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she was studied using positron emission tomography &#40;PET&#41; to identify a small nodule in the lateral and deep region of the left breast&#44; with pathology findings suggesting a metabolic origin &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; which led to an ultrasound-guided biopsy and a histological diagnosis of moderately differentiated infiltrating ductal carcinoma &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Hormonal treatment and lumpectomy of the nodule as well as left axillary lymphadenectomy was performed with a good outcome&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The spine is the most common site of bone metastases&#59; it is estimated that about 10&#37; of cancer patients develop spinal metastases &#40;&#62;50&#37;<span class="elsevierStyleHsp" style=""></span>multilevel metastases&#41;&#44; especially associated to carcinoma of the breast&#44; prostate and lung&#46; While up to 36&#37; of spinal lesions may be asymptomatic&#44; low back pain secondary to a pathologic fracture is the predominant symptom&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Occult breast cancer consists in the appearance of a metastatic axillary lymph node&#44; without a clinically and radiologically primary breast tumor&#59; this is rare&#44; and described in 0&#46;3&#37;&#8211;0&#46;8&#37; of all breast tumors&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The first images&#44; during the initial approach&#44; are based on plain x rays&#46; However&#44; in most cases these findings are often nonspecific&#44; making the use of other complementary imaging tests such as GO&#44; CT&#44; MRI and PET for providing great help in determining the cause of vertebral involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>Of these&#44; PET will identify lesions with an abnormal metabolism without an objective anatomic abnormality &#40;sensitivity 62&#37;&#8211;100&#37; and specificity 96&#37;&#8211;100&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> As for hidden breast cancer&#44; the detection of such small lesions allows for the diagnosis when other conventional imaging tests do not lead to identification&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical Responsibilities</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Protection of people and animals</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that this study did not perform experiments on humans or animals&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Data confidentiality</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their workplace on the publication of data from patients&#44; and all patients included in the study have received sufficient information and gave written informed consent to participate in the study&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Right to privacy and informed consent</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors state that patient data does not appear in this article&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Disclosures</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no disclosures to make&#46;</p></span></span>"
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Journal Information
Vol. 11. Issue 2.
Pages 118-120 (March - April 2015)
Vol. 11. Issue 2.
Pages 118-120 (March - April 2015)
Images in Clinical Rheumatology
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Lumbar Pain as the Single Manifestation of an Occult Breast Cancer. Usefulness of Positron Emission Tomography
Dolor lumbar como única manifestación de un cáncer oculto de mama, utilidad de la tomografía por emisión de positrones
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Marco Aurelio Ramírez Huarangaa,
Corresponding author
hurauma@hotmail.com

Corresponding author.
, Verónica Salas Manzanedoa, Marcos Paulino Huertasa, Yolanda Torres Sousab, Claudia Carolina Ramos Rodríguezc
a Servicio de Reumatología, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
b Servicio de Radiología, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
c Servicio de Anatomía Patológica, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
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A 68-year-old female patient with spondylolysis, fibromyalgia, osteoporosis and recent BI-RADS I (negative mammogram malignancy without nodules or calcifications) mammography screening presented lumbar pain after physical overexertion, with a vertebral crush fracture on D7 and normal laboratory tests (tumor, bone metabolism markers and acute phase reactants). Subsequently, given the progressive worsening, an extension study with bone scintigraphy (BS), computed tomography (CT) and magnetic resonance imaging (MRI) was performed, showing lesions suggestive of an infiltrative process in the D6, D7, D10 and L5 vertebral bodies and nonspecific left axilla lymphadenopathy, without a clear primary origin (Fig. 1) Finally, she was studied using positron emission tomography (PET) to identify a small nodule in the lateral and deep region of the left breast, with pathology findings suggesting a metabolic origin (Fig. 2), which led to an ultrasound-guided biopsy and a histological diagnosis of moderately differentiated infiltrating ductal carcinoma (Fig. 3). Hormonal treatment and lumpectomy of the nodule as well as left axillary lymphadenectomy was performed with a good outcome.

Fig. 1.

(A) Mammography BIRADS I. (B) Adenopathy with cortical thickening suspicious of metastasis. (C–E) A D7 vertebral fracture with a sclerotic pattern is seen in the sagittal CT and a hypointense signal on MR imaging T1.

(0.14MB).
Fig. 2.

(A) Pathological uptake in the GO level of vertebral bodies and at the level of left axillary lymphadenopathy. (B and C) A positive correlation between bone and lymph nodes with an increase of metabolic activity in the PET is observed.

(0.18MB).
Fig. 3.

(A) Hematoxylin–eosin (4×); tumor cells with hyperchromatic nuclei are observed. (B) Immunohistochemical staining (4×) cells with expression of E-cadherin, surrounded by a desmoplastic stroma. (C) At higher magnification (20×), other areas of the cylinder forming gland precursors infiltrating the interstitium, which is fibrous and shows an inflammatory reaction, may be seen.

(0.54MB).

The spine is the most common site of bone metastases; it is estimated that about 10% of cancer patients develop spinal metastases (>50%multilevel metastases), especially associated to carcinoma of the breast, prostate and lung. While up to 36% of spinal lesions may be asymptomatic, low back pain secondary to a pathologic fracture is the predominant symptom.1,2

Occult breast cancer consists in the appearance of a metastatic axillary lymph node, without a clinically and radiologically primary breast tumor; this is rare, and described in 0.3%–0.8% of all breast tumors.3,4

The first images, during the initial approach, are based on plain x rays. However, in most cases these findings are often nonspecific, making the use of other complementary imaging tests such as GO, CT, MRI and PET for providing great help in determining the cause of vertebral involvement.5Of these, PET will identify lesions with an abnormal metabolism without an objective anatomic abnormality (sensitivity 62%–100% and specificity 96%–100%).6 As for hidden breast cancer, the detection of such small lesions allows for the diagnosis when other conventional imaging tests do not lead to identification.7,8

Ethical ResponsibilitiesProtection of people and animals

The authors declare that this study did not perform experiments on humans or animals.

Data confidentiality

The authors declare that they have followed the protocols of their workplace on the publication of data from patients, and all patients included in the study have received sufficient information and gave written informed consent to participate in the study.

Right to privacy and informed consent

The authors state that patient data does not appear in this article.

Disclosures

The authors have no disclosures to make.

References
[1]
D. Togawa, U. Lewandrowsky.
The pathophysiology of spinal metastases.
Cancer in the spine. Current clinical oncology, pp. 17-23
[2]
E. Pirici, A. Pirici, N. Patrana, F. Recareanu, F.L. Badulescu, A.E. Crisan, et al.
Vertebral bone metastasis in breast cancer: a case report.
Rom J Morphol Embryol, 52 (2011), pp. 897-905
[3]
P. Paholpak, W. Sirichativapee, T. Wisanuyotin, W. Kosuwon, P. Jeeravipoolvarn.
Prevalence of known and unknown primary tumor sites in spinal metastasis patients.
Open Orthop J, 6 (2012), pp. 440-444
[4]
M.A. Luna, S. Sánchez-Méndez, A. Mariscal, S. Viscaya, V. Vallejos, M. Solá, et al.
Cancer oculto de mama: caso clínico y revisión de la literatura.
Clin Invest Gin Obst, 39 (2012), pp. 21-28
[5]
J. Farrerons, J. Malouf, A. Laiz, V. Longobardi.
Protocolo de actuación diagnóstica y terapéutica ante una fractura vertebral.
Medicine, 9 (2006), pp. 3913-3915
[6]
C. Gámez, A. Sabaté, J.A. Narváez, L. Rodriguez, F.J. García.
La tomografía por emisión de positrones asociada con la tomografía computarizada en tumores del aparato locomotor.
Radiologia, 54 (2012), pp. 3-13
[7]
E.M. Gil, A. Sánchez, F. Moya, P. González.
Hallazgos con PET de cáncer de mama primario en mujer con tumor de origen desconocido.
Rev Esp Med Nucl, 23 (2004), pp. 206
[8]
D. Takabatke, N. Taira, K. Aogi, S. Ohsumi, S. Takashima, T. Inoue, et al.
Two cases of occult breast cancer in which PET-TACK was helpful in identifying primary tumors.
Breast Cancer, 15 (2008), pp. 181-184

Please cite this article as: Ramírez Huaranga MA, Salas Manzanedo V, Huertas MP, Torres Sousa Y, Ramos Rodríguez CC. Dolor lumbar como única manifestación de un cáncer oculto de mama, utilidad de la tomografía por emisión de positrones. Reumatol Clin. 2015;11:118–120.

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