Metastatic breast cancer masquerading as gastrointestinal primary

Breast cancer: presentation and intervention in women with gastrointestinal metastasis and carcinomatosis

BACKGROUND

Breast cancer metastatic to the gastrointestinal tract or peritoneum is rare. We reviewed the natural history of ductal and lobular carcinoma in women with breast cancer metastatic to the gastrointestinal tract, peritoneum, or both.

METHODS

We performed a retrospective review of all patients (1985-2000) with a pathologic diagnosis of breast cancer metastatic to the gastrointestinal tract or peritoneum. Patients were categorized into three groups: those with gastrointestinal metastasis, carcinomatosis, or both.

RESULTS

Of 73 patients, 23 (32%) had gastrointestinal metastasis only, 32 (44%) had carcinomatosis only, and 18 (25%) had both. The median age at initial breast cancer diagnosis was 55 years. The mean interval between the primary diagnosis and metastatic presentation was 7 years. Sites of gastrointestinal metastases included the esophagus (8%), stomach (28%), small intestine (19%), and colon and rectum (45%). Infiltrating lobular carcinoma represented 34 (64%) of the 53 gastrointestinal metastases. The median overall survival after diagnosis was 28 months. Palliative surgical intervention in 47 patients (64%) did not affect overall survival. Some survival benefit may have accrued to select patients with gastrointestinal metastasis who underwent surgical palliation (44 vs. 9 months). Advanced age at diagnosis and gastric metastases had a negative effect on survival, whereas treatment with systemic chemotherapy or tamoxifen had a positive effect on survival.

CONCLUSIONS

Gastrointestinal metastasis occurred more often in patients with invasive lobular carcinoma. Surgical intervention did not significantly extend overall survival but may be considered in a select group of patients.

Utility of immunohistochemistry in distinguishing primary adenocarcinomas from metastatic breast carcinomas in the gastrointestinal tract

CONTEXT

Breast carcinoma often metastasizes to the gastrointestinal tract, especially the stomach, where it is frequently difficult to distinguish from a primary gastric carcinoma.

OBJECTIVE

To evaluate the utility of immunohistochemical stains in differentiating primary gastric carcinomas from metastatic breast carcinomas.

DESIGN

Mucosal biopsy specimens from 47 adenocarcinomas involving the gastrointestinal tract (28 primary gastric carcinomas and 19 metastatic breast carcinomas) and 16 control cases of primary breast carcinomas without metastasis were immunohistochemically stained for estrogen receptor protein (ER), progesterone receptor protein (PR), gross cystic disease fluid protein (GCDFP), human epidermal growth factor receptor 2 protein, cytokeratin (CK) 5/6, CK/7, CK/20, a panel of mucin glycoprotein antigens (MUC2, MUC3, MUC5AC, and MUC6), monoclonal antibody DAS-1, and caudal-type homeobox transcription factor CDX2 and compared between primary and metastatic adenocarcinomas.

RESULTS

Highly significant proportions of metastatic breast carcinomas were positive for ER (72%), PR (33%), GCDFP (78%), and CK5/6 (61%) compared with primary gastric carcinomas (ER, 0%; PR, 0%; GCDFP, 0%; and CK5/6, 14%) (P < .001, P = .002, P < .001, and P = .004, respectively). Of these immunostains, ER, PR, and GCDFP were 100% specific. Primary breast tumors and their metastases showed a similar phenotypic profile. In contrast, primary gastric carcinomas showed significantly higher proportions of cases that stained with CK20 (50%), MUC2 (54%), MUC5AC (71%), MUC6 (39%), DAS-1 (43%), and CDX2 (67%) compared with metastatic breast carcinomas (CK20, 0%; MUC2, 24%; MUC5AC, 6%; MUC6, 0%; DAS-1, 0%; and CDX2, 0%) (P = .001, P = .01, P < .001, P = .02, P = .009, and P < .001, respectively). No significant differences were observed with regard to any of the other immunostains (human epidermal growth factor receptor 2 protein, CK7, and MUC3) between the patient groups.

CONCLUSIONS

Estrogen receptor protein, PR, GCDFP, CK5/6, CK20, MUC5AC, MUC6, DAS-1, and CDX2 are helpful in distinguishing primary gastric carcinomas from metastatic breast carcinomas. Of these, ER, PR, and GCDFP are highly specific for metastatic breast carcinomas, whereas CK20, DAS-1, MUC2, MUC5AC, MUC6, and CDX2 are highly specific for primary gastric carcinomas.

Prognostically Favorable Abdominal Breast Cancer Metastases with Stomach Involvement

BACKGROUND

Abdominal metastases with stomach involvement are rare in breast cancer. The median disease free interval from the time of breast cancer diagnosis to gastric metastasis is usually very long. Treatment is generally palliative, and expected survival time is less than 1 year.

CASE REPORT

A 59-year-old woman with breast cancer developed diffuse abdominal metastases involving stomach, abdominal lymph nodes, and omentum 9 years after she underwent mastectomy and adjuvant chemotherapy. The histopathologic diagnosis found by stomach specimen examination was invasive lobular carcinoma, and the cells expressed high levels of estrogen and progesterone receptors. The abdominal metastases were treated with surgery, postoperative chemotherapy, and further hormonal therapy. This was successful, and the patient has been in remission for more than 3 years.

CONCLUSION

Once the definitive diagnosis of breast cancer metastases to the abdomen including the stomach is established, treatment that targets systemic breast cancer must be initiated. Our patient's extended survival time suggests that surgical treatment could be considered for selected patients.

A case of invasive lobular carcinoma of the breast first manifesting with duodenal obstruction

Lobular carcinoma of the breast presents with various clinical manifestations. Lobular carcinoma comprises about one fifth of cases of ductal carcinoma. Intestinal metastasis is dominant in cases of lobular carcinoma. Without a prior diagnosis of lobular carcinoma of the breast, the diagnosis of intestinal metastasis from breast cancer is difficult. A 52-year-old women underwent duodenogastrectomy for duodenal cancer. About 18 months later, she underwent mastectomy for lobular carcinoma of the breast. The duodenal cancer consisted mainly of malignant cells invading the submucosa that were identical to those in the breast. Immunohistochemical assays for estrogen receptor also confirmed breast cancer metastasis. Duodenal obstruction was the first sign of isolated metastatic lobular carcinoma of the breast in this case. The characteristic metastatic pattern of lobular carcinoma, which differs from that of ductal carcinoma, should be kept in mind to ensue proper diagnosis. Preceding breast surgery for lobular carcinoma should prompt investigation based on the typical metastatic pattern.

MRI findings of gastric metastases from breast carcinoma

We describe the MR appearance of breast cancer metastases to the stomach. The stomach wall was diffusely thickened with loss of the regular fold pattern best shown on the single shot T2-weighted images and enhanced with moderate mural enhancement on early and late post gadolinium images. The combination of gastric wall thickening and abnormal enhancement should suggest the diagnosis of diffuse mural metastases in a woman with a history of breast cancer.

Solitary Papillary Breast Carcinoma Metastasis to the Large Bowel Presenting as Primary Colon Carcinoma: Case Report and Review of the Literature

Breast carcinoma has the potential for widespread dissemination. Spread to the lower gastrointestinal tract is infrequent, often multifocal, occurs in association with spread to other sites, and most commonly develops from lobular carcinoma. Solitary colorectal metastasis as the first and sole manifestation of spread is a rare occurrence and can be confused with primary intestinal malignancy. We present a case of metastatic papillary breast carcinoma presenting as a perforated primary colon cancer. Identity of the lesion was confirmed by direct histologic comparison of the resected tumor with prior breast specimen, cytokeratin expression, and the presence of estrogen receptors.

Breast cancer masquerading as a primary gastric carcinoma

The differentiation between primary gastric cancer and a metastatic breast tumor to the stomach is important for planning of treatment and to spare the patient unnecessary surgery. We report a rare case of breast cancer with metastasis to the stomach. The diagnosis was established by histologic and immunohistochemical analyses of biopsies of the stomach lesion using gross cystic disease fluid protein-15, cytokeratin, carcinoembryonic antigen, and epithelial membrane antigen. Positivity for gross cystic disease fluid protein-15 with negative staining for carcinoembryonic antigen supported the diagnosis of a breast cancer metastasis. The patient was treated with systemic chemotherapy without surgery and is still alive 2 years after initial referral for a gastric neoplasm.

Bowel obstruction due to extrinsic compression by metastatic lobular carcinoma of the breast

The commonest sites for breast cancer metastases are the bones, lungs, liver, pleura, adrenals and central nervous system. However, although other sites have been reported, solitary metastases to the gastrointestinal tract are extremely uncommon. Widely disseminated gastrointestinal metastases may be found in up to 20% of patients. Although only 15% of patients with breast cancer will have the lobular variety, these make up the majority of patients with solitary gastrointestinal metastases. Here we present three cases where solitary lobular breast cancer metastases have been demonstrated to be the cause of bowel obstruction. In two cases of duodenal obstruction was demonstrated and in the third colonic obstruction. In all cases a focal extrinsic compression was found.

Rectal metastases from lobular carcinoma of the breast: report of a case and literature review

Metastatic involvement of the gastrointestinal (GI) tract secondary to breast cancer is rare. Reported herein is the case of a 74-year-old woman with metastatic lobular breast carcinoma to the rectum presenting with obstruction. The breast tumour was diagnosed nine years prior to the presentation of rectal metastases. Endoscopy was repeated twice until a diagnosis was established. Examination of endoscopy material revealed infiltration of the rectum by malignant signet ring cells identical to those of the primary breast tumour. The patient did not respond to chemotherapy and underwent laparotomy with a defunctioning colostomy. Literature review revealed only a few more cases of metastatic breast carcinoma to the rectum. Awareness of this condition may lead to accurate diagnosis and early initiation of systemic treatment, thus avoiding surgical intervention.

Rectal localization of metastatic lobular breast cancer: report of a case

The incidence of extrahepatic gastrointestinal metastases from breast cancer is reported in the literature only as necroscopy studies (6-18 percent); they usually originate from lobular or a mixed ductal-lobular subtype. Nonspecific presenting symptoms, death of the patients caused by other more frequent metastases, and variable radiographic features mimicking primary neoplasms cause a clinical underestimation of this pathology. We report here a case of rectal metastasis from a lobular carcinoma eight years after mastectomy.

Metastatic carcinoma of the breast resembling early gastric carcinoma

We describe a case of gastric metastasis from a lobular carcinoma of the breast in a 45-year-old woman who had undergone a left mastectomy with axillary dissection 7 years earlier. At the current presentation, she had been experiencing progressive epigastric discomfort for 3 months. The initial diagnosis was early gastric carcinoma, diffuse type, based on gastric biopsy findings and ultrasonographic endoscopy. A definitive diagnosis of metastatic breast cancer was confirmed after subtotal gastrectomy of a presumed primary early gastric carcinoma. Although gastrointestinal metastases from breast cancer are not rare, the early stage of the gastric lesion and the absence of further disease dissemination make this case unusual. The onset of gastrointestinal symptoms in a patient with a history of breast carcinoma should prompt the physician to rule out the possibility of gastric metastases.

Metastasizing signet ring cell carcinoma of the stomach-mimicking bilateral inflammatory breast cancer

We describe a case of unusual metastases of a gastric carcinoma to the female breast, there likely to be an inflammatory breast cancer. A 46-year-old woman was admitted to our institution with bilateral breast tumors, not typical for a breast cancer as tumor growth was synchronically bilateral within a very short period of only 2 months. The woman underwent a palliative gastrectomy 3 months before for a poorly differentiated adenocarcinoma with signet ring appearance presenting as linitis plastica. At the time of the first operation the mammary glands were not suspicious. Breast biopsies assured metastases of the gastric cancer. In addition to this case report, a short overview of the literature concerning the very few cases of metastases of gastric cancer to the breast is given.