ANTICANCER RESEARCH 25: 527-530 (2005) Metastatic Rhabdomyosarcoma to the Breast SHYR-MING SHEEN-CHEN1, HOCK-LIEW ENG2 and SHEUNG-FAT KO3 Departments of 1Surgery, 2Pathology and 3Diagnostic Radiology, Chang Gung Memorial Hospital, Kaohsiung College of Medicine, Chang Gung University, Taiwan Abstract. Secondary malignancy metastatic to the breast is malignancy in the pediatric age group, metastatic deposits to uncommon, with an incidence of 0.5% to 3% of patients with the breast rarely occur and are mainly seen in adolescent girls extramammary malignancy. Although rhabdomyosarcoma is a (4,5). Here, we report an intriguing, rare adult case with common aggressive primary malignancy in the pediatric age metastasis to the breast from nasal rhabdomyosarcoma. group, metastatic deposits to the breast rarely occur and are mainly seen in adolescent girls. Here, we report an intriguing, Case Report rare adult case with metastasis to the breast from nasal rhabdomyosarcoma. A 31-year-old woman with the complaint A 31-year-old woman with the complaint of right neck mass of right neck mass noted recently came to this hospital for help. noted recently came to our hospital. She had a history of She had a history of nasal malignancy treated with nasal malignancy treated with radiotherapy by another radiotherapy in another hospital three months previously. hospital three months previously. Physical examination revealed multiple neck masses at Physical examination revealed multiple neck masses in the bilateral neck areas. Bilateral neck dissection was performed bilateral neck areas, especially the right side. The masses and rhabdomyosarcoma, metastatic to lymph node, was the were non-tender, firm with mild uneven surface, ranging from final diagnosis. One year after operation, the patient felt a large 0.8 cm to 4 cm in maximum diameter. Malignant metastases lump in her left breast. Surgical excision was performed and to the neck area was the initial impression. Bilateral neck histological analysis was consistent with rhabdomyoblastic dissection was performed. Histological examination of the origin. Secondary malignancy metastatic to the breast is neck lymph nodes showed solid sheets of small to medium- uncommon, yet this entity does exist. In view of the therapeutic sized polygonal neoplastic cells bearing pleomorphic nuclei implication, a metastatic breast lesion should not be mistaken with prominent nucleoli, and scant pinkish cytoplasm. They as the primary breast carcinoma. Only with the awareness of were separated by thin fibrous septa. Mitotic figures were such a possibility can prompt diagnosis and optimal treatment frequent. Additional immunohistochemical study showed be achieved. strong positivity of the neoplastic cells for vimentin, sarcomeric actin and desmin. Hence, rhabdomyosarcoma, Secondary malignancy metastatic to the breast is uncommon, metastatic to the lymph nodes, was the final diagnosis. with an incidence of 0.5% to 3% of patients with Chemotherapy and local radiotherapy were arranged and extramammary malignancy (1,2). Most series report an applied about one month postoperatively. association with lymphoma, leukemia and melanoma, One year after operation, the patient felt a large lump in followed by lung carcinoma(3). Other malignancies including her left breast. Surgical excision was performed. Grossly, a ovary, prostate and stomach have been reported in several tumor measuring 10x9x5.5 cm in size was noted. On cutting, patients with breast metastasis (1,2). Although a yellowish-white surface with pus-like substance was noted. rhabdomyosarcoma is a common aggressive primary Microscopically, sections revealed breast tissue with sheets of large cells with vesicular, pleomorphic nuclei and prominent nucleoli separated by fibrous band. Focal lymphocytic infiltration and frequent mitoses were noted (Figure 1). Correspondence to: Shyr-Ming Sheen-Chen, MD, Professor and Immunohistochemical studies showed the tumor cells to be Chairman, Department of Surgery, Chang Gung Memorial negative for cytokeratins and strongly positive for vimentin, Hospital, Kaohsiung, 123, Ta-Pei Road, Niao-Sung Hsiang, Kaohsiung Hsien, Taiwan. Tel: 886-7-7317123, Fax: 886-7-7318762, sarcomeric actin (Figure 2) and desmin, consistent with a e-mail: [email protected] rhabdomyoblastic origin. The patient expired ten months after breast metastasis due to dissemination to the lung and Key Words: Rhabdomyosarcoma, breast, metastatic. peritoneal cavity, in spite of aggressive medical treatment. 0250-7005/2005 $2.00+.40 527 ANTICANCER RESEARCH 25: 527-530 (2005) Figure 1. Photograph showing sheets of neoplastic cells bearing hyperchromatic and pleomorphic nuclei separated by fibrous bands. Mammary ductules are present in the left lower corner (H&E x100). Figure 2. Tumor cells immunostained with sarcomeric actin show strong reaction (x100). 528 Sheen et al: Rhabdomyosarcoma in Breast Discussion needed to further confirm the diagnosis, as in our case (Figure 2). Breast metastses from rhabdomyosarcoma are rare with an Secondary malignancy metastatic to the breast is uncommon, incidence of 6% (4-6). They occur mainly in adolescent yet this entity does exist. In view of the therapeutic implications, females, with the primary tumor originating from the a metastatic breast lesion should not be mistaken as the primary extremities and extremely rarely from elsewhere (5). breast carcinoma. Only with the awareness of such a possibility Metastasis to the breast has been claimed to happen can prompt diagnosis and optimal treatment be achieved. frequently through hematogenous spread (1). Most metastatic breast lesions occur in younger females, probably References owing to the abundant vascularity in their breasts. Such lesions usually present as solitary nodules in the upper, 1 Paulus DD and Lidshitz HI: Metastasis to the breast. Radio Clin outer quadrant which has the most abundant glandular North Am 20: 561-568, 1982. 2 Toombs BD and Kalisher L: Metastatic disease to the breast: tissue with the best blood supply (3). clinical,pathological and radiographic features.Am J Roentgenol The frequency of metastases to the adolescent female 129: 673-676, 1977. breast observed in patients with rhabdomyosarcoma may 3 Vergier B,Trojani M,De Mascarel et al: Metastatic to the breast: suggests a preferential site for metastasis (5). The reason for differential diagnosis from primary breast carcinoma. J Surg such a phenomenon remains unknown, but potential Oncol 48: 112-116, 1991. contributory factors have been described. The 4 Boorthroyd A and Carty H: Breast masses in childhood and rhabdomyosarcoma cells are claimed to have insulin-like adolescence. Pediatr Radiol 24: 81-84, 1994. 5 Hays DM, Donaldson SS, Shimada H, Crist WM et al: Primary growth factor(IGF) receptor and are responsive to insulin- and metastatic rhabdomyosarcoma in the breast: neoplasms of like growth factor receptor-II (7,8). Importantly, the breast adolescent females, a report from the intergroup rhabdomyo- epithelium and stroma are known to express growth factors sarcoma study. Med Pediatr Oncol 29: 181-189, 1997. IGF-I and IGF-II (9,10) and this would, theoretically, provide 6 Beattie M,Kingston JE, Norton AJ and Malpas JS: a suitable environment for metastatic rhabdomyosarcoma cell Nasopharyngeal rhabdomyosarcoma presenting as a breast mass. growth in the growing adolescent breast. Pediatr Hematol Oncol 7: 259-263, 1990. Mammography may be useful in the differential diagnosis 7 Yun K: A new market for rhabdomyosarcoma: insulin-like growth factor II. Lab Invest 67: 653-664,1992 of primary and metastatic breast malignancy. The typical 8 Minniti CP,Tsokos M, Newton WA and Helman LJ: Specific mammographic presentation of metastatic breast malignancy expression of insulin-like growth factor-II in RMS tumor cells. is a round and dense mass (11). Microcalcifications and Am J Clinic Path 101: 198-203, 1994. spiculation are usually not present, except in the rare case of 9 Cullen KL, Allison A, Martine I, Ellis M and Singer C: Insulin- metastasis from ovarian carcinoma, and neither architectural like growth factor expression in breast cancer epithelium and distortion nor thickening of the skin is present (11,12). stroma. Breast Cancer Res Treat 22: 21-29, 1992. Because the metastatic breast lesion evokes minimal 10 Manni A, Wei L, Badger B, Zaenglein A, Leighton J, Shimasaki S and Ling M: Expression of messenger RNA for insulin-like proliferation of fibrous tissue surrounding the lesion, it is growth factors and insulin-like growth factor binding proteins by about the same size on palpitation and mammography. In experimental breast cancer and normal breast tissue in vivo. contrast, the palpable mass of primary breast carcinoma is Endocrinology 130: 1744-1746, 1992. frequently larger than the mammographic size (12). 11 Chaignaud B, Hall TJ, Power C et al: Diagnosis and natural Despite the existence of these basic differences between history of extramammary tumors metastatic to the breast. J Am the presentations of primary breast carcinoma and Coll Surg 179: 49-53, 1994. metastatic breast malignancy as shown in mammography, 12 Bohman LG, Bassett LW, Gold RH and Vovet R: Breast metastases from extramammary malignancies. Radiology 144: there is amazing similarity between the latter and benign 309-312, 1982. breast lesions, especially fibroadenoma (3). Furthermore, 13 Perlet C, Sittek H, Forstpointner R, Kessles M and Reiser M: the majority of patients with metastatic rhabdomyosarcoma Metastases to the breast from rhabdomyosarcoma: