Image Quizzes

Pulling sensation in chest

Reviewed by Avan J. Armaghani, MD

Science Photo Library/Getty Images

A 39-year-old nonsmoking woman in the United States presents with a history of a painful, pulling sensation in her chest that she originally attributed to a change in her exercise regimen. Six years earlier, the patient was diagnosed with estrogen receptor (ER)–positive ductal carcinoma in situ (DCIS) in her left breast. She opted for mastectomy and immediate reconstruction, followed by adjuvant therapy with tamoxifen (20 mg/d for 5 years). Physical examination reveals a palpable mass in the medial half of her left breast with several hard, painful nodules in the left axilla. Mild wheezing throughout the upper lungs is heard on auscultation. Abdominal examination does not reveal any abnormalities. Laboratory findings are all within normal range, apart from C-reactive protein, which is elevated. The patient is 5 ft 7 in and weighs 133 lb.

What is the likely diagnosis?


Fibrocystic disease

Breast cancer with metastasis to the chest wall and lungs

Intraductal papilloma

The history and findings in this case are suggestive of breast cancer with metastatic spread to the chest wall and lungs.

Globally, breast cancer is the most frequently diagnosed life-threatening cancer and the leading cause of cancer death among women. In the United States, an estimated 287,850 new cases of invasive breast cancer will be diagnosed in 2022; in addition, 43,250 deaths because of breast cancer are expected to occur. Despite advances in adjuvant treatment strategies, such as tamoxifen for patients with ER-positive breast cancer, many patients with early breast cancer still experience disease recurrence after primary therapy. Because of its systemic nature and inevitable resistance to therapy, metastatic breast cancer is largely incurable.

Approximately 5%-35% of patients with breast cancer develop locoregional recurrence either alone or with distant metastases. The lung is a frequent site of breast cancer metastasis. In addition, approximately 11% of patients have persistent chest wall progression. Recurrent breast cancer in the chest wall is considered a marker of poor prognosis and is normally accompanied by or a precursor to distant metastases.

Risk factors for chest wall recurrence include primary tumor size, primary stage, and lymph node involvement; in addition, the risk is increased in patients aged 40 years or younger and in those with gross multifocal or multicentric disease. Histopathological risk factors include positive margin status, DCIS, extensive intraductal component, high grade, lymphovascular invasion, tumor oncogene, and tumor suppressor gene expression (eg, p53 and HER2), and ER status.

According to the National Comprehensive Cancer Network (NCCN) 2022 guidelines, the staging evaluation of patients who present with recurrent or stage IV breast cancer should include:

• History and physical exam
• Complete blood count and liver function tests
• Chest diagnostic CT
• Bone scan
• Radiographs of any long or weight-bearing bones that are painful or appear abnormal on bone scan
• Diagnostic CT of the abdomen (with or without diagnostic CT of the pelvis) or MRI of the abdomen
• Biopsy documentation of first recurrence, when possible

The use of sodium fluoride PET or PET-CT for the evaluation of patients with recurrent disease is largely discouraged.

Determination of hormone receptor status (ER and progesterone receptor [PR]) as well as HER2 status should be repeated because ER and PR assays may be falsely negative or falsely positive and there may be discordance between the primary and metastatic tumors.

In the metastatic setting, genetic testing results may have therapeutic implications; specifically, germline mutations in BRCA1/BRCA2 have demonstrated clinical utility and therapeutic impact. Thus, the NCCN panel recommends that germline BRCA1/BRCA2 mutations be evaluated in all patients with recurrent or metastatic breast cancer to identify candidates for appropriate targeted therapies (eg, poly adenosine diphosphate ribose polymerase–inhibitor therapy).

In patients with recurrence of breast cancer to the chest wall, complete chest wall resection and appropriate reconstruction may prolong overall survival, although appropriate patient selection is essential for optimal outcomes. Patients with tumors that display a more aggressive phenotype (eg, triple-negative or HER2-positive disease) may not benefit from this approach and supportive care may be more appropriate.

Avan J. Armaghani, MD, Assistant Member, Department of Breast Oncology, Moffitt Cancer Center, University of South Florida, Tampa, FL.

Avan J. Armaghani, MD, has disclosed no relevant financial relationships.

Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.

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