A case of metaplastic breast cancer in a man
A 59-year-old man was referred to the breast team with a presumed right-sided breast abscess which had not responded to antibiotics. His medical history included epilepsy, hypertension and emphysema for which he takes tegretol and amlodipine.\nHis mother had breast cancer at 50. He works as a caretaker and lives with his partner. He is an ex-smoker with a 60 pack-year history and minimal alcohol intake.\nOn examination he had a painful, fluctuant area in the upper outer quadrant of the right chest wall with skin ulceration. It was presumed that this was a simple abscess; however, an inflammatory cancer needed to be excluded.\nUnder general anaesthesia, an incision was made over the area of flucuance. Clear serous and sanguineous fluid was drained from a 3×4 cm cavity. The base of the cavity was nodular in areas and biopsies were taken. The histology, from the biopsy, revealed a poorly/differentiated carcinoma. The immunoprofile was of a carcinoma and the TTF1 positivity suggested an origin from lung or thyroid. A computed tomography (CT) scan of the chest, abdomen and pelvis showed a 5×4 cm ulcerative right-sided breast mass, with a number of small rounded right axillary lymph nodes. There was moderate emphysema of the lungs and an 18 mm area of scarring in the apex of the left lung. No bony abnormalities were identified.\nIt was decided that local control of the ulcerating breast mass was needed first and a right mastectomy with level 1 axillary clearance and latissimus dorsi flap reconstruction was performed. The tumour was 55 mm in diameter and showed staining with alpha smooth muscle actin and cytokeratins confirming a metaplastic immunophenotype. It was classified as a poorly differentiated grade 3 invasive metaplastic carcinoma. It was oestrogen- and progesterone-receptor negative. There was no evidence of lymph or vascular invasion; however, one of the five lymph nodes removed contained macro metastasis with focal extra capsular tumour excision. The deep resection margin was 0.5 mm.\nA positron emission tomography scan was performed to investigate the lung lesion previously identified on CT. This showed a 2.4 cm hyper-metabolic lesion in the apex of the left lung which abutted the pleural surface but did not invade it. There were no hyper-metabolic hila or mediastinal nodes. We initially felt that this was most likely to be a lung primary with breast metastasis. As a result, our patient underwent a three-port video-assisted thoracic surgery and wedge resection. The lung was grossly emphysematous. A palpable nodule in the apical segment of the left upper lobe was resected with frozen sections sent. Lymph nodes from station 5 were sampled. The histology from the lung demonstrated a poorly differentiated carcinoma with sarcomatous features in keeping with metastasis from a primary breast cancer. The morphology and immune profile of the lung tumour were similar to that of the breast tumour. Vascular and visceral pleural invasion were present, but there was a clear 2 cm margin. The station 5 lymph node did not reveal any malignancy.\nFollowing recovery from surgery, our patient was started on the FEC 100 regimen (5-fluorouracil, epirubicin and cyclophosphamide). A bone scan prior to chemotherapy showed no evidence of bony metastasis and a CT scan showed no focal collection or residual mass in the right breast and no significant intrathoracic adenopathy.\nOur patient completed a course of six cycles of chemotherapy. A CT scan following completion showed no macrometastasis. He was referred for radiotherapy of the chest wall and is about to start a course with 40 Grays in 15 fractions to the right chest wall and supraclavicular fossa.