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Paper text:
renal cell carcinoma , which accounts for approximately 3% of all adult cancers , has a tendency to metastasize , commonly to the lungs , bones , liver , adrenal glands and brain .
metastases to the breast from extramammary tumours are uncommon and metastatic renal cell carcinoma to the breast is extremely rare accounting for 3% of the cases .
we report metastases to the breast and the difficulty in diagnosis . thus far , this is the first case reported as in most cases ; the metastasis to the breast is part of systemic metastases .
the patient is a 67 year old lady , diagnosed with right renal cell carcinoma in 2002 for which she underwent right radical nephrectomy . histological examination showed a clear cell type .
regular follow - ups with computed tomography of the abdomen were negative for 5 years . in march 2007
clinical examination revealed a 2  2 cm right breast swelling and a vague retro - areolar mass 1  1 cm with an enlarged ipsilateral axillary lymph node .
mammogram ( figure 1 ) revealed a dense spiculated mass at right upper outer quadrant and a retroareolar mass which is associated with clustered micro - calcifications suggestive of malignancy .
ct thorax and abdomen showed a speculated hyper - dense lesion in the right breast and there was no evidence of local recurrence of rcc or other organ metastasis .
mammogram : dense speculated mass at the right upper outer quadrant and a retro - areolar mass with clustered mocrocalcification ultrasound : irregular mass with acoustic shadow at right 9 o'clock and another well - defined solid mass with irregular margin at 3 o'clock position . in view of cytological findings , mammogram and absence of distant metastases which suggested a possibility of either multicentric breast carcinoma or metastatic renal cell carcinoma , we proceeded with right mastectomy and axillary clearance .
the diagnosis of metastatic renal cell carcinoma to the breast with one lymph node involvement was made .
the diagnosis of metastatic renal cell carcinoma to the breast with one lymph node involvement was made .
it is represented by nearly up to 2% of all breast swelling which account for nearly 400 cases that have been reported in the literature .
malignant melanoma , leukaemia and lymphoma are the most common among all malignancies that have been described metastasizing to the breast .
8 cases presented as the initial sign of metastasis from rcc while the rest occur after nephrectomy done for rcc .
the cases presented are usually found 1 to 18 years following nephrectomy for rcc [ 3 , 4 ] . in the case presented , the metastasis occurred 5 years after nephrectomy .
the survival rates for the patient with renal cell carcinoma , 5-year and 10-year post nephrectomies were 95% and 91% for pt1 ; 80% and 70% for pt2 ; 66% and 53% for pt3a ; 52% and 43% for pt3b ; and 43% and 42% for pt3c , respectively .
the most common extra mammary metastasis in mammography finding was a well circumscribed mass with increased density but without speculation , calcifications or other signs that characterize the majority of primary carcinomas .
micro calcifications are unusual and are mostly associated with metastatic carcinoma of the ovary , in which psammoma bodies may be abundant . however , in our study , the case presented with microcalcifications as shown in the mammography study along with dense speculated mass at ruq area .
this produce suspicious of primary breast carcinoma with metastatic disease from rcc as a provisional diagnosis .
treatment for metastasis from rcc after a long - term cancer - free survival is removal of the tumour bloc in total followed with immunotheraphy , targetted therapy and chemotherapy .
this is based on a clinical trial indicating that metastasectomy rcc ( mrcc ) whereby solitary and fully resectable lung metastasis , together with adequate performance status , then the treatment of choice should be metastasectomy .
( i do not understand this paragraph from the linguistic point of view ) best outcomes are seen with single site of rcc metastasis to lung where 50% 5 years survival is seen compared with 19% , in patients who had more than one site of cancer removed . usually , rcc metastasis to other tissue is diagnosed after tissue biopsy and most of the time , cytological biopsy is enough to confirm the diagnosis
, the fine needle aspiration cytology ( fnac ) which was repeated twice suggests metastatic disease ( the presence of malignant cells with predominant eosinophillic cytoplasm with minority of them having cytoplasmic clearing cells ) but can not exclude primary breast carcinoma . due to this limitation ,
definitive diagnosis is important such as to prevent unnecessary mastectomy in extramammary tumour such as rcc metastasis .
treament for metastasis from rcc after a long - term cancer - free survival is removal of the tumour bloc in total followed with immunotheraphy , targetted therapy and chemotherapy .
alpha interferon and interleukin ( il)-2 are the two most frequently used types of immunotherapy in metastatic renal cell cancer .
unfortunately , long - term results of clinical trials indicate that only approximately 15% of patients with advanced renal cell carcinoma have an anticancer response when treated with high - dose interleukin 2 and interferon . in the presented case ,
we have proceeded with mastectomy and axillary clearance after full discussion with the patient and the family as cytological and mammogram study were strongly suspicious of breast carcinoma with no evidence of recurrence of rcc and patient opted for mastectomy .
careful assessment and adequate tissue examination is paramount to confirm the diagnosis . resection of isolated metastasis from rcc is feasible and can achieve long term relapse free survival .
breast is an uncommon and rare site for metastasis . 
 primary and secondary tumors of the breast need to be differentiated as management is different . 
 we present a 67 year old female patient with two breast lumps and an axillary lymph node , 5 years after nephrectomy for renal cell carcinoma ( rcc ) . 
 mammogram report showed a dense spiculated mass at right upper outer quadrant and a retroareolar mass associated with clustered micro calcifications . 
 fine needle cytology and trucut biopsy were inconclusive . 
 computer topography ( ct ) abdomen did not show evidence of rcc recurrence . 
 after discussion with the patient , she underwent mastectomy with axillary clearance and the final histopathology report was consistent with metastasis from rcc . 
 the management of this case is discussed .