Metastatic breast cancer to the cervix presented during chemotherapy: A case reportName : Dr. Abdalla SAAD ABDALLA
Affliation : Consultant Breast Surgeon
University : Basildon and Thurrock University Hospital
Country : UK
The most common sites of breast cancer metastasis are the lungs, liver, bones and brain. Uterus is reported as a rare site for metastasis, and even more so for an isolated metastasis. Other sites of extra-genital sources for uterine metastases include the colon, stomach, and thyroid.
Case report: We present a young lady, who has had breast cancer with metastatic disease in the ipsilateral axilla at the age of 32 years. It was Grade II invasive ductal carcinoma ER-ve/ PR-ve, Her-2+ve and Ki67-70%. Initially had chemotherapy and Trastuzumab. This was followed by mastectomy, axillary clearance and radiotherapy. After finishing the Trastuzumab, she developed skin recurrence in the mastectomy site. She received Lapatinib and Capecitabine. No gynaecological abnormality detected earlier. Nine months before the cervical metastasis was detected, she presented with irregular vaginal bleeding . Examination including colposcopy which was unremarkable. Cervical smear showed borderline changes. Trans-vaginal ultrasound , revealed no significant abnormality . HPV screening was negative. Later, she presented with increased vaginal bleeding. CT scan revealed a prominent cervix .A repeat hysteroscopy showed a suspicious cervical and an endometrial polyps. Biopsy from both areas was composed of extensive high grade malignant cells, forming sheets in areas of a gland-like structure; the features were consistent with adenocarcinoma .In IHC , the cells were positive for CK7, GCDFP15 and p53. There was patchy positivity for p16, Vimentin and BCL2, but negativity for CK5, p63, ER , PR, Napsin A and TTF1. The Ki67 proliferation fraction was 80%. The original breast cancer was reported as ER and PR negative, and Her-2 positive. This makes the metastatic breast IDC the most probable diagnosis.
Discussion: The uterus was reported as a rare site of metastasis.ILC metastasises more frequently to the female UGS (80%), than IDC . Metastasis to the cervix is rare; it accounts for only 3.7% of female UGS metastatic disease. Cervix is a less favourable site for metastasis because of its small size, composition of mainly dense fibromuscular components, restricted blood supply and an afferent lymphatic drainage alone.The tumour may present with symptoms identical to primary cervical as abnormal vaginal bleeding which is usually the most frequent symptom.
IHC is crucial to differentiate primary from metastatic cervical malignancy.CK7+/CK20+ pattern is seen in endo-cervical cancer,and CK7+/CK20- pattern is seen in breast cancer , endo-cervical and endometrial carcinoma.GCDFP 15 is used as a specific IHC diagnostic marker for tumours originating in the breast.The marker p16 seen in high grade endometrial and ovarian carcinoma. Patients with metastatic breast disease who are potentially suitable for curative therapeutic strategy represent only 1–3 %.Other treatment optiots are chemotherapy , hormonal manipulation and radiotherapy . Despite the poor prognosis of this group of patients , some patients who achieve a complete response remain disease free for prolonged periods, some even beyond 20 years.
Conclusion: A metastatic cancer should be considered in the differential diagnosis of abnormal vaginal bleeding, suspicious pelvic examination, or radiological findings in women with a previous history of breast cancer.
Dr Abdalla SAAD ABDALLA , MBBCh , SD, PhD, FRCS. Consultant breast surgeon at Basildon and Thurrock University Hospital , Essex-England. He did his postdoctoral research at Karol Marcinkowski Medical University in Poznan-Poland. He has published more than 25 papers in reputed journals and currently involved in some research projects related to breast cancer management in United Kingdom and Poland.