Isolated metastasis to the genital tract is explained as a hematogenous spread from the primary site of disease; mostly, it appears as a concomitant involvement of a broadly disseminated disease [5].

Only two cases of vaginal metastasis from breast cancer have been so far reported in literature [6,7]; both of them are presented as part of a systemic disease involving also endometrium and ovaries.

At admission she was in good general condition, only complaining an un-painful vaginal bleeding. She was still under hormonal treatment.

The recto-vaginal examination, revealed a 4cm solid lesion sited at level of the left upper third of the vagina, which involved the full thickness of the vaginal wall and the obturator fossa. The lesion did not involve the cervix and the trans-vaginal ultrasound did not reveal endometrial or adnexal abnormalities. However a hysteroscopy with endometrial biopsy was performed to exclude endometrial involvement, which was negative. Tumor markers were all within normal range. A Total Body CT-PET scan was performed which showed an isolated iper-captation on the left vaginal wall (Figure 1). A vaginal biopsy confirmed the breast cancer metastatic nature of the nodule.

After careful counseling on the various therapeutic options, it was decided with the patient to treat the vaginal relapse with surgery. She was subjected to a modified vaginectomy [8] with complete resection of the mass (Figure 2) together with a large amount of lympho-fatty tissue around the lesion. Pathology showed a metastatic poorly differentiated lobular breast cancer. Immunohystochemistry showed expression of estrogen and progesterone receptors in 90% and none of neoplastic cells respectively and negative C-Erb-2 expression consistently with the primary tumor. Resection margins were negative.

The patient was subjected to adjuvant chemotherapy with Pegilated Liposomal Doxorubicin 40mg/mq for 6 courses.

After 14months of negative follow up, we decided to perform an elective completion of surgery with prophylactic aims. A total hysterectomy plus bilateral salpingo-oophorectomy was performed. Surprising, Hystological Examination documented. Again micrometastasis from lobular breast cancer in the contest both of the uterus and ovaries. No adjuvant treatment was proposed.

Defining “breast unusual metastasis” as rare systemic failure with a frequency of <1% [3].

Lobular histotype seems to metastasize to the genital tract more frequently than ductal tumors [9], probably for an hematogenous propagation.

Few cases are reported in literature describing isolated metastasis to the cervix [4-8,10]. To our knowledge, this is the first case of an isolated vaginal relapse from breast cancer treated by surgery.

Data regarding vaginal metastasis behavior and treatment are scarce. Most of the cases are treated by radiotherapy [6,7]. In our opinion, surgery is a valid alternative to radiotherapy , and the absence of relevant side effects or complication and the current status of our patient corroborate this strategy.

Furthermore, this case report suggests that cancer survivors should be subjected to a more thorough gynecologic examination. Although a baseline gynecologic assessment is recommended prior to administration of the cancer risk reduction agents (Tamoxifen), and follow up gynecologic assessment should be performed at each visit, as assess by NCCN Guidelines, currently gynecological counseling is not universally part of breast cancer follow up workup.

Globally our experience highlights that breast cancer survivors deserve a periodic gynecological assessment as part of their regular follow up. Also, we can assume that recurrent disease would have been undetected if deeper evaluations had not be carried out and that when it occurs surgery could be a rationale choice of treatment.