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INTRODUCTIONBreast cancer is the top ranking cancer inwomen globally. The incidence of breast can-cer is increasing in the developing world due toincrease in life expectancy, urbanisation andadoption of western lifestyles. Worldwide, 1.38million new cases of breast cancer were diag-nosed in 2008.1 Common sites of breast cancermetastases include regional lymph nodes, bones,liver, lungs and brain. Brachial plexopathy is arare condition, which is a significant cause ofpain and disability in breast cancer patients, withan incidence of less than 0.5%.2 Metastaticbreast and lung cancers are the most commonnon-traumatic causes of brachial plexopathy,after radiation induced fibrosis.3 Because oneof the major lymphatic drainage of the breast isthrough the apex of the axilla, it is not uncom-mon for metastatic breast cancer to invade thebrachial plexus. Metastatic lymphadenopathymay encase the neurovascular bundle, result-ing in vascular or neural symptoms.

CASE REPORTA 29-year-old premenopausal woman presentedto the Medical Oncology outpatient service witha complaint of a lump in her left breast. The

patient had no other medical problems. She at-tained menarche at the age of 12 years. She wasmarried and was mother of 2 children. Therewas no history of oral contraceptive use. Therewas no family history of breast or ovarian can-cer.On examination, the patient had a 5 x 4 cm lumpin the upper outer quadrant of the left breast.Lymph nodes were palpable in left axilla andthese lymphnodes were not fixed. The rest ofthe examination was unremarkable.Mammogram showed a 2 x 2 cm hypoechoicnodule with irregular margins and specks ofcalcification in upper outer quadrant of leftbreast; right breast was normal. Fine needleaspiration cytology (FNAC) of the breast lumpshowed ductal carcinoma. Chest radiograph andultrasonography of the abdomen were normal.The patient underwent left modified radical mas-tectomy with axillary clearance up to level-III.The pTNM was T2N1Mx. Histopathologicalexamination revealed the features of infiltrat-ing duct cell carcinoma - not otherwise speci-fied (NOS). Examination of the excised leftaxillary lymph nodes revealed metastatic ductcell carcinomatous deposits in 4 of the 10 lymphnodes. The tumour cells were negative for im-

Case Report:Metastatic brachial plexopathy in breast cancer

T. Kannan,1 G. Sivaram Naik,2 K.V. Sreedhar Babu,3 B. Vijayalakshmi Devi4

Departments of 1Medical Oncology, 2Medicine, 3Pathology,and 4Radiology, Sri Venkateswara Institute of Medical Sciences, Tirupati

ABSTRACTWe report the case of a 29-year-old woman previously treated for breast cancer who presented 3 years later with painweakness and burning sensation in the left upper limb of one month duration. Electroneuromyography showed re-duced sensory nerve action potential (SNAP) amplitude and reduced conduction velocity in left median nerve sensoryconduction, Magnetic resonance imaging (MRI) of brachial plexus revealed nodular thickening of trunks and cordsof left brachial plexus, suggesting metastasis. Ultrasonography guided fine needle aspiration cytology confirmed thepresence of metastatic ductal cell carcinomatous deposits. Brachial plexopathy due to metastases from breast canceris a rare entity, and should be kept in mind while evaluating patients with breast cancer.Key words: Cancer, Breast, Metastasis, Brachial plexopathy

Corresponding Author: Dr T. Kannan, Professor, Department of Medical Oncology, Sri Venkateswara Institute ofMedical Sciences, Tirupati 517507, India. e-mail: ktsamy@gmail.com

Received: 10 August, 2012.

Kannan T, Sivaram Naik G , Sridhar Babu KV, Vijayalakshmi B. Metastatic brachial plexopathy in breast cancer. J Clin Sci Res 2012;1:196-8.

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munohistochemical markers such as oestrogenand progesterone receptor proteins and p53gene mutation, but tumour cells showed intense(3+) cytoplasmic positivity to c-erb-B2 protein.Patient was given adjuvant chemotherapy con-sisting of 6 cycles of cyclophosphamide, 5- fluo-rouracil and doxorubicin. Thereafter, she wason regular follow up and was assessed to be incomplete clinical remission. She did not receivetrastazumab, lapatinib or adjuvant radiotherapy.After 3 years, patient presented with complaintsof pain, weakness and burning sensation in herleft upper limb of one month duration. Theelectroneuromyography (ENMG) of the leftupper limb showed reduced sensory nerve ac-tion potential (SNAP) amptitude and reducedsensory conduction velocity in the left mediannerve. It also showed reduced compoundmuscle action potential (CMAP) from left del-toid, biceps and triceps muscles.Ultrasound guided fine needle aspiration wasperformed from the thickened nodular lesionof the left brachial plexus. Cytological exami-nation showed the presence of malignant cells,suggesting duct cell carcinomatous deposits inleft brachial plexus (Figure 2). Patient was givensecond line chemotherapy with 4 cycles ofpaclitaxel. There was partial improvement inneurological symptoms.

DISCUSSIONNeoplastic invasion of the brachial plexus is anuncommon, though not rare, cause ofplexopathy. Lesions of the brachial plexus oc-cur secondary to neoplasms that reach theplexus by direct extension (Pancoast tumour)or, by metastases through lymphatics from theaxilla. Primary neoplasms of the brachial plexussuch as schwannoma and neurofibroma are gen-erally benign, while secondary neoplasms aremalignant. Patients with neoplastic brachialplexopathy may present with shoulder pain andparaesthesia with radiating pain onto the me-dial aspect of forearm and/or hand. Symptomsoften are related to metastasis from a primarysite such as breast, lung or from lymphoma in ageneralized plexus involvement, sometimes witha lower trunk predominance. Symptoms maybe diffuse but more often involve the C8-T1dermatomes and myotomes (mimicking ulnarneuropathy or C8-T1 radiculopathy).In patients with breast carcinoma who havesymptoms of brachial plexopathy, radiation in-jury or metastatic spread of the tumour shouldbe considered. About 95% of the patients withbrachial plexopathy have shoulder and arm painwith a dermatomal distribution.4 Our patient hadintractable pain in the left upper limb. This pa-

Figure 2: Photomicrograph showing pleomorphic epi-thelial cells (arrow) entangled in the midst of wavyelongated neuronal cells (arrow-head) (Hamatoxylin andeosin, 400)

Figure 1: T2-weighted axial image showing alteredsignal intensity lesion along the trunks and cords ofleft brachial plexus (arrow)

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tient did not receive radiation therapy becauseof financial constraints, thus radiation inducedbrachial plexopathy was excluded. As the pa-tient had surgery three years before, complica-tion due to surgery was not considered. Thediagnosis of metastatic brachial plexopathy wassuggested on MRI of the left brachial plexusand confirmed by FNAC. In conclusion, meta-static involvement of the brachial plexus is arare condition but commonly associated withbreast cancer. When patients with breast can-cer present with severe pain spreading to theshoulder and arm followed by sensory and mo-tor symptoms, brachial plexus metastases shouldbe considered in the differential diagnosis.

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3. Wittenberg KH, Adkins MC. MR imaging ofnontraumatic brachial plexopathies: frequency andspectrum of findings. Radiographics2000;20:1023-32.

4. Cherny NI, Foley KM. Brachial plexopathy in pa-tients with breast cancer. In: Harris JR, HellmanS, Henderson IC, Kinne DW, editors. Breast dis-eases. Fist edition. Philadelphia: J.B. Lippincottand company;1996.p.722-39.

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