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International Journal of Case Reports and Images - IJCRI - Case Reports, Case Series, Case in Images, Clinical Images

     
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Differentiating a simple cyst or metastatic breast cancer: A medical dilemma
Waqas Jehangir1, Zorawar Singh2, Abdul I Mahmad1, Teena Mathew3
1MD, Raritan Bay Medical Center - Resident, Internal Medicine, Raritan Bay Medical Center, Perth Amboy, New Jersey, USA.
2Medical Student, Ross University School of Medicine - 4th Year Medical Student, Ross University School of Medicine, Portsmouth, Dominica, West Indies.
3MD, Raritan Bay Medical Center - Attending Physician, Internal Medicine, Raritan Bay Medical Center, Perth Amboy, New Jersey, USA.

doi:10.5348/ijcri-201461-CL-10049

Address correspondence to:
Waqas Jehangir
MD, 530 New Brunswick Ave
Perth Amboy, New Jersey
USA. 08861
Phone: 267-844-7119
Email: wjehangir@hotmail.com

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How to cite this article
Jehangir W, Singh Z, Mahmad AI, Mathew T. Differentiating a simple cyst or metastatic breast cancer: A medical dilemma. Int J Case Rep Images 2014;5(9):661–664.


Case Report

A 60-year-old American Hispanic female presented to the emergency room for gradual onset dizziness, associated with lightheadedness, double vision and nausea. She described her symptoms as vertigo-like. She has a known past medical history of breast cancer and was treated with surgery and chemotherapy. The patient had been in remission for over six years. Patient denied any recent travel outside United States. Physical examinations of the patient were within normal limits, apart from the dizziness. Patient did not complain of any weight changes, vision changes, or any focal neurological deficits.

Computed tomography (CT) scan of head (Figure 1) showed a large, 4.3 cm cystic mass projecting in the mid-posterior aspect of the cerebellum causing anterior displacement of the fourth ventricle. It was repeated again and the results were similar. Her last CT scan of head was done a year before which was completely normal. Magnetic resonance imaging (MRI) scan of the brain with and without contrast (Figure 2) showed multiple ring enhancing intra-axial masses, the largest centered at the vermis measuring nearly 4 cm and compressing the fourth ventricle mildly. In the differential was either a metastatic neoplasm from primary breast cancer or a parasitic infection (Table 1). Since the patient did not have any likely risk factors for parasitic infections, such as any recent traveling or interactions with cats or cat feces, the likelihood of a parasitic infection was low. The patient was subsequently treated with radiotherapy with complete resolution of symptoms.


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Figure 1: Computed tomography scan of head without contrast showing a 4.3-cm cystic mass projecting in the mid-posterior aspect of the cerebellum causing anterior displacement of the fourth ventricle.



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Figure 2: Magnetic resonance imaging scan of brain without contrast showing multiple ring enhancing intra-axial masses, the largest centered at the vermis measuring nearly 4 cm and compressing the fourth ventricle mildly.



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Table 1: Differential diagnosis of cystic brain lesion


Discussion

This case illustrates the importance of suspecting a metastatic neoplasm in the brain in a patient who presents with neurological abnormalities and has a past history of a malignancy. Although the patient had been in remission from breast cancer for more than six years, and had a normal head CT scan a year ago, this case shows how quickly a metastatic lesion can resurface and present itself. Breast cancer patients who achieve a pathological complete response after neoadjuvant chemotherapy usually have a favorable prognosis [1] [2][3]. From this case, we can learn that the breast cancer may have been eradicated from the original source, but we should always be suspicious of the malignancy re-emerging in other parts of the body. As physicians, we also must be aware of many of the symptoms of metastasis in women who have been eradicated of breast cancer, those symptoms include, but are not limited to, severe headaches, generalized fatigue, dizziness, vertigo, blurry vision, hypotension, difficulties with balance and coordination, and even polyuria and polydipsia [4] [5] .


Conclusion

For our patient, who presented with dizziness, we should always keep in mind that this simple symptom warrants concern. As physicians, we must always counsel our patients that they may not have the breast cancer physically at the moment but there is always a slight possibility for it to resurface in other parts of the body.


Acknowledgements

AbdallaYousif, MD


References
  1. Tallet A. Brain metastases from breast cancer. Cancer Radiother 2013;17(7):708–14. [Article in French].   [CrossRef]   [Pubmed]    Back to citation no. 1
  2. Murrell DH, Foster PJ, Chambers AF. Brain metastases from breast cancer: Lessons from experimental magnetic resonance imaging studies and clinical implications. J Mol Med (Berl) 2014;92(1):5–12.   [CrossRef]   [Pubmed]    Back to citation no. 2
  3. Shimada K, Ishikawa T, Yoneyama S, et al. Early-onset Brain Metastases in a Breast Cancer Patient after Pathological Complete Response to Neoadjuvant Chemotherapy. Anticancer research 2013;33(11):5119–21.   [Pubmed]    Back to citation no. 3
  4. Peppa M, Papaxoinis G, Xiros N, Raptis SA, Economopoulos T, Hadjidakis D. Panhypopituitarism due to metastases to the hypothalamus and the pituitary resulting from primary breast cancer: A case report and review of the literature. Clinical Breast Cancer 2009;9(4):E4–7.   [CrossRef]   [Pubmed]    Back to citation no. 4
  5. Malin D, Strekalova E, Petrovic V, et al. aβ-Crystallin: A Novel Regulator of Breast Cancer Metastasis to the Brain. Clinical Cancer Research 2014;20(1):56–7.   [CrossRef]   [Pubmed]    Back to citation no. 5
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Author Contributions
Waqas Jehangir – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Zorawar Singh – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Abdul I Mahmad – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Teena Mathew – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of submission
The corresponding author is the guarantor of submission.
Source of support
None
Conflict of interest
Authors declare no conflict of interest.
Copyright
© 2014 Waqas Jehangir et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.



About The Authors

Waqas Jehangir is Internal Medicine Resident at Raritan Bay Medical Center, Perth Amboy, NJ He earned the Medical degree MBBS from Nishtar Medical College/University of Health Sciences, Lahore, Pakistan. He has published 10 research papers in national and international academic journals. His research interests include hematology and oncology. He intends to pursue fellowship in hematology/ oncology.



Zorawar Singh is a fourth year medical student at Ross University School of Medicine. He earned a Bachelor's of Science in Human Biology from Michigan State University and will receive his MD Degree in May 2015 from Ross University. This is his first research paper in national journals. His research interests include hematologic and oncologic disease states, and cardiovascular disease. He intends to pursue a residency in Internal Medicine in the future.



Abdul I Mahmad is Internal Medicine Resident at Raritan Bay Medical Center Perth Amboy New Jersey. He earned the undergraduate degree MBBS from Deccan College of Medical Sciences, Hyderabad, India and postgraduate degree MD Dermatology from Kakatiya Medical College, Warangal, Telangana, India. His research interests include hepatology, gastroenterology and dermatology. He intends to pursue fellowship in gastroenterology in future.




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