A rare case of umbilical metastasis after delayed transverse rectus abdominis myocutaneous flap reconstruction for invasive breast cancer

Introduction

Breast cancer has a distinct metastatic pattern, but can still metastasise anywhere. Metastases to the umbilicus are rare and are usually of gastrointestinal origin [1]. Here we present a case report with an unusual metastatic pattern.

Case report

A 46-year-old female presented with a four-month history of an inflamed and painful umbilicus, which had worsened over this time. There had been no trauma to the area and she was otherwise well with no systemic symptoms.

On examination, the umbilicus was erythematous and contracted, with fluctuance of the underlying skin, but no surrounding lesions or skin nodules (see Fig. 1). Investigations including full blood count, inflammatory and tumour markers, staging computerised tomography and positron emission tomography were all normal.

A core biopsy of the umbilicus was carried out and histological investigations confirmed a recurrence of invasive breast cancer consistent with the primary breast cancer she had treated eleven years previously.

In 2004, aged 35 years, the patient was diagnosed with left sided breast cancer (T2N1M0). She underwent a mastectomy and sentinel node biopsy for an oestrogen (ER), progesterone (PR) positive Grade 2 invasive ductal carcinoma. She had adjuvant chemotherapy comprising of four cycles of Epirubicin and Cyclophosphamide, as well as Taxol as part of a phase three randomized controlled trial (TANGO trial) for women with early stage breast cancer. She also had radiotherapy consisting of 50 Grays in 25 fractions to the chest wall and 45 Grays in 25 fractions to axilla and supreclavicular fossa, as well as hormone therapy with Tamoxifen. One year later a delayed reconstruction with transverse rectus abdominis myocutaneous (TRAM) flap was undertaken.

Two years after the breast cancer diagnosis, the patient presented to her general practitioner with localised sternal pain, which was initially diagnosed as costochondritis. The pain progressively worsening, so she was referred for positron emission tomography (PET) imaging, which confirmed localised metastatic infiltration of the sternum. This was subsequently treated with radical radiotherapy (55 Grays in 20 fractions) with complete response. Soon after, she had a prophylactic bilateral salpingo-oophorectomy, and hormone treatment was changed from Tamoxifen to Letrozole.

Retrospective analysis showed of the original breast cancer confirmed human epidermal growth factor receptor (HER 2) positive, hence, she was started on Trastuzumab in February 2007, which she continued until September 2011.

For nine years between the sternal and umbilical metastasis, she remained well and had annual mammograms and follow up appointments.

Discussion

Breast cancer has a distinct metastatic pattern involving regional lymph nodes, bone, liver, lungs and brain, but can metastasise anywhere. Metastases to the umbilicus are rare, with an incidence of 1%–3% of all intra-abdominal or pelvic malignancies [1]. Gastrointestinal malignancies account for about half of primary sources and are mainly gastric, colonic or pancreatic in origin. Gynaecological cancers account for 25% of cases [1].

There are only a small handful of reports of umbilicus metastasis from a primary breast cancer [2–4]. In the reports by Murata et al. [4] and Basley et al. [3], the umbilicus metastases were seen nine and eleven years respectively after the primary breast cancer was treated. Neither of these cases occurred after TRAM flap reconstruction.

Umbilical metastasis is extremely rare after TRAM reconstruction. The flap consists of the skin, fat and rectus abdominis muscle with its blood supply is tunneled beneath the skin to the chest, tunelled through the skin or breast mound or creates a breast mount itself. Its’ advantages include good cosmetic outcome that looks and feels like normal breast tissue and avoids the use of implants in most cases. Its’ disadvantages can include loss of sensation to the breast and abdominal hernias, which can result from loss of rectus abdominis muscle.

Umbilical metastases are more commonly known as the Sister Mary Joseph nodule. Sister Mary Joseph Dempsey was the surgical assistant of William J. Mayo at St. Mary’s Hospital in Rochester, Minnesota from 1890–1915. She informed Mayo of this trend, and he published an article about it in 1928 [5].

The exact route of metastasis to the umbilicus is mostly unknown. Proposed methods for the spread of cancer cells include direct transperitoneal spread via the lymphatics, which run along the obliterated umbilical vein; hematogenous spread or via remnant structures like the falciform ligament or a remnant of the vitelline duct [6].

To our knowledge this is the first report of a metastasis from any primary cancer to the umbilicus after TRAM flap. This case serves as a reminder that any lesion at any stage after treatment for breast cancer should be viewed with suspicion of recurrence and investigated and treated appropriately.