AJR 2005; 184:S53-S55
© American Roentgen Ray Society
Metastatic Choriocarcinoma to the Breast: Appearance on Mammography and Doppler Sonography
Naveen Kalra1,
Vijayanadh Ojili1,
Madhu Gulati1,
G. R. V. Prasad2,
Kim Vaiphei3 and
Sudha Suri1
1 Department of Radiodiagnosis, Postgraduate Institute of Medical Education and
Research, PGIMER, Sector 12, Chandigarh 160012, India.
2 Department of Obstetrics and Gynaecology, Postgraduate Institute of Medical
Education and Research, Chandigarh 160012, India.
3 Department of Histopathology, Postgraduate Institute of Medical Education and
Research, Chandigarh 160012, India.
Received March 17, 2004;
accepted after revision May 10, 2004.
Address correspondence to N. Kalra.
Introduction
Metastases to the breast are uncommon, and there are few reports of
the radiologic features of metastatic malignant tumors of the breast
[1]. Choriocarcinoma is a rare
extramammary source of breast metastases
[2,
3]. In this case report, we
describe the mammographic and color Doppler appearances of metastatic
choriocarcinoma to the breast that have not been previously described, to our
knowledge, in the literature.
Case Report
A 27-year-old woman presented with a slow-growing, painless lump in the
right breast that had been present for the past 2 months. Her case was
diagnosed as choriocarcinoma that had developed after a molar pregnancy. She
had been receiving systemic chemotherapy for the past year. Physical
examination showed an emaciated young woman with normal vital signs. Breast
palpation revealed a solitary, firm, nontender lump in the lower inner
quadrant of the right breast without any nipple retraction. The HCG beta
subunit was markedly increased. Chest radiographs showed normal findings.
Sonography of the abdomen and pelvis was unremarkable except for small
theca-lutein cysts in both ovaries.
Mammography revealed a large (6.5 x 6.0 x 5.0 cm) solitary,
well-circumscribed lobulated mass located in the lower inner quadrant of the
right breast. There was no spiculation, calcification, nipple retraction, or
skin thickening (Figs. 1A and
1B). Microcalcifications and
architectural distortion were also absent. In view of the fact that the
patient was a diagnosed case of choriocarcinoma, the possibility of this
lesion being a metastasis was considered. However, benign breast lesions such
as giant fibroadenomas could have a similar mammographic appearance. The
patient was further evaluated on sonography and color Doppler sonography to
assess the vascularity of the lesion and to better characterize the
lesion.
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Fig. 1A. —27-year-old woman who presented with a slow-growing, painless
lump in right breast. Mammograms of right breast, craniocaudal (A) and
oblique (B) views, show large (6.5 x 6.0 x 5.0 cm)
well-defined, lobulated, high-density mass in lower inner quadrant of breast.
No focus of calcification or surrounding architectural distortion is
present.
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Fig. 1B. —27-year-old woman who presented with a slow-growing, painless
lump in right breast. Mammograms of right breast, craniocaudal (A) and
oblique (B) views, show large (6.5 x 6.0 x 5.0 cm)
well-defined, lobulated, high-density mass in lower inner quadrant of breast.
No focus of calcification or surrounding architectural distortion is
present.
|
|
Sonography revealed a well-defined, lobulated hypoechoic solid mass without
distortion of the surrounding fibroglandular architecture of the breast
(Fig. 1C). Color Doppler and
power Doppler sonography revealed the presence of both central and peripheral
vascularity and numerous penetrating vessels
(Fig. 1D). The spectral trace
of these vessels showed a high-impedance pulsatile signal with a sudden drop
in systolic flow and no flow in diastole
(Fig. 1E). This flow pattern is
suggestive of a malignant lesion. From the correlation of the clinical,
mammographic, and Doppler findings, a radiologic diagnosis of metastatic
choriocarcinoma was given.
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Fig. 1C. —27-year-old woman who presented with a slow-growing, painless
lump in right breast. Sonogram of right breast shows well-defined, lobulated,
hypoechoic solid mass. No posterior acoustic shadowing or calcification is
seen within mass.
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The patient underwent fine-needle aspiration cytology and biopsy that
revealed numerous malignant mononuclear cells and multinucleated giant cells.
Immunostaining for HCG antibody was also positive, confirming the diagnosis of
metastatic choriocarcinoma (Figs.
1F and
1G).
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Fig. 1F. —27-year-old woman who presented with a slow-growing, painless
lump in right breast. Photomicrograph of breast tumor shows two types of
cells—that is, mononuclear and multinuclear cells with abundant
cytoplasm and prominent nucleoli. (H and E, x240)
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Fig. 1G. —27-year-old woman who presented with a slow-growing, painless
lump in right breast. Photomicrograph shows positivity for HCG antibody, seen
as brownish discoloration of cytoplasm. (peroxidase-antiperoxidase,
x450)
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Discussion
The breast is an uncommon site for metastatic disease from extramammary
neoplasms [1]. The incidence in
various series ranges from 0.5% to 6.6% of all breast malignancies
[4]. These conflicting data are
explained by the inclusion or exclusion of patients with leukemia and those
with lymphoma in different series. According to a recent review of the
literature, the most common primary tumor sources for breast metastases in
order of decreasing frequency are lymphomas, melanomas, rhabdomyosarcomas,
lung tumors, and ovarian tumors
[4].
Metastatic choriocarcinoma to the breast is distinctly unusual and has been
described in a few isolated case reports
[2,
3]. Even in these cases, the
imaging findings have not been reported. Our case suggests that mammographic
findings together with color Doppler findings of a breast lesion may help to
diagnose breast metastasis prospectively.
Mammography is performed in patients with known malignancy presenting with
a breast lump to reinforce the clinical suspicion of metastasis in the breast
and rule out primary breast carcinoma
[4]. The most common
mammographic appearances of breast metastasis are of one or more
well-circumscribed masses that are located in the upper outer quadrant without
spiculation, calcifications, or architectural distortion, which characterize
most primary carcinomas [4].
However, benign lesions such as fibroadenoma can have a similar appearance on
mammography [5].
A variety of sonography findings have been reported in patients with breast
metastases. Characteristic lesions are rounded or oval with low echogenicity
and a well-defined posterior wall
[4]. Color Doppler findings in
patients with breast metastases have been described only rarely in the
literature [6]. In our index
case, we found both peripheral and central vascular channels that showed
high-impedance flow. These findings are similar to those described earlier for
differentiating between malignant and benign solid breast masses
[7,
8].
Malignant tumors stimulate the growth of blood vessels (neovascularization)
by releasing a substance known as angiogenesis factor. Because color Doppler
sonography can detect neovascularization, it has the potential to distinguish
benign from malignant lesions. A low-impedance pulsatile pattern can be seen
in both benign and malignant breast lesions, whereas a turbulent
high-impedance pulsatile pattern and venous signals are significantly more
likely to be seen in malignant lesions
[7,
8]. Thus, spectral patterns on
Doppler analysis are useful indicators of breast malignancy, but radiologists
should also take into account the patient's age, the size of the lesion, and
the sonographic morphology. The best use of color-flow imaging is in
combination with mammography
[8].
In conclusion, our case clearly illustrates the utility of evaluating
mammography together with color Doppler sonography findings in the diagnosis
of metastasis to the breast. Our patient's history and this single lesion with
suspicious sonographic features led us to the prebiopsy diagnosis of
metastatic choriocarcinoma. When a breast lesion in a patient with a known
primary lesion shows intralesional vascularity with high-impedance flow, the
diagnosis of metastasis can be made. However, additional studies are needed to
consolidate this hypothesis.
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Introduction
Case Report
