AJR 2005; 184:1279-1281
© American Roentgen Ray Society
Mammography and Sonography of Pathologically Proven Adrenal Cortical Carcinoma Metastatic to the Breast
Christopher François,
Bhanumathi Rangachari and
Davide Bova
Department of Radiology, Loyola University Medical Center, 2160 S First
Ave., Maywood, IL 60153.
Received May 26, 2004;
accepted after revision July 19, 2004.
Address correspondence to C. J. François
(cfrancois{at}lumc.edu).
Introduction
Metastasis to the breast is uncommon and may present as a solitary
lesion or multiple lesions [1,
2]. The most common primary
neoplasms to metastasize to the breast are those from melanoma, sarcoma, and
tumors of the lung and ovary. Leukemia and lymphoma can also involve the
breast [1,
2]. Adrenal cortical carcinoma
is a rare malignancy with a poor prognosis
[3]. The most common sites of
metastases in adrenal cortical carcinoma are liver, lung, bone, and lymph
nodes
[4-7].
Metastases to other sites, such as the spleen, pancreas, contralateral kidney,
and brain, occur much less commonly. Metastasis to the breast has been
reported once before [8].
However, imaging characteristics of this lesion were not reported. We report
the mammographic and sonographic findings of a pathologically proven adrenal
cortical carcinoma metastatic to the breast.
Case Report
A 56-year-old woman was referred for diagnostic mammography and sonography
because of a new palpable nodule in the lower outer quadrant of the left
breast. Approximately 8 months earlier the patient had undergone left radical
nephrectomy and adrenalectomy for high-grade adrenal cortical carcinoma.
Craniocaudal and mediolateral oblique views of the left breast and spot
compression views of the palpable abnormality were obtained (Figs.
1A,
1B,
1C,
1D). A dense,
well-circumscribed, oval mass was identified in the posterior aspect of the
far lateral, inferior breast. A few pleomorphic calcifications were present in
the center of this lesion. Sonography of this lesion showed a
well-circumscribed, macrolobulated, heterogeneous mass
(Fig. 1E). Color Doppler
sonography revealed vascularity within and along the periphery of the mass
(Fig. 1F). Spectral Doppler
sonography was not performed. No significant posterior acoustic shadowing or
enhancement was seen. Although this lesion had both benign and malignant
sonographic features, the pleomorphic calcifications identified on mammography
made this lesion indeterminate. Therefore, this lesion was classified as
BI-RADS category 4 and biopsy was recommended.
View larger version (89K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A. —56-year-old woman with adrenal cortical carcinoma and new,
palpable nodule in upper, outer aspect of left breast. Craniocaudal mammogram
of left breast shows metallic BB pellet placed over palpable abnormality.
|
|
View larger version (87K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B. —56-year-old woman with adrenal cortical carcinoma and new,
palpable nodule in upper, outer aspect of left breast. Mediolateral oblique
mammogram of left breast obtained on same date as A shows dense,
well-circumscribed nodule in lower outer quadrant.
|
|
View larger version (155K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1C. —56-year-old woman with adrenal cortical carcinoma and new,
palpable nodule in upper, outer aspect of left breast. Spot compression
craniocaudal (C) and mediolateral oblique (D) images show same
nodule as in B.
|
|
View larger version (164K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1D. —56-year-old woman with adrenal cortical carcinoma and new,
palpable nodule in upper, outer aspect of left breast. Spot compression
craniocaudal (C) and mediolateral oblique (D) images show same
nodule as in B.
|
|
View larger version (151K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1E. —56-year-old woman with adrenal cortical carcinoma and new,
palpable nodule in upper, outer aspect of left breast. Sonogram of palpable
nodule in left breast obtained on same date as A-D shows mildly
lobular, heterogeneous nodule.
|
|
View larger version (74K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1F. —56-year-old woman with adrenal cortical carcinoma and new,
palpable nodule in upper, outer aspect of left breast. Color Doppler sonogram
of nodule in E shows increased vascularity within nodule.
|
|
Because the lesion was palpable, multiple palpation-guided core biopsy
specimens were obtained by the surgical service and submitted for pathologic
evaluation. The morphology and staining characteristics of the breast lesion
were similar to those of original adrenal cortical carcinoma, supporting the
diagnosis of metastatic disease.
Discussion
Adrenocortical adenocarcinoma is an uncommon malignancy that most
frequently metastasizes to the lung, liver, bone, and lymph nodes. Only one
case of metastasis to the breast has previously been indicated in the
literature [8]. We have
reported the mammographic and sonographic findings of a pathologically proven
adrenocortical adenocarcinoma metastasis to the breast.
Hematogenous spread of metastases to the breast is rare. The most common
malignancies to metastasize to the breast are melanoma, sarcoma, and tumors of
the lung and ovary [1,
2]. Lymphoma and leukemia can
also involve the breast. The primary malignancy is usually known before the
evaluation of the breast lesion, and metastatic disease is usually present
elsewhere outside of the breast. Initially, these lesions are presumed to be
primary breast neoplasms. However, the differentiation between a primary
breast lesion and a metastatic lesion is important because the treatment is
considerably different.
Differentiation between primary breast cancer and metastatic disease on the
basis of mammographic characteristics can be difficult. Patients with
metastatic disease to the breast usually present with one or more discrete,
well-circumscribed nodules that may be similar to benign nodules and may occur
anywhere in the breast. The presence of a nodule in the subcutaneous fat with
skin thickening and interval growth are radiographic features suggesting
malignancy. In contrast, subcutaneous nodules with no skin thickening are
almost always benign. Architectural distortion and focal skin thickening occur
less commonly [2]. Internal
calcifications are rare in metastatic nodules and are often used to exclude
metastasis, except in the case of metastatic ovarian carcinoma, in which the
calcifications represent psammoma bodies
[1]. In addition, spiculation
is uncommon because of the absence of desmoplasia in these lesions
[2].
Leukemia and lymphoma involving the breast can have a variable mammographic
appearance, usually presenting as a solitary nodule or mass or as multiple
nodules in one or both breasts
[1,
2]. Most commonly, primary or
secondary breast lymphoma presents mammographically as a well-circumscribed
nodule. Less commonly, the mammogram may show an amorphous or spiculated mass,
architectural distortion, or normal findings
[1].
The most striking mammographic feature of the lesion in our patient was a
well-defined nodule and the absence of spiculation, which in the setting of a
known extramammary primary neoplasm should raise the suspicion for metastasis.
Medullary, mucinous, and papillary carcinomas of the breast and breast
carcinomas arising in breast cysts can present as a well-circumscribed lesion
and must be included in the differential diagnosis.
Sonography is widely used to distinguish benign breast nodules from
malignant lesions. Because breast cancers tend to be hypervascular compared
with benign breast nodules, Doppler sonography is often used to help
distinguish between benign and malignant neoplasms. However, the lack of
evidence documenting the ability of Doppler sonography, including spectral
analysis, to distinguish with adequate sensitivity and specificity between
benign and malignant neoplasms, limits its role clinically. Sonographically,
the lesion in our patient appeared as a well-circumscribed, macrolobulated
nodule with its long axis parallel to the skin, characteristics typical of
benign lesions. However, its heterogeneity and vascularity suggested that the
lesion might not be benign.
In summary, we present the mammographic and sonographic characteristics of
a pathologically proven adrenal cortical adenocarcinoma metastatic to the
breast. Metastatic nodules in the breast are uncommon and are usually from
melanomas, sarcomas, or tumors of the lung or ovary. However, when mammography
and sonography show a nodule or mass without the features typical of primary
breast carcinoma in a patient with a known extramammary neoplasm, metastasis
to the breast should be considered.
References
- Paulus DD, Libshitz HI. Metastasis to the breast. Radiol
Clin North Am 1982;20:561
-568[Medline]
- McCrea ES, Johnston C, Haney PJ. Metastases to the breast.
AJR 1983;141:685
-690[Abstract/Free Full Text]
- Stojadinovic A, Ghossein RA, Hoos A, et al. Adrenocortical
carcinoma: clinical, morphologic, and molecular characterization. J
Clin Oncol 2002;20:941
-950[Abstract/Free Full Text]
- Nader S, Hickey RC, Sellin RV, Samaan NA. Adrenal cortical
carcinoma: a study of 77 cases. Cancer1983; 52:707
-711[Medline]
- Venkatesh S, Hickey RC, Sellin RV, Fernandez JF, Samaan NA. Adrenal
cortical carcinoma. Cancer1989; 643:765
-769
- Soreide JA, Brabrand K, Thoresen SO. Adrenal cortical carcinoma in
Norway, 1970-1984. World J Surg1992; 16:663
-667[Medline]
- Crucitti F, Bellantone R, Ferrante A, Boscherini M, Crucitti P. The
Italian Registry for Adrenal Cortical Carcinoma: analysis of a
multiinstitutional series of 129 patients—The ACC Italian Registry Study
Group. Surgery1996; 119:161
-170[Medline]
- Evans HL, Vassilopoulou-Sellin R. Adrenal cortical neoplasms. a
study of 56 cases. Am J Clin Pathol1996; 105:76
-86[Medline]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Top
Introduction
Case Report
