Primary Breast Carcinoma of the Vulva Metastatic to Lymph Nodes and Bones: A Case Report and Literature Review



 

Aneesha Ananthula, MD; Blake Lockwood, MD; John Savage, MD;
Sharp Malak, MD; Chien Chen, MD; Issam Makhoul, MD;
Angela Pennisi, MD

Perm J 2020;24:19.084 [Full Citation]

https://doi.org/10.7812/TPP/19.084
E-pub: 02/14/2020

ABSTRACT

Introduction: Primary breast carcinoma can occur at ectopic sites. The axilla is the most common site of ectopic primary breast cancer, but presentation in the vulva is rare. We discuss a rare presentation of primary breast carcinoma of the vulva with distant lymph node and bone metastases in a premenopausal woman.
Case Presentation:
A vulvar malignancy consistent with adenocarcinoma of the mammary gland type was diagnosed in a 47-year-old premenopausal woman. The patient underwent radical vulvectomy with bilateral superficial and deep inguinal lymphadenectomy. The tumor was positive for estrogen receptor and negative for progesterone receptor and human epidermal growth factor receptor 2/neu on immunohistochemical findings. A positron emission tomography-computed tomography scan demonstrated lymph node and bone metastases. Her disease was treated as stage IV breast cancer with metastases to the bone. Palliative treatment with ovarian suppression, aromatase inhibitor, and cyclin-dependent kinase 4/6 inhibitor was recommended.
Discussion: For a diagnosis of primary breast cancer of the vulva, a thorough metastatic workup should be performed, with attention directed toward detecting a breast primary disease by results of the history, physical examination, and radiologic examination of the breasts mainly to help confirm that the vulvar lesion is the primary site as opposed to metastasis from a breast primary cancer and also for staging. Management of this rare entity is challenging because of a lack of specific guidelines, and treatment, therefore, is similar to that of breast cancer.

Treatment should consist of an individualized combination of surgery, radiotherapy, chemotherapy, and antiestrogen hormonal therapy.

INTRODUCTION

Ectopic breast tissue can occur anywhere along the primitive milk line, extending from the axilla to the groin, as a result of incomplete involution of the ectodermal mammary ridges during embryologic development.1-3 Primary breast carcinoma can occur at ectopic sites. The axilla is the most common site of ectopic primary breast cancer, but presentation in the vulva is rare. To date, approximately 36 cases of ectopic primary breast carcinomas of the vulva have been reported in the literature. Here, we discuss a rare presentation of primary breast carcinoma of the vulva with distant metastases to lymph nodes and bone in a premenopausal woman.

CASE PRESENTATION

Presenting Concerns

A 47-year-old, multiparous, premenopausal woman was referred to the Gynecologic Oncology Department at our institution with a diagnosis of a vulvar malignancy. The patient noted a mass in the right vulva approximately 1 year before presentation. She presented to her local gynecologist about 6 months later when she noted more swelling, pain, and some bleeding from the mass. Excision of the right labium majus was performed. The patient was otherwise healthy and had no remarkable medical history.

A review of pathologic slides from her presenting institution showed a 2.7-cm adenocarcinoma invading subcutaneous tissue, epidermis, and dermis with skin ulceration. Multifocal lymphovascular and extensive perineural invasion was noted. Deep surgical margins were involved by adenocarcinoma, but the peripheral surgical margins were clear. Immunohistochemical stains demonstrated that the adenocarcinoma was diffusely positive for GATA-3 and negative for CK7, CK20, CDX2, PAX-8, and CD56. The morphologic characteristics and immunophenotype were consistent with adenocarcinoma of mammary gland type vs a poorly differentiated vulvar adnexal tumor (less likely) and was considered to either originate from the vulva or be metastatic from the breast. No benign ectopic breast tissue was identified.

Therapeutic Intervention and Treatment

The patient underwent radical vulvectomy with bilateral superficial and deep inguinal lymphadenectomy. Final pathologic findings showed multiple (4/17) matted lymph nodes positive for carcinoma with extracapsular extension and residual grade 3, mammary-type adenocarcinoma. Focal ectopic breast tissue, separate from the residual tumor, was identified. Surgical margins were negative for cancer. Estrogen receptor expression was strong, with diffuse nuclear positivity. Progesterone receptor and human epidermal growth factor receptor 2 (HER2/neu) were negative on immunohistochemical testing. The patient was referred to a medical oncologist for further management.

A positron emission tomography-computed tomography (PET/CT) scan was performed to complete the staging. The scan showed multiple right iliac lymph nodes with mild to moderate activity and a 1-cm lytic lesion at the first thoracic vertebral body with moderate activity (standardized uptake value maximum of 2.2), which was concerning for metastatic disease (Figures 1 and 2). A biopsy of pelvic nodes or bone was requested, but was not feasible. Results of imaging of the brain were negative for metastases. A bilateral mammogram was repeated and showed heterogeneous dense fibroglandular tissue and a 3.6-cm, circumscribed mass in the upper outer quadrant of the right breast (Figure 3). The mass underwent a biopsy and pathologic analysis confirmed a fibroadenoma. The patient was referred to genetic counseling given her young age. Her family history was remarkable only for a maternal grandmother (smoker) with a diagnosis of lung cancer and a paternal grandfather (smoker) in whom head and neck cancer had been diagnosed. She, however, did not follow-up for genetic testing.

The multidisciplinary team decided to treat her disease as a stage IV breast cancer with metastasis to the bone. Palliative treatment with ovarian suppression, aromatase inhibitor, and cyclin-dependent kinase (CDK) 4/6 inhibitor was recommended; however, she declined this treatment regimen. As an alternative, tamoxifen was recommended, but the patient decided against any form of therapy at that time.

Follow-up and Outcomes

The patient did not return for follow-up until 4 months later, when she had bilateral malignant pleural effusions. The patient was started on tamoxifen, which was later stopped because of progression of disease. She refused any type of chemotherapy. She was started on a regimen of goserelin for ovarian suppression, an aromatase inhibitor (letrozole), and the CDK4/6 inhibitor palbociclib. Palbociclib was later changed to abemaciclib because of difficulty swallowing capsules. She received CDK4/6 for 6 months with stable metastatic disease on CT scan (Table 1). She also received zoledronic acid to reduce the incidence of skeletal-related events. During her course of treatments, she was admitted multiple times to the hospital because of acute respiratory failure secondary to malignant pleural effusions, and she received thoracentesis and PleurX catheter placement. During her last admission, she was placed into hospice care and died. Table 2 presents a timeline of the case.

19.084

DISCUSSION

The primitive embryonic milk line extends from the axilla to the groin, including the vulva. Ectopic (accessory) breast tissue can develop if the involution of the mammary ridge is incomplete.4 The incidence of ectopic mammary gland tissue is 1% to 6% of the general population.1 Ectopic breast tissue can be found along the milk line as extranumerary nipples, extranumerary nipple areola complexes, and extranumerary breasts. The most common location of ectopic breast tissue is the axilla, followed by the area immediately inferior to the normal breast. In addition to these areas, its location in the acromial or scapular region, the vulva, and the midline of the thorax and abdomen has also been rarely reported. In 1872, Hartung reportedly presented the first case of a fully formed mammary gland in the left labium majus of a 30-year-old woman.5-8

Ectopic primary breast cancer of the vulva is rare. The first case of ectopic breast tissues in the vulva was reported by Greene9 in 1936. Since then, an additional 36 cases of primary ectopic breast cancers have been described in the literature (Table 3).1,5,10-42 Any of the various histologic subtypes of breast cancer may occur in the vulva, including infiltrating ductal, lobular, mucinous, and mixed ductal and lobular carcinomas.33,43

An alternative theory, other than the incomplete involution of the mammary ridges, exists to explain the presence of ectopic breast tissue in the vulva.27 van der Putte44 described a variant of cutaneous glands in the anogenital region that resembled mammary glands. Because of the similarity to breast parenchyma, these structures were called mammarylike glands of the vulva and have similar neoplastic potential. Adenocarcinoma developing from mammarylike glands is called mammarylike adenocarcinomas of the vulva. These are locally aggressive tumors that frequently recur and involve lymph node metastases in approximately 60% of cases.31

For a diagnosis of this disease, a thorough metastatic workup should be performed, with attention directed toward detecting a breast primary cancer by the results of the history, physical examination, and radiologic examination of the breasts to confirm that the vulvar lesion is the primary site as opposed to a metastasis from a primary breast cancer. The possible rare association of these lesions with synchronous or metachronous breast cancers (16 cases in the literature) makes the exclusion of breast lesions an important part of management. Irvin et al20 defined the criteria for diagnosing this disease. When an in situ component is not present, in the absence of concurrent breast carcinoma, the following should be sufficient to categorize the lesion of primary vulvar origin: 1) a morphologic pattern consistent with breast carcinoma; 2) the presence of estrogen and progesterone receptors; and/or 3) positivity for common breast cancer markers such as epithelial membrane antigen, carcinoembryonic antigen, and glandular keratins. On the basis of these criteria, we diagnosed this disease as an adenocarcinoma of mammarylike glands in the vulva.

In most cases, surgical treatment of primary ectopic breast cancer of the vulva includes surgical excision with inguinal lymph node dissection. Sentinel lymph node biopsy could be considered as an effective alternative to inguinal node dissection.34 In a randomized controlled clinical trial of patients with vulvar cancer with inguinal node metastasis, postoperative pelvic and inguinal radiation therapy showed significant recurrence-free and cancer-related death benefit compared with ipsilateral pelvic node resection after radical vulvectomy and inguinal lymphadenectomy.45

Because of the rarity of the diagnosis and the lack of definitive treatment guidelines, this type of cancer is currently staged and treated according to current Tumor, Node, Metastasis (TNM)-based classification applicable to primary breast cancer. Therefore, treatment should consist of an individualized combination of surgery, chemotherapy, monoclonal antibody therapy, radiation, and adjuvant endocrine therapy, as appropriate.

The combination of a CDK4/6 inhibitor with endocrine therapy represents the standard first-line treatment of metastatic hormone receptor-positive breast cancer, for both premenopausal (like the patient described in our case report) and postmenopausal women. Dysregulated cellular proliferation is considered one of the “hallmarks” of cancer, and in many breast cancer cells, tumor proliferation is related to hyperactivity of the cyclin D-CDK4/6 axis, making pharmacologic blockade of this axis an attractive therapeutic strategy.10,11,46 Three CDK4/6 inhibitors have now been approved by the US Food and Drug Administration for the treatment of estrogen receptor-positive metastatic breast cancer: palbociclib (PD0332991), ribociclib (LEE011), and abemaciclib (LY835219). The addition of these agents to endocrine therapy has resulted in significant improvement of progression-free survival (Table 3). Of note, the results of the phase III MONALEESA-7 trial showed that the efficacy of the CDK4/6 inhibitor ribociclib in premenopausal or perimenopausal women when they receive ovarian function suppression together with oral endocrine therapy (tamoxifen or an aromatase inhibitor) is very similar to that observed in the postmenopausal trials (Table 1).46 This was the first major study to include tamoxifen as one of the endocrine therapy partners to CDK4/6 inhibition, and a similar improvement in progression-free survival was observed with either endocrine regimen.46

CONCLUSION

Primary breast cancer, arising from embryonic mammary ridge remnants, is an extremely rare histologic subtype of vulvar cancer. Diagnosis rests on the pathologic findings, with recognition of the characteristic histologic features and the presence of estrogen and/or progesterone receptors after the possibility of metastatic disease from breast primary cancer has been ruled out. Therapy should consist of an individualized combination of surgery, radiotherapy, chemotherapy, antiestrogen therapy, and monoclonal antibody therapy, similar to cancer of the orthotopic breast of similar stage. Owing to the rarity of this lesion, clinical trials to determine optimum treatment are not available, and management guidelines will rely on small series or case studies.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgments

Kathleen Louden, ELS, of Louden Health Communications performed a primary copy edit.

Author Affiliations

1 Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock
2 Department of Hematology/Oncology, University of Arkansas for Medical Sciences, Little Rock
3 Department of Gynecologic Oncology, University of Arkansas for Medical Sciences, Little Rock
4 Department of Radiology and Epidemiology, University of Arkansas for Medical Sciences, Little Rock
5 Department of Pathology, University of Arkansas for Medical Sciences, Little Rock

Corresponding Author

Aneesha Ananthula, MD ()

How to Cite this Article

Ananthula A, Lockwood B, Savage J, Malak S, Chen C, Makhoul I, Pennisi A. Primary breast carcinoma of the vulva metastatic to lymph nodes and bones: A case report and literature review. Perm J 2020;24:19.084. DOI: https://doi.org/10.7812/TPP/19.084

References
1.    Eom H-J, Ko BS, Song IH, Gong G, Kim HH. Ectopic male breast cancer in the perineum. J Breast Cancer 2017 Dec;20(4):404-7. DOI: https://doi.org/10.4048/jbc.2017.20.4.404
    2.    Hamilton WJ, Mossman Boyd. Hamilton, Boyd and Mossman’s human embryology. 4th ed. Cambridge, UK: Heffer; 1972
    3.    Aksoy HM, Aksoy B, Portakal S, Ozdemir A. An uncommon location for accessory breast tissue: Inner thigh. Eur J Plast Surg 2008 Sep;31(6):339-40. DOI: https://doi.org/10.1007/s00238-008-0286-3
    4.    Miles RC, Amornsiripanitch N, Scheel J. Inflammatory breast cancer in accessory abdominal breast tissue. Radiol Case Rep 2017 Dec;12(4):639-41. DOI: https://doi.org/10.1016/j.radcr.2017.08.008
    5.    Simon KE, Dutcher JP, Runowicz CD, Wiernik PH. Adenocarcinoma arising in vulvar breast tissue. Cancer 1988 Nov 15;62(10):2234-8. DOI: https://doi.org/10.1002/1097-0142(19881115)62:10<2234::AID-CNCR2820621027>3.0.CO;2-F
    6.    Haagensen DC. The lymphatics of the breast. In: Haagensen DC, editor. Diseases of the breast. Philadelphia, PA: WB Saunders Co; 1986:25-46
    7.    Grossl NA. Supernumerary breast tissue: Historical perspectives and clinical features. South Med J 2000 Jan;93(1):29-32. DOI: https://doi.org/10.1097/00007611-200093010-00005
    8.    Velanovich V. Ectopic breast tissue, supernumerary breasts, and supernumerary nipples. South Med J 1995 Sep;88(9):903-6. DOI: https://doi.org/10.1097/00007611-199509000-00002
    9.    Greene HJ. Adenocarcinoma of supernumerary breasts of the labia majora in a case of epidermoid carcinoma of the vulva. Am J Obstet Gynecol 1936 Apr;31(4):660-3. DOI: https://doi.org/10.1016/S0002-9378(36)90467-2
    10.    Hendrix RC, Behrman SJ. Adenocarcinoma arising in a supernumerary mammary gland in the vulva. Obstet Gynecol 1956;8(2):238-41
    11.    Guerry RL, Pratt-Thomas HR. Carcinoma of supernumerary breast of vulva with bilateral mammary cancer. Cancer 1976;38(6):2570-4. DOI: https://doi.org/10.1002/1097-0142(197612)38:6<2570::aid-cncr2820380650>3.0.co;2-t
    12.    Guercio E, Cesone P, Saracino A, Gatti M, Arisio R, Oberto F. Adenocarcinoma in sorto su ghiandola mammaria aberante in sede vulvare [Adenocarcinoma occurring in an aberrant mammary gland located in the vulva]. Minerva Ginecol 1984 Jun;36(6):315-9
    13.    Cho D, Buscema J, Rosenshein NB, Woodruff JD. Primary breast cancer of the vulva. Obstet Gynecol 1985 Sep;66(3 suppl):79S-81S
    14.    Rose PG, Roman LD, Reale FR, Tak WK, Hunter RE. Primary adenocarcinoma of the breast arising in the vulva. Obstet Gynecol 1990 Sep;76(3 pt 2):537-9. DOI: https://doi.org/10.1016/0020-7292(91)90836-t
    15.    Di Bonito L, Patriarca S, Falconieri G. Aggressive “breast-like” adenocarcinoma of vulva. Pathol Res Pract 1992;188(1-2):211-4. DOI: https://doi.org/10.1016/S0344-0338(11)81181-7
    16.    Bailey CL, Sankey HZ, Donovan JT, Beith KA, Otis CN, Powell JL. Primary breast cancer of the vulva. Gynecol Oncol 1993 Sep;50(3):379-83. DOI: https://doi.org/10.1006/gyno.1993.1230
    17.    Levin M, Pakarakas RM, Chang HA, Maiman M, Goldberg SL. Primary breast carcinoma of the vulva: A case report and review of the literature. Gynecol Oncol 1995 Mar;56(3):448-51. DOI: https://doi.org/10.1006/gyno.1995.1080
    18.    Kennedy DA, Hermina MS, Xanos ET, Schink JC, Hafez GR. Infiltrating ductal carcinoma of the vulva. Pathol Res Pract 1997;193(10):723-6. DOI: https://doi.org/10.1016/s0344-0338(97)80033-7
    19.    Erb-Gremillet S, Gunther M, Amiaux F, Parache RM. Breast-like carcinoma of the vulva [article in French]. Ann Pathol 1999 Apr;19(2):124-7
    20.    Irvin WP, Cathro HP, Grosh WW, Rice LW, Andersen WA. Primary breast carcinoma of the vulva: A case report and literature review. Gynecol Oncol 1999 Apr;73(1):155-9. DOI: https://doi.org/10.1006/GYNO.1998.5269
    21.    Gorisek B, Zegura B, Kavalar R, But I, Krajnc I. Primary breast cancer of the vulva: A case report and review of the literature. Wien Klin Wochenschr 2000 Oct 13;112(19):855-8
    22.    Neumann I, Strauss HG, Buchmann J, Koelbl H. Ectopic lobular breast cancer of the vulva. Anticancer Res 2000;20(6C):4805-8
    23.    Piura B, Gemer O, Rabinovich A, Yanai-Inbar I. Primary breast carcinoma of the vulva: Case report and review of literature. Eur J Gynaecol Oncol 2002;23(1):21-4
    24.    Chung-Park M, Zheng Liu C, Giampoli EJ, Emery JD, Shalodi A. Mucinous adenocarcinoma of ectopic breast tissue of the vulva. Arch Pathol 2002 Oct;126(10):1216-8
    25.    Yin C, Chapman J, Tawfik O. Invasive mucinous (colloid) adenocarcinoma of ectopic breast tissue in the vulva: A case report. Breast J 2003 Mar/Apr;9(2):113-5. DOI: https://doi.org/10.1046/j.1524-4741.2003.09213.x
    26.    Ohira S, Itoh K, Osada K, et al. Vulvar Paget’s disease with underlying adenocarcinoma simulating breast carcinoma: Case report and review of the literature. Int J Gynecol Cancer 2004;14(5):1012-7. DOI: https://doi.org/10.1136/ijgc-00009577-200409000-00040
    27.    Tanaka H, Umekawa T, Nagao K, Ishihara A, Toyoda N. Adenocarcinoma of mammary-like glands in the vulva successfully treated by weekly paclitaxel. Int J Gynecol Cancer 2005 May-Jun;15(3):568-71. DOI: https://doi.org/10.1111/j.1525-1438.2005.15328.x
    28.    Lopes G, DeCesare T, Ghurani G, et al. Primary ectopic breast cancer presenting as a vulvar mass. Clin Breast Cancer 2006 Aug;7(3):278-9. DOI: https://doi.org/10.3816/CBC.2006.n.041
    29.    Intra M, Maggioni A, Sonzogni A, et al. A rare association of synchronous intraductal carcinoma of the breast and invasive carcinoma of ectopic breast tissue of the vulva: Case report and literature review. Int J Gynecol Cancer 2006 Jan-Feb;16(suppl 1):428-33. DOI: https://doi.org/10.1111/j.1525-1438.2006.00237.x
    30.    Fracchioli S, Puopolo M, De La Longrais IA, et al. Primary “breast-like” cancer of the vulva: A case report and critical review of the literature. Int J Gynecol Cancer 2006 Jan-Feb;16(suppl 1):423-8. DOI: https://doi.org/10.1111/j.1525-1438.2006.00364.x
    31.    Abbott JJ, Ahmed I. Adenocarcinoma of mammary-like glands of the vulva: Report of a case and review of the literature. Am J Dermatopathol 2006 Apr;28(2):127-33. DOI: https://doi.org/10.1097/01.dad.0000171601.25315.2b
    32.    Martinez-Palones JM, Perez-Benavente A, Diaz-Feijoo B, et al. Sentinel lymph node identification in a primary ductal carcinoma arising in the vulva. Int J Gynecol Cancer 2007 Mar-Apr;17(2):471-7. DOI: https://doi.org/10.1111/j.1525-1438.2007.00817.x
    33.    North J, Perez D, Fentiman G, Sykes P, Dempster A, Pearse M. Primary breast cancer of the vulva: Case report and literature review. Aust N Z J Obstet Gynaecol 2007 Feb;47(1):77-9. DOI: https://doi.org/10.1111/j.1479-828X.2006.00685.x
    34.    Tseung J, Russell P. “Breast-like” lesions in the vulva: histology, origin and significance. Pathology. 2008 Apr;40(3):321-6. DOI: https://doi.org/10.1080/00313020701813628
    35.    Naseer MA, Mohammed SS, George SM, Das Majumdar SK. Primary ectopic breast cancer mimicking as vulval malignancy. J Obstet Gynaecol 2011 Aug;31(6):553-4. DOI: https://doi.org/10.3109/01443615.2011.587054
    36.    Diniz da Costa AT, Coelho AM, Lourenço AV, Bernardino M, Ribeirinho AL, Jorge CC. Primary breast cancer of the vulva: A case report. J Low Genit Tract Dis 2012 Apr;16(2):155-7. DOI: https://doi.org/10.1097/LGT.0b013e31823b3bc6
    37.    McMaster J, Dua A, Dowdy SC, et al. Primary breast adenocarcinoma in ectopic breast tissue in the vulva [case report]. Case Rep Obstet Gynecol 2013;2013:721696. DOI: https://doi.org/10.1155/2013/721696
    38.    Bogani G, Uccella S, Cromi A, Casarin J, Donadello N, Ghezzi F. Primary mammary-like ductal carcinoma of the vulva. Am J Dermatopathol 2013 Aug;35(6):685-7. DOI: https://doi.org/10.1097/DAD.0b013e31828484c0
    39.    Lamb A, Darus CJ, Skripenova S, Weisberg T, Miesfeldt S. Association of primary breast cancer of the vulva with hereditary breast and ovarian cancer. J Clin Oncol 2013 May 1;31(13):e231-2. DOI: https://doi.org/10.1200/JCO.2012.45.5972
    40.    Benito V, Arribas S, Martínez D, Medina N, Lubrano A, Arencibia O. Metastatic adenocarcinoma of mammary-like glands of the vulva successfully treated with surgery and hormonal therapy. J Obstet Gynaecol Res 2013 Jan;39(1):450-4. DOI: https://doi.org/10.1111/j.1447-0756.2012.01937.x
    41.    Cripe J, Eskander R, Tewari K. Sentinel lymph node mapping of a breast cancer of the vulva: Case report and literature review. World J Clin Oncol 2015 Apr 10;6(2):16-21. DOI: https://doi.org/10.5306/wjco.v6.i2.16
    42.    Ishigaki T, Toriumi Y, Nosaka R, et al. Primary ectopic breast cancer of the vulva, treated with local excision of the vulva and sentinel lymph node biopsy: A case report. 2017 Dec;1:69. DOI: https://doi.org/10.1186/s40792-017-0343-x
    43.    Kazakov DV, Spagnolo DV, Kacerovska D, Michal M. Lesions of anogenital mammary-like glands: An update. Adv Anat Pathol 2011 Jan;18(1):1-28. DOI: https://doi.org/10.1097/PAP.0b013e318202eba5
    44.    van der Putte SC. Mammary-like glands of the vulva and their disorders. Int J Gynecol Pathol 1994;13(2):150-60. DOI: https://doi.org/10.1097/00004347-199404000-00009
    45.    Kunos C, Simpkins F, Gibbons H, Tian C, Homesley H. Radiation therapy compared with pelvic node resection for node-positive vulvar cancer: A randomized controlled trial. Obstet Gynecol 2009 Sep;114(3):537-46. DOI: https://doi.org/10.1097/AOG.0b013e3181b12f99
    46.    Tripathy D, Im S-A, Colleoni M, et al. Ribociclib plus endocrine therapy for premenopausal women with hormone-receptor-positive, advanced breast cancer (MONALEESA-7): A randomised phase 3 trial. Lancet Oncol 2018 Jul 1;19(7):904-15. DOI: https://doi.org/10.1016/S1470-2045(18)30292-4

Keywords: adenocarcinoma of mammary‐like glands in the vulva, ectopic primary breast cancer, primary breast carcinoma of the vulva

ETOC

Click here to join the eTOC list or text ETOC to 22828. You will receive an email notice with the Table of Contents of The Permanente Journal.

CIRCULATION

2 million page views of TPJ articles in PubMed from a broad international readership.

Indexing

Indexed in MEDLINE, PubMed Central, HINARI, EMBASE, EBSCO Academic Search Complete, rdrb, CrossRef, and SciVerse/Scopus.


                                             

 

 

ISSN 1552-5767 Copyright © 2020 thepermanentejournal.org.

All Rights Reserved.