- Open Access
Metastatic breast ductal carcinoma detected in a toremifene-associated endometrial polyp: case report and literature review
© Springer-Verlag 2009
- Received: 24 October 2008
- Accepted: 16 December 2008
- Published: 10 February 2009
Uterine metastases are rare events, but when they occur, the first extragenital neoplasm responsible is breast carcinoma. Toremifene, used in breast cancer hormonotherapy, has a partial estrogenic agonist effect in the endometrium, responsible for potential abnormalities, like polyps. A 53-year-old woman, receiving toremifene due to previously excised breast ductal carcinoma, presented with endometrial thickness during an abdominopelvic ultrasound follow-up. Hysteroscopy revealed an endometrial polyp, which was removed. Microscopic examination showed infiltration by a malignant ductal pattern neoplasm, with signet ring cells. The patient underwent hysterectomy and bilateral salpingo-oophorectomy. The final pathological diagnosis was metastatic breast carcinoma to the endometrium and cervix. This is the first reported case of breast metastases detected in a toremifene-associated endometrial polyp.
- Endometrial polyp
- Uterine metastases
- Breast cancer
- Toremifene therapy
The female reproductive tract, especially the ovaries and vagina, are at risk of metastatic involvement from extragenital neoplasm . The uterus is seldom involved, and when it occurs, the first extragenital neoplasm responsible is breast cancer (in 42.9% of cases). Metastization is mainly to the myometrium and, exceptionally, to the endometrium .
Metastization to an endometrial polyp is an even rarer occurrence. To our knowledge, there are only 11 cases in the literature of endometrial polyp involvement by a metastatic neoplasia: one case of cutaneous melanoma  and breast cancer in the others [4–12]. Of these latter, seven patients were reported to be receiving adjuvant endocrine treatment with tamoxifene at the time of the diagnosis [6, 8–12].
We report a case of metastatic disease from breast ductal carcinoma, detected in an endometrial polyp, in a patient receiving toremifene as adjuvant endocrine treatment, found also to have involvement of the endometrium and cervix.
In 2003, a 53-year-old gravida 2 para 2 caucasian female underwent a right modified radical mastectomy with ipsilateral axillary lymphadenectomy (Madden technique), due to a 35 × 40 mm multifocal infiltrating ductal breast carcinoma of the right upper outer quadrant. Sixteen of 18 axillary lymph nodes resected showed evidence of metastatic involvement. Both estrogen and progesterone receptors were positive and Cerb-B2 oncogene was negative. The tumor was reported as pT2N3aMx (according to the 2002 American Joint Committee on Cancer staging system for breast cancer). Postsurgery treatment consisted of six-cycle multiagent chemotherapy (with 5-fluorouracil, adriamicine, and cyclophosphamide), external beam radiotherapy (50 Gys), and toremifene (60 mg/day).
Follow-up was uneventful for 3 years. After that period, a routine abdominopelvic ultrasound showed an endometrial thickening of 13 mm. The patient was asymptomatic and the gynaecological examination was normal. A transvaginal ultrasound with hysterosonography revealed the presence of a cystic intracavitary polypoid mass, measuring 24.9 × 20.1 mm, originating from the anterior uterine wall. Adnexes had a normal appearance. Surgical hysteroscopy was performed, confirming the presence of a large, nacreous, hypervascular polypoid mass, originating from the anterior and left lateral uterine walls, which was removed with bipolar spring electrode. The microscopic examination showed fragments of endometrium, some with polypoid morphology with simple glandular hyperplasia. In one fragment, the fibrovascular stroma was infiltrated by malignant neoplasm of ductal pattern and some signet ring cells.
The patient underwent a positron emission tomography with 2-deoxy-2-[18F]-fluoro-d-glucose, which revealed an intense uptake in the uterine area and excluded the presence of metastatic disease in other sites. Total abdominal hysterectomy and bilateral salpingo-ophorectomy was then performed. On exploration, the uterus appeared enlarged, the adnexes were normal, and no gross evidence of tumor was observed elsewhere in the abdominal cavity.
Macroscopic examination of the specimen showed an enlarged uterus with unremarkable serosal surface, but with slight cervical irregularity and thickened endometrium. Both fallopian tubes and ovaries were grossly normal. Microscopically, the endometrium was diffusely infiltrated by a malignant epithelial neoplasm, consisting mainly of isolated cells with intracitoplasmatic vacuoles and some poorly differentiated residual glands. The tumor also invaded the cervix. The myometrium, ovaries, and fallopian tubes were free of tumoral infiltration. Washing cytology was negative for the malignant cells. The final pathological diagnosis was metastatic breast ductal carcinoma to the endometrium, endocervix, and exocervix.
After surgery, the patient underwent a cycle of palliative external beam radiotherapy (50 Gys) and began anastrazol (1 mg/day) in replacement of toremifene. She remained clinically well and follow-up exams did not show any sign of relapse for 15 months when she was admitted to the hospital due to syncope and right hemiparesis. Brain computerized axial tomography was inconclusive, but brain nuclear magnetic resonance revealed metastatic foci in the third ventricle, right orbit, and right temporal fossa and several lytic lesions on the scull. Bone isotopic scan detected extensive bone metastization (scull, humeri, scapulae, sternum, ribs, vertebral bodies, hip bones, and femurs). It was decided to initiate cerebral palliative radiotherapy but the patient died 1 week later.
Conflict of interest
I certify that there is no actual or potential conflict of interest in relation to this article.
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