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ovarian cancer is the most common cause of death among women with gynecologic malignancies and the fifth leading cause of cancer death in women in the united states .
approximately 21 550 new cases and 14 600 deaths are estimated annually in the us .
there are , however , large variations in the incidence of ovarian cancer in different areas of the world .
the highest incidence areas are in europe ( especially austria , germany and the united kingdom ) and north america [ 24 ] .
the estimated number of newly diagnosed cases in the european union was 42 700 in 2004 with a mortality of 12/100 000 women / year .
metastasis of ovarian serous carcinoma to the breast and axillary lymph nodes is very rare and usually occurs very late in the course of the disease [ 5 , 6 ] .
therefore , metastatic cancer to the breast from an ovarian primary is associated with shortened survival , most of the patients dying a few months after the metastasis .
reported a retrospective analysis of 29 patients with epithelial ovarian cancer and breast / axillary mass from 1990 to 2007 .
ten of them were metastatic to breast , and 19 patients had secondary primary carcinoma of the breast . the mean disease - free survival ( dfs ) was 14.9 versus 77.4 months for patients with epithelial ovarian cancer metastatic to breast and for patients with secondary primary breast cancer respectively .
a 52-year - old woman with complaints of inguinal tenderness and increased abdominal size for three months was admitted to our hospital , izmir ataturk training and research hospital , department of gynecology , in september 2006 .
an irregular , fixed pelvic mass and ascites were detected in her physical and pelvic examination .
she underwent an abdominal ultrasound examination , abdominopelvic computerized tomography ( ct ) , and a plain chest radiography .
these imaging studies demonstrated ascites , bilateral adnexal masses , and a right - sided minimal pleural effusion .
after preoperative evaluation , the patient underwent laparotomy and an optimal cytoreduction procedure with total abdominal hysterectomy , bilateral salpingo - oophorectomy , omentectomy , and lymphadenectomy .
an 8 cm diameter tumor on the right ovary and a 10 cm tumor on the left ovary and 2 liters of ascites were detected .
the frozen and final pathology was compatible with well differentiated , malignant serous carcinoma ( fig .
1 ) , with invasion of the omentum , peritoneum , and uterine wall ( stage iiic ) .
immediate postoperative ct scan showed a solid 4 - 5 sized mass in the right inguinal region , and multiple millimetric lymph nodes .
malignant serous tumor of the ovary she received a combination therapy of carboplatin ( auc = 6 , d1 of a 21-day cycle ) and paclitaxel ( 175 mg / m , on day 1 of a 21-day cycle ) which was initiated in december 2006 . after 6 chemotherapy cycles , in april 2007 , serum ca 125 level was 860 u / ml without any radiological improvement .
then she was treated with a combination therapy of liposomal doxorubicin ( 30 mg / m , on day 1 of a 21-day cycle ) and gemcitabine ( 1000 mg / m , on days 1 and 8 of a 21-day cycle ) .
the chemotherapy was completed in july 2008 and serum ca125 level was 95.5 u / ml at that time .
the solid size of the solid mass in the right inguinal region was same , but lymph nodes were not seen in the follow - up ct of the abdomen / pelvis .
surgery was not planned because it was considered as a postoperative benign lesion by her gynecologist .
five months later , in the thorax ct , a 2 cm - sized lymph node in right axillary fossa was seen .
the mammography showed a 9 mm sized opacity without malignant features in the right breast . during the follow - up ,
for that reason , oral etoposide ( 100 mg / day , 14/28 day ) was started .
after 6 cycles , the ca125 level increased to 914 u / ml and the axillary lymph node and intramammary lesion showed progression .
surgical biopsy of the intramammary lymph node was compatible with metastasis of ovarian serous carcinoma ( fig .
3 ) . following this diagnosis , a combination of carboplatin ( auc = 6 , on day 1 of a 21-day cycle ) and cyclophosphamide ( 750 mg / m , on day 1 of a 21-day cycle ) was started in december 2009 .
after 6 cycles , the number and size of axillary and intramammary lymph nodes increased and newly appearing intra - abdominal lymph nodes were seen in the ct scan .
after then , the patient was treated with topotecan ( 4 mg / m , weekly ) , however she progressed after 4 months , and paclitaxel ( 80 mg / m , weekly ) was treated with
. she has been still treated by weekly paclitaxel for 4 months and has a stable radiological and clinical response .
metastatic ovarian serous carcinoma in the mammary lymph node wt-1 positivity ( seen as brown ) in metastatic serous ovarian cancer cells
approximately 21 550 women in the united states are diagnosed with ovarian cancer annually , and an estimated 15 520 women die of the disease .
metastasis of ovarian serous carcinoma to the breast and axillary lymph nodes is very rare [ 5 , 6 ] .
moreira et al .   reported a 29-year - old woman who presented with an intramammary lymph node metastasis of a borderline papillary ovarian tumor which had been resected a year before diagnosis .
reported a series of 14 cases of ovarian serous carcinoma which had metastases to breast and axillary lymph nodes .
one of them was stage i at the initial diagnosis while 10 of them were stage iii and 3 of them were stage iv at the time of the diagnosis .
only one patient had stage iv disease initially with both axillary lymph node metastasis and breast lesion .
the breast and/or axillary lymph node metastases were discovered at an average of 30 months after presentation ( in patients with stage iii ) .
all of them had stage iii disease and presented with a mass in the breast .
metastatic cancer to the breast from an ovarian primary is associated with a poor prognosis , with a majority of patients dying within one year [ 6 , 11 ] .
after two years , she presented with bilateral metastatic breast disease derived from the primary ovarian cancer .
differentiation between metastatic and primary tumors of the breast is of great importance because treatment and prognosis differ significantly .
clinical history , the presence of papillary architecture , and immunohistochemical features are important in establishing the correct diagnosis .
wt-1 , the wilms tumor gene product , can be expressed in some types of ovarian tumors , other solid tumors ( such as stomach , prostate , biliary and urinary system tumors , malignant melanoma ) and leukemias .
most of the studies showed that serous carcinomas are usually positive and endometrioid ovarian cancers are usually negative for this marker   yamamoto et al .  
analyzed wt-1 immunoreactivity in 119 patients with ovarian serous cancer and showed that wt-1 positivity is positively correlated with high grade , advanced stage and higher ki-67 labeling index , higher bcl-2 expression and poorer outcome in a study .
although wt-1 positivity can be seen in many solid tumors , it has been identified as a possible marker mostly for ovarian cancer .
a study of 117 patients involving primary breast cancer , breast cancer metastatic to ovary , and primary ovarian cancer showed that 76% of primary ovarian cancer patients were positive for wt-1 , but none of the patients with breast cancer showed wt-1 positivity .
gross cystic disease fluid protein ( gcdfp-15 ) and mammaglobin are both widely used and accepted markers for epithelia of breast origin .
cytoplasmic expression of gcdfp-15 and mammaglobin was observed in respectively 73.3% and 72.1% of invasive breast carcinomas in a study .
these two markers were studied in paraffin - embedded tissues of the patients with primary breast cancer , serous carcinoma ( ovarian and uterine ) , and metastatic breast cancer to the ovary .
mammaglobin was negative in all serous carcinomas , while it was more frequently and diffusely expressed in breast carcinomas when compared to gcdfp-15 ( 14/21 patients vs. 8/21 patients for gcdfp-15 ) .
chia et al . compared the diagnostic utility of these two markers in confirming a breast origin for recurrent tumors in a recent study ; they demonstrated that metastases to the breast from other organs and metastatic lesions from non - breast primaries were uniformly negative for both mammaglobin and gcdfp-15 , and also mammaglobin was superior to gcdfp-15 in detecting a tumor of breast origin . as a result , in addition to papillary morphology , metastatic breast lesions from ovarian serous tumor origin are usually negative for gcdfp-15 and mammaglobin and positive for wt-1 .
we established the diagnosis of metastasis from ovarian cancer by using wt-1 immunoreactivity and typical papillary architecture of serous cancer cells in this case .
the present patient had a primary ovarian carcinoma and had been heavily treated with multiple chemotherapy regimens .
the patient has been receiving a sixth - line chemotherapy protocol and she is still alive 29 months after intramammary lymph node metastasis was detected .
although she has an advanced disease , she has no visceral organ metastasis and she has in total a 56-month survival time since diagnosis .
metastasis from serous carcinoma of the ovary usually occurs in the subdiaphragmatic region . 
 metastasis to the breast and/or axillary - intramammary lymph node is very rare . 
 it usually occurs in advanced disease , and it is important to distinguish a primary breast cancer from an ovarian cancer metastasis since the management of these two entities is totally different . here 
 we present a patient with metastasis to the breast and intramammary lymph nodes from ovarian serous carcinoma 25 months after diagnosis .