Presentation
Weight loss of 9 kilograms in a year. Abdominal mass palpated in the left flank.
Patient Data
Large calcified gallstone in a thin-walled gallbladder. No biliary dilatation.
Atrophic pancreas but no focal pancreatic mass lesion or pancreatic ductal dilatation.
Non-obstructing right kidney interpolar region caliceal calculus, diameter 6 mm.
Small simple left renal cyst. Kidneys otherwise normal.
Normal liver, adrenals and spleen.
The ascending and transverse colon are moderately dilated with fecal material, the colon is collapsed from splenic flexure downwards, no focal abnormality at the transition.
Left adnexal cysts, measuring 4.9 cm and 5.3 cm. No calcification or soft tissue component.
No adnexal mass on the right.
No free fluid. No size significant abdominal or pelvic nodal enlargement.
Small hiatus hernia.
Bibasal atelectasis/scarring. Small left pleural effusion, new from prior CT. Imaged lung bases are otherwise clear.
Left 7th, 8th and 10th rib fractures with evidence of healing, new from prior.
Impression of lytic focus in left 9th and right 10th lateral ribs.
Mixed lytic and sclerotic change of T12 and L5 vertebral bodies, the T12 appearances have worsened since March 2022, though vertebral body heights are preserved in the imaged spine.
Further destructive lytic focus in T12 spinous process, new from prior.
A few scattered sclerotic foci in the bony pelvis.
Normal imaged proximal femora.
Some asymmetrical soft tissue in the imaged left breast.
Opinion:
Appearances of the imaged skeleton are concerning for bone metastases, no pathological vertebral fracture demonstrated. Appearances are not typical for myeloma but consider screening and breast examination. CT chest advised to complete staging.
Moderate density breasts. There are benign coarse calcification seen right nipple areolar region, the right breast is otherwise normal on mammography.
Within the left lower outer quadrant there is an ill-defined 19 mm mass suspicious of malignancy. There is increasing calcifications seen left upper inner quadrant extending over an area of 26 mm. Additional tomosynthesis views (not shown here), lateral and lateral magnification views shows these calcifications to have an indeterminate appearance.
Right breast R2, benign; left breast R4, suspicious.
Ultrasound of the left lower outer quadrant to include the marked area at 3 o'clock and corresponding to the mammographic abnormality there is an ill-defined heterogeneous mass measuring 20 mm x 14 mm, appearances would be those of a carcinoma.
Left breast U5, malignant
The left axilla and areas corresponding to the calcification on mammography were also scanned and appeared normal on ultrasound (images not shown here).
There are multifocal bone metastases in the axial and proximal appendicular skeleton including the sternum, bilateral ribs, right clavicle, multiple regions in the spine, sacrum, both sides of the pelvis, and both humeri and femora.
Impression: multifocal bone metastases.
Case Discussion
This is a case of incidental metastatic breast cancer in a patient referred for abdominal symptoms.
The importance of review areas, including the breasts in female patients even when only partially imaged, is illustrated here; there is the impression of a focal density in the partially imaged left breast on the initial CT abdomen and pelvis.
The left breast lesion was sampled. The histopathology and immunohistochemistry demonstrated invasive carcinoma ER positive, PR positive, and HER2 positive.
The patient was initially managed with hormone therapy but follow-up imaging demonstrated disease progression and will commence chemotherapy (paclitaxel/trastuzumab).
Acknowledgements: Dr Maryam Mohsin, Dr Dilani Manuel, Dr Sriram Vaidyanathan.
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