The Gulf Journal of

Oncology

ISSUE 17 JANUARY 2015TAblE of CoNTENTS

Original Articles /StudiesImpact of bMI on locoregional Control among Saudi Patients with breast Cancer after breast Conserving surgery and Modified Radical Mastectomy ...................................................................................................................................... 07E.F. Al Saeed, A.J. Al Ghabbban, M.A. Tunio

A statistical quantification of radiobiological metrics in Intensity Modulated Radiation Therapy evaluation ........................ 15A. Surega, J. Punitha, S. Sajitha, BS Ramesh, A. Pichandi, P. Sasikala

A method for assessment of radiation treatment chain of cervical cancer with combined external and brachy radiation therapy ................................................................................................................................................................................ 24A. Chaparian, P. Shokrani

Role of Lymphadenectomy and Its Impact On Survival In Endometrial Carcinoma – An Institutional Experience .............. 30S. Suchetha, P. Rema, S. Vikram, P.S. George, I. Ahmed

Breast Cancer—Epidemiology, Risk Factors and Tumor Profiles in Bangladeshi underprivileged women.............................. 34M. Rahman, A. Ahsan, F. Begum, K. Rahman

Early hematological effects of chemo-radiation therapy in cancer patients and their pattern of recovery- A prospective single institution study ............................................................................................................................... 43H.N. Lee, M.K. Mahajan, S. Das, P. Jeyaraj, J. Sachdeva, M.S. Tiwana

Platinum-based chemotherapy in metastatic triple negative breast cancer: Experience of a tertiary referral centre in India ....................................................................................................................................................................... 52V.V. Maka, H. Panchal, S.N. Shukla, S.S. Talati, P.M. Sha, K.M. Patel, A.S. Anand, S.A. Shah, A.A. Patel, S. Parikh

A Single Institution 18-Years Retrospective Analysis of Malignant Melanoma ............................................................................ 58A. Mukherji, A.K. Rathi, P.K. Mohanta, K. Singh

MRI and ultrasonography for assessing multifocal disease and tumor size in breast cancer: Comparison with histopathological results. ............................................................................................................................................................ 65V. Rudat, A. Nour, N. Almuraikhi, I. Ghoniemy, I. Brune-Erber, N. Almasri, T. El-Maghraby

Patient’s Compliance On the Use of Extended Low Molecular Weight Heparin Post Major Pelvic Surgeries in Cancer Patients at King Hussein Cancer Center ...................................................................................................... 73M. Baba, M. Al Masri, M. Salhab, M. El Ghanem

Can we use Sorafenib for advanced Hepatocellular Carcinoma (HCC) Child Pugh B? ............................................................. 82K. Rasul, A. Elessam, S. Elazzazi, R. Ghasoub, A. Gulied

Case ReportsThe external auditory canal as an unusual site for metastasis of breast carcinoma: A case report ............................................ 85B.A. Baraka, B.J. Al Bahrani, S.S. Al Kharusi, I. Mehdi, A.M. Nada, N.H. Al Rahabi

Primary Mixed Cellularity Classical Hodgkin lymphoma of the Lumbar spine – An unusual presentation ............................ 88K.R. Anila, R. A. Nair, S. Prem, K. Ramachandran

Subdural hematoma during therapy of gastro-intestinal stromal tumor (GIST) with Imatinib mesylate ................................ 92J. Feki, G. Marrekchi, T. Boudawara, N. Rekik, S. Maatoug, Z. Boudawara, M. Frikha

Conference Highlights /Scientific Contribution • Workshop Highlights –The Second Regional Training Of The Trainers’ (TOT) Workshop On Palliative

Care, Kuwait, 23-26 November 2014 ...........................................................................................................................................96• News Notes ....................................................................................................................................................................................102• Advertisements .............................................................................................................................................................................107• Scientific events in the GCC and the Arab World for the 1st Semester of 2015......................................................................108

8585

External auditory canal as an unusual site for metastasis of breast cancer: A case report

B.A. Baraka1, B.J. Al Bahrani1, S.S. Al Kharusi1, I. Mehdi1, A.M. Nada1, N.H. Al Rahabi2

1Medical Oncology Department, National Oncology Center, Royal Hospital, Muscat, Oman 2Histopathology Department, Royal Hospital, Muscat, Oman

Corresponding Author: Dr. Bahaaeldin A. Baraka, MBBS, MRCP Sce Oncology UK, Medical Oncology Department, National Oncology Center, Royal Hospital, PB 1331, PC 111 Mobile No. +96893564880, Email: bahaabaraka@gmail.com

AbstractMetastatic breast cancer is one of most

common cause of death in women worldwide. The estimated incidence of breast cancer to be metastatic at diagnosis is 6%, with a five year survival rate of about 21%. There are three types of breast cancer recurrence: local, regional and distant metastasis mainly to the lung, liver,

bone or brain. Review of literature indicate a relatively few reported cases about metastatic breast cancer to soft tissue. We present a case of metastatic breast cancer to left external auditory canal.

Keywords:breast cancer, auditory, unusual, metastatic,

Oman

IntroductionBreast cancer is the most common cancer

in women worldwide. In developed countries, women have a greater life-time risk of breast cancer than women who live in developing countries(1). The prevalence of metastatic breast cancer is high because many women live with this disease for many years(1). The most common sites for breast cancer metastasis include the bone, lung, liver, lymph nodes, chest wall, and the brain. However, case reports have documented breast cancer dissemination to almost every organ in the body. Hormone-receptors positive tumors are more likely to spread to the bone as the initial site of metastasis; hormone-receptors negative and/or HER-2-positive tumors are more likely to recur initially in viscera. Lobular (as opposed to ductal) cancers are more often associated with serosal metastases to the pleura and abdomen(2). Only about 10% of newly diagnosed breast cancer patients have metastatic disease at presentation. This proportion is far higher in areas where screening programs are not available(3).

Breast metastases from extra-mammary malignancies are uncommon, constituting

about only two per cent of all breast tumors(4). The most common cancers to metastasize to the breast are, in declining order of frequency: malignant melanoma, lymphoma, lung cancer, ovarian carcinoma, soft tissue sarcoma, and gastrointestinal and genitourinary tumors. Besides these, metastases from osteosarcoma, thyroid neoplasms, and cervical, vaginal and endometrial carcinomas to the breast have been sporadically reported(5). The breast as a site for distant metastasis from head and neck cancers is highly uncommon. The first case of breast metastasis from head and neck carcinoma which appeared in the literature in 1972 was an autopsy finding. The first clinical cases were reported in 1977(6).

Cancer of the external auditory canal is infrequent, with an incidence of approximately 1 per million population per year and almost always is of primary origin(7). Breast cancer metastasis to soft tissue is rare. We present a case of metastatic breast cancer to left external auditory canal.

Case reportA 53 year old patient, female, a known case of

breast cancer where conservative breast surgery and SLN biopsy were performed in February 2009 and was staged as pT2N0 (AJCC2007). Histopathologically diagnosed as IDC, G3, with vascular invasion, immunologically confirmed

86

Unusual site for metastasis of breast cancer, B.A. Baraka, et. al.Unusual site for metastasis of breast cancer, B.A. Baraka, et. al.

to be luminal A. The patient received post-operative sequential chemotherapy (4 cycles of cyclophosphamide/Doxorubicin), radiotherapy followed by hormonal treatment (Tamoxifen).

She presented on September 2013 with left ear pain for which temporal bone CT was performed to her revealing left external auditory canal polyp. Hence she underwent excisional biopsy and histopathological examination yielded high grade metastatic ductal carcinoma (Figure 1), with central comedo-type necrosis (Figure 2) and receptor study revealed tumor positives for estrogen, positive to progesterone and negative for Her-2. A thorough search was then carried out to detect any other distant metastasis; Bone scan showed widespread, multiple bony metastasis skull, sternum, multiple ribs bilaterally, pelvic bones, bilateral femori and both knees, PET CT scan revealed diffuse uptake throughout the axial and appendicular skeleton, no abnormal FDG uptake within head and neck region, but there was relatively non FDG avid left pleural effusion. Head MRI showed few clavicular sclerotic bony metastasis, and a tiny enhancement in the cerebellar hemisphere which suggested early leptomeningeal metastasis. Interestingly Chest and abdomen CT were performed and showed left pleural effusion and multiple bilateral tiny pulmonary nodules highly suspicious of metastasis.

Patient received local radiotherapy to left ear with 3DCRT and 6MV photon with left anterior and posterior oblique portals to a dose of 3000 cGy/ 10 fractions, with good tolerability, thereafter and in view of patient’s general condition and asymptomatic visceral metastasis, the patient commenced on palliative hormonal treatment: letrazole by dose of 2.5 mg daily.

DiscussionMetastatic tumors presenting as soft tissue

masses are relatively rare and can be the source of diagnostic confusion both clinically and pathologically. Although soft tissue represents approximately 55% of our body mass hematogenous metastases to these areas are rare. Direct extension of a primary tumor to soft tissue is a much more common event than distant soft tissue metastases. Several factors have been implicated in the rarity of this phenomenon such as changes in pH, accumulation of metabolites, and the local temperature at soft tissue sites (8).

Breast cancer is known to metastasize to anywhere in the body, either by hematogenous or lymphogenous routes. Our patient has previously been treated for breast cancer and now had metastatic soft tissue mass on the left external auditory canal (EAC). Prognosis of neglected soft tissue metastases from breast cancer has been death in a span of about five months (9)

Figure 1. Microphotograph showing deposits of metastatic ductal carcinoma

Figure 2. Infiltrative ductal carcinoma with central comedo-type necrosis

Unusual site for metastasis of breast cancer, B.A. Baraka, et. al.

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G. J. O. Issue 17, 2015Unusual site for metastasis of breast cancer, B.A. Baraka, et. al.

With a thorough literature search, only two large reports on distant soft tissue metastasis(10,11) were available. Plaza JA et al., (2008) have a series of 118 patients having metastasis to the soft tissue and out of those only 13 cases corresponds to metastasis from breast cancer; 6 of those were having metastasis to shoulder and arm, 3 cases were having metastasis to the back, 2 cases to chest wall, one case to abdominal wall and one of those was to forearm (11). However, we have not found any report of soft tissue mass of external auditory canal as a metastasis from distant cancer.

Metastatic breast cancer at presentation or first recurrence should be biopsied as part of work up which ensures accurate determination of recurrence, tumor histology and allow for biomarkers’ determination and selection of proper treatment. Determination of hormone receptor status should be repeated when it was previously unknown, negative or not overexpressed. ER and PR assay and Her-2 neu may be falsely negative,

falsely positive and there may be discordance between primary and metastatic tumor (13).

ConclusionMetastases to soft tissue are rare and can be

easily misdiagnosed histologically for a primary soft-tissue sarcoma. The clinical distinction between a metastatic neoplasm to soft tissue and a primary soft-tissue sarcoma is critical because treatment and prognosis are markedly different. Soft tissue metastasis from breast cancer though uncommon, can present even to unexpected sites like external auditory canal where it can be confused as a soft tissue tumor.

Both painful and painless growing soft tissue masses, irrespective of their distance from the primary breast cancer, should be examined and biopsied to rule out possible metastatic breast cancer(14) even after a curative breast cancer operation. In doing so, patients will be saved from dismal prognoses due to improper and delayed diagnosis and treatment.

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