The objective of this report is to present a rare case of primary cutaneous mucinous carcinoma (PCMC) manifesting with granuloma annulare (GA), and to discuss the association as a paraneoplastic phenomenon.A 65-year-old female presented with a painless, slow-growing, cystic nodule less than 1 cm over the left lateral canthus. The clinical presentation was highly suspicious of sebaceous cyst.The histopathologic examination revealed variable sizes of neoplastic cell clusters in a pool of abundant mucin. A focus of palisading lympho-histiocytic infiltrate surrounding a necrobiosis suggestive of granuloma annulare adjacent to the tumor is identified. Series of extensive investigations performed did not reveal any primary origin.GA can rarely be associated with various malignant conditions. Its association and prognostic importance to these conditions are unclear. The presence with certain malignancies and the resolution of GA with the treatment of underlying malignancy are an indicator that this condition can very well be a paraneoplastic phenomenon.
INTRODUCTION:
Breast cancer is the most common cancer in women worldwide. The leading cause of morbidity and mortality is due to distal metastasis. While metastasis to the brain, bones, lungs, liver and adrenal glands is usually seen, metastasis to the gastrointestinal tract is a rare, with colorectal involvement being an even rarer entity. We present a case of metastatic breast cancer presenting as a benign-appearing polyp on a colonoscopy.
CASE DESCRIPTION/METHODS:
A 56-year-old female with no significant past medical history except for schizophrenia presented with chief complaints of left breast mass with diffuse lymphadenopathy. Biopsy of the mass revealed invasive ductal carcinoma which was ER/PR (+) and HER2 (−) on immunohistology. PET/CT revealed diffuse bone metastasis. Contrast brain MRI showed isolated cerebellar brain lesion suggestive of neoplasm, likely secondary to the metastatic lesion. Patient was evaluated by Radiation oncology and radiation therapy started. During the hospital course, she was noted to have a gradual decrease in hemoglobin from 11 to 8.6 g/dl, while the reticulocyte count was normal. Although fecal occult blood testing was negative, Gastroenterology was consulted and EGD revealed gastritis and biopsies revealed inflammatory gastritis that was negative for H.Pylori. Colonoscopy revealed a 4 mm sessile polyp in the transverse colon (Figure 1). Biopsy of the polyp was consistent with adenocarcinoma which was ER/PR (+) (Figure 2) and HER2 (−) on immunohistology. Additional nuclear staining with breast markers including mammoglobin, and gross cystic disease fluid protein-15 was performed, and metastatic breast cancer was highly suggested. Unfortunately, due to the advanced nature of her breast cancer and poor overall nutritional status, the patient expired.
DISCUSSION:
In a review of cases reporting primary breast cancer with metastasis to the gastrointestinal tract, invasive lobular carcinoma of the breast is much more frequently represented. In our case presented above, the diagnosis was invasive ductal carcinoma of the breast with metastasis to the transverse colon. Diagnosis of metastasis to the colon may be difficult, as symptoms may be nonspecific. Due to this, patients with this entity often present late in disease progression. PET/CT often are non-contributory and do not show colonic metastasis. In conclusion, while gastrointestinal, especially colorectal, metastasis is rare, metastatic breast cancer can mimic a benign-appearing colon polyp on colonoscopy.
Carcinosarcoma of the female genital tract is a rare and highly malignant neoplasm comprising histologically epithelial and mesenchymal components. Clinicopathologic factors potentially associated with this tumor were evaluated retrospectively using a data set of 27 patients at the Istanbul University Medical School Hospital during 1995 to 2004. Carcinosarcoma occurred in the uterus in 13 cases, in the ovary in 12 cases, in the ovary and uterus in 1 case, and in the fallopian tube in 1 case. For each tissue section, immunohistochemical expression levels of estrogen receptor (ER), progesterone receptor (PR), Ki-67, p53, and p63 were determined separately for the epithelial and mesenchymal components by the percentage of cells staining positively. Multivariate analysis with the Cox proportional hazards model was used to establish statistical significance for the censored data. The results show that age older than 62 years (median) (P = .006), FIGO stage more than II (P = .003), and epithelial Ki-67 expression percentage (P = .016) were independently associated with shortened survival and that epithelial ER expression percentage (P = .04) along with epithelial p63 expression percentage (P = .008) were independently associated with longer survival. Because epithelial ER and PR expression percentages had a significantly positive correlation, they were entered separately in the model to prevent multicollinearity resulting in borderline significance (P = .053) for the PR expression level's association with longer survival. Interaction terms of the aforementioned factors with the location of the tumor revealed no statistical significance, implying that the noted associations apply generally to all carcinosarcomas of the female genital tract. Other variates considered but that have no significant association with survival include expression levels of the aforementioned markers in the mesenchymal component, p53 expression level, tumor size, depth of myometrial invasion, presence of the heterologous component, and histologic types of the carcinomatous component. The prognostic factors identified in this study may improve clinical decision making concerning adjuvant treatment of female patients with genital carcinosarcoma. Furthermore, the identification of the level of ER and, to a less extent, PR expression as positive prognostic factors for survival may present a potential therapeutic target for this highly aggressive tumor type.
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