Medical Image of the Month: Metastatic Spindle Cell Carcinoma of the Breast

Figure 1. A coronal reconstruction of the patient’s CT of the chest with contrast in lung windows demonstrates extensive, bilateral metastatic disease, with the greatest burden of disease situated in the right lower lobe. Areas of cystic change (blue arrows) and cavitary disease (red arrow) are present.

Clinical Scenario: A 71-year-old woman with primary malignancy of the breast in remission post bilateral mastectomy in 2005 and 2008, presented to the emergency room with progressive shortness of breath for the past 6 months. Upon arrival to the emergency room, she described localized sharp chest pain along the right thoracic wall which had gradually worsened over the past three months. The pain was exacerbated with movement and with deep inspiration. She also endorsed significant hemoptysis, expectorating approximately 500 ml of bloody sputum on the morning of her presentation. Pertinent vitals revealed that she was both tachycardic and tachypneic, saturating 94% on room air with an increased work of breathing. Physical examination was significant for coarse breath sounds and diminished right sided lung sounds. Initial labs demonstrated a normal troponin and an unremarkable EKG. A chest radiograph demonstrated a large left mediastinal and hilar mass with numerous parenchymal nodules bilaterally. A CT of the chest with contrast (Figure 1) demonstrated widespread lung nodules, most notably in the right lung with a confluent mass in the right base. No significant focal lesions were seen in the chest wall or breast regions. A biopsy of the left mediastinal mass was performed and confirmed metastatic spindle cell carcinoma originating from her primary breast cancer.

Discussion: Spindle cell carcinoma of the breast, a variant classified under metaplastic carcinoma, is a rare entity occurring in less than 1% of all incidences of primary breast cancer, and most commonly seen in postmenopausal women (2,5). Treatment is primarily surgical resection. The role of radiation and chemotherapy is unclear and varies per patient treatment plan. Tumors are typically triple-negative, limiting therapeutic options (1,2,5). Primary tumor diameter and grade may be the most important prognostic factors, although prognosis regarding spindle cell carcinoma is generally poor. At the time of diagnosis, incidence of axillary lymph node metastasis was 40 – 56% with a high grade of recurrence at 57% - 63% (1,4,5). Most common extra nodal metastasis was to the lungs. In addition to the poor prognosis of spindle cell carcinomas and high rates of local recurrence, metastatic disease is also frequently seeing in patients, such as the metastatic disease seen with our patient (2-4).

Our patient’s primary breast cancer was treated with a bilateral mastectomy followed by neither chemotherapy nor radiation therapy based on patient’s preference and discussion with her oncology team. The primary tumor was in the left breast with recurrence to the right breast and metastasis to bilateral lungs. Like other cases, a biopsy revealed a triple-negative tumor. She was discharged on supplemental oxygen and is expected to receive P13K inhibitor therapy for targeted palliative treatment.

Vinita Kusupati MD, MBA and Stefano Natali DO

Department of Internal Medicine,

Banner University Medical Center-Tucson Campus

Tucson, AZ USA

References

1. Adem C, Reynolds C, Ingle JN, Nascimento AG. Primary breast sarcoma: clinicopathologic series from the Mayo Clinic and review of the literature. Br J Cancer. 2004 Jul 19;91(2):237-41. [CrossRef] [PubMed]
2. Alaoui M'hamdi H, Abbad F, Rais H, Asmouki H, Soumani A, Khouchani M, Belbaraka R. Rare variant of metaplastic carcinoma of the breast: a case report and review of the literature. J Med Case Rep. 2018 Feb 21;12(1):43. [CrossRef] [PubMed]
3. Carter MR, Hornick JL, Lester S, Fletcher CD. Spindle cell (sarcomatoid) carcinoma of the breast: a clinicopathologic and immunohistochemical analysis of 29 cases. Am J Surg Pathol. 2006 Mar;30(3):300-9. [CrossRef] [PubMed]
4. Khan HN, Wyld L, Dunne B, Lee AH, Pinder SE, Evans AJ, Robertson JF. Spindle cell carcinoma of the breast: a case series of a rare histological subtype. Eur J Surg Oncol. 2003 Sep;29(7):600-3. [CrossRef] [PubMed]
5. Tse GM, Tan PH, Putti TC, Lui PC, Chaiwun B, Law BK. Metaplastic carcinoma of the breast: a clinicopathological review. J Clin Pathol. 2006 Oct;59(10):1079-83. [CrossRef] [PubMed]
6. Tse GM, Tan PH, Lui PC, Putti TC. Spindle cell lesions of the breast--the pathologic differential diagnosis. Breast Cancer Res Treat. 2008 May;109(2):199-207. [CrossRef] [PubMed]

Cite as: Kusupati V, Natali S. Medical image of the month: metastatic spindle cell carcinoma of the breast. Southwest J Pulm Crit Care. 2021;22(6):114-5. doi: https://doi.org/10.13175/swjpcc021-21 PDF 

Medical Image of the Month: Radiation-induced Organizing Pneumonia

Figure 1. Axial contrast enhanced CT depicting marked skin thickening of the right breast with fibrotic changes in the adjacent costal lung parenchyma.

Figure 2. Axial/Coronal CT images in lung window showing central ground glass attenuation with surrounding consolidation areas in both lung fields involving regions beyond the radiation field.

Radiotherapy post breast conserving surgery has been in vogue for the treatment of early breast cancer. Organizing pneumonia is one of the responses the lung has to acute lung injury. However, an unusual organizing pneumonia is being recognized with peculiarity of involving the lung zones beyond the actual irradiated parenchyma. Clinically patients may be asymptomatic or present with fever, nonproductive cough, dyspnea, malaise, fatigue and weight loss. The “reverse halo” sign describes the central ground glass haze surrounded by consolidation. Subsequent imaging may reveal migratory infiltrates.

The recognition of this entity is important as a differential with a good prognosis. Though the response to steroids is marked, radiation-induced organizing pneumonia can quickly relapse once the steroid is withdrawn (1,2).

Saika Amreen MD, Nidha Nazir MBBS, Naseer A. Choh MD, and Tariq Gojwari MD.

Department of Radiodiagnosis

Sher-i-Kashmir Institute of Medical Sciences (SKIMS)

Soura, Srinagar, India

References

1. Takigawa N, Segawa Y, Saeki T, et al. Bronchiolitis obliterans organizing pneumonia syndrome in breast-conserving therapy for early breast cancer: radiation-induced lung toxicity. Int J Radiat Oncol Biol Phys. 2000 Oct 1;48(3):751-5. [CrossRef] [PubMed]
2. Otani K, Seo Y, Ogawa K. Radiation-induced organizing pneumonia: a characteristic disease that requires symptom-oriented management. Int J Mol Sci. 2017 Jan 27;18(2). pii: E281. [CrossRef] [PubMed]

Cite as: Amreen S, Nazir N, Choh NA, Gojwari T. Medical image of the month: radiation-induced organizing pneumonia. Southwest J Pulm Crit Care. 2019;19(6):167-8. doi: https://doi.org/10.13175/swjpcc014-19 PDF

Medical Image of the Month: Malignant Pleural and Pericardial Effusions

Figure 1. CTA chest axial view showing moderate pericardial effusion, bilateral pleural effusions and an anterior mediastinal mass.

Figure 2. Echocardiography subcostal four-chambered view showing a large pericardial effusion with right ventricular collapse during diastole.

A 67-year-old woman with a history of presumed thymoma presented to the emergency department with four weeks of progressive shortness of breath and wheezing. CT imaging of the chest on arrival demonstrated a 13.1 x 8.6 x 8.2 cm anterior mediastinal mass with compression of the SVC, pulmonary veins, and right pulmonary artery (Figure 1). A moderate pericardial effusion was also seen. A transthoracic echocardiogram was performed to further evaluate the pericardial effusion, which revealed diastolic collapse of the right ventricle consistent with cardiac tamponade (Figure 2). The patient was taken for urgent pericardiocentesis, which drained 450cc of sanguineous fluid. Percutaneous biopsy of the mass revealed poorly differentiated carcinoma suspicious for a primary breast malignancy. Cytology of the pericardial fluid did not demonstrate malignancy, however. Cytology of subsequent pleural effusion also was not positive for malignancy, although, both effusions are believed to be related to the malignancy even if no malignant cells were present on analysis.

Malignant pericardial effusions account for 18-23% of cases, and are one of the most common causes of hemorrhagic effusions. Multiple types of cancers can involve the pericardium; lung cancer is the most common but lymphoma, leukemia, melanoma, and breast cancer are other potentially causative malignancies. Presence of a symptomatic malignant effusion is a poor prognostic indicator with median survival on the order of 2-4 months after diagnosis, although certain malignancies (e.g. hematologic rather than solid) may have better results (1).

Nathan Coffman MD and Jessica Vondrak MD

Department of Internal Medicine

Banner University Medical Center

University of Arizona

Tucson, AZ USA

Reference

1. Dequanter D, Lothaire P, Berghmans T, Sculier JP. Severe pericardial effusion in patients with concurrent malignancy: a retrospective analysis of prognostic factors influencing survival. Ann Surg Oncol. 2008 Nov;15(11):3268-71. [CrossRef] [PubMed] 

Cite as: Coffman N, Vondrak J. Medical image of the month: Malignant pleural and pericardial effusions. Southwest J Pulm Crit Care. 2018;17(5): . doi: https://doi.org/10.13175/swjpcc107-18 PDF 

Medical Image of the Week: Lung Entrapment

Figure 1. Pleural Fluid (a) and the collapsed left lung within the hemi-thorax (b).

Figure 2. Malignant involvement of the visceral pleura (arrows).

Figure 3.  Persistent pneumothorax (white arrows) after several days of pleural catheter (black arrow) drainage.

A 74-year-old woman with a history of breast cancer 10 years ago treated with lumpectomy and radiation presented for evaluation of shortness of breath. She was diagnosed with left sided pleural effusion which was recurrent requiring multiple thoracenteses. There was increased pleural fludeoxyglucose (FDG) uptake on PET-CT indicative of recurrent metastatic disease. She underwent a medical pleuroscopy since the pleural effusion analysis did not reveal malignant cells although the suspicion was high and tunneled pleural catheter placement as adjuvant chemotherapy was initiated.

Figure 1 shows a pleurscopic view of the collapsed left lung and the effusion in the left hemi thorax. Figure 2 shows extensive involvement of the visceral pleura with metastatic disease preventing complete lung inflation. Figure 3 shows persistent pneumothorax-ex-vacuo despite pleural catheter placement confirming the diagnosis of entrapment.

Incomplete lung inflation can be due to pleural disease, endobronchial lesions or chronic telecasts.

Lung entrapment and trapped lung are related but distinct clinical entities (1). A trapped lung is a proper diagnosis when there is no active pleural disease however a fibrous peel has been formed due to a remote process and the mechanical effects of the pleura are the primary problem. Lung entrapment is used when incomplete lung inflation is secondary to visceral pleural peel secondary to active infection, inflammation or malignancy and the underlying process then becomes the primary problem.

The parietal pleural biopsies obtained during the pleuroscopy confirmed recurrent metastatic disease and the patient is currently undergoing chemotherapy.

Bhupinder Natt MD and James Knepler MD

Division of Pulmonary, Allergy, Critical Care and Sleep

University of Arizona Health Sciences,

Tucson, AZ USA

Reference

1. Huggins JT, Doelken P, Sahn SA. The unexpandable lung. F1000 Med Rep. 2010 Oct 21;2:77. [CrossRef] [PubMed]

Cite as: Natt B, Knepler J. Medical image of the week: lung entrapment. Southwest J Pulm Crit Care. 2016;13(1):36-7. doi: http://dx.doi.org/10.13175/swjpcc059-16 PDF

July 2015 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology 

Mayo Clinic Arizona

Scottsdale, AZ

Clinical History: A 40-year-old woman with a history of left breast malignancy diagnosed 11 years earlier, initially treated with lumpectomy, radiation, and chemotherapy (doxorubicin, cyclophosphamide, paclitaxel, followed by Herceptin), later treated with mastectomy following recurrence 2 years after diagnosis, presented with a several month history of upper respiratory infectious symptoms, including congestion, productive cough, and rhinorrhea. The patient also complained of some fatigue, although she was still active; she denied shortness of breath initially, but claimed that increasing breathlessness had developed more recently, limiting her exercise tolerance. The patient denied gastrointestinal, gynecological, musculoskeletal, or neurological complaints and no weight loss had occurred.

On admission to the hospital, her white blood cell count was mildly elevated at 14 x 10⁹ cells/L, with anemia as well (hemoglobin / hematocrit= 10 gm/dL / 28%, respectively). Her platelet count was also borderline decreased at 183 x 10⁹ cells/L. Electrolyte and liver panels showed normal values.

A frontal chest radiograph (Figure 1) was performed.

Figure 1. Frontal (A) and lateral (B) chest radiography.

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of six panels)

1. The frontal chest radiograph shows abnormal mediastinal contours
2. The frontal chest radiograph shows basal predominant fibrotic abnormalities
3. The frontal chest radiograph shows large lung volumes with a cystic appearance
4. The frontal chest radiograph shows mildly enlarged central pulmonary arteries
5. The frontal chest radiograph shows no abnormal findings

Reference as: Gotway MB. July 2015 imaging case of the month. Southwest J Pulm Crit Care. 2015;11(1):26-35. doi: http://dx.doi.org/10.13175/swjpcc090-15 PDF

Medical Image of the Week: Leptomeningeal Carcinomatosis

Figure 1. PET/CT scan showing metabolic activity in the mid 3^rd of the left breast without significant adenopathy (arrows).

Figure 2. Panel A: Brain MRI T1 pre contrast image shows normal signal intensity in cerebrum, brain stem and cerebellum with no evidence of acute infarction. Panels B and C: Post contrast images show diffuse leptomeningeal enhancement involving bilateral cerebellar folia and around the surface of brainstem (arrows).

A 65 year old woman with a history of breast cancer presented to the emergency department (ED) with dizziness and disequilibrium, which started a week prior to admission. A year ago, she was diagnosed with locally advanced lobular carcinoma confined to the left breast (Figure 1). She underwent mastectomy followed by chemoradiation including taxol, sunitinib, cyclophosphamide and doxorubicin with remarkable response, and achieved complete remission. In the ED, her neurologic status deteriorated rapidly, she developed tonic-clonic seizures and became unresponsive to verbal and painful stimuli. CT of the head showed no evidence of acute intracranial abnormality or metastatic lesion, however, a brain MRI brain showed contrast enhancement and increased fluid attenuated inversion recovery (FLAIR) signal of the leptomeninges in cranial nerves III, V, VII and VIII as well as cerebellar surface, suggesting meningeal carcinomatosis (Figure 2B and 2C). A lumbar puncture demonstrated malignant cells in the cerebospinal fluid confirming the diagnosis of leptomeningeal carcinomatosis. Palliative radiation therapy with thiotepa was planned, however, her family opted for comfort care only and the patient passed away 6^th day of hospital stay.

Leptomeningeal carcinomatosis (LC) is a devastating complication of systemic cancer that can occur in patients with solid or hematologic malignancies. LC has been described in 5% to 10% of patients with solid tumors, more frequently breast adenocarcinoma, lung adenocarcinoma and melanoma (1,2). LC may be the first manifestation of cancer in 5% to 11% of patients and maybe the sole site of relapse in patients successfully treated for cancer (2). Treatment of LC is currently palliative for most patients, with an expected median survival of less than 6 months (1,2)

Roberto Bernardo MD, Seongseok Yun MD PhD, Ateefa Chaudhury MD, Keri Maher DO, and Tauseef Siddiqi MD

Department of Medicine, University of Arizona, Tucson, AZ

References

1. Bruna J, González L, Miró J, Velasco R, Gil M, Tortosa A. Leptomeningeal carcinomatosis: prognostic implications of clinical and cerebrospinal fluid features. Cancer. 2009;115(2):381–9. [CrossRef] [PubMed] 
2. Kesari S, Batchelor TT. Leptomeningeal metastases. Neurol Clin. 2003:21(1): 25-66. [CrossRef] [PubMed]

Referece as: Bernardo R, Yun S, Chaudhury A, Maher K, Siddiqi T. Medical image of the week: leptomeningeal carcinomatosis. Southwest J Pulm Crit Care. 2014;8(3):190-1. doi: http://dx.doi.org/10.13175/swjpcc028-14 PDF