our patient , a 60-year - old woman , originally presented to her primary care physician for pelvic discomfort in september 2006 . at that time
, she underwent a pelvic ultrasound as well as a computed tomography ( ct ) scan of the abdomen and pelvis , which showed a complex ovarian mass .
a pap smear performed one month later was positive for atypical glandular cells suspicious for adenocarcinoma . in november 2006
, she underwent a total abdominal hysterectomy with bilateral salpingoophorectomy , omentectomy , and periaortic lymphadenectomy . upon intraoperative exam , her surgeons noted involvement of the omentum and appendix , as well as studding of the small bowel mesentery and right diaphragm .
the pathologic specimen showed extension of the tumor throughout the fallopian tubes , appendix , omentum , and 5 out of 5 positive lymph nodes .
the patient underwent placement of an intraperitoneal catheter and an intravenous port - a - cath for initiation of chemotherapy in december 2006 .
the remainder of the patient 's past medical history is noncontributory as she was previously in excellent health prior to the diagnosis of ovarian cancer .
unfortunately , she suffered a hypersensitivity reaction to the taxol , and was therefore switched to carboplatin and abraxane .
she received a total of 8 cycles of that combination , with only 1 cycle postponed secondary to neutropenia . just before the 8th cycle , in order to assess her response to treatment , she underwent a ct scan of the chest , abdomen , and pelvis .
in addition , her ca-125 level , which had previously reached a plateau of 30 u / ml , had risen to 123 u / ml . concerned about the possibility of drug - resistant disease , she was evaluated for enrollment in a trial of avastin and tarceva .
she underwent a new ct scan of the chest , abdomen , and pelvis , in order to obtain baseline data for the trial ( 3 months after her previous ct scan ) .
the new ct scan showed interval development of right axillary lymphadenopathy ; the largest lymph node was 1.1 x 1.8 cm and suspicion of a new primary breast cancer was raised .
we proceeded with breast magnetic resonance imaging ( mri ) with gadolinium which showed no suspicious lesions or masses .
however , she developed a significant rash in association with these drugs and required dose reduction . in october 2007 , almost a year after her initial ovarian cancer diagnosis , the patient reported the new - onset of right breast edema .
although she had been previously followed for the right axillary lymphadenopathy , she had recently noticed an increase in erythema , thickness , and warmth of the skin of her right breast [ fig 1 , 2 ] .
she was treated with a 10-day course of antibiotics , with no change in symptoms .
she then underwent an ultrasound of her breast that showed an ill - defined hypoechoic area in the right upper outer quadrant with multiple enlarged lymph nodes .
a subsequent mammogram showed scattered fibroglandular densities and an area of architectural distortion with a few small punctate calcifications .
her gynecologic oncologist performed a fine - needle aspiration of the breast , which showed cells consistent with adenocarcinoma .
she then underwent a second bilateral breast mri , which confirmed the presence of an area of heterogeneous enhancement measuring 8 x 4 cm , highly suggestive of cancer , with areas suspicious for tumoral extension to the chest wall [ fig 3 , 4 ] .
because of these findings , the patient was referred to a breast surgical oncologist , who performed a punch biopsy of her right breast .
pathologic analysis showed multiple foci of high - grade adenocarcinoma with dermal lymphatic invasion , with morphology similar to that of the previous ovarian cancer [ fig 5 ] .
furthermore , the breast tissue specimen immunohistochemistry results were positive for ca-125 , but negative for estrogen receptor ( er ) , progestin receptor ( pr ) , and the her-2/neu oncoprotein . upon review by our institution 's multidisciplinary tumor board , it was concluded that these results were consistent with an ovarian primary tumor .
breast cancer is one of the most common primary malignancies in women , yet metastatic tumors to the breast are infrequent , accounting for only 0.5% to 1.3% of breast cancer cases 1 . the most common source of metastasis to the breast is a contralateral primary breast tumor , frequently from transthoracic or lymphatic spread .
a study by hadju and urban involving 4,051 breast cancer patients found an overall incidence of primary gynecologic cancers metastatic to the breast of 0.17% , with only 0.07% of metastatic disease originating from a primary ovarian tumor 3 .
the first case report of ovarian cancer with metastasis to the breast was in 1907 by sitzenfrey 4 .
to date , a total of only 39 such cases have been reported in the english - language literature 5 .
ovarian metastasis to the breast mimicking primary inflammatory breast carcinoma is even more infrequent , with only 6 previous cases reported [ table 1 ] .
inflammatory metastasis to a single breast was first reported by ibach in 1964 6 , followed by 5 other case reports 2 , 4 , 7 , 8 , 9 . of note , the most recent patients , including ours , all had a diagnosis of stage iiic papillary serous adenocarcinoma .
in contrast to primary breast tumors , metastasis to the breast generally consists of firm , well - circumscribed , multinodular masses .
in addition , the masses are usually superficial and less fixed to surrounding tissues , with the overlying skin generally of normal consistency .
the most common form of clinical presentation ( in 85% of patients ) was a solitary tumor ; only 4% of patients had diffuse involvement 4 .
furthermore , the most common location was the upper outer quadrant in 62% of patients 3 .
metastatic tumors to the breast more frequently present as well - circumscribed , non - calcified dense masses .
they generally lack spiculation and microcalcifications as well as architectural distortion and other skin changes .
however , because of the presence of psammoma bodies associated with some ovarian cancers , microcalcifications can be seen with ovarian metastasis 3 , 10 .
breast metastasis from a primary ovarian tumor , however , commonly lacks a characteristic pattern , may be morphologically indistinguishable from its primary , and is associated with widespread dissemination .
in addition , breast metastasis from a primary ovarian tumor generally is diagnosed an average of 2 years after the initial diagnosis of ovarian cancer 2 .
our patient developed a markedly diffuse inflammatory process of her right breast with features consistent with inflammatory breast cancer within 1 year after her initial diagnosis .
histopathological analysis of breast and ovarian tumors can yield similar results . therefore , accurate differentiation is necessary , because treatment and prognosis differ significantly .
the most common histologic variant of ovarian cancer associated with metastatic disease to the breast is papillary serous adenocarcinoma 3 .
immunohistochemistry may provide additional insight into the origin of the tumor . by combining the tumor markers oc125 and ov632 , yamaski et al .
found a sensitivity of 86% and a specificity of 89% for the diagnosis of metastatic ovarian cancer 10 .
secondary breast involvement from an ovarian tumor suggests widespread dissemination and is associated with a poor prognosis . according to several studies , after the detection of metastatic breast disease secondary to an ovarian primary tumor , survival times ranged from 13 days to 3.5 years 2 , with most patients dying within 1 year 11 .
another study found a 1-year survival rate of 40% for patients with ovarian cancer who also had breast metastasis , as opposed to a 4-year survival rate of 75% for patients with primary breast cancer 12 .
inflammatory metastatic disease to the breast also confers a grave prognosis : patient survival ranges from 3 to 18 months ( median , 6 months ) after diagnosis of the metastasis to the breast [ table 1 ] .
extramammary tumors should be distinguished from primary breast tumors to avoid any unnecessary surgical procedures .
correct diagnosis is vital : surgical interventions for patients with secondary breast cancers are potentially both diagnostic and palliative .
ovarian metastasis to the breast should be treated as a systemic disease , with appropriate chemotherapeutic agents .
mastectomy of the breast mass is likely best reserved for patients who are unresponsive to systemic therapy and require palliation 11 .
although ovarian metastasis to the breast presenting as inflammatory breast cancer is rare , it should be included in the differential diagnosis for any patient with a personal history of ovarian cancer .
accurate differentiation is necessary because treatment differs significantly for patients with ovarian metastasis to the breast , as compared with patients with primary inflammatory breast cancer .
ovarian metastasis to the breast confers a poor prognosis : patient survival ranged from 3 to 18 months , with a median survival of 6 months after the diagnosis of the breast metastasis .
 background . 
 primary ovarian carcinoma with metastasis to the breast is rare , with only 39 cases reported in the current literature . 
 ovarian metastasis to the breast presenting as inflammatory breast carcinoma is even more infrequent , with only 6 cases reported.case . 
 we present a patient who developed metastatic inflammatory cancer of the breast from a stage iiic papillary serous ovarian adenocarcinoma approximately 1 year after the original diagnosis . 
 pathologic analysis confirmed the origin of the tumor : a high - grade adenocarcinoma morphologically similar to the previously diagnosed ovarian cancer . 
 in addition , the tumor was strongly positive on immunohistochemistry for ca-125 , identical to the ovarian primary . 
 the patient died of diffuse metastasis 5 months after the breast tumor was noted.conclusion . 
 although ovarian metastasis to the breast presenting as inflammatory breast cancer is rare , it should be included in the differential diagnosis for any patient with a personal history of ovarian cancer . 
 accurate differentiation is necessary because treatment differs significantly for patients with ovarian metastasis to the breast , as compared with patients with primary inflammatory breast cancer . 
 ovarian metastasis to the breast confers a poor prognosis : patient survival ranged from 3 to 18 months , with a median survival of 6 months after the diagnosis of the breast metastasis . 