Metastatic breast cancer masquerading as gastrointestinal primary

Metastases of lobular breast carcinoma in the terminal ileum and ileocaecal valve

Gastrointestinal (GI) metastases from primary breast carcinoma are rare but more common in invasive lobular carcinoma than invasive ductal carcinoma. The symptoms may be non-specific and the presentation can occur many years after the initial primary breast carcinoma. Radiological and endoscopic findings can be difficult to distinguish from inflammatory bowel disease and primary carcinoma of the GI tract. Histological and immunohistopathology assessment will usually confirm the diagnosis of metastatic breast carcinoma. We report the first case of lobular breast carcinoma metastasizing to the terminal ileum and ileocaecal valve 19 years following treatment for breast cancer in an 82-year-old woman. Staging investigations revealed synchronous metastases in bones and the pleura. A high index of suspicion and awareness of the potential long interval in the presentation of metastatic breast cancer help in making an accurate diagnosis and rapid clinical management.

Clinicopathological features and treatment outcomes of metastatic tumors in the stomach

The metastasis of tumors to the stomach is rare, which underlies the clinical problems regarding their diagnosis and treatment. The present review summarizes the current knowledge regarding the clinicopathological characteristics, therapeutic strategies and outcomes for metastatic tumors in the stomach. The primary malignancies of the metastatic tumors in the stomach were most often breast cancers (27.9 %), followed by lung cancer (23.8 %), esophageal cancer (19.1 %), renal cell carcinoma (RCC; 7.6 %) and malignant melanoma (7.0 %). In cases of breast cancer and RCC as the primary malignancy, the median interval between the treatment of the primary tumor and diagnosis of the metastatic tumor in the stomach (IPM) was 50-78 and 75.6 months, respectively, highlighting the fact that the metastatic spread to the stomach may occur many years after the initial treatment of the cancer. In nine patients with metastatic gastric tumors arising from ovarian cancer, an endoscopic examination revealed submucosal tumors in six patients (66.7 %), with a median IPM of 30 months. Appropriate systemic treatment for these tumors is the preferred therapeutic strategy. Although solitary metachronous gastric metastasis several years after treatment of the primary tumor is an exceptionally rare event, surgical resection of metastatic gastric tumors may be recommended to control hemorrhaging or for selected tumors.

Synchronous gist, colon and breast adenocarcinoma with double colonic polyp metastases

INTRODUCTION

Long term survivors of breast cancer are at risk of developing distant metastasis years after the initial treatment. We report a case of breast adenocarcinoma with colonic polyp metastases, as well as synchronous primary colonic adenocarcinoma and a gastric GIST.

PRESENTATION OF CASE

An 83 year old female underwent colonoscopy for rectal bleeding. This showed a primary colonic adenocarcinoma, a pedunculated polyp in the ascending colon and two polyps in the sigmoid colon. A staging CT scan did not show distant metastasis, but revealed a small gastric GIST which was managed conservatively. A right hemicolectomy showed a T3N0 colonic adenocarcinoma and a polyp contained metastatic adenocarcinoma from a breast primary. The patient had undergone surgery 30 years ago for an invasive lobular carcinoma. Further clinical assessment demonstrated an impalpable grade II Invasive ductal carcinoma in the contralateral breast. She was started on hormonal treatment and at 18 months follow-up, she was well with stable disease.

DISCUSSION

Invasive lobular cancer is the most common histological type of breast cancer that metastasizes to the colon. There is no consensus on the management of breast cancer metastasis to the gastrointestinal tract. Co-existence of a GIST and an adenocarcinoma at two separate locations is uncommon. These are two different cancer entities and it is unclear whether these two are related by as causal relationship.

CONCLUSION

This is a rare case of three distinct tumours; association between them is unlikely. However, the case highlights the importance of a multidisciplinary approach to cancer treatment.

Gastrointestinal tract metastasis from tubulolobular carcinoma of the breast: a case report and review of the literature

Metastasis of breast cancer into the gastrointestinal tract happens rarely. The diagnosis of this kind of disease is difficult because of the nonspecific symptoms and the long interval between primary manifestations and recurrence. Awareness of this condition may lead to an accurate diagnosis and an earlier initiation of systemic treatment, thus avoiding unnecessary surgical intervention. In this paper, we report a rare case of a patient with tubulolobular carcinoma metastases to the colon, presenting with abdominal pain, discomfort, and weight loss. The patient underwent radical mastectomy and received postoperative radiotherapy and chemotherapy. Ten years later, she presented with gastrointestinal tract symptoms. Surgery combined with systemic treatment was chosen for the colon lesion. Immunohistochemical staining suggested a breast origin. The patient was still living 24 months after the diagnosis of the metastasis. This is the fourth case report in our literature review.

Pancreatic solitary and synchronous metastasis from breast cancer: a case report and systematic review of controversies in diagnosis and treatment

Background

Metastases from breast cancer cause the frequent involvement of lung, bone, liver, and brain, while the occurrence of metastases to the gastrointestinal tract is rare, and more frequently discovered after a primary diagnosis of breast cancer. Solitary pancreatic metastases from breast cancer, without widespread disease, are actually unusual, and only 19 cases have been previously described; truly exceptional is a solitary pancreatic metastasis becoming evident together with the primary breast cancer.

Case presentation

A 68-year-old woman reported general fatigue, lethargy, and jaundice. Abdominal ultrasound (US) and magnetic resonance imaging (MRI) showed an ampulloma of Vater’s papilla; moreover, a neoplastic nodule in the left breast was diagnosed. She underwent surgery for both breast cancer and ampulloma of Vater’s papilla. Pathological examination of pancreatic specimen, however, did not confirm primary carcinoma of the duodenal papilla, but showed a metastatic involvement of pancreas from lobular breast cancer. Immunohistochemistry has been essential to confirm the origin of the malignancy: hormone receptors and mammaglobin were expressed in both the primary breast tumor and the pancreatic metastasis.

Conclusions

This is one of the few reported cases in literature of an isolated and synchronous pancreatic metastasis from breast cancer, where the definitive diagnosis was obtained only after surgery. We discuss the controversies in this diagnosis and the choice of correct treatment. The surgical resection of solitary metastases can be performed in the absence of disseminated disease.

Scirrhous colonic metastasis from lobular carcinoma of breast

A 68-year-old woman presented complaining of 2 months vague abdominal fullness and constipation. She had a history of surgery 5 years ago for invasive lobular carcinoma of the left breast. She had good appetite without any severe symptoms such as vomiting, diarrhea, or hematochezia. No abnormal subcutaneous lymph nodes were detected, and blood tests showed no abnormalities including serum tumor markers. Whole-body computed tomography and bone scintigraphy revealed no tumor recurrences. However, endoscopic findings demonstrated a smooth stenotic lesion with submucosal thickening in the transverse colon, but the colonic mucous membrane was grossly normal. The 3-cm-long stenotic lesion was confirmed by colon imaging using water-soluble contrast medium. A biopsy specimen revealed diffuse infiltration of noncohesive malignant cells with round, atypical nuclei from lamina propria to subserosa. Taken together with immunohistochemistry, a diagnosis of metastatic lobular carcinoma from the breast was made, and transverse segmentectomy was done. Colonic metastasis of breast cancer should be included as a differential diagnosis of any abdominal symptoms, even though mild, when patients have a present or previous history of breast cancer.

Case report of small bowel obstruction caused by small intestinal metastasis of bilateral breast cancer

A 41-year-old female was admitted into hospital due to recurrent abdominal pain with bloating. An enteroscopy was carried out and stenosis in the lower jejunal lumen was identified. This led to a diagnosis of small bowel obstruction caused by inflammation. During the laparotomy, the resection and anastomosis of a narrow segment of small intestine was performed. In combination with the results of immunohistochemical analysis, the postoperative pathology indicated the presence of a poorly differentiated/undifferentiated carcinoma of the small intestine, which was considered to have arisen from breast cancer. Postoperative examination showed bilateral breast masses, and the pathology of the right breast tumor biopsy prompted the diagnosis of invasive lobular carcinoma. A breast MRI was reviewed following five cycles of XT chemotherapy and the evaluation was stable disease (SD). Since the mass was not sensitive to chemotherapy, a bilateral modified radical mastectomy was performed, and postoperative pathology confirmed the mass to be primary bilateral invasive lobular carcinoma.

Metastatic breast carcinoma presenting as a sigmoid stricture: report of a case and review of the literature

Metastatic spread of breast carcinoma to the colon and rectum is rare. We report the case of a patient treated for lobular breast carcinoma presenting 17 years later with metastatic breast cancer of the colon. A 63-year-old lady with a past history of right-sided invasive lobular carcinoma of the breast presented with persistent diarrhoea. Colonoscopy with biopsies revealed a benign-looking stricture at the rectosigmoid junction. A CT scan of the abdomen and pelvis revealed a benign-looking stricture in keeping with a probable diverticular stricture. A Hartmann procedure was performed and histology revealed a metastatic lobular carcinoma with oestrogen and progesterone receptor-positive status. Treatment was commenced with letrozole and the patient remains well under clinical surveillance. In a patient with a history of breast carcinoma who presents with gastrointestinal symptoms the possibility of gastrointestinal tract spread should always be considered. Endoscopic diagnosis may be misleading with pathological diagnosis only being made following surgical resection. A history of breast carcinoma must be declared to the histopathologist following surgical resection so that an accurate diagnosis is made and appropriate treatment is commenced.

Invasive ductal breast cancer metastatic to the sigmoid colon

The most common sites of breast cancer metastasis are the bone, lung, liver and brain. However, colonic metastases from breast cancer are very rare in the clinic. We describe an unusual case of sigmoid colonic metastasis from invasive ductal breast cancer. With this report, we should increase the clinical awareness that any patient with a colorectal lesion and a history of malignancy should be considered to have a metastasis until proven otherwise. Early diagnosis is very important, which enables prompt initiation of systemic treatment, such as chemotherapy, endocrine therapy or both, thus avoiding unnecessary radical surgical resection and improving the prognosis.

Metastatic lobular carcinoma of the breast masquerading as a primary rectal cancer

Background

Colorectal metastasis of lobular carcinoma of the breast is a diagnostic challenge. It may macroscopically simulate primary colon cancer or inflammatory bowel disease. In some cases, the interval between the primary breast cancer and metastatic colorectal lesions is so long that the critical records for diagnosis including history might be lost or missed.

Case presentation

Reported herein is a case of metastatic lobular carcinoma of the breast masquerading as a primary rectal cancer developed in a 62-year-old Japanese woman. The case initially presented as a circumferential rectal lesion, and information on the patient’s history of breast cancer was not noted. As the result of endoscopic biopsy, diagnosis of poorly differentiated rectal adenocarcinoma was made. The lesion was surgically resected after chemo-radiotherapy. Histopathological examination of the resected specimen with hematoxylin and eosin (HE) stain revealed a single-file arrangement of the tumor cells, reminiscent of lobular carcinoma of the breast. Immunohistochemical analysis revealed an immunophenotype consistent with lobular carcinoma of the breast. Because further review of the patient’s history revealed an occurrence of ‘poorly differentiated adenocarcinoma of the breast’, which she had experienced 24 years earlier, the final diagnosis of the lesion was made as rectal metastasis from lobular breast carcinoma.

Conclusions

Poorly differentiated adenocarcinoma of the colorectum is rarer than that of the stomach. Linitis plastica-type cancer of the colorectum is also rarer than that of the stomach. A lesson from the present case is that before we conclude a linitis plastica-type cancer of poorly differentiated type as a primary colorectal cancer, it is critical to exclude a possibility of metastatic colorectal cancer.

Metastatic breast cancer to the gastrointestinal tract: report of five cases and review of the literature

Luminal gastrointestinal (GI) metastases from breast cancer are rare, reports are fragmentary and poor. The purposes of this study are to assess the gastrointestinal involvement from breast cancer in a retrospective study at a single institution and reviewing the related literature. Between January 2007 and December 2011 a total of 980 patients with breast cancer were treated at our institution, patients' records and report database were analysed. Institutional Review Board approval was obtained for this study. A search of the literature using PubMed, CancerLit, Embase, was performed. Selected for the present review were papers published in English before June 2012. Five of 980 patients (0.5%) showed gastrointestinal metastases from breast cancer, 3 patients had gastric involvement, 1 jejunum, and 1 rectum. Reviewing the literature, 206 patients affected by gastrointestinal metastasis from breast cancer were identified: the most frequent site of metastasis was the stomach (60%). The majority of the patients underwent chemotherapy and endocrine therapy, someone surgery and radiotherapy. GI metastases from breast cancer are rare, but possible, and a very late recurrence can also occur. Cyto-histological diagnosis is mandatory, to differentiate GI metastases from breast cancer to other diseases and to allow an adequate treatment.

Infiltrating lobular carcinoma of the breast presenting as gastrointestinal obstruction: a mini review

One in twelve American women will develop breast cancer, with infiltrating lobular carcinoma (ILC) comprising approximately 15% of these cases. The incidence of ILC has been increasing over the last several decades. It has been hypothesized that this increase is associated with combined replacement hormonal therapy. Although pathologically distinct from infiltrating ductal carcinoma (IDC), ILC is treated in the same manner as IDC. However, ILC demonstrates significantly different patterns of late local recurrence and distant metastasis. The incidence of extra-hepatic gastrointestinal metastases is reported to be 6% to 18%, with stomach being most common. Herein, we present a brief review of the literature and a typical case involving ILC initially presenting as a small bowel obstruction. Evidence suggests that the late clinical patterns of ILC are distinctly separate from IDC and physicians need be cognizant of its late local recurrence and unique late metastatic pattern. Different follow up strategy should be entertained in patients with ILC.

Ductal carcinoma of the breast metastasizing to the rectum

Gastrointestinal metastasis of the breast cancer is rare and its management varies significantly from that of a primary bowel cancer. We report a case of invasive ductal cancer metastasizing to the rectum and masquerading as a rectal primary.

A 60 year old caucasian woman presented with fresh rectal bleeding nine years after treatment of her primary breast cancer. The investigations revealed features suggestive of primary rectal malignancy and was managed accordingly. However, the surgical histopathology revealed poorly differentiated metastatic adenocarcinoma and the immunohistochemical evaluation confirmed origin from a breast primary. She had an uneventful post-operative recovery and remains disease free thus far.

The continuing advancement in the management of breast cancer patients with resulting increase in the overall survival will lead to such unusual metastatic presentations. Hence, the awareness, identification and differentiation of such rare metastatic presentation are important in order to manage the patients appropriately in the future.

Hepatocyte nuclear factor 4A expression discriminates gastric involvement by metastatic breast carcinomas from primary gastric adenocarcinomas

Breast carcinomas sometimes metastasize to the stomach, and the histopathologic distinction of such metastases from primary gastric adenocarcinomas is often difficult. We characterized the clinicopathologic features of 21 breast carcinomas that had metastasized to the stomach and examined the use of a panel of antibodies, including hepatocyte nuclear factor 4A, for distinguishing the metastases from primary gastric diffuse-type adenocarcinomas. Histologically, all the metastatic breast carcinomas showed a poorly differentiated and/or signet ring cell morphology. Although most metastatic breast and primary gastric carcinomas contained signet ring cell components, the cases that were predominantly or exclusively composed of univacuolated-type signet ring cells were limited to metastatic breast carcinomas. Immunohistochemically, hepatocyte nuclear factor 4A was expressed in all 33 primary gastric carcinomas that were examined but was never expressed in metastatic breast carcinomas. Previously reported markers for breast and gastric carcinomas also showed a high specificity, but their sensitivities were quite variable. Estrogen receptor α, progesterone receptor, mammaglobin, and gross cystic disease fluid protein 15 were expressed in 76%, 33%, 52%, and 62%, respectively, of the metastatic breast carcinomas, whereas none of the primary gastric carcinomas expressed these antigens. CDX2, MUC5AC, MUC6, and CK20 were expressed in 36%, 85%, 27%, and 55%, respectively, of the primary gastric carcinomas. All the metastatic breast carcinomas were negative for these antibodies except for 1 case that expressed MUC5AC. Overall, the use of immunohistochemistry efficiently discriminated metastatic breast carcinomas from primary gastric carcinomas. In particular, the present study identified hepatocyte nuclear factor 4A as an excellent marker for differentiating the 2 lesions.

Case report and literature review: Metastatic lobular carcinoma of the breast an unusual presentation

INTRODUCTION

Invasive lobular carcinoma is the second most common type of invasive breast carcinoma (between 5% and 15%). The incidence of invasive lobular carcinoma has been increasing while the incidence of invasive duct carcinoma has not changed in the last two decades. This increase is postulated to be secondary to an increased use of combined replacement hormonal therapy. Patients with invasive lobular carcinoma tend to be slightly older than those with non-lobular invasive carcinoma with a reported mean age of 57 years compared to 64 years. On mammography, architectural distortion is more common and microcalcifications less common with invasive lobular carcinoma than invasive ductal carcinoma. The incidence of extrahepatic gastrointestinal (GI) tract metastases observed in autopsy studies varies in the literature from 6% to 18% with the most commonly affected organ being the stomach, followed by colon and rectum. Gastric lesions seem to be slightly more frequent, compared to colorectal lesions (6-18% compared to 8-12%, respectively).

PRESENTATION OF CASE

We present the case of a 70-year-old woman who was referred to our institution with a concurrent gastric and rectal cancer that on further evaluation was diagnosed as metastatic invasive lobular carcinoma of the breast. She has a stage IV clinical T3N1M1 left breast invasive lobular carcinoma (ER positive at 250, PR negative, HER-2/neu 1+ negative) with biopsy proven metastases to left axillary lymph nodes, gastric mucosa, peritoneum, rectal mass, and bone who presented with a partial large bowel obstruction. She is currently being treated with weekly intravenous paclitaxel, bevacizumab that was added after her third cycle, and she is also receiving monthly zoledronic acid. She is currently undergoing her 12-month of treatment and is tolerating it well. Discussion Breast cancer is the most common site-specific cancer in women and is the leading cause of death from cancer for women aged 20-59 years. It accounts for 26% of all newly diagnosed cancers in females and is responsible for 15% of the cancer-related deaths in women.(9) Breast cancer is one of the most common malignancies that metastasize to the GI tract, along with melanoma, ovarian and bladder cancer.

CONCLUSION

We present one of the first reports of metastatic lobular breast cancer presenting as a synchronous rectal and gastric tumors. Metastatic lobular carcinoma of the breast is a rare entity with a wide range of clinical presentations. A high level of suspicion, repetition of endoscopic procedures, and a detailed pathological analysis is necessary for early diagnosis, which might help to avoid surgical treatment due to incorrect diagnosis. Patients with a history of breast cancer who present with new gastrointestinal lesions should have these lesions evaluated for evidence of metastasis through histopathologic evaluation and immunohistochemical analysis. Differentiating between a primary GI lesion and metastatic breast cancer will allow initiation of appropriate treatment and help prevent unnecessary operations.

Gastric metastasis of breast cancer: a single centre retrospective study

BACKGROUND

Digestive metastasis of breast cancer are rare but when they do occur the stomach is one of the commoner sites.

AIM

To describe the clinical, endoscopic, pathological features and treatment.

METHODS

35 cases of gastric metastasis were identified retrospectively between 1980 and 2008.

RESULTS

The location of the gastric metastasis was fundus (n=15, 43%), antrum (n=15, 43%) or both (n=5, 14%). The histological subtype of primary breast cancer was invasive lobular carcinoma in 34 patients (97%). Hormonal receptors were positive in 19 out of 24 cases (79%), two out of 22 analysed were HER2 positive (9%). There were 16 (46%) patients with peritoneal carcinosis. The treatment was chemotherapy (n=13, 37%), hormonotherapy (n=2, 6%) or both (n=13, 37%). The 2-year survival rate after gastric metastasis diagnosis was 53% with a median follow up of 31 months [7-84 months].

CONCLUSION

Ninety-seven percent of gastric metastasis from breast cancers are derived from invasive lobular carcinoma. Seventy-nine percent of these are HER+ and comparison with the original histopathological slides of primary breast carcinoma should be performed to differentiate gastric metastasis from primary gastric carcinoma. Peritoneal carcinomatosis accompanied gastric metastasis in almost half the cases in this series and treatment was generally chemotherapy.

Metastatic deposits of breast lobular carcinoma to small bowel and rectum

Breast cancer is the most frequent malignancy in women accounting for approximately 32% of all cancers, with a lifetime risk of 1 in 10. It causes considerable morbidity and mortality. Recently, the survival rate has dramatically increased due to early detection of the disease and improvement in the treatment measures. However, more than 30% of the patients develop metastatic diseases following surgical treatment, radiotherapy, hormonal therapy, or chemotherapy. Distant spread is usually found in bones, lungs, liver, brain and skin. Rarely, it spreads to bowel, spleen, gallbladder, pancreas, urinary bladder, and eyes. Breast cancer is the second commonest primary tumour responsible for gastrointestinal metastases after malignant melanoma. We report a case of a Caucasian female who developed an intestinal obstruction secondary to metastatic deposits to the small bowel and later to the rectum from breast lobular carcinoma 2 years after mastectomy, axillary clearance, radiotherapy, hormonal therapy, and transverse rectus abdominis myocutaneous (TRAM) flap for reconstruction.

Clinicopathological features of gastric metastasis from breast cancer in three cases

The common sites for metastases from breast cancer are lymph nodes, bone, lung, liver, and brain. Gastrointestinal (GI) metastasis is rarely found or diagnosed in patients with breast cancer. This report presents three cases of gastric metastasis from breast cancer. Case 1 was a 42-year-old female diagnosed with gastric metastasis after mastectomy with axillary lymph node dissection for invasive lobular carcinoma of the left breast. Case 2 was a 54-year-old female who was diagnosed to have invasive lobular carcinoma of the left breast with systemic bone and gastric metastasis. Case 3 was a 54-year-old female who was diagnosed to have bilateral invasive ductal carcinoma of the breast with simultaneous bone and gastric metastasis. The immunohistochemical statuses for estrogen receptor, progesterone receptor, mammaglobin, and gross cystic disease fluid protein-15 (GCDFP-15) between the primary and gastric metastatic lesions were all well matched. All three cases were treated with systemic chemotherapy, hormone therapy or both, without surgical intervention for gastric lesions. Two patients with disseminated disease died 27 and 58 months after diagnosis of gastric metastasis, while one patient without organ metastasis is still alive at 56 months after diagnosis. It is important to make a correct diagnosis by distinguishing gastric metastasis from breast cancer in order to select the optimal initial treatment for systemic disease of breast cancer.

Duodenal metastasis from recurrent invasive lobular carcinoma of breast: a case report and literature review

We present a rare case of duodenal metastasis from invasive breast lobular carcinoma, which first presented clinically as elevated serum tumor marker levels, followed by jaundice but with no other clinical evidence of recurrence and metastasis. A 53-year-old woman underwent modified radical mastectomy of the left breast (pT2 N3 M0 stage III c) followed by postoperative chemo-radiotherapy and hormonal therapy. After about 3 years, the patient presented with elevated serum tumor marker levels and mild jaundice. She was subsequently admitted to the hospital for nausea and severe vomiting. A duodenoscopy revealed the thickening of duodenal papilla on the lateral wall and stenosis. A duodenal tissue biopsy revealed poorly differentiated adenocarcinoma, and immunohistochemical staining suggested that the carcinoma was of breast origin. The patient received further radiation and chemotherapy. Although duodenal metastases of breast cancer are rare, physicans should be alert and vigilant when a patient with a history of breast cancer presents with new gastrointestinal symptoms.

Solitary small bowel metastasis from breast cancer

The common sites of metastasis of breast cancer are bone, lung, and liver, but gastrointestinal metastasis from breast cancer is rare. We experienced a case of solitary ileal metastasis from breast cancer. A 45-years-old woman presented with melena for several weeks. She showed no other abdominal symptoms. Colonoscopy findings showed an ulcerative mucosal lesion in the terminal ileum, and biopsy was performed. Pathologic examination revealed metastatic carcinoma, originated from breast. The tumor cells were positive for estrogen receptor and negative for Cdx-2. She had had a previous medical history of bilateral breast cancer and undergone breast conserving surgery with sentinel lymph node biopsy for both breasts. The torso positron emission tomography scan at 19 months after surgery showed mildly increased uptake in the terminal ileum which was considered as inflammation. Finally, she was diagnosed with solitary ileal metastasis from breast cancer at 22 months after surgery.

Metastatic breast carcinoma simulating linitis plastica of the colon: report of a case

A 48-year-old woman developed a mobile abdominal mass in the course of treatment for recurrent breast cancer. Imaging studies indicated linitis plastica of the colon. She underwent surgery because of the stenosis of the transverse colon. An examination of the resected specimen revealed a segmental stricture, thickening of the entire wall, and a granular mucosa resembling cobblestones. Microscopic findings of the colon lesion were very similar to those of her primary, invasive lobular carcinoma of the breast. Atypical cells showed immunoreactivity for cytokeratin-7, but not for cytokeratin-20. These findings suggested that the lesion of the colon was a colonic metastasis of breast cancer. Metastatic gastrointestinal diseases originating from breast carcinoma are unusual, and colonic metastases are especially rare. Although colon cancer may occur in patients with a history of breast cancer, metastatic colon cancer should be suspected if linitis plastica is detected.

Cystic brain metastases radiologically simulating neurocysticercosis

CONTEXT

Brain metastases are common complications of cancer. Magnetic resonance imaging (MRI), the main diagnostic imaging method in these cases, rarely shows cystic images.

CASE REPORT

The patient was a 45-year-old woman who had had severe headache for a month that was refractory to medication, and had previously had breast cancer, which had been treated. The MRI showed the criteria for neurocysticercosis. Since there was no improvement with clinical treatment, we chose to excise the lesions. Histopathological analysis showed an epithelioid malignant neoplasm.

CONCLUSION

From immunohistochemical analysis, it was concluded that this was a metastasis of breast carcinoma. Even when the MRI is not characteristic of cerebral metastasis, this hypothesis needs to be ruled out in patients with a previous history of cancer.

Gastric metastases. An endoscopic series of ten cases

We report a series of ten cases of the clinical, endoscopic and pathological features of gastric metastases. Patients were six women and four men between 54 and 88 years old, with gastric metastases from breast carcinoma (4), lung carcinoma (4) and melanoma (2). Patients underwent an upper gastrointestinal endoscopy for epigastralgia (2), hematemesis (2), dysphagia (1) and anemia (5). On endoscopy, tumors appeared as nodules with a central ulceration (5), an ulceration (4) or simulating linitis plastica (1). Metastases were located in the cardia (2), fundus (5) and antrum (3). Primary tumors had been diagnosed between one day and 20 years before upper endoscopy. Eight patients had multivisceral metastases. The microscopic features of the gastric metastases resembled a primary gastric cancer in eight cases. Thanks to clinical data, the pathologist confirmed the diagnosis of gastric metastases on immunohistochemistry. Nine patients died in the eight-month follow-up period. Gastric metastases are rare, occur at a late stage of the neoplastic disease, and have a poor prognosis. Diagnosis of gastric metastases is difficult because they simulate primary gastric cancer on endoscopy and on microscopic examination. A correct diagnosis is based on good communication between gastroenterologists and pathologists.

Isolated gastrointestinal metastasis of breast carcinoma: a case report

Purpose. Gastrointestinal tract is one of the rare locations for breast cancer metastasis. This paper shows such metastasis may occur even in the absence of breast metastasis in other more common locations. Case Report. A 64-year old female was admitted to the hospital with abdominal discomfort and diarrhea. She had breast carcinoma treated 7 years previously with normal follow-up since. Colonoscopy showed hepatic flexure thickening that was confirmed to be breast metastasis. Staging investigations showed upper and lower gastrointestinal tract metastasis with negative findings elsewhere. Conclusion. Although more common causes for gastrointestinal symptoms should be excluded, however, a high index of suspicion of metastatic breast cancer is needed when such patients develop gastrointestinal symptoms.

Rectal metastasis from lobular breast carcinoma 15 years after primary diagnosis

Lobular breast carcinoma represents 2-20% of infiltrative carcinomas of the breast. The incidence of extrahepatic gastrointestinal (GI) tract metastases observed in necropsy studies varies from 6% to 18% and the most commonly affected organ is the stomach, followed by colon and rectum [1-4]. Reported herein is the case of a 67-year-old woman who was primarily diagnosed and surgically treated for a lobular carcinoma of the breast 15 years ago and is now referred with back pain and right hydronephrosis caused by a metastasis in rectum. Frequently, the absence of specific symptoms of digestive metastases of breast cancer leads to a misdiagnosis of this pathology [5-7]. The treatment will be based on a detailed clinical history and histopathological findings. Metastases from breast cancer in GI tract tumours must be excluded in a patient with previous history of breast carcinoma, as in the case reported herein.

Colorectal breast carcinoma metastasis diagnosed as an obstructive colonic primary tumor. A case report and review of the literature

Common sites of colorectal breast carcinoma metastasis are bones, lungs, the central nervous system and the liver. Metastases in the gastrointestinal (GI) tract are rare and especially involve the stomach rather than the colon. Clinical or radiological features usually cannot differentiate them from a primary colorectal tumor, resulting in inappropriate treatment. In some cases, this lesion suggests multifocal spread of breast cancer with peritoneal carcinomatosis. Colorectal breast cancer metastasis is a rare finding and there is no consensus on the management of these lesions. The present case report describes a 69-year-old female with metastatic breast cancer presenting as an obstructive tumor of the transverse colon.

Occult breast carcinoma presenting as gastrointestinal metastases

Occult breast cancer has frequently been described as presenting as axillary lymph node metastases but rarely as gastrointestinal metastases, Varadarajan et al. (2007). In extremely rare situations, cancerous lesions identified in the gastrointestinal tract have been determined to be metastatic lesions from primary breast cancers, Taal et al. (2000). We report a case of an occult lobular adenocarcinoma presenting as gastrointestinal metastases. It is essential that the possibility of lesions found in the gastrointestinal tract originating from distant or occult cancers be considered in order that appropriate therapeutic options may be discussed and considered early after diagnosis.

[Large bowel obstruction due to colonic and omental metastasis as the first clinical sign of metastatic ductal carcinoma of the breast]

Distant spread from breast cancer is commonly found in bones, lungs, liver and central nervous system. Metastatic involvement of peritoneum, omentum or/and gastro-intestinal tract is unusual and unexpected. We present the case of a 48 year-old woman who presented with gastro-intestinal symptoms as signs of omental and colonic metastasis of an invasive ductal breast cancer, which was not diagnosed before her admission. Ileus was diagnosed and urgent surgery was performed. Histology revealed metastatic ductal breast carcinoma. Mastectomy and axillary lymphadenectomy were performed therefore. Reviewing the literature--to the best of our knowledge--such a case has never been published before.

Gastric malignancies in breast cancer survivors: pathology and outcomes

BACKGROUND

As the number of breast cancer survivors increases, the appearance of second malignancies and unusual metastatic patterns likely also is increasing. In particular, we and others have observed gastric malignancies in breast cancer survivors.

METHODS

We reviewed 3 regional hospital system tumor databases, comprising 19,049 analytic breast cancer cases, to determine the number, types, and outcomes of subsequent gastric malignancies.

RESULTS

Twenty-eight patients developed subsequent gastric malignancies, representing .15% of breast cancer survivors; 82% of patients had gastric symptoms. Overall survival for the cohort was 39%. Twenty-four patients (86%) had gastric primaries and 13 died of their second cancers. Four patients had gastric metastases; all had lobular histology in both their primary tumors and metastatic lesions. Five patients had gastrointestinal stromal tumors; all patients underwent resection and currently are alive.

CONCLUSION

Gastric symptoms in breast cancer survivors may represent malignant lesions, often second primaries. All gastric metastases in our series were of lobular histology.

Anal metastasis from recurrent breast lobular carcinoma: A case report

We report a case of isolated gastrointestinal metastasis from breast lobular carcinoma, which mimicked primary anal cancer. In July 2000, an 88-year-old woman presented with infiltrating lobular cancer (pT1/G2/N2). The patient received postoperative radiotherapy and hormonal therapy. Four years later, she presented with an anal polypoid lesion. The mass was removed for biopsy. Immunohistochemical staining suggested a breast origin. Radiotherapy was chosen for this patient, which resulted in complete regression of the lesion. The patient died 3 years after the first manifestation of gastrointestinal metastasis. According to the current literature, we consider the immunohistochemistry features that are essential to support the suspicion of gastrointestinal breast metastasis, and since we consider the gastrointestinal involvement as a sign of systemic disease, the therapy should be less aggressive and systemic.

Metastasis of malignant peritoneal epithelioid mesothelioma in endoscopic gastric biopsy: a diagnostic pitfall

AIM

To describe a case of metastasis of malignant peritoneal epithelioid mesothelioma in gastric antral mucosa in a patient with a cryptogenic liver cirrhosis associated with esophageal varices, abdominal pain and distension, ascites, and weight loss.

MATERIALS AND METHOD

The patient underwent esophageal gastric endoscopy for varices, and a biopsy of a polypoid antral lesion was performed. The latter revealed a proliferation of polygonal cells with moderately atypical nuclei and pale eosinophilic, peripherally condensed cytoplasm infiltrating into the lamina propria between the normal mucosal glands of the antrum. The tumor cells were diffusely positive to anticalretinin antibody, whereas anti-claudin 4 and anti-CEA antisera were negative.

CONCLUSIONS

Metastases of malignant peritoneal mesotheliomas are unusual, and a predominantly gastrointestinal localization is rare. Pathologists should be aware of this possibility to avoid misdiagnosis, particularly in small biopsy specimens.

Gastric metastases originating from occult breast lobular carcinoma: diagnostic and therapeutic problems

Background

Breast cancer is the most frequent malignant tumour to metastasize into the gastrointestinal tract in female and is second only to malignant melanoma. Nevertheless gastrointestinal metastases arising from breast cancer are quite rare. The upper gastrointestinal tract is more frequently involved and lobular infiltrating carcinoma has a greater predilection compared to the ductal type.

Case presentation

The authors describe the case of a 70 years old woman with a preoperative diagnosis of gastric undifferentiated medullary – type carcinoma, which was the first manifestation of an occult breast carcinoma. The primary site of carcinoma was identified with the use of a panel of selected immunohistochemical markers.

Conclusion

Our goal in this case report is to increase the awareness of surgeons and clinicians to rule out the possibility of mammary origin in circumstance of gastric cancer occurring in female, even in patients without a previous or concurrent history of breast carcinoma. Although not a particularly common event, it is, nevertheless, reported in the literature. The differentiation between primary gastric carcinoma and metastatic breast carcinoma is essential for planning the correct therapeutic approach, in order to avoid the patient unnecessary surgery.

A case of metastatic lobular breast carcinoma with detection of the primary tumor after ten years

Lobular carcinoma of the breast is known to metastasize to unusual sites such as the gastrointestinal tract, peritoneum, and gynecologic organs. We report a patient with intraperitoneal metastases from lobular carcinoma who was originally treated for an unknown primary cancer. Ten years later, a tumor was found in her left breast and the diagnosis was changed to peritoneal metastases from invasive lobular carcinoma. Immunohistochemistry revealed that the metastases were high molecular weight cytokeratin (CK34betaE12) and estrogen receptor-positive, but were E-cadherin-negative. These results assisted in diagnosis. Surgeons should be aware of the characteristics of metastasis lobular carcinoma.

Breast signet-ring cell lobular carcinoma presenting with duodenal obstruction and acute pancreatitis

We report here an extremely rare case of breast signet-ring cell carcinoma (SRCC) initially manifesting as duodenal metastasis and acute pancreatitis. A 62-year-old female presented with duodenal obstruction and swollen head of the pancreas, and the diagnosis of acute pancreatitis was initially made. Upper gastrointestinal endoscopy revealed duodenal stenosis with erosive mucosa, with signet-ring cells infiltrating the submucosal layer, suggesting duodenal metastasis of SRCC. Despite absence of a palpable mass in both breasts, computed tomography revealed diffuse enhancement of the left breast in addition to left axillary lymphadenopathy. Histological examination of mammary needle biopsy samples revealed SRCC with a non-invasive lobular carcinoma component. Primary breast SRCC with duodenal metastasis was therefore diagnosed. The patient underwent palliative surgery twice for intestinal obstruction due to peritoneal dissemination. She has remained alive without bowel obstruction for 18 months while being treated with cytotoxic chemotherapies.

Perianal metastases from lobular breast carcinoma

Breast cancer gastrointestinal and soft tissue metastases are extremely rare. We present the case of a woman with perianal metastases from a primary lobular breast carcinoma 11 years after mastectomy and local radiotherapy.

Breast cancer metastasis to the stomach may mimic primary gastric cancer: report of two cases and review of literature

Background

The stomach is an infrequent site of breast cancer metastasis. It may prove very difficult to distinguish a breast cancer metastasis to the stomach from a primary gastric cancer on the basis of clinical, endoscopic, radiological and histopathological features. It is important to make this distinction as the basis of treatment for breast cancer metastasis to the stomach is usually with systemic therapies rather than surgery.

Case presentations

The first patient, a 51 year old woman, developed an apparently localised signet-ring gastric adenocarcinoma 3 years after treatment for lobular breast cancer with no clinical evidence of recurrence. Initial gastric biopsies were negative for both oestrogen and progesterone receptors. Histopathology after a D2 total gastrectomy was reported as T4 N3 Mx. Immunohistochemistry for Gross Cystic Disease Fluid Protein was positive, suggesting metastatic breast cancer. The second patient, a 61 year old woman, developed a proximal gastric signet-ring adenocarcinoma 14 years after initial treatment for breast cancer which had subsequently recurred with bony and pleural metastases. In this case, initial gastric biopsies were positive for both oestrogen and progesterone receptors; subsequent investigations revealed widespread metastases and surgery was avoided.

Conclusion

In patients with a history of breast cancer, a high index of suspicion for potential breast cancer metastasis to the stomach should be maintained when new gastrointestinal symptoms develop or an apparent primary gastric cancer is diagnosed. Complete histopathological and immunohistochemical analysis of the gastric biopsies and comparison with the original breast cancer pathology is important.

Esophagogastric Cancers Secondary to a Breast Primary Tumor Do Not Require Resection

BACKGROUND

Breast cancer metastasis to the gastrointestinal tract (GIT) is rare. When it does occur, the upper GIT is more frequently involved, and lobular infiltrating carcinoma apparently has a greater apparent predilection for the GIT than the ductal type does. This study reviewed the clinicopathological features of esophagogastric secondary tumors from breast cancer.

PATIENTS AND METHODS

Patients with breast cancer metastases to the upper GIT referred to us for treatment of either esophageal or gastric cancers between November 1997 and November 2004 were identified from our database. The medical records of these patients were then reviewed for clinicopathological data and outcome.

RESULTS

Nine patients with mean age of 71 (range: 57-90) years had median time of 6.5 (2.8-32.8) years between primary breast cancer diagnosis and upper GI metastasis. The sites of metastatic lesions included the lower esophagus (2 patients), gastroesophageal junction (1 patient), gastric body (3 patients), and pylorus (3 patients). Histological typing indicated 7 cases of the lobular form and 2 cases of ductal carcinoma. All but one biopsy specimen were estrogen receptor and CK7 positive. Treatment included hormonal therapy and stent in 3 patients, hormonal therapy alone in 1 patient, chemotherapy alone in 1 patient, chemotherapy and gastrojejunostomy in 1 patient, dilatation and stent in 1 patient, and palliative care only in 2 patients. The median survival following treatment of these metastases was 20 (range: 2.1-96.6) months.

CONCLUSIONS

The onset of nonspecific GIT symptoms in patients with a history of breast carcinoma should prompt the clinician to rule out the possibility of upper GIT metastasis even many years after the original breast cancer. The use of systemic therapy for breast cancer may result in longer survival.

Metastatic breast cancer to the gastrointestinal tract: A case series and review of the literature

Metastatic breast cancer involving the hepatobiliary tract or ascites secondary to peritoneal carcinomatosis has been well described. Luminal gastrointestinal tract involvement is less common and recognition of the range of possible presentations is important for early and accurate diagnosis and treatment. We report 6 patients with a variety of presentations of metastatic breast cancer of the luminal gastrointestinal tract. These include oropharyngeal and esophageal involvement presenting as dysphagia with one case of pseudoachalasia, a linitis plastica-like picture with gastric narrowing and thickened folds, small bowel obstruction and multiple strictures mimicking Crohn’s disease, and a colonic neoplasm presenting with obstruction. Lobular carcinoma, representing only 10% of breast cancers is more likely to metastasize to the gastrointestinal tract. These patients presented with gastrointestinal manifestations after an average of 9.5 years and as long as 20 years from initial diagnosis of breast cancer. Given the increased survival of breast cancer patients with current therapeutic regimes, more unusual presentations of metastatic disease, including involvement of the gastrointestinal tract can be anticipated.

Colonic metastasis from carcinoma of the breast that mimics a primary intestinal cancer

Although the lung, liver, or bones are the most common location for distant metastases in breast cancer patients, metastases to the intestinal tract are very rarely recognized in the clinic. We will present an unusual case of colonic metastasis from a carcinoma of the breast that mimics a primary intestinal cancer, along with a through review of English language medical literature. Despite the fact that isolated gastrointestinal (GI) metastases are very rare and much less common than benign disease processes or second primaries of the intestinal tract in patients with a history of breast cancer, metastatic disease should be given consideration whenever a patient experiences GI symptoms.

Small bowel obstruction caused by secondary tumors

Small bowel obstruction in an oncology patient is a common and serious medical problem which is associated with diagnostic as well as therapeutic dilemmas. While the condition is most commonly caused by postoperative adhesions and peritoneal carcinomatosis, other causes have been reported [Cormier WJ, Gaffey TA, Welch JM, et al. Linitis plastica caused by metastatic lobular carcinoma of the breast. Mayo Clinical Proceedings 1980;55:747-53; Clavien P-A, Laffer U, Torhos J, et al. Gastrointestinal metastases as first clinical manifestation of the dissemination of a breast cancer. European Journal of Surgical Oncology 1990;16:121-6; Bender GN, Maglinte DD, McLarney JH, et al. Malignant melanoma: patterns of metastasis to the small bowel, reliability of imaging studies, and clinical relevance. American Journal of Gastroenterology 2001;96:2392-400; Gatsoulis N, Roukounakis N, Kafetzis I, et al. Small bowel intussusception due to metastatic malignant melanoma. A case report. Technical Coloproctology 2004;8:141-3; Hung GY, Chiou T, Hsieh YL, et al. Intestinal metastasis causing intussusception in a patient treated for osteosarcoma with history of multiple metastases: a case report. Japanese Journal of Clinical Oncology 2001;31(4):165-7; Chen TF, Eardley I, Doyle PT, Bullock KN. Rectal obstruction secondary to carcinoma of the prostate treated by transanal resection of the prostate. British Journal of Urology 1992;70(6):643-7; Kamal HS, Farah RE, Hamzi HA, et al. Unusual presentation of rectal adenocarcinoma. Roman Journal of Gastroenterology 2003;12(1):47-50; Hofflander R, Beckes D, Kapre S, et al. A case of jejunal intussusception with gastrointestinal bleeding caused by metastatic testicular germ cell cancer. Digestive Surgery 1999;16(5):439-40]. One of these, reported thus far in only very few patients, is obstruction caused by secondary tumors, i.e. metastases from other organs to the small bowel wall. As cancer patients live longer with improved therapy, physicians are more likely to cope with rare phenomena of neoplasms, such as small bowel obstruction caused by secondary tumors. We hereby present a review of the relevant medical literature. The goal of this article is to define current knowledge on this phenomenon, with emphasis on its epidemiology and clinical characteristics, and to increase the awareness of the clinician treating cancer patients of such possibility.

Gastro-intestinal symptoms as clinical manifestation of peritoneal and retroperitoneal spread of an invasive lobular breast cancer: report of a case and review of the literature

Background

Distant spread from breast cancer is commonly found in bones, lungs, liver and central nervous system. Metastatic involvement of peritoneum and retroperitoneum is unusual and unexpected.

Case presentation

We report the case of a 67 year-old-woman who presented with gastrointestinal symptoms which revealed to be the clinical manifestations of peritoneal and retroperitoneal metastatic spread of an invasive lobular breast cancer diagnosed 15 years before.

Conclusion

To the best of our knowledge, the case presented is the third one reported in literature showing a wide peritoneal and extraperitoneal diffusion of an invasive lobular breast cancer. The long and complex diagnostic work up which led us to the diagnosis is illustrated, with particular emphasis on the multidisciplinary approach, which is mandatory to obtain such a result in these cases. Awareness of such a condition by clinicians is mandatory in order to make an early diagnosis and start a prompt and correct therapeutic approach.

Metastatic cancer to the stomach

BACKGROUND

Metastases in the stomach are rare. The increased use of esophagogastroduodenoscopy (EGD), associated with better treatment results for malignancies, requires them to be acknowledged. The aim of this study was to describe a series of cases of metastasis to the stomach, their primary sites, clinical and endoscopic features, treatment, and results.

METHODS

Twenty cases were diagnosed between December 1999 and January 2004. Their analysis included symptomatology, macroscopic presentation, time from diagnosis of the primary tumor to the detection of the gastric metastasis, treatment approach, and survival.

RESULTS

The primary sites were the esophagus, skin, lung, cervix, breast, sigmoid colon, and testis. The symptom most frequently requiring EGD was upper gastrointestinal bleeding. Ten patients showed concomitant metastases to other organs. The mean time between diagnosis of the primary tumor and diagnosis of gastric metastasis was 16 months (range, 0 to 56 months). Only seven patients were given some form of treatment after diagnosis of the gastric metastasis. The median survival was 4.75 months. Overall survival during the first year was 20% and survival was nil at 2 years.

CONCLUSIONS

Gastric metastasis marks advanced disease and the prognosis is poor. New advances in diagnosis and treatment are required for better results.

Gastric metastasis 14 years after mastectomy for breast lobular carcinoma: case report and literature review

In planning treatment of a gastric neoplasm in a patient previously treated for lobular breast carcinoma, it is important to differentiate a primary gastrointestinal tract tumor from a metastatic form. We report a case of a breast lobular carcinoma metastatic to the stomach. The patient underwent a subtotal gastrectomy for symptomatic disease. Although gastric symptoms appeared 14 years after the breast carcinoma, immunohistochemical analysis of the surgical specimen helped to establish that the gastric lesion, thought to be primary, was effectively a metastatic repetition of the breast neoplasm. To better define treatment in a gastric neoplasm patient previously treated for breast carcinoma, the preoperative diagnosis should rule out a metastatic disease. The patient described received an adjuvant chemotherapy according to breast cancer protocol after gastric resection for symptomatic disease. The patient is still alive and undergoing chemotherapy for peritoneal carcinosis.