Vulvar metastasis from carcinoma breast unveiling distant metastasis: Exploring an unusual metastatic pattern

A 76 year old woman with a previous history of infiltrating ductal carcinoma of right breast (diagnosed and treated 14 years back) presented to us with a non-healing ulcer on the left side of the vulva along with two satellite nodules close to the vulvar lesion. Biopsy showed an infiltrating ductal carcinoma of breast with a strong positivity for estrogen/progesterone receptors. Further, (18)F-FDG PET-CT (Fluoro-deoxy glucose positron emission tomography computed tomography) showed multiple bilateral lung metastases. She responded well to hormone therapy (Letrozole) with decrease in the size of primary vulvar lesion and disappearance of the satellite nodules. Repeating PET-CT at 6 months showed partial response of the lung lesions. The present case is unique in the way of metastatic presentation of breast cancer to vulva after a long gap of primary diagnosis (longest reported till date) and also in unveiling of further metastatic sites in otherwise asymptomatic case. Patients (particularly elderly) with this unusual and clinically isolated pattern of metastasis might remain misdiagnosed for a long period of time and this case report aims to increase the awareness of clinicians toward the same. Gynecological surveillance remains of paramount importance in the follow up of breast cancer.