A 53 years old female was found to have double breast neoplasm in local hospital during physical examination more than 1 years ago. The invasive breast cancer in both sides of the diagnosis was made at the time. The patient was received a neoadjuvant chemotherapy (120mg docetaxel, 800mg cyclophosphamide and 800mg doxorubicin) for four cycles. Regrettably, the tumor continued to grow, and then the patient transfered to our hospital for further treatment. The patient had no familial genetic, psychosocial and exposure to toxins history. Furthermore, he was conducted in line with the care check-list.
Laboratory tests of the tumor biomarkers such as CA125 (34.70 U/ml), CA153 (23.40 U/ml), CA724 (6.98 mIU/ml) and CEA (71.20 ng/ml) showed slightly higher.
Then, the patient was admitted and underwent chest computed tomography (CT) and magnetic resonance imaging (MRI). The CT demonstrated bilateral breast masses, multiple enlarged lymph nodes and increased metabolism of the masses (Fig. 1A). The MRI shown that a large mass in the outer part of the right breast, and invaded the chest wall and skin. New skin nodules were detected in the inner part of the right breast, nodules in the axillary and caudal region of the right breast, and a mass of the left breast (Fig. 1B-C). In addition, pelvic MRI showed no lesions (Fig. 1D).
To verify the previous diagnosis from the local hospital, puncture biopsy of the breast mass of both sides was performed. An invasive carcinoma of left breast and an invasive carcinoma with mucus-rich of right breast was detected (Fig. 2A-B).
The patient was received a new neoadjuvant chemotherapy (40mg d1, d8, navelbine, 50mg d1,lobaplatin) for two cycles. The tumor was significantly shrink and became soft, and then, the radical mastectomy of both breasts was performed.
The mass about 4×3.5×2.5cm3 in size of the left breast. The histological characteristics were hard and with unclear boundaries. At lower magnification, tumor cells were arranged in cords, clusters, some areas the growth pattern was map-like pattern with central necrosis. At high magnification, the tumor cells were large, the nucleoli were easily visible (about 22/2 mm2). The histopathological type was invasive breast carcinoma of no special type, Nottingham grade 3. There was little stroma, no clear inflammatory cell infiltration, and no clear withdrawal response in the tumor. Reaction grading after neochemotherapy (Miller-payne system): G1. Regional lymph nodes dissection showed no definite metastasis (0/36). Immunohistochemical staining showed that the tumor cells were negative for ER, PR and HER2 (Fig. 3C-E)
In particularly, the macroscopic observation showed that the huge mass almost occupied the whole right breast, about 15×13.5×10cm3, with a little of normal compressed breast tissue remaining around. Multiple ulcerations were seen on the surface of the skin, accompanied by a large amount of necrosis and purulent secretions. The section of the mass was cystic and solid, filled with translucent to bloody mucus, and the solid area was pale and gelatinous.
Histopathological findings of the right resected mass revealed the tumor formed mucus-filled spaces of varying sizes, and with mucus-rich tumor cells lining the walls. The tumor cells were arranged in papillary structures of low power appearance. At high magnification, the tumor cells showed moderate to severe atypia, which were most of simple columnar cells with nuclei in the base and cytoplasm rich in mucin. In some areas, tumor cells proliferated, stratified, and clustered that protruded into the cyst cavity, or formed papillary structures with thin fibrovascular core. Ductal carcinoma in situ was seen around the peripher of the tumor (Fig. 4A-B). Response grading after neoadjuvant chemotherapy (Miller-payne system) was Grade 1. Immunohistochemical staining showed that the tumor cells were negative for ER, PR and HER2 (Fig. 4C-E). MCA metastasis was observed in the right axillary lymph node (8/26, Fig. 4F).
Immunohistochemical staining showed that the tumor cells were positive for CK5/6 (focal), CK7 and EGFR (Fig. 5A-C), but negative for CK20, CDX2, and PAX8 (Fig. 5D-F).
In addition, thoracic wall metastasis of right MCA was detected (Fig. 6A). Immunohistochemical staining showed that the tumor cells were negative for ER, PR, HER2 and GATA-3 (Fig. 6B-E).
The process of the thoracic wall metastasis from mammary MCA was conjectured in this case, the migration and invasion of the cancer cells break through basement membrane and went through endothelial cells of related vessels, and then transfered into lymph-vessel. Hence, further metastases to the thoracic wall and skin (Fig. 7). This process required further studies by clinicians.
The final diagnosis was made by Dr. Juanhui Dong, Dr. Zhenyu Li, Dr. Qingming Jiang, and Dr. Dongfang Guo of the department of pathology in Chongqing University Cancer Hospital.
The patient remained under careful observation by endoscopy and CT follow-up, and there was no recurrence or metastasis in the 6 months follow-up. The patient got appropriate perspective including the assessment and the episode of care in every 3 months.