Duodenal obstruction as the presenting manifestation of recurrent breast cancer ABSTRACT In this report, we present a case of duodenal obstruction as the initial presenting manifestation of a patient with recurrent invasive lobular breast carcinoma. KEY WORDS: Breast cancer, duodenal obstruction, lobular carcinoma
INTRODUCTION Breast carcinoma is the most common cause of cancer death in women in both developing and developed countries. We present a case of duodenal obstruction as a presenting feature of recurrent invasive lobular carcinoma of the breast. Case history A 53‑year‑old female presented to emergency room with progressive nausea and vomiting for 1 month. She also complained of early satiety and a weight loss of 3 pounds in 6 weeks. Her past medical history was significant for right‑sided stage IIIB (T2 N3a M0) estrogen receptor (ER) positive, progesterone receptor (PR) positive, and human epidermal growth factor receptor 2 (HER2) negative infiltrating lobular carcinoma of the right breast diagnosed 4 years ago. Her breast cancer treatment included right modified radical mastectomy, adjuvant chemotherapy with 4 cycles of doxorubicin and cyclophosphamide followed by 12 cycles of paclitaxel, and adjuvant radiotherapy. Patient had been on anastrozole for the last three and a half years.
biopsies were taken from the gastric wall. Pathology examination of the biopsy specimens showed poorly differentiated carcinoma consistent with metastatic lobular carcinoma of breast origin. The neoplastic cells were positive for estrogen receptor [Figure 1], CK‑7, and pancytokeratin plus and were negative for E‑cadherin and CDX2 [Figure 2].
Sunita Shrestha, Binay K Shah1, Srijan Tandukar Clinical Observer, St. Joseph Regional Medical Center, 1 Hematologist and Medical Oncologist, St. Joseph Regional Medical Center, Lewiston ID, USA For correspondence: Dr. Binay Kumar Shah, 1250 Idaho Street, Lewiston ID 83501, USA. E‑mail: [email protected] gmail.com
Patient underwent gastrojejunostomy to relieve the gastric outlet obstruction. During surgery, a mass posterior to pylorus of the stomach and duodenum was found. Areas of implants within the omentum and the mesentery of the small bowel and colon were present. A positron emission tomography ‑ computed tomography scan showed multiple bone metastases throughout the visualized skeleton. Patient was treated with 4 cycles of chemotherapy with docetaxel 75 mg/m 2 and cyclophosphamide 600 mg/m2 at 3‑week intervals. A positron emission tomography (PET) scan performed 4 weeks after completion of chemotherapy showed complete response without evidence of residual metabolically
On examination, her vital signs were normal. Abdominal examination revealed a firm, non‑tender mass measuring roughly 5‑6 cm in the epigastric region.
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A computed tomography (CT) scan of abdomen was obtained, but it did not show the mass that was evident on clinical examination. On esophagogastroduodenoscopy, there was complete obstruction of the third part of duodenum, apparently related to an extrinsic mass completely compressing the duodenal outlet between the second and third part of duodenum. Random
Figure 1: Showing neoplastic cells uniformly positive for estrogen receptors
Journal of Cancer Research and Therapeutics - July-September 2014 - Volume 10 - Issue 3
Shreshta, et al.: Breast cancer presenting with duodenal obstruction
carcinoma is rare.[7,8] The major differential diagnosis is primary duodenal carcinoma, which can present and morphologically appear similar to a breast lobular carcinoma. The main features that make our case a lobular carcinoma are: 1. The patient has a history of breast lobular carcinoma, 2) the primary and stomach tumors are morphologically similar, and 3) the immunohistochemical pattern is suggestive of a breast rather than GI primary (ER+/CDX2‑). CONCLUSION It is important to consider recurrent breast cancer as a probable cause of duodenal obstruction in a patient with a history of invasive lobular breast carcinoma and should be differentiated from duodenal primaries and other metastases. Figure 2: Neoplastic cells negative for CDX2
active metastasis. Patient was then switched to hormonal therapy with monthly fulvestrant. DISCUSSION Distant metastasis from breast cancer usually occurs in the bones, lungs, liver, and brain. Gastrointestinal involvement is less frequent. Invasive lobular carcinoma is the most common histological type of breast carcinoma that metastasizes to the gastrointestinal tract.[2,3] Compared to other invasive breast carcinomas, lobular carcinoma has a greater tendency to involve serosal, meningeal, skeletal, and visceral areas including peritoneal and retroperitoneal organs. This may be because of small size and shape of invasive lobular carcinoma cells and overexpression of E‑cadherin causing discohesiveness and migration of the tumor cells. A metastasis to the stomach from lobular carcinoma of breast generally causes a linitis plastica type involvement, whereas a ductal type causes a nodular type involvement.  The non‑specific gastric symptoms may resemble gastric primaries, even in terms of radiological and endoscopic findings. Isolated duodenal obstruction as the first sign of invasive lobular
1. Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin 2011;61:69‑90. 2. Harris M, Howell A, Chrissohou M, Swindell RI, Hudson M, Sellwood RA. A comparison of the metastatic pattern of infiltrating lobular carcinoma and infiltrating duct carcinoma of the breast. Br J Cancer 1984;50:23‑30. 3. Macías‑García F, Sobrino‑Faya M, Domínguez‑Muñoz JE. Metastasis of lobular breast carcinoma diagnosed by rectal macrobiopsies. Rev Esp Enferm Dig 2010;102:660‑1. 4. Kidney DD, Cohen AJ, Butler J. Abdominal metastases of infiltrating lobular breast carcinoma: CT and fluoroscopic imaging findings. Abdom Imaging 1997;22:156‑9. 5. Lehr HA, Folpe A, Yaziji H, Kommoss F, Gown AM. Cytokeratin 8 immunostaining pattern and E‑cadherin expression distinguish lobular from ductal breast carcinoma. Am J Clin Pathol 2000;114:190‑6. 6. Whitty LA, Crawford DL, Woodland JH, Patel JC, Nattier B, Thomas CR Jr. Metastatic breast cancer presenting as linitis plastica of the stomach. Gastric Cancer 2005;8:193‑7. 7. Lottini M, Neri A, Vuolo G, Testa M, Pergola L, Cintorino M, et al. Duodenal obstruction from isolated breast cancer metastasis: A case report. Tumori 2002;88:427‑9. 8. Houghton AD, Pheils P. Isolated duodenal metastasis from breast carcinoma. Eur J Surg Oncol 1987;13:367‑9. Cite this article as: Shrestha S, Shah BK, Tandukar S. Duodenal obstruction as the presenting manifestation of recurrent breast cancer. J Can Res Ther 2014;10:761-2. Source of Support: Nil, Conflict of Interest: No.
Journal of Cancer Research and Therapeutics - July-September 2014 - Volume 10 - Issue 3
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