the bowel, a diagnostic laparoscopy was performed. Findings at surgery revealed a normal uterus with no evidence of perforation and normal tubes and ovaries. In the anterior cul-de-sac and right pericolic gutter moderate amounts of yellowish exudates were noted and aspirated. Gram stain of the fluid revealed abundant white blood cells with no organisms. Careful exploration of the abdomen was conducted, and no pathology was found. The peritoneal cavity was copiously lavaged with 3 L of saline, and surgery was terminated. Postoperatively the patient was maintained on antibiotics. The patient’s symptoms resolved quickly, and in 36 hours the patient’s leukocytosis and pain had resolved. The peritoneal fluid cultures ultimately did not grow any anaerobic or aerobic bacteria or fungus. COMMENT Sorbitol is a six-carbon alditol isomer. Absorbed sorbitol is metabolized in the liver to fructose and glucose. It is well known that distending medium used during hysteroscopy will percolate through the tubes and spill into the peritoneal cavity. Yet, there have been no reports of distending medium causing reactive peritonitis. To the author’s knowledge this is the first reported case of
Metastatic Lobular Breast Carcinoma to an Endometrial Polyp Diagnosed by Hysteroscopic Biopsy C. A´lvarez, MD, J. A. Ortiz-Rey, MD, F. Este´vez, MD, and A. de la Fuente, MD
peritonitis presumptively due to sorbitol distending medium. The unique features of this case were the almost immediate onset of symptoms after the procedure. As more serious complications like perforation of the uterus and the bowel can also present with similar clinical findings, the clinician should be diligent in determining the etiology of the peritonitis and only consider reactive peritonitis as a diagnosis of exclusion. Reactive peritonitis due to sorbitol should be on the differential diagnostic list of patients who develop acute abdominal pain after hysteroscopy. REFERENCES 1. Propst AM, Liberman RF, Harlow BL, Ginsburg ES. Complications of hysteroscopic surgery: Predicting patients at risk. Obstet Gynecol 2000;97:517–20. 2. Witz CA, Schenken RS, Silverberg KM, Olive DL, Burns WN. Complications associated with the absorption of hysteroscopic fluid media. Fertil Steril 1993;60:745–56. 3. McLucus B. Hyskon complications in hysteroscopic surgery. Obstet Gynecol Surv 1991;46:196–200. Received September 25, 2002. Received in revised form October 19, 2002. Accepted November 13, 2002.
chemical studies confirmed the diagnosis of metastatic lobular breast carcinoma. CONCLUSION: Although rare, breast tumors can metastasize to an endometrial polyp, even in the absence of other disseminations. Abnormal vaginal bleeding in a patient with known breast carcinoma can be the first sign of metastasis. (Obstet Gynecol 2003;102:1149 –51. © 2003 by The American College of Obstetricians and Gynecologists.)
Departments of Pathology and Gynecology, Centro Me´dico POVISA, Vigo, Spain
BACKGROUND: Secondary tumors involving the uterus are rare, and most come from the close vicinity. Among nongynecologic origins, breast tumors are the most frequent, being predominantly of the lobular carcinoma type. CASE: A 69-year-old woman presented with metrorrhagia. The patient had been diagnosed 4 years before with infiltrating lobular breast carcinoma. Follow-up was uneventful. She underwent hysteroscopy with biopsy. An endometrial polyp was seen. Microscopically, small malignant cells diffusely infiltrated the endometrial stroma and surrounded the atrophic endometrial glands. ImmunohistoAddress reprint requests to: Carlos A´lvarez, MD, Servicio de Anatomı´a Patolo´gica, Centro Me´dico POVISA, C/Salamanca 5. 36211 Vigo (Pontevedra), Spain; E-mail:
[email protected].
The extragenital tumors most often metastasizing to the uterine corpus are breast carcinoma (47.3%), stomach carcinoma (29%), and melanoma (5.4%).1 Among breast metastatic carcinomas, those of lobular type are the most common.2 A search of the MEDLINE database using the PubMed retrieval service, with key words “breast,” “metastasis,” “endometrial,” and “polyp,” for the period from 1966 to July 2002, showed only three previously described cases of metastatic breast tumors to an endometrial polyp.3–5 To our knowledge, the fourth case of breast carcinoma with involvement of an endometrial polyp is presented here, which was diagnosed in a hysteroscopic-guided biopsy 4 years after the primary diagnosis in a patient without evidence of disease on follow-up.
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Figure 1. Small-to-medium-sized malignant epithelial cells set in stroma that contains thick-walled blood vessels (arrow), sparing endometrial glands (hematoxylin– eosin; ⫻ 40, original magnification). Inset shows some signet ring cells with eccentrically placed nuclei (arrow) (hematoxylin– eosin; ⫻ 400, original magnification). A´lvarez. Metastasis to Endometrium. Obstet Gynecol 2003.
CASE A 69-year-old woman presented with a 1-month history of mild metrorrhagia. The patient had undergone radical left mastectomy with ipsilateral axillary lymphadenec-
tomy 4 years previously for an infiltrating lobular breast carcinoma. The tumor had been reported as pT2 pN1 M0 in accordance with the 1997 International Union Against Cancer staging of breast tumors. Postsurgery
Figure 2. Immunohistochemistry for GCDFP-15 showing strong cytoplasmic (arrow) positivity (⫻ 100, original magnification). Inset shows nuclear (arrow) positive immunostaining for estrogen receptors (⫻ 400, original magnification). A´lvarez. Metastasis to Endometrium. Obstet Gynecol 2003.
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treatment consisted of six-cycle multiagent chemotherapy with the CMF regimen (cyclophosphamide 100 mg/m2; methotrexate 40 mg/m2; and 5-fluorouracil at 600 mg/m2), external beam radiotherapy, and tamoxifen therapy (20 mg/day, 39 months). Follow-up, including mammography, chest x-ray, computed tomography, and bone isotopic scan, was uneventful for 4 years. All this had occurred before her admission to our hospital. An abdominal ultrasound revealed a polypoid mass 1.5 cm in length appended to the uterine dome. Complete blood count showed hemoglobin of 11.1 g/dL (normal range, 12–16 g/dL) and hematocrit of 31.5% (normal range, 37– 47%). Hysteroscopy showed several small elevated nodules, and a hysteroscopic-guided biopsy was performed. Microscopically, the lesion was composed of fairly uniform cells diffusely replacing the stroma and separating residual cystically dilated glands lined by low columnar cells. Some tumor cells showed a signet ring morphology (Figure 1), and mitoses were rare. Immunohistochemical techniques using monoclonal antibodies against estrogen and progesterone receptors (Dako, Glostrup, Denmark) and gross cystic disease fluid protein-15 (GCDFP-15) (Novocastra, Newcastle, UK) were positive (Figure 2). Immunoreactivity for protein S-100 (BioGenex, San Ramon, CA) and E-cadherin (Becton Dickinson, San Jose, CA) was not observed. This profile was similar to the primary tumor. A diagnosis of metastatic lobular breast carcinoma was rendered. After the diagnosis, magnetic resonance imaging showed widespread dissemination with skull, spine, and uterus metastasis.
COMMENT Tamoxifen-treated breast cancer patients can sometimes develop endometrial polyps that exhibit a wide range of metaplasias in the glandular and stromal components, and 3–10.7% of these polyps may show primary endometrial malignant changes.6 Metastatic tumors involving an endometrial polyp have been reported and are predominantly of breast origin.3–5 Uterine metastasis presenting as the first indication of an extragenital cancer are extremely rare, because when extragenital tumors metastasize to the uterus, it is usually a manifestation of widespread dissemination.1,3–5 In our case, the patient had a prior history of lobular breast cancer diagnosed 4 years before, with an uneventful follow-up. After the diagnosis, a bone isotopic scan and computed tomography were carried out, showing widespread metastatic disease.
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The histologic diagnosis of metastatic breast lobular carcinoma could be difficult, because fairly uniform cells might be mistaken for endometrial stromal cells with decidual changes due to tamoxifen therapy. Signet ring carcinoma and endometrial carcinoma are also in the differential diagnosis. A positive immunohistochemical stain for hormone receptors suggests metastatic breast carcinoma, but GCDFP-15 is more specific for breast carcinoma, especially if signet ring cells are present,7 as in our case. Besides, virtually all cases of lobular carcinoma are characterized by loss of immunostaining with antibodies to E-cadherin.8 In conclusion, if atypical bleeding in patients with known breast carcinoma occurs, endometrial metastasis should be excluded by gynecologists, and a histopathologic study of the specimen is mandatory.
REFERENCES 1. Kumar NB, Hart WH. Metastasis to the uterine corpus from extragenital cancers. A clinicopathologic study of 63 cases. Cancer 1982;50:2163–9. 2. Kemp B, Schroder W, Hermann A, Biesterfeld S, Rath W. Uterine metastasis of invasive lobular breast carcinoma. Case report and review of the literature with reference to differential diagnostic problems and clinical consequences. Zentralbl Gynakol 1997;119:500–2. 3. Sullivan LG, Sullivan JL, Fairey WF. Breast carcinoma metastatic to endometrial polyp. Gynecol Oncol 1990;39: 96–8. 4. Aranda FI, Laforga JB, Martı´nez MA. Metastasis from breast lobular carcinoma to an endometrial polyp. Report of a case with immunohistochemical study. Acta Obstet Gynecol Scand 1993;72:585–7. 5. Lambot MA, Eddafali B, Simon P, Fayt I, Noe¨l JC. Metastasis from apocrine carcinoma of the breast to an endometrial polyp. Virchows Arch 2001;438:517–8. 6. Cohen I, Azaria R, Bernheim J, Shapira J, Beyth Y. Risk factors of endometrial polyps resected from postmenopausal patients with breast carcinoma treated with tamoxifen. Cancer 2001;92:1151–5. 7. Raju U, Ma CK, Shaw A. Signet ring variant of lobular carcinoma of the breast: A clinicopathologic and immunohistochemical study. Mod Pathol 1993;6:516–20. 8. Lehr HA, Folpe A, Yaziji H, Kommoss F, Gown AM. Cytokeratin 8 immunostaining pattern and E-cadherin expression distinguish lobular from ductal breast carcinoma. Am J Clin Pathol 2000;114:190–6. Received August 7, 2002. Received in revised form September 12, 2002. Accepted September 19, 2002.
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