Abstract Background The coracoid process of the scapula is a rare site of involvement for metastatic disease or for primary tumors. We are unaware of any reports in the literature of pathologic coracoid process fractures and only one report of metastatic disease to the coracoid. Methods and Results In this case report, we present two cases with metastatic breast carcinoma of the coracoid process, one of which presented with a pathologic fracture of the coracoid. Conclusions An orthopaedic surgeon must be aware of the potential for metastatic disease to the coracoid as they may be the first medical provider to encounter evidence of malignant disease.</p

A Ogose

AI Froimson

AR Sandrock

CSB Galasko

Darren S Drosdowech

DW Boyer Jr

Eric C Benson

G Bauer

GH Heyse-Moore

GN Hortobagyi

GP DeRosa

J Guiral

JF Gil

K Ogawa

KK Kopecky

KS Eyres

MT Travers

OH Petty

OV Batson

PP Mariani

RC Rounds

RL Theriault

RP Goldberg

S Asbury

T Martin-Herrero

Y Kato

Z Zilberman

English

PubMed

Springer - Publisher Connector

Metastatic breast carcinoma of the coracoid process: two case reports

Abstract Background The coracoid process of the scapula is a rare site of involvement for metastatic disease or for primary tumors. We are unaware of any reports in the literature of pathologic coracoid process fractures and only one report of metastatic disease to the coracoid. Methods and Results In this case report, we present two cases with metastatic breast carcinoma of the coracoid process, one of which presented with a pathologic fracture of the coracoid. Conclusions An orthopaedic surgeon must be aware of the potential for metastatic disease to the coracoid as they may be the first medical provider to encounter evidence of malignant disease.</p

Drosdowech Darren S

Benson Eric C

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Journal of Orthopaedic Surgery and Research

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CASE REPORT Open Access
Metastatic breast carcinoma of the coracoid
process: two case reports
Eric C Benson1*†, Darren S Drosdowech2
Abstract
Background: The coracoid process of the scapula is a rare site of involvement for metastatic disease or for primary
tumors. We are unaware of any reports in the literature of pathologic coracoid process fractures and only one
report of metastatic disease to the coracoid.
Methods and Results: In this case report, we present two cases with metastatic breast carcinoma of the coracoid
process, one of which presented with a pathologic fracture of the coracoid.
Conclusions: An orthopaedic surgeon must be aware of the potential for metastatic disease to the coracoid as
they may be the first medical provider to encounter evidence of malignant disease.
Introduction
The coracoid process of the scapula is a rare site of
involvement for metastatic disease or for primary
tumors. Bone metastases are common in patients with
breast carcinoma, with an incidence as high as 73%
(range 47-85%) [1]. The exact mechanism of metastases
to bone remains unknown.
We are unaware of any reports in the literature of
pathologic coracoid process fractures, and only one
report of metastatic disease to the coracoid [2]. We pre-
sent the cases of two patients with metastatic breast car-
cinoma of the coracoid process, one of which presented
with a pathologic fracture of the coracoid. We informed
the patients or their families that the data concerning
their cases would be submitted for publication, and they
consented.
Case 1
A 40-year-old, right-hand dominant female who had a
known history of right breast carcinoma presented to our
clinic for evaluation for open biopsy of a lesion at the base
of the coracoid. Four months prior to clinic presentation,
she underwent right breast lumpectomy and lymph node
dissection. Surgical pathology revealed invasive mammary
carcinoma, SBR grade 2 with no involvement of the lymph
nodes. Resection margins were negative. She was Her-2-
neu negative, estrogen receptor negative, and progesterone
receptor positive. A bone scan revealed increased uptake
at the eighth thoracic vertebra and in the region of the
coracoid in the right shoulder. Further CT imaging of
both regions indicated a fracture through the transverse
process of T8, though the patient was asymptomatic at
this level and had a prior history of a fall from a horse that
correlated with this finding. There was no history of any
shoulder pain resulting from or subsequent to that fall. CT
imaging of the scapula showed osteolytic change at the
base of the coracoid. Radiographs and relevant CT scan
images are shown (Figures 1 and 2). She had received the
first cycle of adjuvant chemotherapy with FEC-100 but
further cycles were discontinued until further information
regarding the possible sites of metastases was collected.
Instead, she was placed on Tamoxifen and Clodronate.
She was otherwise healthy and took no other medications.
On physical exam there was no palpable mass in the
region of the right shoulder, no skin discoloration or
changes, and her range of motion and strength were
normal. She was nontender to palpation over the cora-
coid process. She had no tenderness to palpation over
T8 or elsewhere throughout the spine. Upper and lower
extremity neurovascular exam showed no focal deficits.
The patient consented to open biopsy of the coracoid
and was taken to the operating room. Through a delto-
pectoral approach, the coracoid was identified and
* Correspondence: ebenson@salud.unm.edu
† Contributed equally
1Department of Orthopaedic Surgery and Rehabilitation, Division of Shoulder
and Elbow Surgery, MSC10 - 5600, 1 University of New Mexico, Albuquerque,
NM 87131, USA
Benson and Drosdowech Journal of Orthopaedic Surgery and Research 2010, 5:22
http://www.josr-online.com/content/5/1/22
© 2010 Benson and Drosdowech; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
biopsy specimens from the lesion at the base of the cor-
acoid were sent to pathology for frozen section and per-
manent sections. The intra-operative frozen section was
positive for adenocarcinoma.
The patient had no complications following the biopsy
and the surgical pathology report confirmed the lesion
was a metastatic breast adenocarcinoma. The immuno-
histochemical stains showed moderately to strongly
positive progesterone receptors in about 15% and mod-
erately positive estrogen receptors in about 2% of malig-
nant cells.
Approximately twenty months after her initial lum-
pectomy, the patient underwent right partial mastect-
omy for recurrent carcinoma. At most recent follow-up,
two years after initial diagnosis, she is doing well with
no evidence of local recurrence or progression of meta-
static disease.
Case 2
A 23-year-old, right-hand dominant female sports coach
fell backwards onto outstretched arms while snowboarding
one week prior to presentation. She noted immediate left
shoulder pain, was seen at on outside Emergency Depart-
ment, and was referred to orthopedics for management of
her shoulder injury. She sustained no other injuries in the
fall. She noted no other previous complaints with regard
to her left shoulder. She took Naprosyn for pain relief.
Over the months leading up to the fall, she was treated
with NSAIDs at another center for chest wall pain pre-
sumed to be osteochondritis. Otherwise, she had no signif-
icant findings in review of her past medical history. Prior
surgeries included removal of a Bartholin’s cyst.
Physical examination revealed isolated point tender-
ness over the tip of the coracoid. She had full neck,
shoulder, and elbow range of motion with some discom-
fort at the terminal range of internal and external rota-
tion of the shoulder. Her neurovascular exam showed
no focal deficits.
Radiographs showed a nondisplaced fracture of the
coracoid (Figures 3 and 4). These were compared to her
outside films taken immediately after her fall and
showed no interval change in position of the fragment.
We recommended non-operative management of this
stable injury. Short-term immobilization using a sling
followed by initiation of physiotherapy was arranged.
Gentle strengthening was to start after approximately
four to six weeks as tolerated.
Figure 1 AP radiograph demonstrating the metastatic lesion of
the coracoid process.
Figure 2 CT scan showing the metastatic lesion at the base of
the coracoid.
Figure 3 AP radiograph of the nondisplaced pathologic
coracoid process fracture.
Benson and Drosdowech Journal of Orthopaedic Surgery and Research 2010, 5:22
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Page 2 of 4
Tragically, this previously healthy, active, young
woman was admitted to an outside facility only two
weeks later with hypercalcemia, multiple sites of bone
metastases noted on skeletal survey, and an abnormal
liver scan. She was diagnosed with metastatic adenocar-
cinoma of the left breast. In addition to the coracoid,
she had multiple metastatic lesions in her thoracic spine
and bilateral femurs as well as brain and liver metas-
tases. Over the course of the following four months she
suffered from encephalopathy, SIADH, leptomeningeal
carcinomatosis, and eventually passed away in her home
receiving palliative care.
Though the patient’s mechanism of injury was consis-
tent with an acute coracoid fracture, in retrospect her
injury was likely a pathologic fracture secondary to her
metastatic breast adenocarcinoma.
Discussion
Tumors of the coracoid process are rare. We could only
identify one report of a metastatic lesion to the coracoid
using a PubMed search of the literature [2]. Primary
bone tumors of the coracoid include osteoid osteoma,
osteosarcoma, giant cell tumor, chondrosarcoma, capil-
lary hemangioma, aneurysmal bone cyst, lymphoma, and
plasmacytoma [3]. In our PubMed literature search, we
found no reports of pathologic coracoid fractures.
Breast cancer’s propensity to metastasize to bone is
not clearly understood. Batson described the valveless
venous plexus commonly thought to contribute to the
spread of breast and prostate carcinoma to sites in the
axial and appendicular skeleton [4]. More recently, stu-
dies suggest some of the mechanisms for bone destruc-
tion once tumor cells have gained access to a distant
site. These include osteoclast activating factors such as
parathyroid hormone-related protein (PTH-rP), tumor
necrosis factor (TNF) a and b, epidermal growth factor
(EGF), and prostaglandins [5]. These changes to the
bone architecture lead to structural weakness, and typi-
cally, the radiographic appearance of breast metastases
to bone is one of mixed osteoblastic and osteolytic
appearance.
Often, the orthopaedic surgeon is the first medical pro-
vider to encounter evidence of malignant disease and as
such must be aware of potential sites of involvement.
When interpreting radiographs, especially in an area as
difficult as the coracoid, it is important to maintain an
index of suspicion for underlying pathologic processes,
especially since isolated fractures of the coracoid process
are rare [6-23]. When present, it may be difficult to iden-
tify the bony architecture at the fracture site secondary to
overlying structures. It may be prudent to obtain extra
imaging to clearly show the bony characteristics of the
injury. A 20 degree posterior oblique film with 20 degrees
of cephalad angulation can show coracoid fractures and
bone morphology more clearly if other views are incon-
clusive [24]. CT scans may also be useful.
The role of the orthopaedic surgeon may also include
recommendations for bisphosphonate use. In concert with
the consulting medical oncologist, administering bispho-
sphonates may reduce the risk of skeletal complications in
patients receiving systemic therapy who have lytic bone
metastatic lesions secondary to breast cancer [25,26].
The coracoid process of the scapula is a rare site of
acute isolated trauma, primary tumors, or of metastatic
disease. We present what we believe to be the first
reported case of a pathologic fracture of the coracoid in
one of two patients who presented with metastatic
breast carcinoma of the coracoid. Although rare, ortho-
paedic surgeons must be aware of the potential for a
pathologic process involving the coracoid.
Consent
Informed consent was obtained from the patient or
patient’s family for publication of this case report and
all accompanying radiographic images.
Author details
1Department of Orthopaedic Surgery and Rehabilitation, Division of Shoulder
and Elbow Surgery, MSC10 - 5600, 1 University of New Mexico, Albuquerque,
NM 87131, USA. 2University of Western Ontario, Division of Orthopedic
Surgery, Hand and Upper Limb Centre, St. Joseph’s Health Centre, 268
Grosvenor St, London, ON N6A 4V2, Canada.
Authors’ contributions
DD performed all clinical evaluations and interactions with the patients. EB
reviewed the case files, contacted the patients’ or patients’ families to obtain
informed consent, and prepared the manuscript and image files. Both EB
and DD read, revised, and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 6 May 2009 Accepted: 26 March 2010
Published: 26 March 2010
Figure 4 Axillary radiograph showing the pathologic coracoid
fracture.
Benson and Drosdowech Journal of Orthopaedic Surgery and Research 2010, 5:22
http://www.josr-online.com/content/5/1/22
Page 3 of 4
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doi:10.1186/1749-799X-5-22
Cite this article as: Benson and Drosdowech: Metastatic breast
carcinoma of the coracoid process: two case reports. Journal of
Orthopaedic Surgery and Research 2010 5:22.
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BACKGROUND: The coracoid process of the scapula is a rare site of involvement for metastatic disease or for primary tumors. We are unaware of any reports in the literature of pathologic coracoid process fractures and only one report of metastatic disease to the coracoid.
METHODS AND RESULTS: In this case report, we present two cases with metastatic breast carcinoma of the coracoid process, one of which presented with a pathologic fracture of the coracoid.
CONCLUSIONS: An orthopaedic surgeon must be aware of the potential for metastatic disease to the coracoid as they may be the first medical provider to encounter evidence of malignant disease

Metastatic breast carcinoma of the coracoid process: two case reports

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