A fortuitous discovery of uterine metastasis from invasive ductal carcinoma: a case report

¹Charles Nicolle University Hospital of Tunis, Department A of Gynecology and Obstetrics, 1006, Tunis, Tunisia, ²University of Sousse, Faculty of Medicine of Sousse, 4000, Sousse, Tunisia, ³University of Tunis El Manar, Faculty of Medicine of Tunis, 1007, Tunis, Tunisia

^&Corresponding author
Ghada Abdelmoula, Charles Nicolle University Hospital of Tunis, Department A of Gynecology and Obstetrics, 1006, Tunis, Tunisia

Introduction    

The most common organs to which breast cancer metastasize frequently are the liver, bones, and lungs [1]. In breast metastases to gynecological organs, only 3.8% of cases involve the uterus. In the context of uterine metastases, the myometrium is more often involved than the endometrium. Nearly 80% of genital metastases of breast origin are invasive lobular carcinomas, while invasive ductal carcinomas are exceptional [2]. The aim of this article is to report and discuss a new case of uterine metastasis from invasive ductal carcinoma, given its rarity and to emphasize that the possibility of secondary and primary tumors should be considered by clinicians independently of hormone therapy.

Patient and observation     

Patient information: mrs. JZ, a 68-year-old, hypertensive, dyslipidemic, hypothyroid under treatment, Gravida 7 Para6 Abortus1 (6 vaginal deliveries), postmenopausal for 20 years, underwent in 2015 a left radical mastectomy for a left breast carcinoma classified as T2N0M0 (Invasive ductal carcinoma (IDC), grade nuclear components of Scarff-Bloom-Richardson (SBR) 2, Hormone-receptor positive (HR+), HER2 scored as 1 by IHC, Ki-67 at 20%), having required 20 sessions of radiotherapy, 12 courses of chemotherapy and hormonal therapy based on tamoxifen. She consulted, 7 years later, for sensation of vaginal lump without urinary associated symptoms

Clinical findings: on examination, a urogenital prolapse classified cystocele 3, hysterocele 3 and rectocele 1.

Timeline of current episode and diagnostic assessment: pelvic ultrasound came back without abnormalities, showing a small, homogeneous, regular uterus with a thin endometrium and atrophic ovaries. The patient had a hysterectomy with bilateral adnexectomy and promontofixation by laparotomy. On pathologist's examination, we discovered a 5 mm intramyometrial nodule corresponding to a metastatic localization of the previously diagnosed infiltrating breast carcinoma (Figure 1).

Diagnosis: uterine metastasis of the previously diagnosed infiltrating breast carcinoma.

Follow-up and outcome of interventions: a full body scan confirmed bone and liver metastases. The patient died from her disease in August 2022.

Informed consent: written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Discussion     

Genital metastases of malignant tumors are rare. Uterine metastases constitute 4% of these genital metastases of all gynecological and extra gynecological tumors. These are often asymptomatic lesions discovered incidentally or during autopsies performed in patients already followed for breast cancer. It is therefore exceptional for such metastases to be indicative of the disease [3]. Tumor dissemination of breast cancer is done by hematogenous and lymphatic route, it primarily involves the skeleton (31%), the lung (19%), the pleura (12%), the liver (9%), brain (4%), lymph nodes (24%), local skin (22%) and distant skin (7%) [3]. The study by Caskey et al. [4] which included the results of five series of autopsies, relating to 1552 cases, raised the frequency of other rare abdominal metastatic localizations on the peritoneum, the digestive tract, the urinary tract, the retroperitoneum and the genital tract. Involvement of the uterus is found in 1 to 15% of cases [3], metastases are located preferentially on the myometrium [3], the cervix or more rarely at the level of the endometrium. Genital metastases of breast cancer are the prerogative of infiltrating lobular carcinoma [5] especially with positive hormone receptors [3]. Such metastases can be asymptomatic, as reported in the present case, or manifest as metrorrhagia. Endometrial involvement appears to occur by contiguous spread from the myometrium. The tumor tends to infiltrate the stroma while preserving the endometrial glands and forms myometrial tumor nodules [4] as found on pathological examination in our case.

Weingold and Boltuch proposed that metastases spread from the ovaries via the lymphatic system to the uterus [6]. Most uterine metastases from extra-pelvic tumors are secondary to local retrograde lymphatic dissemination from previous ovarian metastases or possibly secondary to hematogenous dissemination when the ovaries are not affected [5] as is highly probable in our case since we found no ovarian metastases. It should be remembered that women with breast cancer can develop isolated uterine metastases or primary tumors of the uterus. The relationship between the different hormone-dependent tumors and the impact of hormone therapy makes gynecological follow-up mandatory. It is necessary to distinguish breast metastases from primary genital tumors because the treatment and the prognosis are quite different; primary uterine tumors can be surgically resected, while uterine metastases do not appear to require surgery and systemic chemotherapy may be preferable. However, based on the Kaplan-Meier survival analysis, it is unclear whether hysterectomy improves survival [7]. On the other hand, prognostic data are currently insufficient due to the limited number of case reports. Although most studies consider uterine metastases to be a pre-fatal event of poor prognosis, further research is needed to improve our knowledge of optimal treatment and precise prognosis [8]. Stemmermann reminds gynecologists that a diagnosis of metastatic neoplasia should be considered if abnormal bleeding occurs in women who have had previous cancer surgery, particularly in the presence of palpable ovarian lesions [9]. According to the 1996 statement from the American College of Obstetricians and Gynecologists, breast cancer patients taking tamoxifen should have annual gynecological exams. Any abnormal uterine bleeding or signs of gynecological disorder should warrant further investigation. Endometrial biopsy should also be considered.

Conclusion     

We discovered a rare metastatic localization in unexpected circumstances. From this experience, we have learned that even in the absence of clinical symptoms such as abnormal uterine bleeding, women with breast cancer who have received hormone therapy should have annual and regular gynecological follow-up to ensure rapid management and improve the prognosis.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Nabil Mathlouthi, Olfa Slimani and Cyrine Belghith ensured the validation process. Amine Ben Mansour ensured formal analysis and investigation. Ghada Abdelmoula wrote the original draft preparation. Saoussam Armi and Mariem Garci administered and supervised this project. All authors have read and agreed to the published version of the manuscript.

Figures     

Figure 1: A,B) pathological microscopic examination showing a 5 mm intramyometrial nodule corresponding to a metastatic localization of invasive ductal carcinoma

References