
Surgeons at the New York Presbyterian Hospital, 161 Fort Washington Ave., AP
10, New York, NY 10032.
2
Present address: Department of Radiology, Beth Israel Medical Center, 10 Union
Square E., Ste. 4L, New York, NY 10003.
3
Columbia University, College of Physicians and Surgeons, 630 W. 168th St., New
York, NY 10032.
Received September 14, 2000;
accepted after revision November 7, 2000.
Address correspondence to C. Singer.
Abstract
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CONCLUSION. Axillary lymph node calcification may be identified mammographically in patients with metastatic ovarian carcinoma and may be evidence of unsuspected metastatic disease. The pattern of calcification differs from that seen with metastatic breast carcinoma.
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Patients ranged in age from 46 to 68 years. All three had previously undergone total hysterectomy and bilateral salpingo-oophorectomy, which revealed ovarian carcinoma in two patients.
One patient had a history of bilateral ovarian papillary serous tumors with psammoma bodies, believed to be of low malignant potential, 15 years before her current presentation. This patient also had a previous lumpectomy of the right breast for a 7-mm invasive ductal carcinoma and ductal carcinoma in situ, solid type, performed 5 years before her current presentation. Right axillary lymph node dissection at that time revealed no evidence of metastatic breast carcinoma. Two years before her current presentation, the patient presented with ascites, and paracentesis revealed adenocarcinoma with calcifications suggestive of psammoma bodies. At current presentation, a calcified left axillary lymph node was detected mammographically.
The time interval from initial surgery to current presentation ranged from 4 to 15 years. All three patients had received systemic chemotherapy.
In one patient, mammography was requested to examine a palpable axillary lymph node. In the other two patients, mammography was performed as a screening study; one of these patients was thought to be free of metastatic disease at the time of mammography.
Standard mammography of both breasts was performed in all patients, with additional magnification images of the axilla performed in one patient. Sonography of the axilla was also performed in two patients, with either a 7.5-MHz or variable frequency 5- to 13-MHz transducer (Sonoline Versa or Elegra; Siemens Medical Systems, Iselin, NJ).
Pathologic diagnosis was made by surgical excision of a palpable axillary lymph node in one patient and by sonographically guided percutaneous vacuum-assisted 11-gauge needle biopsy of the axillary lymph nodes in two patients.
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Sonography of the axillary lymph nodes was performed in two patients. This revealed abnormal foci of increased echogenicity, thought to represent calcifications (Figs. 2A,2B,2C,2D,3A,3B,3C,3D). Loss of normal reniform shape was also noted in both patients. Associated shadowing was identified in one patient.
In all three patients, pathologic evaluation revealed papillary carcinoma with psammomatous calcification consistent with metastatic ovarian carcinoma.
Immunohistochemical stains, performed in one patient who also had a prior history of contralateral breast carcinoma, were positive for estrogen receptor and cytokeratin and negative for progesterone receptor, gross cystic disease fluid protein-15 (GCDFP-15), and thyroglobulin [3].
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Malignant axillary nodal calcifications may be identified radiographically in patients with metastatic breast carcinoma and are reported to be of the same type as the primary tumor [1]. Pleomorphic malignant-appearing axillary nodal calcifications due to metastatic breast carcinoma may be seen, however, in the absence of suspicious micro-calcifications in the breast [6, 7].
Malignant axillary lymph node calcifications due to metastases from extramammary primary carcinoma are extremely rare. Walsh et al. [6] reviewed 76 cases of abnormal axillary adenopathy, which included three patients with extramammary breast carcinoma and three patients with unknown primary carcinoma. All had unilateral adenopathy. None, however, had axillary nodal calcification identified mammographically.
To our knowledge, only one case report describes the mammographic appearance of axillary lymph node calcification due to metastases from extramammary primary carcinoma. Chen et al. [2] reported a case of psammomatous calcification in an axillary lymph node due to metastatic papillary carcinoma, presumed to be of thyroid origin. Mammographically, they described a well-circumscribed lymph node containing dense granular calcifications. On a prior mammogram, 3 years earlier, faint amorphous calcifications were noted. Pathologically, metastatic papillary carcinoma was identified with psammomatous calcification.
In all three of our patients, axillary lymph node calcifications were amorphous, with many calcifications in a peripheral distribution (Figs. 1A,1B,2A,2B,2C,2D,3A,3B,3C,3D). This appearance differs from the pleomorphic malignant-appearing calcifications that may be seen in axillary lymph nodes with metastatic breast carcinoma (Fig. 4).
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This distinctive mammographic pattern of calcification may relate to the pathologic finding of psammoma body formation, which was present in all three patients. Histologic calcification in the form of psammoma bodies is present in the primary tumor in 35% of cases of serous adenocarcinoma of the ovary [8]. Ovarian metastases to the breast may present with nodules, sometimes calcified because of psammoma bodies.
Supradiaphragmatic calcified lymph nodes due to metastatic ovarian carcinoma have previously been reported, appearing as densely calcified nodes on CT, in mediastinal, hilar, costophrenic angles, and supraclavicular locations [8, 9]. The detection of calcification in the nodes may occur years after complete remission of abdominal-pelvic disease and may be the only clue to relapsing disease [8], as was the case in one of our patients.
Axillary lymph nodes are an uncommon site for spread of ovarian carcinoma [10]. Axillary metastases due to ovarian carcinoma are usually seen in conjunction with metastatic disease to the breast but rarely may be seen without breast involvement [11]. None of our three patients had mammographic evidence of metastatic disease to the breast.
All three of our patients had received systemic chemotherapy. It is uncertain what effect, if any, this may have on the propensity for metastatic disease to the axilla to calcify.
One of our patients had a history of breast carcinoma before the subsequent development of contralateral calcified axillary adenopathy. However, on the basis of histopathologic differences between the patient's prior breast carcinoma and the subsequent contralateral axillary metastases, as well as the clinical history, the pathologic findings were attributed to metastatic ovarian carcinoma.
In conclusion, although an uncommon occurrence, metastatic ovarian carcinoma may be a cause of axillary lymph node calcification detected on mammography. These amorphous calcifications may be distributed peripherally and observed either unilaterally or bilaterally. The mammographic appearance of these calcifications differs from the pleomorphic malignant-appearing calcifications described with axillary metastases from primary breast carcinoma. This appearance is suspicious for metastatic disease and may be the sole radiographic indicator of metastatic disease in a patient believed to be otherwise disease-free.
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This article has been cited by other articles:
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  M. M. Honegger, S. M. Hesseltine, J. D. Gross, C. Singer, and J.-M. Cohen Tattoo Pigment Mimicking Axillary Lymph Node Calcifications on Mammography Am. J. Roentgenol., September 1, 2004; 183(3): 831 - 832. [Full Text] [PDF]
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R. A. Cooper and C. Singer Calcified Ovarian Metastases Am. J. Roentgenol., January 1, 2002; 178(1): 243 - 243. [Full Text] [PDF]
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