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

The analysis about the metastases to Gastrointestinal tract: a literature review, 2000-2023

Background

Cancers of the gastrointestinal tract exhibit a high detection rate, ranking as the fifth most common malignant tumor and the fourth leading cause of cancer-related death. In addition to primary malignant tumors of the gastrointestinal tract, secondary metastatic tumors significantly impact patient survival. The differentiation between primary and secondary gastrointestinal tumors remains a critical issue requiring further research and analysis.

Methods

This is a retrospective, observational study conducted from 2000 to 2023. We systematically searched the literature in PubMed, EMBASE, and COCHRANE databases from January 1, 2000, to November 31, 2023. Patients diagnosed with gastrointestinal (GI) tract metastasis were included in the study.

Results

A total of 165 patients were enrolled in this study. The most prevalent primary tumors were breast cancer (50.30%), renal cancer (16.96%), lung cancer (16.36%), melanoma (12.72%), and liver cancer (3.63%). The median interval between the diagnosis of the primary tumor and the detection of GI metastatic lesions was 8.53 years (range: 1-25 years). The most frequent endoscopic finding was a solitary mucosal or submucosal lesion situated in the gastric body. Metastases to extra-gastrointestinal organs were observed in the majority of patients. The integration of endoscopic biopsy with pathological and immunohistochemical analyses is essential for identifying the tumor origin. Surgical intervention in patients lacking extra-gastrointestinal metastases may improve prognosis.

Conclusions

Breast, renal, lung, liver cancer, and melanoma were identified as the most frequent primary tumors. Clinical symptoms and endoscopic features were unable to predict the primary sites, which still require immunohistochemical analysis for accurate identification. The intervention modality and the presence or absence of distant metastasis significantly influenced patient prognosis.

An Uncommon Breast Odyssey: A Rare Case of Carcinoma Breast with Mesenteric Metastasis

We present an unusual case of invasive ductal breast carcinoma in a postmenopausal female with a clinically node-negative disease that was incidentally found to have mesenteric metastatic deposits on 18F-fluorodeoxyglucose positron emission tomography/computed tomography scan. Mesenteric metastasis from invasive breast carcinoma is rare, with <1% cases reported worldwide and limited availability of diagnostic and therapeutic protocols for carcinoma breast with mesenteric metastasis, this proved to be a challenging and intriguing case. To further accentuate the complexity, the primary tumor of this mesenteric metastasis was found to be invasive ductal carcinoma, which is even more infrequent, and <0.5% of cases have been reported till date.

Small bowel obstruction as first presentation of metastatic lobular breast cancer for pilgrim patient

INTRODUCTION AND IMPORTANCE

The most common cancer among females worldwide and in Saudi Arabia is breast cancer. Lobular breast carcinoma is the second most common subtype of breast cancer. There are different patterns of metastasis as ductal breast cancer spreads to the liver, lung, brain, and bone while the lobular subtype metastasizes to the gastrointestinal tract.

CASE PRESENTATION

A 69-year-old Indian pilgrim presented to the ER complaining of abdominal pain, vomiting, and abdominal distention admitted as a case of intestinal obstruction. CT scan demonstrated intestinal obstruction with transition zone at the terminal ileum. The patient underwent exploratory laparotomy where she was found to have a mass at the terminal ileum. Resection of around 8 cm of small bowel and primary anastomosis were done, histopathology revealed metastatic lobular breast carcinoma.

CLINICAL DISCUSSION

Patients with metastatic breast cancer to the gastrointestinal tract often present with nonspecific symptoms, while acute cases present with complications such as perforation. In a retrospective review of metastatic breast cancer, the majority metastasizes to the colon and rectum, while 19 % to the small bowel. Palliative surgery is considered the first-line treatment of complicated patients, while stable cases are referred to medical oncology.

CONCLUSION

Breast cancer is the second most common cancer leading to death and lobular subtype has more propensity to metastasize to the gastrointestinal tract compared to ductal breast cancer. Regarding patients presenting to the emergency bay, treating the emergency complaints is the standard management. For immigrant patients, we highly recommend creating a data system for sending histopathology reports to facilitate follow-up in their countries.

CASE PRESENTATION

A 69-year-old Indian pilgrim patient presented to the ER complaining of abdominal pain for 3 days associated with nausea and vomiting, not passing stool nor flatus was admitted as a case of intestinal obstruction. On examination patient was in pain with tachycardia, abdominal distended with generalized tenderness. Labs revealed metabolic alkalosis with hypokalemia. Abdomen X-ray showed signs of intestinal obstruction with multiple air-fluid levels and dilated small bowel loops. CT scan abdomen and pelvis with IV contrast reported (Figs. 1,2) distended ileum around 5 cm proximal to the transition zone at the terminal ileum with mild free fluid in the abdomen and pelvis. The patient underwent exploratory laparotomy where she was found to have a mass at the terminal ileum with the proximal loop dilated and distal loops collapsed, and further exploration showed enlarged mesenteric lymph nodes. Small bowel resection of around 8 cm and side to side anastomosis was done to relive the intestinal obstruction. Gross pathology showed a solid lesion protruding into the lumen measuring 1.5*1.5*1.5 cm, while the microscopic description consists of small cells with round ovoid nuclei which lack cohesion and appear individually dispersed through a fibrous connective tissue and arranged in single file linear cords that invade the stroma (Fig. 4) concluded as metastatic lobular carcinoma of the breast. Immunohistochemistry reported CK7 + ve, ER + ve, EMA + ve and CKAE1/AE3 + ve. The patient had an uneventful recovery, then she was discharged against medical advice and traveled to her country after two days before the histopathology result and she lost follow-up with us.

Traumatic sigmoid colon rupture due to breast cancer metastasis: a case report

The metastasis of breast cancer to the gastrointestinal tract is rare. Herein, we presented the case of an 85-year-old woman who had a history of invasive lobular carcinoma and experienced complete colon rupture due to relatively low-energy trauma. The patient underwent bilateral total mastectomy and axillary dissection following preoperative chemotherapy 6 years ago. She had a local recurrence 2 years after the surgery and underwent chemotherapy. Subsequently, the cancer metastasized to the thoracolumbar area and retroperitoneum. In addition, the patient fell from a height of 30 cm while hanging laundry and her abdomen hit a hose reel. Emergency surgery was performed, and the entire circumference of the sigmoid colon was ruptured. The ruptured colon lesion was resected, and the stump was closed. A double-barrel transverse colostomy was created as it was impossible to lift the stump up to the abdominal wall. Histopathological examination revealed the invasive lobular carcinoma metastasis and a linitis plastica-like change of the colon wall, which probably consequently weakened. In addition, minimal trauma can damage the gastrointestinal tract that had invasive lobular carcinoma metastasis.

A Unique Endoscopic Presentation of Colon Metastases From Primary Invasive Lobular Carcinoma of the Breast

Breast cancer is the leading cause of female malignancy-associated death worldwide. The most common sites of metastases are the lung, liver, brain, and skeleton. A 68-year-old female with invasive lobular carcinoma metastatic to the axial skeleton was found to have new skin and colonic metastases discovered on serial surveillance positron emission tomography-computed tomography scans. The colonic metastases did not present with any gastrointestinal symptoms and did not form exophytic masses, which are typically associated. Instead, her colonic metastases presented as unusual diaphragm-like strictures within the left colon discovered on endoscopy, which is a relatively rare phenomenon. This case raises awareness of and elucidates new manners of presentation of metastatic invasive lobular carcinoma within the colon.

A case of breast cancer with extensive colon metastasis

Breast cancer is one of the most common malignancies in women worldwide. Although most breast cancers are curable, in cases of metastasis, many are often found in the lungs, bones, liver, and central nervous system; however, metastasis to the gastrointestinal tract is rare. Invasive lobular carcinoma, which represents only 5%-10% of breast cancers, has a higher risk of metastasis to the gastrointestinal tract than invasive ductal carcinoma. Here, we report a rare case of gastrointestinal metastasis of invasive lobular carcinoma that spread extensively to the colonic mucosa. Given the improved survival rates of breast cancer patients with current treatments, many rarer metastatic diseases, including gastrointestinal metastases, are likely to be increased in the future.

The Role of 68 Ga-FAPI PET/CT in Detection of Metastatic Lobular Breast Cancer

PURPOSE

Invasive lobular breast cancer (ILC) may be hard to detect using conventional imaging modalities and usually shows less avidity to 18 F-FDG PET/CT. 68 Ga-fibroblast activation protein inhibitor (FAPI) PET/CT has shown promising results in detecting non- 18 F-FDG-avid cancers. We aimed to assess the feasibility of detecting metastatic disease in patients with non- 18 F-FDG-avid ILC.

METHODS

This prospective study included patients with metastatic ILC, infiltrative to soft tissues, which was not 18 F-FDG avid. The patients underwent 68 Ga-FAPI PET/CT for evaluation, which was correlated with the fully diagnostic CT performed at the same time.

RESULTS

Seven women (aged 57 ± 10 years) were included. Among the 30 organs and structures found to be involved by tumor, the number of findings observed by FAPI PET/CT was significantly higher than that observed by CT alone ( P = 0.022), especially in infiltrative soft tissue and serosal locations.

CONCLUSIONS

This small pilot trial suggests a role for 68 Ga-FAPI PET/CT in ILC, which needs to be confirmed by subsequent trials.

Presentation of metastatic breast cancer as a large bowel obstruction in an elderly female with resultant diverting ileostomy: case report

Background

Breast cancer metastases generally occur in the lymph nodes, bone, lungs, or liver. Very rarely does a primary breast cancer metastasize to the colon, and even more rarely does the metastasis cause a large bowel obstruction. To our knowledge, there are no reports in the literature of the surgical management of elderly patients presenting with metastatic breast cancer as a large bowel obstruction. Here we present an unusual case of breast cancer metastasis of an elderly female, years after initial diagnosis and treatment of the primary breast cancer, that metastasized to the ascending colon and presented as a large bowel obstruction, ultimately treated with diverting ileostomy. The patient's rare presentation illustrates the necessity to consider metastatic breast cancer among patients with large bowel obstruction, and the consideration for palliation of symptoms with diversion.

Case Description

The patient is an 84-year-old otherwise healthy female with history of right breast invasive lobular carcinoma, who underwent bilateral mastectomy, right axillary lymph node dissection, and adjuvant chemotherapy, radiation, and letrozole in 2017. In March of 2022, the patient presented with radiographic evidence of a proximal large bowel obstruction. On exploratory laparotomy she was found to have an ascending colon mass as well as widespread intra-abdominal carcinomatosis consistent with metastatic breast cancer. She underwent a diverting loop ileostomy for palliation of her obstructive symptoms and later followed with oncology for palliative chemotherapy and anti-hormone therapy. She overall recovered well without any future plans for surgical intervention.

Conclusions

Although uncommon, it is important to consider metastatic disease when evaluating patients with history of breast cancer for large bowel obstruction. Failure to do so can result in a delay in recognition of metastatic tumor biology or even a misdiagnosis. This may impede appropriate treatment and may contribute to significant morbidity or even mortality for patients.

Invasive Lobular Carcinoma of the Breast With Rectal Metastasis: A Rare Case Report

The rectum is a relatively unusual site for metastasis from invasive lobular carcinoma (ILC) of the breast, and it carries dangers such as perforation and blockage. We reported a case of a 47-year-old female patient complaining of breast ILC for one year. Recently, the patient complained of abdominal distention, mild generalized abdominal pain, and weight loss. The abdominal ultrasound (US) showed moderate ascites without hepatomegaly, and ascitic tapping was positive for malignant cells. Lower colonoscopy showed a congested mass of 8 cm, and anal verge biopsy showed colonic mucosa laminal propria infiltrated with atypical cells and adenocarcinoma metastatic from the breast. In a patient with breast cancer, particularly ILC, who has developed new gastrointestinal tract (GIT) symptoms, there is significantly a high chance of rectal metastatic illness. Early detection is critical for successful treatment.

When a Late Metastasis Is Hard to Swallow

Pseudoachalasia is an uncommon disorder characterised by aperistalsis in the tubular oesophagus and impaired relaxation of the lower oesophageal sphincter (LES). It presents with symptoms and radiologic, endoscopic and manometric findings that mimic idiopathic achalasia. There is a huge spectrum of underlying causes for pseudoachalasia, although malignancy is the most common aetiology.

We report the case of a 70-year-old Portuguese female with a history of breast cancer, submitted to tumourectomy, radiotherapy and hormonotherapy, in complete remission for 16 years, who presented in the emergency department with a two-month history of dysphagia, weight loss, heartburn and nausea. Blood work, body computed tomography (CT) scan, mammography, upper endoscopy, colonoscopy and skeletal scintigraphy did not show any alterations, but barium swallow scan and oesophageal manometry suggested achalasia. She was submitted to oesophageal dilatation with partial symptomatic improvement. Six months later, new onset of dysphonia and worsening of initial symptoms was noticed. A new CT scan revealed unilateral pleural effusion, large mediastinal adenopathy and multiple pulmonary nodules highly suggestive of a metastatic malignancy. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) from mediastinal adenopathies confirmed the tumoural invasion by a carcinoma, and immunohistochemistry suggested a breast origin. She underwent a nasoendoscopy that revealed bilateral vocal cord paralysis. After chemotherapy was started, symptoms of achalasia completely resolved, and tumour markers, which were increased, have normalised.

The presented case highlights a pseudoachalasia as the first manifestation of a late breast metastasis. It is essential to always have in mind patients’ past history as a key that can help resolve clinical doubts.

Infiltrative pattern of metastatic invasive lobular breast carcinoma in the abdomen: a pictorial review

Invasive lobular carcinoma (ILC) has a greater tendency to metastasize to the peritoneum, retroperitoneum, and gastrointestinal (GI) tract as compared to invasive carcinoma of no special type (NST). Like primary ILC in the breast, ILC metastases are frequently infiltrative and hypometabolic, rather than mass forming and hypermetabolic in nature. This renders them difficult to detect on conventional and metabolic imaging studies. As a result, intra-abdominal ILC metastases are often detected late, with patients presenting with clinical complications such as liver failure, hydronephrosis, or bowel obstruction. In patients with known history of ILC, certain imaging features are very suggestive of infiltrative metastatic ILC. These include retroperitoneal or peritoneal nodularity and linitis plastica appearance of the bowel. Recognition of linitis plastica on imaging should prompt deep or repeat biopsies. In this pictorial review, the authors aim to familiarize readers with imaging features and pitfalls for evaluation of intra-abdominal metastatic ILC. Awareness of these will allow the radiologist to assess these patients with a high index of suspicion and aid detection of metastatic disease. Also, this can direct histopathology and immunohistochemical staining to obtain the correct diagnosis in suspected metastatic disease.

Duodenal and Biliary Obstruction due to Extrinsic CompressionDuodenal and Biliary Obstruction due to Extrinsic Compression by Recurrent Lobular Breast Carcinoma: A Case Report

Metastases to the gastrointestinal tract (GIT) from breast carcinoma are rare, detected in approximately <5% of all breast cancer patients. Invasive lobular carcinoma (ILC) is the most common histological type of breast cancer to metastasize to the GIT. We report a case of abdominal recurrence of ILC of the breast causing intra-abdominal contracture leading to extrinsic compression of the duodenum and periampullary biliary tree. Four years after the patient's diagnosis of a left breast pT1c, pN2, cM0 invasive lobular breast cancer, she presented with liver function tests consistent with biliary obstruction, and there was concern for a periampullary malignancy. Definitive diagnosis was achieved at laparotomy. This case demonstrates the importance of considering metastatic breast cancer as a potential cause of GI symptoms and radiological abnormalities affecting any part of the GIT of women with a previous history of lobular breast cancer. This case also highlights the effectiveness of chemotherapy in improving the survival and quality of life of these patients. Early recognition of this scenario enables prompt initiation of systemic therapy and avoids unnecessary surgical treatment. Despite the rarity, such patients will be encountered in clinical practice given the high prevalence of breast cancer. Moreover, the fact that the presenting symptoms of GI metastasis from breast cancer are usually not specific to the origin and mimic a primary intestinal disorder, health-care professionals beyond oncologists, especially gastroenterologists and primary care physicians, should be aware of this entity.

Case report of metastatic breast cancer mimicking ileal Crohn's disease

Introduction

Lobular breast cancer (LBC) has an increased risk of gastrointestinal (GI) spread compared with ductal breast carcinoma. Breast cancer commonly metastasises to bone, lung, liver, central nervous system and rarely to the gastrointestinal tract. As the prognosis for breast cancer continues to improve with modern medical practice it is important to be aware of the various clinical presentations and the appropriate management of breast cancer metastases.

Case presentation

We describe a case of a 60-year-old woman who presented with symptoms of bowel obstruction 30 months after undergoing mastectomy and adjuvant chemotherapy for LBC. A Computer Tomography (CT) scan showed terminal ileal thickening suggestive of Crohn's disease but histopathology revealed metastatic lobular carcinoma. Surgical resection to relieve her small bowel obstruction confirmed LBC.

Clinical discussion

This case illustrates an unusual presentation of metastatic breast cancer causing small bowel obstruction with radiological features mimicking Crohn's disease.

Conclusion

Patients with breast cancer can present with intestinal obstruction due to metastatic spread to the small intestine; this may resemble Crohn's disease clinically and radiologically.

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Lobular breast cancer is more likely to metastasize to the gastrointestinal tract.

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Breast cancer metastases can appear radiologically as Crohn’s disease.

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Endoscopic biopsies in cases of GI spread of breast cancer can be nondiagnostic.

Intestinal metastasis from breast cancer: Presentation, treatment and survival from a systematic literature review

BACKGROUND

Intestinal metastases from breast cancer (BC) arerare; available data depend mainly on case reports and case series.

AIM

To conduct a review of the literature regarding presentation, diagnosis, treatment and survival of patients with intestinal metastasis from BC.

METHODS

We identified all articles that described patients with intestinal metastasis (from duodenum to anum) from BC using MEDLINE (1975 to 2020) and EMBASE (1975 to 2020) electronic databases.

RESULTS

We found 96 cases of intestinal metastasis of BC. Metastasization involved large bowel (cecum, colon, sigmoid, rectum) (51%), small bowel (duodenum, jejunum, ileum) (49%), and anum (< 1%). Median age of patients was 61-years. The most frequent histology was infiltrating lobular carcinoma followed by infiltrating ductal carcinoma. In more than half of patients, the diagnosis was made after the diagnosis of BC (median: 7.2 years) and in many cases of emergency, for bowel obstruction, bleeding or perforation. Diagnosis was achieved through endoscopy, radiological examination or both. In most of the cases, patients underwent surgery with or without systemic therapies. Survival of patients included in this review was available in less than 50% of patients and showed an overall median of 12 mo since diagnosis of the intestinal metastasis.

CONCLUSION

Although, intestinal metastases of BC are considered a rare condition, clinicians should consider the possibility of intestinal involvement in case of abdominal symptoms even in acute setting and many years after the diagnosis of BC, especially in patients with a histology of lobular carcinoma.

Colonic Metastases from a Luminal A Type Invasive Ductal Carcinoma Breast: A Rare Case Report

Metastatic carcinoma breast involving hepatobiliary system and peritoneum is a common and well-described entity. However, colonic luminal involvement by breast metastases is rare and its early recognition is important for accurate management planning. We report a case of an elderly woman with luminal A type invasive ductal carcinoma (IDC) breast, initially controlled/stabilized on hormonal treatment and later progressed to involve colon presenting with intestinal obstructive symptoms. Lobular carcinoma breast which constitutes around 10% of breast cancers is more likely to have gastrointestinal tract (GIT) involvement. On the other hand, GIT metastasis from IDC breast is quite rare. Given the progressively increasing survival with current and forthcoming novel treatment modalities, it is very important to recognize and understand unusual presentation of metastatic breast cancer, such as colonic metastasis, for timely treatment planning and implementation.

The Mechanisms for the Association of Cancer and Esophageal Dysmotility Disorders

BACKGROUND

Achalasia and other esophageal dysmotility disorders mimicking achalasia can be associated with cancer. This study aimed to review the main mechanisms for which cancer may develop in esophageal dysmotility disorder patients.

METHODS

A narrative review was performed.

RESULTS

The mechanism for developing squamous cell carcinoma and adenocarcinoma are discussed. Besides, achalasia-like syndromes related to familial KIT-gene mutation and pseudoachalasia are discussed.

CONCLUSIONS

Knowing the main mechanism for which achalasia can be related to cancer is essential for clinicians to conduct the proper investigation, surveillance, and treatment.

Acute appendicitis as an unusual cause of invasive ductal breast carcinoma metastasis

Acute appendicitis is one of the most common causes of abdominal pain at the emergency room. In rare cases, it can be caused by malignancy, even metastatic lesions from extra-abdominal neoplasia. Herein, we report a case of a 64-year-old female with a history of invasive ductal carcinoma of the breast treated by chemotherapy, surgery, radiotherapy and hormonotherapy, relapsing several years later as a bone and a pleura metastasis successfully cured by locoregional therapy and hormonal treatment. She presented with acute abdominal pain without signs of peritonitis. Abdominal computed tomodensitometry showed sign of appendicitis. Therefore, laparoscopic exploration and appendicectomy was performed. During surgery, multiple peritoneal nodules were found and harvested. Pathology showed metastatic nodules of invasive ductal breast carcinoma, including in the appendicular wall, concluding to peritoneal carcinomatosis. The postoperative course was uneventful, but the patient died 1 year later after refusing anticancer treatment.

Back to Basics: History and Physical Examination Uncover Colonic Metastasis in a Patient With Remote History of Breast Cancer

We present the cast of a 74-year-old woman with a remote history of recurrent localized breast cancer who presented with nonspecific gastrointestinal symptoms who was subsequently found to have metastatic breast cancer in the transverse colon. Nonspecific gastrointestinal complaints can be the first sign of cancer recurrence in these patients. Providers should maintain a high index of suspicion for disease recurrence when evaluating cancer survivors.

An Uncommon Presentation of a Common Disease: A Review of Gastric Metastasis From Breast Carcinoma

Breast cancer is the most common cancer in women, and the leading cause of cancer-related deaths worldwide. Despite advances in screening and treatment modalities, distant metastasis still develops. Breast cancer metastasis to the gastrointestinal tract is very rare, therefore, its diagnosis, therapeutic strategies, and prognosis pose a clinical problem for clinicians. We summarize the current knowledge regarding the clinicopathological characteristics and diagnostic strategies for metastatic tumors in the stomach of breast origin.

Gastric metastases from primary breast cancers: rare causes of common gastrointestinal disorders

We report two cases of gastric metastases from primary breast cancers. In case 1, a 31-year-old woman with right-sided ductal breast carcinoma presented with nausea, vomiting and frank haematemesis, 8 months after mastectomy and adjuvant chemotherapy. An esophagogastroduodenoscopy (EGD) revealed multiple ulcerated gastric lesions secondary to metastatic adenocarcinoma from primary breast tumour. In case 2, an 84-year-old woman with a history of left lobular carcinoma presented with early satiety, 17 years after initial mastectomy and adjuvant endocrine therapy. An EGD revealed unspecific gastric mucosa with thickened and erythematous folds and biopsies revealed adenocarcinoma from primary breast carcinoma. Our cases demonstrate how gastric metastases have variable, non-specific clinical and endoscopic presentations. Symptoms may include nausea, vomiting, early satiety and gastrointestinal (GI) bleeding. Endoscopic appearance may range from thickened gastric folds to ulcerating lesions. Our cases demonstrate that gastric metastases should be considered in patients with breast cancer history presenting with GI symptoms.

Colonic Metastases from a Luminal A Type Invasive Ductal Carcinoma Breast: A Rare Case Report

Metastatic carcinoma breast involving hepatobiliary system and peritoneum is a common and well-described entity. However, colonic luminal involvement by breast metastases is rare and its early recognition is important for accurate management planning. We report a case of an elderly woman with luminal A type invasive ductal carcinoma (IDC) breast, initially controlled/stabilized on hormonal treatment and later progressed to involve colon presenting with intestinal obstructive symptoms. Lobular carcinoma breast which constitutes around 10% of breast cancers is more likely to have gastrointestinal tract (GIT) involvement. On the other hand, GIT metastasis from IDC breast is quite rare. Given the progressively increasing survival with current and forthcoming novel treatment modalities, it is very important to recognize and understand unusual presentation of metastatic breast cancer, such as colonic metastasis, for timely treatment planning and implementation.

Colonic Metastases from a Luminal A Type Invasive Ductal Carcinoma Breast: A Rare Case Report

Metastatic carcinoma breast involving hepatobiliary system and peritoneum is a common and well-described entity. However, colonic luminal involvement by breast metastases is rare and its early recognition is important for accurate management planning. We report a case of an elderly woman with luminal A type invasive ductal carcinoma (IDC) breast, initially controlled/stabilized on hormonal treatment and later progressed to involve colon presenting with intestinal obstructive symptoms. Lobular carcinoma breast which constitutes around 10% of breast cancers is more likely to have gastrointestinal tract (GIT) involvement. On the other hand, GIT metastasis from IDC breast is quite rare. Given the progressively increasing survival with current and forthcoming novel treatment modalities, it is very important to recognize and understand unusual presentation of metastatic breast cancer, such as colonic metastasis, for timely treatment planning and implementation.

Gastrointestinal tract metastasis presenting as intussusception in invasive lobular carcinoma of the breast: A case report

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Gastrointestinal (GI) tract metastasis in breast cancer is rare and occurs more commonly in invasive lobular carcinoma.

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The interval between the index breast cancer and GI tract spread may be as long as 30 years.

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20% of patients with GI tract metastasis are asymptomatic, and detection may rely on physical examination and imaging.

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Management follows the principles of treatment in systemic disease in breast cancer, with consideration for surgery in obstruction, perforation or bleeding.

Introduction

Breast cancer metastasis to the gastrointestinal (GI) tract is rare and occurs more frequently in invasive lobular carcinoma. Patients may be asymptomatic or present with variable vague symptoms that may be mistakenly attributed to side effects of chemotherapy or other benign GI diseases. Treatment follows the principles of systemic disease and includes hormonal therapy, chemotherapy and signal transduction inhibitors, with surgical intervention indicated for complications such as obstruction, perforation and hemorrhage.

Presentation of case

We present the case of a female patient with a history of invasive lobular breast carcinoma who had undergone mastectomy and axillary dissection, followed by chemoradiotherapy. Over the next nine years, she developed ovarian and bone metastases for which appropriate treatment was provided. A right iliac fossa mass was discovered during routine clinic review, though she remained asymptomatic. Computed tomography scan showed ileocecal intussusception. Histopathological examination of the right hemicolectomy specimen following emergency surgery confirmed metastatic invasive lobular carcinoma to the GI tract.

Discussion

GI tract metastasis may present 30 years after the primary breast cancer. Up to 20% of patients may be asymptomatic as shown by Montagna et al. When present, symptoms are commonly non-specific and vague. Histological diagnosis is challenging. GI metastasis typically appears as intramural infiltration of the bowel wall by small cells arranged in cords.

Conclusion

It is important to maintain a suspicion for GI tract metastasis in breast cancer patients who present with abdominal mass or GI symptoms, as this aids in prompt institution of accurate and appropriate management.

Large Bowel Obstruction Subsequent to Resected Lobular Breast Carcinoma: An Unconventional Etiology of Malignant Obstruction

Introduction

Breast cancer metastasis to the gastrointestinal tract is rare and mostly limited to case reports which recommend consideration of metastasis when breast cancer patients particularly those with invasive lobular carcinoma present with new gastrointestinal complaints.

Presentation of case

We report a 50-year-old female who presented with gastrointestinal symptoms of nausea and vomiting determined to be the result of large bowel obstruction secondary to rectosigmoid metastasis and carcinomatosis of breast invasive lobular carcinoma. She was treated with diverting loop sigmoid colostomy for her large bowel obstruction.

Discussion

Our case reflects the importance of gastrointestinal surveillance of patients with a history of breast cancer. Current National Comprehensive Cancer Network (NCCN) guidelines for stage I-II breast cancer suggest posttreatment lab and imaging evaluation for metastasis only if new symptoms present.

Conclusion

We observed an unusually rapid disease progression, requiring evaluation of new gastrointestinal symptoms. Assessment for GI tract metastatic involvement should be done as early as progression to symptomatic disease can result in need for further invasive surgery in advanced stages of cancer.

Metastatic ductal carcinoma of the breast to colonic mucosa

Breast cancer is the most common malignancy among women, while invasive ductal carcinoma is the most common type of invasive breast cancer. Metastatic spread to the colon and rectum in breast cancer is rare. This report describes a case of a 69-year-old woman with metastatic ductal breast cancer to the rectosigmoid, presenting as an incidental finding on screening colonoscopy. The breast carcinoma was first diagnosed 2 years prior. Colonic biopsies from colonoscopy confirmed metastatic adenocarcinoma consistent with a breast primary. Ultimately her clinical condition worsened as she developed malignant ascites, a small bowel obstruction, and new bone metastases, and the patient succumbed to her illness. Cases of metastatic breast cancer to the gastrointestinal tract have predominantly been lobular breast carcinoma. Increased awareness of colonic metastasis may lead to more accurate diagnosis and earlier systemic treatment.

Colonic Obstruction from an Unusual Cause: A Rare Case of Metastatic Invasive Ductal Carcinoma to the Colon

Colon metastasis from breast cancer is rare. Gastrointestinal (GI) metastasis is more frequently seen in patients with invasive lobular carcinoma of the breast compared to invasive ductal carcinoma; however, the most common sites of metastasis still remain the lymph nodes, lungs, liver, and bones. We describe a 68-year-old female with a remote history of invasive ductal carcinoma of the breast who presented with abdominal pain and a palpable mass. On imaging, she was found to have a colonic obstruction and underwent a right hemicolectomy that proved to be metastatic invasive ductal carcinoma of the breast.

Use of Endoscopic Ultrasound in a Diagnostic Dilemma: Metastatic Breast Cancer to the Stomach

A 55-year-old woman presented with persistent nausea, vomiting, and weight loss previously attributed to Ménétrier's disease. On further workup, she was found to have metastatic lobular breast carcinoma causing gastric outlet obstruction, diagnosed by endoscopic ultrasound with fine needle aspiration after previous gastric mucosal biopsies were unremarkable. In most reported cases of gastric metastasis from breast cancer, a diagnosis was established by mucosal biopsy. This case is an important reminder that mucosal biopsies can be negative in about 20% of patients with gastric metastasis, which may lead to a delay in diagnosis and treatment. Gastroenterologists should be diligent in taking deeper biopsies if there is a suspicion for gastric metastasis.

Obstructive Colon Metastases from Lobular Breast Cancer: Report of a Case and Review of the Literature

Introduction

Gastrointestinal metastases from breast cancer are rare. One large series reported a rate of 0.7% of gastrointestinal metastatic manifestations from breast cancer, but its true incidence could be underestimated. Here we report a case of bowel obstruction caused by sigmoid metastases from breast cancer and describe its relevance to histological origin and clinical practice.

Methods

The clinical course and histopathology of the case are reviewed and compared with reports of similar cases in the literature.

Results

An 80-year-old woman presented with bowel obstruction. Her medical history included infiltrating lobular breast cancer treated with left radical mastectomy 25 years before the current presentation; 13 years later bone metastases developed and were treated with hormone therapy. In 2003 the patient came to our emergency department because of symptoms of bowel obstruction. A computed tomography (CT) scan revealed a mass in the distal sigmoid causing the obstruction. A colostomy was performed, followed by a second operation completed with Hartmann's procedure. Histological examination revealed metastases from invasive lobular carcinoma. The patient was discharged 45 days postoperatively and died 9 months later because of disease progression.

Conclusions

Although gastrointestinal metastases from breast cancer are rare, patients with diagnosed breast cancer, particularly invasive lobular carcinoma, should be regularly followed up with endoscopy, CT, endosonography and PET-CT when abdominal symptoms are present. This could permit early diagnosis of gastrointestinal metastases and improve treatment planning.

Clinical presentation and treatment of gastric metastasis from other malignancies of solid organs

The aim of the present study was to analyze the clinicopathologic features and treatment outcomes of gastric metastasis from other malignancies of solid organs. A review was conducted of patients with metastatic tumors in the stomach from other malignancies of solid organs detected endoscopically at the Department of Surgery, Kochi Medical School, from January 1991 to December 2015. Seven patients (four men and three women), with a median age of 64 years (range, 42-71 years), had metastatic gastric tumors. Median tumor size was 7.3 cm (range, 2.5-12.0 cm). The primary malignancy leading to metastatic tumors in the stomach was esophageal cancer in three patients, breast cancer in two patients, renal cell carcinoma in one patient, and ovarian cancer in one patient. Gastric metastasis presented as solitary lesions in six patients and as multiple lesions in one patient. Four patients had solitary gastric metastasis, whereas three had multiple metastases in other organs. The median tumor size was significantly smaller in patients with solitary rather than multiple metastases (4.6 vs. 12.0 cm, respectively; P=0.038). Three patients received systemic therapy and four underwent surgical resection of the metastatic tumor, and of these, only one was alive 58 months after surgery. Clinicians should be aware of the possible existence of metastatic gastric cancer, especially in breast carcinoma and esophageal cancer. Surgical resection may considerably improve patients' quality of life, and could be of benefit when there is a risk of bleeding and/or a solitary metastasis.

Triple negative invasive lobular carcinoma of the breast presents as small bowel obstruction

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Metastatic breast carcinoma rarely spreads to the Gastrointestinal Tract (GIT).

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GIT breast carcinoma rarely has triple: ER, PR and HER2-neu negative histology.

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We report a case of triple negative breast carcinoma that spread to the jejunum.

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This is the first reported case in the U.S.

Metastasis from breast carcinoma to the gastrointestinal tract (GIT) is very uncommon. To date, only a few cases have been described worldwide. Of those which do metastasize to the GIT, only estrogen receptor (ER), progesterone receptor (PR) and HER2-neu receptor positive cancers have been reported and none have been mentioned in the U.S. We report a case of a 70-year-old white female with history of triple negative lobular carcinoma eight years earlier who presented with solitary jejunal mass causing obstruction.

Metastatic Invasive Lobular Breast Cancer Presenting Clinically with Esophageal Dysphagia

Background. Intra-abdominal metastases of invasive lobular breast cancer (ILBC) may be insidious. We report a case of metastatic ILBC that presented with dysphagia within weeks of a negative mammogram and before the development of intra-abdominal symptoms. Case. A 70-year-old female developed esophageal dysphagia. She underwent EGD which showed a short segment of stricture of the distal esophagus without significant mucosal changes. Biopsy was unremarkable and patient underwent lower esophageal sphincter (LES) dilation. Severe progressive dysphagia led to esophageal impaction and three LES dilatations. CT scan showed bilateral pleural effusions, more prominent on right side, and ascites. The pleural effusions were transudative. Repeat EGD with biopsy showed lymphocytic esophagitis, and she was started on swallowed fluticasone. Abdominal ultrasound with Doppler showed that the main portal vein had atypical turbulent flow that was felt to possibly be due to retroperitoneal process. The patient underwent diagnostic laparoscopy which revealed diffuse punctate lesions on the peritoneum. Pathology was consistent with metastatic ILBC. Conclusion. Dysphagia in the setting of peritoneal carcinomatosis from metastatic ILBC is a rare finding. The case highlights the importance of metastatic ILBC as a differential diagnosis for female patients with progressive dysphagia and associated ascites or pleural effusions.

Single Jejunum Metastasis from Breast Cancer Arising Twelve Years after the Initial Treatment

Metastatic involvement of gastrointestinal tract from breast cancer is a rare event. We report the case of a 61-year-old woman presenting with bowel obstruction, related to metastasis of a primary breast cancer she had 12 years earlier (a triple-negative invasive ductal carcinoma treated with surgery and chemotherapy). Bowel obstruction was caused by a 20-centimeter tumor in the jejunum, involving also the transverse colon. The patient underwent en bloc resection of tumor with jejunum and transverse bowel segment and received adjuvant chemotherapy with carboplatin and paclitaxel. Twenty months later, she was alive without disease recurrence.

Ductal Breast Carcinoma Metastatic to the Stomach Resembling Primary Linitis Plastica in a Male Patient

Breast cancer metastases to the gastrointestinal tract are very rare occurrences. Among the histological subtypes of breast cancer, invasive lobular carcinomas have a high capacity of metastasis to uncommon sites including the stomach. Conversely, there has not been sufficient evidence supporting the gastric metastasis of invasive ductal carcinoma. Herein, we report a unique case of metastatic ductal breast carcinoma mimicking primary linitis plastica in a male patient, particularly focusing on the clinical and pathological features of presentation. Moreover, we propose a immunohistochemical panel of selected antibodies including those for cytokeratin 20, cytokeratin 7, estrogen receptor, progesterone receptor, E-cadherin, gross cystic disease fluid protein 15, and GATA binding protein 3 for an accurate differential diagnosis.

Imaging of metastases from breast cancer to uncommon sites: a pictorial review

There are three types of breast cancer recurrence which can occur after initial treatment: local, regional, and distant. Distant metastases are more frequent than local and regional recurrences. It usually occurs several years after the primary breast cancer, although it is sometimes diagnosed at the same time as the primary breast cancer. Although the common distant metastases are bone, lung and liver, breast cancer has the potential to metastasize to almost any region of the body. Early detection and treatment of distant metastases improves the prognosis, therefore radiologists and clinicians should recognize the possibility of metastasis from breast cancer and grasp the imaging characteristics. In this report, we demonstrate the imaging characteristics of metastases from breast cancer to uncommon sites.

Myeloid differentiation primary response gene 88-leukotriene B4 receptor 2 cascade mediates lipopolysaccharide-potentiated invasiveness of breast cancer cells

Inflammation and local inflammatory mediators are inextricably linked to tumor progression through complex pathways in the tumor microenvironment. Lipopolysaccharide (LPS) exposure to tumor cells has been suggested to promote tumor invasiveness and metastasis. However, the detailed signaling mechanism involved has not been elucidated. In this study, we showed that LPS upregulated the expression of leukotriene B₄ receptor-2 (BLT2) and the synthesis of BLT2 ligands in MDA-MB-231 and MDA-MB-435 breast cancer cells, thereby promoting invasiveness. BLT2 depletion with siRNA clearly attenuated LPS-induced invasiveness. In addition, we demonstrated that myeloid differentiation primary response gene 88 (MyD88) lies upstream of BLT2 in LPS-potentiated invasiveness and that this ‘MyD88-BLT2’ cascade mediates activation of NF-κB and the synthesis of IL-6 and IL-8, which are critical for the invasiveness and aggression of breast cancer cells. LPS-driven metastasis of MDA-MB-231 cells was also markedly suppressed by the inhibition of BLT2. Together, our results demonstrate, for the first time, that LPS potentiates the invasiveness and metastasis of breast cancer cells via a ‘MyD88-BLT2’-linked signaling cascade.

Small Bowel Metastatic Cancer Observed With Double Balloon Enteroscopy in a Patient With a Past History of Multiple Cancers

Small bowel tumors are very rare and generally malignant. As a result of the anatomical location and nonspecific manifestations of small bowel tumors, they are very difficult to diagnose. Balloon-assisted enteroscopy is a relatively noninvasive method compared to surgical resection, and allows for real-time observation, tissue confirmation with biopsy, and interventional procedures. Here, we report the case of a 69-year-old woman with a small bowel metastatic carcinoma observed with double balloon enteroscopy (DBE). She had a history of multiple cancers including ovarian cancer, bladder cancer, and breast cancer. The antegrade DBE procedure was performed before surgery for biopsy tissue confirmation. The patient underwent small bowel resection, and the final diagnosis was the same as that determined by preoperative biopsy. The final diagnosis was metastatic small bowel cancer originating from a cancer of the breast. This is the first detailed report of the preoperative diagnosis of small intestinal metastatic breast cancer by DBE.

Gastric metastasis as the first manifestation of an invasive lobular carcinoma of the breast

Gastrointestinal metastases from breast cancer are rare and generally occur several years after the diagnosis of the primary lesion. The diagnosis of gastric metastasis as the initial presentation of breast cancer is even rarer and can potentially mimic gastric carcinoma. We report the case of a 66-year-old female patient submitted to a total gastrectomy because of the histological diagnosis of undifferentiated gastric carcinoma. During the surgical procedure, biopsies of the peritoneum and the liver were performed, which were consistent with metastatic breast invasive lobular carcinoma (ILC). The primary lesion of the breast was detected during the post-operative period, when a 4-cm-long lesion was detected on physical examination and mammography. The revision of the gastric biopsy confirmed the diagnosis of ILC. The authors call attention to the rarity of gastrointestinal metastases as the initial presentation of breast ILC.