Carcinoma of the breast metastatic to the peritoneum as a source of positive vaginal smears

T HE vaginal smear has proved itself to be a valuable adjunct in the detection and diagnosis of female genital cancer.L 2, 3 Exfoliation of cells from a primary malignant tumor of the uterus, vagina, or occasionall)the tubes4 is the usual source of the tumor cells appearing in the vaginal smear. Malignant lesions of other organs metastatic to the endometrium or endosalpinx can shed tumor cells that will likewise appear in the smear. Occasionally carcinoma of the ovary, either directly through the tubes or by means of metastatic spread, can also give rise to positive cells. The following case is an unusual one in that the primary lesion was a scirrhous carcinoma of the breast, and in addition the surfaces of the secondary lesion from which the exfoliated cells were derived were contiguous with the peritoneal cavity and not in contact with the internal surfaces of the uterus or tubes. Mrs. B. P., a 66-year-old woman, was first admitted to the Massachusetts General Hospital in October, 1946, at which time a right radical mastectomy was performed. The pathological report was scirrhous carcinoma of the breast with metastases to all 7 axillary lymph nodes. She was asymptomatic for 5 years. In October, 1951, at the age of 71, she noted the onset of a vaginal discharge. Pelvic examination performed 2 weeks later was negative, but a vaginal smear was reported as positive (Fig. 1). A second vaginal smear two weeks later was also positive. The patient was readmitted to.the hospital on Nov. 25, 1951. A preliminary dilatation and curettage were grossly negative and examination of the pelvic organs under anesthesia revealed the uterus and adnexa to be of normal size. However, because of the presence of a firm irregularity in the cul-de-sac and of ascites, exploratory laparotom: was carried out. The peritoneal cavity contained 300 C.C. of straw-colored fluid and was studded with careinomatous implants. The nodules were present over the surfaces of the omentum, broad ligaments, and tubes. The ovaries and uterus were negative. Ascitic fluid was obtained for cytological study. Bilateral oophorectomy was carried out to determine what effect the removal of these organs would have on the metastatic disease. At this point it seemed quite apparent that the peritoneal implants were the source of the positive tumor cells appearing in the vaginal smear, The tubes and fundus of the uterus were therefore removed to allow thorough pathological study of these organs and rule out a genital source of the tumor cells. The remainder of the uterus was thoroughly inspected, curetted, and closed. The patient made an uneventful recovery and was discharged on 1.5 mg. of ethinyl estradiol daily. Pathological examination of the operative specimen confirmed the presence of metristatic carcinoma of the omentum, broad ligaments, and serosal surfaces of the tubes. The ovaries, the tubal walls and endosalpinx, and the uterus were negative for tumor. The histological appearance of the tumor was consistent with a breast origin. Cytological examination of the aseitic fluid revealed tumor cells similar to those found in the previous vaginal smears (Fig. 2).