Lobular breast carcinoma metastatic to the vulva: a case report and literature review

A Metastasis of Ovarian Cancer in the Bartholin Gland: A Case Report with Systematic Literature Review

The metastasis of a gynecological malignancy to the Bartholin gland is rare. We report the case of a 62-year-old patient who had undergone extensive treatment of metastatic ovarian cancer that involved the liver, spleen, and peritoneum. She presented with painful swelling of the left vulva. Clinical and sonographic examinations showed a solid tumor in loco typico of the Bartholin gland. Surgical excision was performed. The patient died 3 months after the diagnosis of this metastasis. We performed a systematic search of PubMed, which yielded 453 entries. We selected those with at least an abstract available in English that described metastatic lesions on the Bartholin gland (n = 5). The review showed that a variety of primary cancers (colorectal, medullary thyroid, breast cancer, and endometrial cancers) metastasize to this location. Some patients showed signs of visceral metastasis. Bartholin gland metastases appeared as initial and metachronous manifestations. Most patients were symptomatic, with painful swelling or abscess. Genetic alterations were mentioned in some cases. The main pathways of metastasis discussed were lymphatic, but the mechanism of such metastasis remains unclear. Surgical resection was the preferred treatment option. The literature review indicated that Bartholin gland metastasis of ovarian cancer is rare and associated with poor prognosis. Oncological reasons for vulvar pathologies should be taken into consideration in patients with metastases.

The diagnostic challenge of primary adenocarcinoma of the vulva: a case report

The diagnosis and classification of primary adenocarcinoma of the vulva is a complicated and understudied area, as this is a rare histological subtype of vulvar cancers. The differential diagnoses include extramammary Paget disease with invasion, adenocarcinoma arising from mammary-like glands, skin adnexal structures as well as Bartholin’s glands in the vicinity. We report a case of extramammary Paget disease which first presented as primary vulvar adenocarcinoma. The patient was a 71-year-old woman who presented with a swelling at the external genitalia. Clinical examination revealed a right vulvar lump, with eczematous features on the overlying skin. The lump was biopsied and was called Paget disease with underlying adenocarcinoma. Subsequently, the patient underwent radical vulvectomy and bilateral groin and pelvis dissection. The resection specimen was reported as extramammary Paget disease, with dermal invasion forming a poorly differentiated adenocarcinoma showing strong HER-2 expression on immunohistochemistry. This case illustrates the diagnostic challenge in the classification of primary vulvar adenocarcinoma. Positivity for HER-2 has been reported in Paget-associated vulvar adenocarcinoma and might offer potentially actionable targets on the selection of therapy, especially in advanced metastatic disease.

Breast cancer metastasis to the vulva 20 years remote from initial diagnosis: A case report and literature review

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This is the 20th documented case of metastatic breast carcinoma to the vulva.

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Greater than 21 years have passed from initial diagnosis to vulvar metastasis.

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Existing literature supports long term surveillance in women with invasive lobular carcinoma of the breast.

Clitoral metastasis from ductal breast cancer revealing metastases in multiple sites and review of the literature

BACKGROUND

Clitoral metastasis from breast cancer is extremely rare.

CASE

A 68-year-old woman with a 6-year previous history of breast cancer consulted her physician regarding a papillary and ulcerated clitoral lesion consistent with the appearance of vulvar squamous cell carcinoma. We analyzed the literature. Biopsy showed a ductal breast carcinoma with strongly positive estrogen and progesterone receptors. Magnetic resonance imaging of the pelvic area showed a second site on the right labium majus. Multiples metastases were detected. A right hemivulvectomy including the clitoris was performed, removing the 2 vulvar lesions. A nodule in the right breast and a cutaneaous lesion under the mastectomy scar were also removed. She refused chemotherapy, and initial hormonal therapy with anastrozole was switched to letrozol.

CONCLUSIONS

First, breast carcinoma on the vulva has 2 origins: primary breast carcinoma corresponding to ectopic breast tissue and--less frequently--breast cancer metastasis to the vulva. Second, the treatment of vulvar breast metastasis is the same as it would be on other sites: maximal reduction of the tumoral mass followed by chemotherapy-hormonal therapy.

Lesions of anogenital mammary-like glands: an update

Long considered to be ectopic breast tissue representing the caudal remnants of the milk ridges, anogenital mammary-like glands are nowadays thought to represent a normal constituent of the anogenital area. Lesions involving these glands, benign or malignant, epithelial or stromal manifest a striking similarity to their mammary counterparts. This review addresses the recent literature on lesions of anogenital mammary-like glands and our personal experience with various lesions related to these structures. Discussed are the normal anatomy and histology of these glands as well as the clinical presentation, histopathological and immunohistochemical features, molecular biological aspects, and differential diagnosis of various lesions involving anogenital mammary-like glands, including lactating adenoma, hidradenoma papilliferum, hidradenocarcinoma papilliferum, fibroadenomas, phyllodes tumor, pseudoangiomatous stromal hyperplasia, extramammary Paget disease, and other carcinomas. In addition, "nonspecific" epithelial or stromal changes some of which can be likened to similar changes occurring in a range of benign breast disease, including sclerosing adenosis, columnar cell lesions, ductal lesions and various metaplastic changes affecting epithelium and myoepithelium are discussed. Although lesions of anogenital mammary-like glands are often discussed in many dermatopathology textbooks in the context of cutaneous adnexal neoplasms we advocate that the best approach to the diagnosis of these lesions is to relate them to analogous well recognized lesions occurring in the breast, that is, through the eyes of a breast pathologist. This will enable their recognition, precise classification and should introduce greater uniformity in how they are reported in the literature so that more meaningful clinicopathological comparisons and correlations may be made.

Sentinel lymph node identification in a primary ductal carcinoma arising in the vulva

Primary or metastasic breast-like carcinoma of the vulva is a rare event. Because of the similarity with breast ductal carcinoma, we think that the same principles used for treatment of orthotopic breast cancer can be applied, as well as the use of sentinel lymph node technique, which is widely accepted in the management of early-stage breast cancer. We report a 49-old-year postmenopausal woman who was referred to our institution after small biopsy of a 3.5- × 3-cm right vulvar tumor. Histopathologically, infiltration of the vulvar dermis by a ductal carcinoma of mammary gland type was reported. At operation, the sentinel node technique revealed two sentinel nodes in the right inguinal area. Although these nodes proved negative for malignancy, the patient underwent wide local excision of tumor and complete ipsilateral inguinofemoral lymphadenectomy. The remaining excised nodes were negative. Surgical specimen proved estrogen- and progesterone-positive receptors, the reason for which the patient received tamoxifen adjuvant therapy. This report represents the first case in the world literature of primary breast carcinoma arising in the vulva in which sentinel lymph node identification has been possible. Because of the rarity of this condition, the pathologic similarity of this tumor along with currently accepted guidelines for the management of breast cancer supports the possibility of local excision and sentinel lymph node identification as a possible alternative to inguinofemoral lymphadenectomy

A rare association of synchronous intraductal carcinoma of the breast and invasive carcinoma of ectopic breast tissue of the vulva: case report and literature review

Only 17 cases of breast carcinoma arising in vulvar ectopic mammary tissue have been reported. We present a unique case of synchronous pure intraductal carcinoma of the breast (DCIS) and invasive carcinoma of ectopic breast tissue of the vulva. A 53-year-old woman presented with a 2-cm nodule in left labium major of the vulva. A surgical biopsy revealed an invasive carcinoma of ectopic mammary tissue. The mammography showed irregular microcalcifications of the right breast. The patient underwent left hemivulvectomy, bilateral inguinal sentinel lymph node biopsy, and radioguided breast resection (radioguided occult lesion localization) of the microcalcifications. The definitive histology revealed negative inguinal sentinel nodes, no further residual tumor in the vulva, and a high-grade (grade 3) DCIS in the breast. The synchronous occurrence of primary breast carcinoma and ectopic breast tissue carcinoma in the vulva is an extremely rare finding, only once previously being reported and leading to unsolved problems of differential diagnosis. The presence of a pure DCIS of the breast makes this case really unique, definitively confirming the independent primary origin of both mammary tumors. The inguinal sentinel node biopsy avoided a bilateral inguinal dissection.

Adenocarcinoma of Mammary-Like Glands of the Vulva

Mammary-like glands are a poorly recognized structure of normal vulvar skin. Adenocarcinomas arising from these glands are rare and represent a distinct clinicopathologic entity that must be distinguished from metastatic tumors. We reviewed 19 cases reported in the literature and describe a 51-year-old patient with a long-standing nodule on her right interlabial sulcus. Excisional biopsy and Mohs micrographic surgery demonstrated an infiltrating adenocarcinoma of the mammary-like glands involving the dermis and subcutis. On review of all 20 cases, the mean age at diagnosis was 59.6 years, the labia majora were involved in 13 cases (65%), and the mean lesional size was 2.5 cm. The tumor's histologic patterns varied greatly, although the histomorphologic similarity among this neoplasm, sweat gland carcinomas, and invasive extramammary Paget disease suggested a morphologic spectrum among these tumors. Criteria for establishing the diagnosis of adenocarcinoma of mammary-like glands include identifying transition zones between normal mammary-like glands and adenocarcinomatous areas. This tumor is best categorized as a locally aggressive neoplasm with a low risk for widespread metastasis. Use of aggressive surgical therapeutic regimens, particularly in the case of tumors localized to the skin, must be reassessed, especially given the likelihood of long-term morbidity with such regimens. In our patient, successful Mohs micrographic surgery suggests that alternate management may be adopted for tumors localized to the skin, especially in elderly patients.

Breast cancer metastatic to the vulva

BACKGROUND

Primary cancer of the vulva is not common, constituting only 3-5% of all gynecologic malignancies and <1% of all cancer in the female. Metastatic tumors of the vulva are even more unusual, constituting only 5-8% of all vulvar cancers.

CASE

A 32-year-old female underwent total mastectomy with axillary lymph node dissection for left breast cancer. The patient was well with a postoperative follow-up period of 40 months till a 1.2-cm lump was noted in her left labium majus. Excisional biopsy was performed and histologic examination was done. Pathologic examination of the breast cancer revealed coexistence of intraductal carcinoma and invasive lobular carcinoma. The histologic feature of the invasive lobular carcinoma was consistent with that of the vulvar lesion. The vulvar cancer was consistent with a metastatic lobular carcinoma from the breast.

CONCLUSION

Only with careful gynecologic surveillance in women with breast cancer can the unusual sites of metastasis be detected earlier and appropriately treated.

Metastatic tumors of the vulva: a clinicopathologic study of 66 cases

Metastatic tumors involving the vulva are rare, with only a few series and case reports published in the English literature to date. In this study, we present the clinicopathologic features of 66 cases of metastatic tumors of the vulva seen at the University of Texas M. D. Anderson Cancer Center from 1944 to 2001. The patients' age ranged from 18 to 84 years (mean 54.8 years). The most common presentations were vulvar nodules or a mass (39 cases), pain (7 cases), and ulceration (5 cases). In 46.9% of cases, the primary tumor was of gynecologic origin, whereas in 43.9% of cases the primary tumor was of nongynecologic origin. The remainder had unknown primaries. The site most frequently involved by metastasis was the labium majus (44 cases: 18 on the right, 13 on the left, 6 bilateral, and 7 unspecified side). Thirty percent of the patients received chemotherapy as treatment for the metastasis, 27% received radiotherapy, and the rest received some combination of chemotherapy, radiotherapy, and surgery. Of the 60 patients with available follow-up, 52 died of disease within 1-81 months (median 7.5 months) from diagnosis of the metastasis. Metastatic tumors of the vulva are rare; however, the diagnosis of these tumors is facilitated by the knowledge of a preexistent malignancy and the lack of a mucocutaneous intraepithelial lesion.

Mucinous Adenocarcinoma of Ectopic Breast Tissue of the Vulva

Ectopic breast tissue has been described rarely in the vulva and is known to develop a variety of pathologic changes. Our review of the literature found a total of 11 reported cases of primary infiltrating ductal adenocarcinoma arising in ectopic breast tissue of the vulva. We report what we believe is the first case of primary mucinous adenocarcinoma arising in ectopic breast tissue of the vulva diagnosed by characteristic histopathologic features and immunohistochemical stain results. We discuss the criteria used in diagnosis of primary breast carcinoma of the vulva and review previously reported cases.