| Abstract|| |
Metastasis to the breast is rare and most commonly represents spread from a contra-lateral primary mammary carcinoma. Metastasis of solid non-mammary carcinoma is very rare and melanoma and neuro-endocrine bronchogenic carcinoma are the more common primary neoplasms implicated. In up to half of affected individuals, there may be no prior diagnosis of malignancy. Breast metastasis by melanoma to our knowledge has never been described to an augmented breast, moreover, to a ruptured implant capsule.
Keywords: Breast, metastasis, melanoma
|How to cite this article:|
Wilsher MJ, Moncrieff NJ. Melanoma metastatic to a ruptured silicone breast implant capsule. Indian J Pathol Microbiol 2012;55:86-8
| Introduction|| |
Metastasis to the breast is rare. Once contralateral primary adenocarcinoma and haematological malignancies have been excluded, melanoma and neuroendocrine carcinoma of lung are the next most common. ,,, They most often present as a rapidly enlarging mass in the upper outer quadrant and half of patients have local pain or discomfort.  No previous report was found of melanoma metastatic to an augmented breast. We describe a case of cutaneous melanoma, metastatic to a ruptured breast implant capsule in a post-menopausal woman.
| Case Report|| |
The patient, a 58-year-old female, had bilateral breast augmentation with silicone implants in 1981 and in mid-2010 presented with significant swelling and pain in her left breast. Breast ultrasound reported implant rupture 26 × 25 mm across, with capsule herniation in the left axillary region, at a site corresponding to clinical tenderness. No such changes were seen in a 2008 study. A small rupture was also not excluded on the right side by the same scan. The patient had a history of an ulcerated, 1.4-mm deep, Clark level 4, primary cutaneous malignant melanoma with a satellite nodule, on her right back in mid-2007, treated by wide excision and a skin graft. A bilateral axillary sentinel node biopsy revealed two left (contralateral) axillary nodes containing metastatic melanoma and was followed by left axillary lymphadenectomy. In early 2008, she had three subcutaneous in-transit metastases excised from her left back, followed in mid-2008 by repeat left axillary dissection for additional nodal metastases, and subsequently, radiotherapy to the left axilla and left chest wall.
Both implants and capsules were surgically removed and sent for pathological analysis. The left capsule measured 125 × 80 × 40 mm and weighed 110 g. Slicing revealed a solid area, 40 × 40 × 30 mm with a pale, homogeneous cut surface [Figure 1]. The right side measured 110 × 70×20 mm, weighed 47 g, and showed no solid areas. There was free silicone. Microscopy demonstrated fibrous pseudocapsules with evidence of rupture of both silicone implants, with a resultant florid histiocytic response to silicone droplets. Additionally, on the left, there was a poorly differentiated and partly necrotic, epithelioid and partially spindle cell malignant neoplasm, forming the solid area described macroscopically, but also seen extending, even as single cells, along the inner aspect of the capsule. The tumor cells were non-pigmented, pleomorphic, and highly mitotically active. In areas of necrosis, viable tumor cells often clustered around vessels. The tumor was intimately admixed with the florid histiocytic response to free silicone [Figure 2]. It mimicked a poorly differentiated primary ductal carcinoma and because of the silicone droplets, in areas it even mimicked pleomorphic liposarcoma. However, supported by the clinical history and immunohistochemical studies which demonstrated expression by tumor cells of S100 [Figure 2], [insert] and WT-1 (but not HMB45, Melan-A, CD31, pancytokeratin, AE1/AE3, CK7, CK20, TTF-1, ER, PR and Her-2), a diagnosis of metastatic malignant melanoma was given.
|Figure 1: Macroscopic view of 40 mm solid mass in wall of implant capsule|
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|Figure 2: Microscopic view of melanoma admixed with histiocytic response to silicone. H and E, medium power. Insert: S100|
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The patient progressively deteriorated and died 4 months later, following multiple pulmonary and mediastinal nodal metastases, a left pleural effusion requiring pleurodesis and possible colitis (on PET scan).
| Discussion|| |
Breast metastasis is rare and less than 500 cases of secondary mammary involvement by solid neoplasms have been reported in the English literature.  They may mimic malignant and even benign neoplasms.  The most commonly reported mammographic characteristics are of single or multiple circumscribed masses of varying size, with well-defined contours or irregular margins, in the upper outer quadrant, without spiculation, calcifications, or other signs of a desmoplastic response one associates with a primary breast neoplasm. 
Breast metastasis accounts for 0.5-6.6% of malignant breast neoplasms.  In Georgiannos'  series of autopsy and clinical cases, secondary tumors comprised up to 3% of breast neoplasms. 87% of metastases arise from a contralateral breast primary carcinoma, so genuine non-mammary metastasis is very uncommon. In up to half of non-mammary metastasis, there may be no prior diagnosis of malignancy. ,, Hemopoietic neoplasms, especially lymphomas, involve the breast secondarily more frequently than solid tumors. Among the latter, the most common primary neoplasms are cutaneous melanoma and bronchogenic carcinoma, particularly neuroendocrine carcinoma. ,,, In children and adolescent girls, rhabdomyosarcoma is the most common solid organ primary neoplasm. ,, Breast metastasis is most common in premenopausal woman, which may reflect breast tissue vascularity and hormonal influences. , In males, prostatic adenocarcinoma is the most common primary. 
Approximately 20% of melanoma patients will develop metastasis and breast is a rare site for metastasis. Interestingly, in up to 40% of patients affected by melanoma breast metastasis, the breast metastasis is the first disease manifestation (7). In one study, the median interval between primary cutaneous melanoma diagnosis and presentation with a breast metastasis is 33 months.  Primary melanoma resulting in a breast metastasis, most often arise in cutaneous sites, particularly the upper trunk and upper limbs, and less commonly from other sites such as choroid and anorectum. , Direct lymphatic drainage from the upper limbs and trunk to the breast may occur.  Melanoma metastasis in childhood is most often from an extremity and in 38% of cases from a congenital naevus. 
Breast metastasis from solid tumors generally has a poor prognosis and is often associated with disseminated disease. ,, The same is generally true for melanoma with an average survival of 10 months after diagnosis. , However, there may be a small subgroup of patients with a solitary melanoma breast metastasis, whose prognosis may be more favorable. , Although, this observation may reflect the duration of follow up.
Microscopically, breast metastasis (not only melanoma) may be suspected based on atypical histological features, such as the finding of a well circumscribed, but un-encapsulated tumor with a periductal and/or perilobular distribution, absence of an in-situ component, the presence of multiple foci, and of numerous tumor emboli.  However, primary breast carcinoma has a varied phenotype, so they are just guidelines. Preoperative diagnosis of breast metastasis may help avoid inappropriate radical surgery such as mastectomy, and this includes the use of immunohistochemistry, which is often mandatory. 
The current case was unusual because it involved an augmented breast, with a ruptured implant. No reference to this occurrence was found in a thorough literature search (SNOMED).
Silicone implant rupture is defined as a breach of any size in the implant shell. Estimates of the prevalence of implant rupture vary widely, in part reflecting methods of determination (clinical, ultrasound, mammography or MRI). Implant age is the most common determinant of rupture with the risk increasing significantly with implant age. Rupture-free survival rates at 10 years may be 83-85% versus 98% at only 5 years, as determined by MRI. For most women, implant rupture is thought to be a non-progressive, symptomless, and harmless condition. 
Previously, breast implants were thought to be associated with the development of connective tissue disease and malignancy (breast and non-breast) and this led to the Food and Drug Administration (FDA) in 1991 to ban the use of silicone implants apart from post-mastectomy, replacement of a pre-existing silicone implant and in clinical studies, until 2006. Major reviews determined that there is no increased risk for connective tissue disease, primary breast carcinoma, and malignancy other than breast.  Interestingly, there is an observed association between primary breast ALK1-negative anaplastic large cell lymphoma (ALCL) and silicone implants. Of the only 30 cases of ALK1-negative ALCL reported in the English literature thus far, 22 were associated with silicone implants. This association requires more follow-up study. 
The subject of this case report is post-menopausal, when breast metastasis is reportedly less common. The history of prior left axillary metastasis and undoubtedly increased blood flow to the breast because of the inflammation associated with the breast implant may both be contributing factors. The mass was formed of both metastatic melanoma and a florid foreign body reaction to silicone following rupture of a 29-year-old implant. The ultrasound changes were interpreted as being due to the latter, and as a result despite the history, breast metastasis was not suspected. The history of prior melanoma was paramount to achieving a correct histological diagnosis of metastatic melanoma (and not of triple negative high grade ductal carcinoma of breast), because the histology of a predominantly epithelioid neoplasm was already sufficiently unusual due to the presence abundant silicone granulomata. This case serves to increase the spectrum of settings in which breast metastasis may present.
| Acknowledgments|| |
Lisa O'Conner and Alexandra Thomas.
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Mark J Wilsher
Department of Histopathology, Douglass Hanly Moir Pathology, 14 Giffnock Avenue, Macquarie Park, NSW 2113
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]