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Unusual Aspects of Breast Cancer

Case 2. Synchronous Bilateral Lung and Breast Cancers

Dana-Farber Cancer Institute, Brigham & Women’s Hospital, Harvard Medical School, Boston, MACopyright © 2001 American Society of Clinical Oncology

A 53-year-old postmenopausal woman with a history of smoking, hypertension, and arthritis was evaluated for bilateral chest radiograph findings and bilateral findings on screening mammography. The lung findings included a small peripheral left upper lobe lesion and a more centrally located lesion in the right upper lobe. Thoracoscopic wedge resection of a left lung nodule and mediastinal lymph node sampling revealed bronchioloalveolar adenocarcinoma, without involvement of mediastinal lymph nodes ( Fig 1A, stage T1N0). Subsequent right upper lobectomy and node dissection disclosed poorly differentiated non–small-cell carcinoma with adenosquamous features (Fig 1B, stage T1N0) but with negative nodes. Mammography revealed an area of architectural distortion with spiculated margins in the left breast and fine linear punctate calcifications in the right breast. Both these findings were new compared with previous mammograms obtained the prior year. Stereotactic core biopsy of the left breast revealed invasive lobular cancer moderately differentiated (Fig 1C), which was subsequently found to affect multiple axillary lymph nodes (stage T2N1). Stereotactic core biopsy of the right breast identified ductal carcinoma in situ cribriform type, low nuclear grade, with a focus of microinvasion (< 0.1 cm; stage TmicN0; Fig 1D; arrow indicates microinvasion). The four synchronous tumors had distinct histologic features. Immunohistochemistry showed that the invasive lobular breast tumor was positive for estrogen and progesterone receptors and negative for HER2/neu. The invasive component of the contralateral breast tumor was too small to further characterize by immunohistochemistry, and the lung cancers were negative for all three markers. There was no evidence of metastatic disease on staging serum chemistry and tumor marker tests, bone scan, or head/chest/abdomen/pelvis computed tomography scans. The patient’s mother had died of lung cancer at age 73; there was no other history of cancer in first- or second-degree relatives.

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Pulmonary nodules arising in women with histories of breast cancer may reflect metastatic disease, primary lung cancers, or other benign etiologies. Several large institutions have reported historic experience in evaluating solitary pulmonary nodules among women with prior or synchronous breast cancer.^5-7 Among such women, the pulmonary nodule represented metastatic breast cancer in 37% of the patients, a primary lung cancer in 55% of the cases, and a benign lesion in 8%. Women with breast cancer and a solitary nodule merit pathologic evaluation of the pulmonary lesion, as more than half of such women will not have metastatic breast cancer and may be treated with curative intent. Distinguishing metastatic breast carcinoma from a new primary lung cancer can be difficult if the tumors are adenocarcinomas or poorly differentiated carcinomas that share histologic features. Immunohistochemistry may be useful for discriminating between different adenocarcinomas.⁸

Patients with synchronous or metachronous primary lung cancers or lung and breast cancers seem to have a worse prognosis than patients with a single tumor, principally because of excess mortality from lung cancer.^9,10 Nonetheless, patients with potentially curable tumors may benefit from definitive lung surgery and consideration of curative adjunctive treatments.

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6. Cahan WG, Castro EB: Significance of a solitary lung shadow in patients with breast cancer. Ann Surg 181: 137-143, 1974

7. Adkins PC, Wesselhoeft CW, Newman W, et al: Thoracotomy on the patient with previous malignancy: Metastasis or new primary? J Thorac Cardiovasc Surg 56: 351-361, 1968[Medline]

8. Raab SS, Berg LC, Maj MC, et al: Adenocarcinoma in the lung in patients with breast cancer: A prospective analysis of the discriminatory value of immunohistology. Am J Clin Pathol 100: 27-35, 1993[Medline]

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This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Burstein, H. J. Articles by McMenamin, M. E. Search for Related Content PubMed PubMed Citation Articles by Burstein, H. J. Articles by McMenamin, M. E. Social Bookmarking                            What's this?