A woman with primary breast cancer and a solitary sternal metastasis.

The patient requested CT/PET imaging as part of her preoperative evaluation. This scan revealed a metabolically active lytic lesion in the manubrium of the sternum (Figure 1). Several different radiologists were consulted, and opinions differed as to whether or not this likely represented a metastatic lesion. After reviewing the case with several radiologists, the surgeon chose to proceed with definitive surgery and monitor the sternal lesion. The patient elected to undergo bilateral mastectomies with immediate reconstruction. Pathology from the mastectomy specimens revealed a 1.1-cm left infiltrating ductal carcinoma, combined histologic grade 2. There was no vascular or lymphatic invasion. Six sentinel lymph nodes were examined and found to be free of tumor on H and E (hematoxylin and eosin) stains and cytokeratin immunostaining. The tumor was stained for estrogen and progesterone receptors, which demonstrated 58% estrogen-receptor positivity, 3% progesterone-receptor positivity, and Ki-67 staining of 13%. HER2/neu fluorescence in situ hybridization analysis revealed HER2 amplification of 7.0. The patient's right prophylactic mastectomy revealed atypical hyperplasia. Postoperatively, the patient saw a medical oncologist in town. The medical oncologist reviewed the workup and elected to obtain a fine-needle aspirate of the sternal lesion prior to finalizing recommendations for adjuvant therapy. The fine-needle aspirate of the sternal lesion demonstrated metastatic adenocarcinoma consistent with a breast primary. After discussing a variety of treatment options with the primary oncologist, the patient presents to the University of Colorado Breast Cancer Program for a second opinion. The patient has no other significant past medical history. The patient is G2 P2, with menarche at age 12 and ongoing regular menses. She bore her first child at age 32 and breast-fed both of her children. She is a former smoker and drinks alcohol socially. There is no family history of breast, ovarian, or prostate cancer.