Case Study: Supraclavicular nodules in females: May be primary duct carcinoma

Summary

A 47-year-old female presented with recent weight loss, loss of appetite and general weakness. Left supraclavicular nodules were palpable and aspiration smears were inconclusive. Trucut biopsy from the lesion confirmed primary duct carcinoma.

Background

Duct carcinoma in females generally presents as an immobile non-tender intra-mammary lump. Any nodules outside the breast tissue in these patients are regarded as secondary deposits. Primary carcinomas of the axillary tail of the breast or axillary breast tissue are reported, but primary duct carcinoma is still not known to arise de-novo in ectopic breast tissues in the supraclavicular or neck region.

Case Presentation

A 47-year-old female presented with recent weight loss, loss of appetite and general weakness. Her routine hemogram, chest X-ray, liver function tests and abdominal ultrasonography were normal. Bilateral breasts contained no lumps, and the axillae were normal. Only the left supraclavicular region revealed 3 to 4 firm, discrete, immobile nodules which were non-tender.

Investigations

  • Routine hemogram to rule out leukemiasupraclavicular nodule histology1samanta
  • Chest X-ray, Monteux test, Sputum for AFB to rule out malignancy and tuberculosis
  • Liver function tests and abdominal ultrasonography to rule out gastrointestinal pathology
  • Mammography to rule out breast tumor
  • FNAC to rule out malignancy and tuberculosis (inconclusive in this case)
  • Trucut biopsy for the confirmatory diagnosis

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Differential Diagnosissupraclavicular nodule histology2samanta

  • Lymphoma
  • Tuberculosis
  • Metastatic carcinoma
  • Adnexal tumor
  • Pseudotumorous pathology

Treatment

Radical surgery with regional lymphadenectomy was performed, followed by chemotherapy and radiotherapy.

Outcome and Follow-Up

The patient is doing well 6 months after radical surgery and following 4 cycles of Herceptin-based chemotherapy.

Discussion

In addition to cervical lymphadenitis, tuberculosis in the head and neck region can produce isolated disease in the oral cavity, ear, salivary glands, temporomandibular joint, nose and larynx. Seventy-five percent of the head and neck tuberculosis patients do not have pulmonary involvement. Fine needle aspiration cytology is highly effective in the diagnosis of nodal tuberculosis. Malignancies in lymph nodes in our country are predominantly metastatic in nature with an incidence varying from 65.7% to 80.4%, and lymphomas range from 2% to 15.3% among lymph nodes aspirated from all sites. Enlarged lymph nodes are accessible for FNAC and are of importance especially to diagnose secondary or primary malignancies. It plays a significant role in developing countries like India, as it is a cheap procedure, simple to perform and has almost no complications. The diagnosis given on the cytological material is often the only diagnosis accepted and sometimes there is no further correlation with histopathology, especially in cases of advanced malignancies. It also provides clues for occult primaries and sometimes also surprises the clinician who does not suspect a malignancy. Cutaneous and subcutaneous metastases are very common in the head neck region, especially lymph nodes and also the breast tissues from a variety of primaries like the kidney, lung, colon and ovaries — but duct carcinoma primarily arising in the ectopic breast tissue in the neck is an unusual finding and easily missed on routine investigations, including FNAC, and therefore it needs a biopsy for confirmation. A high degree of clinical suspicion should be exercised.

Learning Points/Take Home Messages

Nodules over the upper chest or neck: primary carcinomas should also be suspected and investigated accordingly.

About The Author

Dr-Swapan-Samanta-64x80
Dr. Samanta, MBBS, MD is currently a consultant at Suraksha diagnostic PVT. LTD. Kolkata, India for histopath, cytopath and hematology. His other interests are: oncopathology, bone marrow and neuropathology.

Sources:
Prasad KC, Sreedharan S, Chakravarthy Y, Prasad SC. Tuberculosis in the head and neck: experience in India. J Laryngol Otol. 2007; 121(10):979-85. http://www.ncbi.nlm.nih.gov/pubmed/17367564

Bagwan IN, Kane SV, Chinoy RF. Cytologic evaluaton of the enlarged neck node: FNAC utility in metastatic neck disease. Int J Pathol. 2007;6:2. http://archive.ispub.com/journal/the-internet-journal-of-pathology/volume-6-number-2/cytologic-evaluation-of-the-enlarged-neck-node-fnac-utility-in-metastatic-neck-disease.html#sthash.ZxxEa9EY.dpbs

Alam K, Khan A, Siddiqui F, Jain A, Haider N, Maheshwari V. Fine needle aspiration cytology (FNAC): A handy tool for metastatic lymphadenopathy. Int J Pathol. 2010;10:2. http://archive.ispub.com/journal/the-internet-journal-of-pathology/volume-10-number-2/fine-needle-aspiration-cytology-fnac-a-handy-tool-for-metastatic-lymphadenopathy.html#sthash.H6OVwOIL.dpbs

Khajuria R, Goswami KC, Singh K, Dubey VK. Pattern of lymphadenopathy on fine needle aspiration cytology in Jammu. JK Sci. 2006; 8:157–9. http://www.jkscience.org/archive/Volume83/patlymph.pdf

Fernandez-Flores A: Cutaneous metastases: a study of 78 biopsies from 69 patients.Am J Dermatopathol 2010; 32(3):222-239. http://www.ncbi.nlm.nih.gov/pubmed/20051816

Chaignaud B, Hall TJ, Powers C, Subramony C, Scott-Conner CE. Diagnosis and natural history of extramammary tumors metastatic to the breast. J Am Coll Surg.1994; 179:49–53. http://www.ncbi.nlm.nih.gov/pubmed/8019724

Dreizen S, Dhingra HM, Chiuten DF, et al. Cutaneous and subcutaneous metastases of lung cancer. Clinical characteristics. Postgrad Med J. 1986 ; 80:111–116. http://www.ncbi.nlm.nih.gov/pubmed/3786272

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