The Utility of Ultrasound-guided Tru-cut Biopsy in the Diagnosis of Occult Breast Carcinoma Presenting as Ovarian Malignancy with Multiple Metastases: A Case of Unknown Primary

Abstract

This paper documents the utility of ultrasound-guided tru-cut biopsy in the diagnosis and subsequent management of a case of occult breast carcinoma presenting with multiple distant metastases in the absence of a primary breast lesion. She was initially diagnosed as primary ovarian malignancy with metastatic disease and subsequently underwent transvaginal ultrasound-guided tru-cut biopsy of the right ovarian mass. Histologic and immunohistochemical studies were consistent with a metastatic adenocarcinoma of breast origin. The patient underwent chemotherapy for primary breast carcinoma and has responded well.

Keywords: carcinoma of unknown primary; occult breast cancer; ovarian metastases; tru-cut biopsy; ultrasound.

Figure 1

¹⁸F-fluorodeoxyglucose PET-CT showing hyper-metabolic areas with intense FDG uptake in the liver, right adnexal region and multiple lymph nodes in the mediastinum and abdomen.

Figure 2

Transvaginal ultrasound showing a solid ovarian mass with abundant central and peripheral branching vascularity (Color Score – 4).

Figure 3

Transabdominal scan showing multiple hyperechogenic hepatic masses with hypoechogenic halo (“bull’s eye” or “target” sign, yellow arrows), suggestive of hepatic metastases.

Figure 4

Tru-cut biopsy of the right ovarian mass done under transvaginal ultrasound guidance. The tru-cut needle is inserted through the needle guide attached to the transvaginal probe. After securing placement of the needle within the tumor, the biopsy gun is fired. The biopsy needle (yellow arrows) is shown penetrating into the lesion. The dotted line represents the track of the needle.

Figure 5

Tissue specimen obtained from tru-cut biopsy fixed in 10% formaldehyde solution.