Extensive thoracic vertebral and chest wall metastases as the initial presentation of breast cancer: a case report and literature review

Abstract

Metastatic involvement of the bones remains the most common form of distant metastasis in breast cancer, largely due to the anatomical and functional characteristics of the thoracic spine, ribs, and sternum. These structures are notable for their high content of red bone marrow, rich vascularization, and their connection to Batson's venous plexus, all of which facilitate their early involvement in oncologic dissemination. In certain cases, multiple metastases in the thoracic skeleton may represent the first and sole clinical manifestation of an undiagnosed malignant process, presenting considerable diagnostic challenges at the initial presentation in patients without a known oncologic history. A 60-year-old female patient presented with severe thoracic back pain. Imaging revealed multiple lytic lesions in the vertebral bodies of the thoracic spine, ribs, and sternum. The initial differential diagnosis included multiple myeloma and bone metastases. The patient underwent minimally invasive neurosurgical intervention involving spinal canal decompression and percutaneous vertebral biopsy. A percutaneous vertebral biopsy confirmed the presence of undifferentiated carcinoma. Subsequent PET-CT identified a metabolically active lesion in the breast, establishing the primary diagnosis, followed by the initiation of systemic therapy. This case, in conjunction with a review of the current literature, highlights the diagnostic complexity of presentations where pain is the sole initial symptom of an undetected malignancy. Such situations demand a high index of oncologic suspicion from the outset, timely application of advanced imaging modalities such as MRI and PET-CT, mandatory histological verification of affected regions, and strong interdisciplinary coordination to achieve accurate diagnosis and formulate a personalized treatment strategy.

Keywords: bone metastases; breast cancer; rib metastases; spinal pain; sternal metastases; thoracic spine.

Figure 1

Preoperative CT/MRI imaging: (A, B) Multislice CT: sagittal (A) and frontal (B) reconstructions show multiple osteolytic lesions in the vertebral bodies from Th1 to Th12, with vertebral body collapse primarily at Th6-Th10, reduced intervertebral disc height, cortical bone destruction, and involvement of the posterior vertebral elements including the arches and facet joints. Extensive vertebral destruction is accompanied by lytic changes in the ribs and sternum. (C, D) Sagittal thoracic spine MRI: on T1-weighted images (C), hypointense metastatic lesions are seen replacing the bone marrow of thoracic vertebrae. On T2-weighted images (D), a distinct posterior paravertebral soft tissue component is evident, with spinal cord compression at Th10-Th11, associated with dural sac deformation and spinal canal stenosis. (E–G) 3D CT reconstructions of the thorax in various projections: anterior (E), frontal (F), and posterior (G) views demonstrate multiple metastatic rib lesions with lytic destruction, predominantly along the posterolateral arcs, as well as involvement of the sternum, including both the manubrium and body. Notable findings include thoracic cage deformation and signs of pathological fractures with resulting bone defects.

Figure 2

Postoperative CT imaging: (A) Sagittal view: confirmed decompression of the spinal canal at the Th10-Th11 level with partial removal of destructive masses and partial restoration of canal patency. Metastatic lesions persist within the vertebral bodies; however, compression is visually reduced due to surgical debridement. (B) Axial view: deformed Th10 vertebra with marked osteolytic destruction of the vertebral body and posterior wall; the spinal canal appears reconstructed. Paravertebral soft tissue components are present without evidence of volume progression.

Figure 3

Histological examination: Hematoxylin and eosin-stained sections reveal tumor fragments displaying well-defined lobular and alveolar-like structures, along with areas resembling ductal formations [(A), ×100; (B), ×200]. The tumor cells are monomorphic, uniform, and cylindrical in shape, with pale perinuclear cytoplasmic halos and moderately basophilic nuclei. Focal zonal necrosis is observed in the centers of some duct-like structures, consistent with comedo-type necrosis. The stroma is fibrous, predominantly dense, with isolated sclerotic regions containing polymorphic hyperchromatic cells. At the periphery of the tumor nests, adherence to bony trabeculae is noted, indicating invasion into adjacent osseous tissue.