63
Breast Disease 35 (2015) 63–65 DOI 10.3233/BD-140376 IOS Press
Case report
Occult bilateral invasive lobular carcinoma of the breast presenting as gastroduodenal metastases: A case report Abu-Rahmeh Zuhaira,∗ and Abu-Rahmeh Maronb a
Radiology Department, Holy Family Hospital Nazareth, Faculty of Medicine in the Galilee, Bar-Ilan University, Ramat Gan, Israel b Department of Internal Medicine, Holy Family Hospital Nazareth, Faculty of Medicine in the Galilee, Bar-Ilan, Israel
Abstract. Breast cancer, after malignant melanoma, is the most common cancer metastasizing to the gastrointestinal tract [1, 4]. Isolated gastrointestinal metastasis from breast cancer is a quite rare finding. We describe a female patient with a gastric metastasis from an undiagnosed breast cancer who presented to gastroenterology department with a symptoms of abdominal pain. Keywords: Breast cancer metastasis, breast cancer, gastrointestinal metastasis
1. Introduction Breast carcinoma is the most common malignancy in women after skin cancer and, after lung cancer, is the most frequent cause of cancer death in females, fewer than ten percent of patients will present with metastatic breast carcinoma at the time of diagnosis, Even though breast cancer, after malignant melanoma, is the most common cancer metastasizing to the gastrointestinal trac [5], isolated gastrointestinal metastasis from breast cancer is a quite rare finding. According to the different patients series reported, including autopsy studies, the most common site within the gastrointestinal tract is the stomach (6–18%), whereas colon and small bowel localization is less frequent 2–12%) [6]. (Interestingly, compared to ductal carcinoma and other his∗ Corresponding author: Abu-Rahmeh Zuhair, Radiology Department, Holy Family Hospital Nazareth, Faculty of Medicine in the Galilee, Bar-Ilan University, Ramat Gan, Israel. E-mail: zuheir@ bezeqint.net.
tological subtypes, lobular breast carcinoma shows a greater propensity to metastasize to the gastrointestinal tract [9].
2. Case report A 47-year-old female presented to an outpatient clinic with a one-month complaint of abdominal pain. An upper gastrointestinal endoscopic study with biopsies of the antrum and duodenum was performed. No evidence of H. pylori or celiac sprue was noted. The biopsy revealed metastatic material suspected of a breast primary with the suspicions for other primaries, body ct was normal. Estrogen receptor was strongly positive and progesterone receptor was Negative. HER2 was negative. No history of breast cancer complaints at the time of diagnosis. Clinical examination of the breasts and axillae was normal. Screening mammograms performed previously showed heterogeneously dense nodular Parenchyma bilaterally.
c 2015 – IOS Press and the authors. All rights reserved 0888-6008/15/$27.50
64
A.-R. Zuhair and A.-R. Maron / Occult bilateral invasive lobular carcinoma of the breast presenting as gastroduodenal metastases
Fig. 1. Mammography, which show heterogeneously dense nodular parenchyma.
Fig. 2. Sonography show 2 hypoechogenic masses 0.6, 0.8 cm in the rt breast and hypoechogenic mass 0.8 cm in the left breast.
Minimal architectural distortion was present in the superior portion of the left breast but this was previously noted and felt to be benign. Family history of breast carcinoma (her mother). She underwent mammography, which showed heterogeneously dense nodular parenchyma (Fig. 1) due to the dense breast parenchyma breast ultrasound was recommended. Sonography showed 2 hypoechogenic masses 0.6, 0.8 cm in the right breast and hypoechogenic mass 0.8 cm in the left breast (Fig. 2). Bilateral breast Core biopsy was done, the histopathology finding consistent with bilateral ILC with LCIS. She was treated with bilateral mastectomy with hormone therapy and chemotherapy with good results, 3 years after treatment still in good health.
3. Discussion The reported patient was diagnosed with lobular breast carcinoma with a simultaneous single gastric metastasis without any evident metastasis elsewhere. Solitary metastases from breast cancer to the gastrointestinal tract are extremely uncommon [5,6]. It is very rare that gastric metastasis is the initial sign of invasive breast carcinoma without any other metastatic spread [7]. Metastatic breast cancer can be difficult to distinguish from primary gastric cancer. Metastasis to the stomach from lobular type carcinoma tends to exhibit tumor cells that are infiltrating in single file pro-
cess between benign gastric glands. Signet cells may be occasionally noted. This histological finding resembles primary diffuse type gastric carcinomas (linitis plastica). Metastasis from ductal type carcinoma can resemble poorly differentiated type gastric adenocarcinomas [10]. Features that are typically used to make this distinction include the gross configuration of the tumor [8] and a detailed immunohistochemical analysis. Metastatic breast cancers are usually positive for CK7, CEA, ER, PR and GCDFP-15. CK7 and CEA positivity is nonspecific. CK20, on the other hand, is almost always present in gastrointestinal tumors and absent in breast carcinomas [9]. Not surprisingly, the metastasis detected in our case was from invasive lobular carcinoma, which differs from invasive ductal carcinoma not only in histological and mammographic characteristics but also by a different pattern of metastatic spread [4]. In our case, upper abdominal pain was the first clinical sign. Importantly, simultaneous breast cancer and intestinal obstruction have been described in very few reports [7,10]. But gastric metastasis as first clinical sign has been published in rare cases. Patients with linitis plastica from breast cancer metastases have been known to respond to hormone therapy or chemotherapy, or both, particularly if the metastases are strongly positive for estrogen receptors. Surgery should be only reserved for palliation in cases of intestinal obstruction or bleeding. The progno-
A.-R. Zuhair and A.-R. Maron / Occult bilateral invasive lobular carcinoma of the breast presenting as gastroduodenal metastases
Fig. 3. Gastric biopsy; infiltrating tumoral cells involving gastric wall (hematoxilin’ eosin). (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/BD-140376)
65
We suggest an algorithmic use of targeted immunohistochemical markers in order to determine the primary site of gastrointestinal tumors. Making a primary gastric cancer appear different from a metastatic one, especially if it is of mammary origin, is a great challenge for a correct planning of the therapeutic approach, not only to act on survival but also to spare the patient unnecessary surgery. Our goal is to increase the awareness on this event among clinicians, pathologists and surgeons.
References sis of these patients is still uncertain. Generally gastric metastases reflect a poor prognosis [3]. To the best of our knowledge, very rare cases reported of a solitary gastro duodenal metastasis from breast carcinoma presenting as upper abdomen pain. Interestingly, no other organs were involved in the metastatic spread.
4. Conclusion We report a rare case of metastatic disease to the stomach arising from a non palpable lesion of the breast. Unlike previously reported cases, in which the primary breast lesion had been well recognized or was clinically evident, in this our case a breast cancer was found to be the primary tumor only after that biopsy had been performed, in a woman with no other pathological history than a diagnosed gastric metastases. Furthermore we describe a history report of young female patient with a dyspeptic disorder and with no clinical signs of unhealthy breast; an esophagogastroduodenoscopy wish biopsy revealed the metastatic material to be from adenocarcinoma origin, only after the r/u origin from other organs, mammographic study with breast biopsy was done and the breast origin of the gastric metastasis was clear.
[1]
Bognel C, Lasser P, Zimmermann P, Gastric metastases: apropos of 17 cases. Ann Chir 1992, 46: 436-441. [2] Taal BG, Peterse H, Boot H, Clinical presentation, endoscopic features, and treatment of gastric metastases from breast carcinoma. Cancer 2000, 89(11), 2214-2221. [3] Ayantunde AA, Agrawal A, Parsons SL, Welch NT, Esophagogastric cancers secondary to a breast primary tumor do not require resection. World J Surg 2007, 31(8): 1597-1601. [4] Karamlou TB, Vetto JT, Corless C, Deloughery T, Faigel D, Blanke C, Metastatic breast cancer manifested as refractory anemia and gastric polyps. South Med J 2002, 95(8): 922-925. [5] Washington K, McDonagh D, Secondary tumors of the gastrointestinal tract: surgical pathologic findings and comparison with autopsy survey. Mod Pathol 1995, 8: 427-433 [6] Cifuentes N, Pickren JW: Metastases from carcinoma of mammary gland: An autopsy study. J Surg Oncol 1979, 11: 193-205. [7] Hansen RM, Lewis JD, Janjan NA, Komorowski RA, Occult carcinoma of the breast masquerading as primary adenocarcinoma of the small intestine. A case report. Journal of Clinical Gastroenterology 1988, 10(2): 213-217. [8] Winston CB, Hadar O, Teitcher JB, Caravelli JF, Sklarin NT, Panicek DM, Liberman L, Metastatic lobular carcinoma of the breast: patterns of spread in the chest, abdomen, and pelvis on CT. AJR Am J Roentgenol 2000, 175: 795-800. [9] Borst MJ, Ingold JA, Metastatic patterns of invasive Lobular versus invasive ductal carcinoma of the breast. Surgery 1993, 114(4): 637-641. [10] Schwarz RE, Klimstra DS, Turnbull ADM, Metastatic breast cancer masquerading as gastrointestinal primary. American Journal of Gastroenterology 1998, 93(1): 111-114.
Copyright of Breast Disease is the property of IOS Press and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Breast Disease 35 (2015) 63–65 DOI 10.3233/BD-140376 IOS Press
Case report
Occult bilateral invasive lobular carcinoma of the breast presenting as gastroduodenal metastases: A case report Abu-Rahmeh Zuhaira,∗ and Abu-Rahmeh Maronb a
Radiology Department, Holy Family Hospital Nazareth, Faculty of Medicine in the Galilee, Bar-Ilan University, Ramat Gan, Israel b Department of Internal Medicine, Holy Family Hospital Nazareth, Faculty of Medicine in the Galilee, Bar-Ilan, Israel
Abstract. Breast cancer, after malignant melanoma, is the most common cancer metastasizing to the gastrointestinal tract [1, 4]. Isolated gastrointestinal metastasis from breast cancer is a quite rare finding. We describe a female patient with a gastric metastasis from an undiagnosed breast cancer who presented to gastroenterology department with a symptoms of abdominal pain. Keywords: Breast cancer metastasis, breast cancer, gastrointestinal metastasis
1. Introduction Breast carcinoma is the most common malignancy in women after skin cancer and, after lung cancer, is the most frequent cause of cancer death in females, fewer than ten percent of patients will present with metastatic breast carcinoma at the time of diagnosis, Even though breast cancer, after malignant melanoma, is the most common cancer metastasizing to the gastrointestinal trac [5], isolated gastrointestinal metastasis from breast cancer is a quite rare finding. According to the different patients series reported, including autopsy studies, the most common site within the gastrointestinal tract is the stomach (6–18%), whereas colon and small bowel localization is less frequent 2–12%) [6]. (Interestingly, compared to ductal carcinoma and other his∗ Corresponding author: Abu-Rahmeh Zuhair, Radiology Department, Holy Family Hospital Nazareth, Faculty of Medicine in the Galilee, Bar-Ilan University, Ramat Gan, Israel. E-mail: zuheir@ bezeqint.net.
tological subtypes, lobular breast carcinoma shows a greater propensity to metastasize to the gastrointestinal tract [9].
2. Case report A 47-year-old female presented to an outpatient clinic with a one-month complaint of abdominal pain. An upper gastrointestinal endoscopic study with biopsies of the antrum and duodenum was performed. No evidence of H. pylori or celiac sprue was noted. The biopsy revealed metastatic material suspected of a breast primary with the suspicions for other primaries, body ct was normal. Estrogen receptor was strongly positive and progesterone receptor was Negative. HER2 was negative. No history of breast cancer complaints at the time of diagnosis. Clinical examination of the breasts and axillae was normal. Screening mammograms performed previously showed heterogeneously dense nodular Parenchyma bilaterally.
c 2015 – IOS Press and the authors. All rights reserved 0888-6008/15/$27.50
64
A.-R. Zuhair and A.-R. Maron / Occult bilateral invasive lobular carcinoma of the breast presenting as gastroduodenal metastases
Fig. 1. Mammography, which show heterogeneously dense nodular parenchyma.
Fig. 2. Sonography show 2 hypoechogenic masses 0.6, 0.8 cm in the rt breast and hypoechogenic mass 0.8 cm in the left breast.
Minimal architectural distortion was present in the superior portion of the left breast but this was previously noted and felt to be benign. Family history of breast carcinoma (her mother). She underwent mammography, which showed heterogeneously dense nodular parenchyma (Fig. 1) due to the dense breast parenchyma breast ultrasound was recommended. Sonography showed 2 hypoechogenic masses 0.6, 0.8 cm in the right breast and hypoechogenic mass 0.8 cm in the left breast (Fig. 2). Bilateral breast Core biopsy was done, the histopathology finding consistent with bilateral ILC with LCIS. She was treated with bilateral mastectomy with hormone therapy and chemotherapy with good results, 3 years after treatment still in good health.
3. Discussion The reported patient was diagnosed with lobular breast carcinoma with a simultaneous single gastric metastasis without any evident metastasis elsewhere. Solitary metastases from breast cancer to the gastrointestinal tract are extremely uncommon [5,6]. It is very rare that gastric metastasis is the initial sign of invasive breast carcinoma without any other metastatic spread [7]. Metastatic breast cancer can be difficult to distinguish from primary gastric cancer. Metastasis to the stomach from lobular type carcinoma tends to exhibit tumor cells that are infiltrating in single file pro-
cess between benign gastric glands. Signet cells may be occasionally noted. This histological finding resembles primary diffuse type gastric carcinomas (linitis plastica). Metastasis from ductal type carcinoma can resemble poorly differentiated type gastric adenocarcinomas [10]. Features that are typically used to make this distinction include the gross configuration of the tumor [8] and a detailed immunohistochemical analysis. Metastatic breast cancers are usually positive for CK7, CEA, ER, PR and GCDFP-15. CK7 and CEA positivity is nonspecific. CK20, on the other hand, is almost always present in gastrointestinal tumors and absent in breast carcinomas [9]. Not surprisingly, the metastasis detected in our case was from invasive lobular carcinoma, which differs from invasive ductal carcinoma not only in histological and mammographic characteristics but also by a different pattern of metastatic spread [4]. In our case, upper abdominal pain was the first clinical sign. Importantly, simultaneous breast cancer and intestinal obstruction have been described in very few reports [7,10]. But gastric metastasis as first clinical sign has been published in rare cases. Patients with linitis plastica from breast cancer metastases have been known to respond to hormone therapy or chemotherapy, or both, particularly if the metastases are strongly positive for estrogen receptors. Surgery should be only reserved for palliation in cases of intestinal obstruction or bleeding. The progno-
A.-R. Zuhair and A.-R. Maron / Occult bilateral invasive lobular carcinoma of the breast presenting as gastroduodenal metastases
Fig. 3. Gastric biopsy; infiltrating tumoral cells involving gastric wall (hematoxilin’ eosin). (Colours are visible in the online version of the article; http://dx.doi.org/10.3233/BD-140376)
65
We suggest an algorithmic use of targeted immunohistochemical markers in order to determine the primary site of gastrointestinal tumors. Making a primary gastric cancer appear different from a metastatic one, especially if it is of mammary origin, is a great challenge for a correct planning of the therapeutic approach, not only to act on survival but also to spare the patient unnecessary surgery. Our goal is to increase the awareness on this event among clinicians, pathologists and surgeons.
References sis of these patients is still uncertain. Generally gastric metastases reflect a poor prognosis [3]. To the best of our knowledge, very rare cases reported of a solitary gastro duodenal metastasis from breast carcinoma presenting as upper abdomen pain. Interestingly, no other organs were involved in the metastatic spread.
4. Conclusion We report a rare case of metastatic disease to the stomach arising from a non palpable lesion of the breast. Unlike previously reported cases, in which the primary breast lesion had been well recognized or was clinically evident, in this our case a breast cancer was found to be the primary tumor only after that biopsy had been performed, in a woman with no other pathological history than a diagnosed gastric metastases. Furthermore we describe a history report of young female patient with a dyspeptic disorder and with no clinical signs of unhealthy breast; an esophagogastroduodenoscopy wish biopsy revealed the metastatic material to be from adenocarcinoma origin, only after the r/u origin from other organs, mammographic study with breast biopsy was done and the breast origin of the gastric metastasis was clear.
[1]
Bognel C, Lasser P, Zimmermann P, Gastric metastases: apropos of 17 cases. Ann Chir 1992, 46: 436-441. [2] Taal BG, Peterse H, Boot H, Clinical presentation, endoscopic features, and treatment of gastric metastases from breast carcinoma. Cancer 2000, 89(11), 2214-2221. [3] Ayantunde AA, Agrawal A, Parsons SL, Welch NT, Esophagogastric cancers secondary to a breast primary tumor do not require resection. World J Surg 2007, 31(8): 1597-1601. [4] Karamlou TB, Vetto JT, Corless C, Deloughery T, Faigel D, Blanke C, Metastatic breast cancer manifested as refractory anemia and gastric polyps. South Med J 2002, 95(8): 922-925. [5] Washington K, McDonagh D, Secondary tumors of the gastrointestinal tract: surgical pathologic findings and comparison with autopsy survey. Mod Pathol 1995, 8: 427-433 [6] Cifuentes N, Pickren JW: Metastases from carcinoma of mammary gland: An autopsy study. J Surg Oncol 1979, 11: 193-205. [7] Hansen RM, Lewis JD, Janjan NA, Komorowski RA, Occult carcinoma of the breast masquerading as primary adenocarcinoma of the small intestine. A case report. Journal of Clinical Gastroenterology 1988, 10(2): 213-217. [8] Winston CB, Hadar O, Teitcher JB, Caravelli JF, Sklarin NT, Panicek DM, Liberman L, Metastatic lobular carcinoma of the breast: patterns of spread in the chest, abdomen, and pelvis on CT. AJR Am J Roentgenol 2000, 175: 795-800. [9] Borst MJ, Ingold JA, Metastatic patterns of invasive Lobular versus invasive ductal carcinoma of the breast. Surgery 1993, 114(4): 637-641. [10] Schwarz RE, Klimstra DS, Turnbull ADM, Metastatic breast cancer masquerading as gastrointestinal primary. American Journal of Gastroenterology 1998, 93(1): 111-114.
Copyright of Breast Disease is the property of IOS Press and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
