Malignant Adnexal Tumors in Breast Cancer Patients are often Primary Ovarian Carcinomas
Abstract & Commentary
Synopsis: In a series of 54 women with breast cancer and adnexal masses evaluated with ultrasound, half of the malignant adnexal masses were primary ovarian carcinomas, and half were metastatic breast cancer. Adnexal metastases of breast cancer often manifest as solid bilateral adnexal masses at ultrasound in women with stage IV breast cancer.
Source: Hann LE, et al. Adnexal masses in women with breast cancer: US findings with clinical and histopathologic correlation. Radiology 2000;216:242-247.
Many women with breast cancer undergo periodic radiologic evaluations, some of which result in the demonstration of an adnexal mass. Because women with breast cancer are at increased risk of ovarian carcinoma as well as at risk for metastatic deposits of breast cancer in the adnexa, and because each of those two situations has different therapeutic implications, it often is important to know the cause of the adnexal mass in a given patient. In order to assist in the radiologic differential diagnosis of adnexal masses detected in women with breast cancer, researchers at Memorial Sloan-Kettering Cancer Center performed a retrospective study of 54 such women who had undergone pelvic ultrasound (US) and histopathologic examination of 72 adnexal masses. They found that 40 (74%) of the women had benign adnexal masses, and 14 (26%) women had malignant adnexal masses; both benign and malignant masses were present in an adnexa in three women. Malignant adnexal masses were found as often in premenopausal as in postmenopausal women (seven [27%] of 26 premenopausal women, seven [25%] of 28 postmenopausal women). Of the 14 women with malignant adnexal masses, seven (50%) had metastases of breast cancer (infiltrating ductal carcinoma [n = 4], lobular carcinoma [n = 3]) to the ovary. Of note, the breast cancer metastases affected both adnexa in each of these seven women, and all seven women had known stage IV breast carcinoma at the time of US examination. In the other seven (50%) women, the malignant adnexal masses were primary ovarian carcinoma; none of these women had stage IV breast carcinoma. In four of seven women whose adnexal masses were due to primary ovarian carcinoma, both adnexa were involved.
Although all the breast cancer metastases in the adnexa were solid at histopathologic examination, three of those adnexal masses appeared both solid and cystic at US due to the presence of hemorrhage or concomitant benign adnexal cysts. Seven of 11 ovaries containing ovarian carcinoma were mostly cystic at US.
COMMENT BY DAVID M. PANICEK, MD
The majority of adnexal masses evident at US in women with breast cancer who undergo surgery for those masses are benign lesions (such as simple cysts, serous cystadenomas, endometriomas, and corpus luteum cysts). However, breast cancer metastases to the ovary and primary ovarian carcinomas are not rare causes of adnexal masses in women with breast cancer and adnexal masses visible at US, having occurred in 26% of such women in this study.
Differentiation between a breast cancer metastasis to the ovary and a primary ovarian carcinoma can have substantial clinical importance in a woman with known breast cancer because a metastasis may be treated with laparoscopic surgery and medical therapy, whereas an ovarian carcinoma generally requires a formal staging laparotomy. Although the number of patients in this study was relatively small and further studies are needed to confirm and refine the conclusions, the current findings do provide some useful guidance when formulating a radiologic differential diagnosis for an adnexal mass in a woman with breast cancer. For example, it seems that the menopausal status of the woman should not be given much weight (given that similar percentages of adnexal masses were malignant in the premenopausal and postmenopausal groups), whereas the stage of her breast cancer should be given strong weight (because all the women with metastases to the ovary—and none of the women with primary ovarian carcinoma—had known stage IV breast cancer at the time of US examination). A unilateral adnexal mass would more likely represent a primary ovarian carcinoma than a metastasis of breast cancer (given that the adnexal metastases of breast cancer involved both adnexa in each of the 7 women with adnexal metastases in this study). A solid adnexal mass at US would more likely be a metastasis from breast cancer than a primary ovarian carcinoma (which usually is cystic). Nevertheless, histopathologic examination of an adnexal mass often will be required to allow definitive treatment decisions to be made in women with breast cancer.
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