Int J Colorectal Dis (2015) 30:427–428 DOI 10.1007/s00384-014-1992-x
LETTER TO THE EDITOR
Massive colonic metastasis from breast cancer 23 years after mastectomy Valeria Andriola & Domenico Piscitelli & Michele De Fazio & Donato Francesco Altomare
Accepted: 10 August 2014 / Published online: 17 August 2014 # Springer-Verlag Berlin Heidelberg 2014
Dear Editor: Breast cancer is the most common malignant tumor in women worldwide, and although survival from this cancer is greatly improved in the last decades, these patients are still at risk of distant metastases even in the long term. Common sites of breast cancer metastasis include the lungs, pleura, liver, soft tissues, brain, adrenal glands, and sometimes the bones. More rarely, metastasis is discovered in the gastrointestinal (GI) tract (oropharynx, esophagus, stomach, small intestine, colon, rectum, and anus) where they can simulate a primary GI cancer [1]. In these cases, clinical presentation may be non-specific, including abdominal pain and diarrhea, pain, or bleeding, but in most of the cases, they are asymptomatic. Colonic involvement from breast cancer is hardly distinguished by a primary cancer or a Crohn's disease both clinically and at imaging studies. Endoscopy with biopsy is mandatory to perform a definite diagnosis. Exceptionally, metastasis to the GI tract can be the first manifestation of breast cancer metastasis, but more frequently, they represent cancer recurrence many years after the diagnosis of the primary tumor. A 63-year-old woman was admitted to our hospital with a diagnosis of colonic neoplasm involving completely the right colon and terminal ileum. Twenty-three years ago, she was submitted to a left radical mastectomy with axillary lymph nodes dissection for infiltrating ductal and lobular breast carcinoma. After surgery, the patient received adjuvant chemotherapy, but 10 years later, she developed a right ovarian metastasis treated with hysteroannessiectomy. In the following years, bone metastases (sacrum) were
V. Andriola : D. Piscitelli : M. De Fazio : D. F. Altomare (*) Department of Emergency and Organ Transplantation, University Aldo Moro of Bari, Bari, Italy e-mail: [email protected]
identified and treated with radiotherapy, chemotherapy, and anti-estrogen therapy. At physical examination, the tumor was easily palpable in the right iliac space as a hard, painful, and fixed mass. The patient was free from other gastrointestinal symptoms other than a moderate abdominal pain despite the cancer already involving the terminal ileum. Abdominal magnetic resonance imaging (MRI) demonstrated a thickened wall of the right colon and multiple enlarged retroperitoneal and mesenteric lymph nodes. The enhanced computed tomography (CT) scan also showed a marked concentric wall thickening of the whole right colon and multiple lymph node involvement. PET/TC total body showed increase in glucose metabolism in the sacrum, retroperitoneal and mesenteric lymph nodes, and right colon. CEA levels were slightly high (7.6 ng/mL), while CA-15.3, CA125, and CA-19.9 levels were normal. At the time of recovery, bone metastasis was unchanged in size and site. Finally, a colonoscopy demonstrated a massive substenotic lesion involving the whole right colon and terminal ileum covered with hypertrophic and irregular mucous membrane. An endoscopic biopsy demonstrated that the neoplasia was of metastatic nature from “apocrine breast carcinoma.” At the operation, the right colon was affected by the cancer, and its removal was difficult due to the absence of clear cleavage from the retroperitoneal tissue and infiltration of the great gastric curvature, antrum, and duodenum. Large and numerous lymph nodes were present along the ileo-colic artery and the vena cava. A right colectomy with ileocolonic termino-lateral mechanical anastomosis was performed leaving the cancer tissue in the retroperitoneum. Histopathology on the resected specimen showed apocrine breast carcinoma infiltrating all the colonic wall layers involving the serosa and metastasis in 13 of 15 lymph nodes. Immunohistochemical stain showed tumor cells cytokeratin 19 (CK 19) +++, gross cystic disease fluid protein-15
428
(GCFDP-15) +++, and human epidermal growth factor receptor (Her neu) score 3+. During the sixth postoperative day, the patient had a discharge of enteric juice from the drainage, and the day after, she had a massive hemorrhage leading to an emergency operation to repair a lateral duodenal fistula of the third portion of the duodenum and to control venous bleeding from the ileo-colic vein. The long (30 days) postoperative period was characterized by a progressive deterioration of the general condition and cachexia with occurrence of a multiorgan failure. The patient and her relatives then asked a voluntary hospital discharge. Occurrence of GI metastases from breast carcinoma is a rare but possible event, even reported 30 years after mastectomy [2], and among the histotypes of breast cancer, the lobular carcinoma is the most frequently involved in metastasis to unusual sites, including the GI tract, peritoneum, and genital organs. The literature reports nine cases of colorectal breast cancer metastasis: In five patients, it was localized in the rectum and, in the others, like in our case, in the ascending colon. There is no consensus on the management of breast cancer metastasis to the GI tract since surgery in such patients must always be considered as non-curative. In fact, in most of the colon-rectal involvement from breast cancer, the disease was already disseminated. Early diagnosis and differentiation between a primary GI lesion and metastatic breast cancer is sometimes difficult, and although the anamnesis of previous operation for breast cancer and clinical appearance of the colonic involvement could suggest the metastatic origin of this cancer, immunohistochemistry is the only tool for a correct diagnosis. Clinical decision-making, however, should take into consideration the advanced stage of the primary disease which makes an aggressive surgery a useless hazard without
Int J Colorectal Dis (2015) 30:427–428
significant extension of patient survival [3]. In the case described here, for example, surgery could have been limited to a palliative ileocolonic bypass to prevent intestinal occlusion associated with systemic chemotherapy. The true incidence of GI metastases from breast cancer is probably underestimated due to the scarcity of symptoms and the frequent metastatic dissemination in other organs, leading to a rapid deterioration of the health status and death from cachexia. In fact, colonic metastasis detected at the autopsy is reported in 8–15 % of patients dying from disseminated breast cancer [4]. In conclusion, such a rare condition must be taken into consideration in the oncologic follow-up of patients operated from breast cancer, particularly those with the lobular (or mixed lobular) type carcinoma, even after a long disease-free period. Clinical decision-making should be tailored according to the dissemination of the metastatic disease and the risk of intestinal occlusion or bleeding.
References 1. Ambroggi M, Stroppa EM, Mordenti P, Biasini C, Zangrandi A, Michieletti E, Belloni E, Cavanna L (2012) Metastatic breast cancer to the gastrointestinal tract: report of five cases and review of the literature. Int J Breast Cancer 2012:439023. doi:10.1155/2012/439023 2. Benfiguig A, Anciaux ML, Eugene C, Benkémoun G, Etienne JC (1992) Gastric metastasis of breast cancer occurring after a cancer-free interval of 30 years. Ann Gastroentetol Hepatol 28:175–177, PMID: 1444182 3. McLemore EC, Pockaj BA, Reynolds C, Gray RJ, Hernandez JL, Grant CS, Donohue JH (2005) Breast cancer: presentation and intervention in women with gastrointestinal metastasis and carcinomatosis. Ann Surg Oncol 12:886–894, PMID:16177864 4. Cifuentes N, Pickren JW (1979) Metastases from carcinoma of mammary gland: an autopsy study. J Surg Oncol 11:193–205, PMID: 459515
LETTER TO THE EDITOR
Massive colonic metastasis from breast cancer 23 years after mastectomy Valeria Andriola & Domenico Piscitelli & Michele De Fazio & Donato Francesco Altomare
Accepted: 10 August 2014 / Published online: 17 August 2014 # Springer-Verlag Berlin Heidelberg 2014
Dear Editor: Breast cancer is the most common malignant tumor in women worldwide, and although survival from this cancer is greatly improved in the last decades, these patients are still at risk of distant metastases even in the long term. Common sites of breast cancer metastasis include the lungs, pleura, liver, soft tissues, brain, adrenal glands, and sometimes the bones. More rarely, metastasis is discovered in the gastrointestinal (GI) tract (oropharynx, esophagus, stomach, small intestine, colon, rectum, and anus) where they can simulate a primary GI cancer [1]. In these cases, clinical presentation may be non-specific, including abdominal pain and diarrhea, pain, or bleeding, but in most of the cases, they are asymptomatic. Colonic involvement from breast cancer is hardly distinguished by a primary cancer or a Crohn's disease both clinically and at imaging studies. Endoscopy with biopsy is mandatory to perform a definite diagnosis. Exceptionally, metastasis to the GI tract can be the first manifestation of breast cancer metastasis, but more frequently, they represent cancer recurrence many years after the diagnosis of the primary tumor. A 63-year-old woman was admitted to our hospital with a diagnosis of colonic neoplasm involving completely the right colon and terminal ileum. Twenty-three years ago, she was submitted to a left radical mastectomy with axillary lymph nodes dissection for infiltrating ductal and lobular breast carcinoma. After surgery, the patient received adjuvant chemotherapy, but 10 years later, she developed a right ovarian metastasis treated with hysteroannessiectomy. In the following years, bone metastases (sacrum) were
V. Andriola : D. Piscitelli : M. De Fazio : D. F. Altomare (*) Department of Emergency and Organ Transplantation, University Aldo Moro of Bari, Bari, Italy e-mail: [email protected]
identified and treated with radiotherapy, chemotherapy, and anti-estrogen therapy. At physical examination, the tumor was easily palpable in the right iliac space as a hard, painful, and fixed mass. The patient was free from other gastrointestinal symptoms other than a moderate abdominal pain despite the cancer already involving the terminal ileum. Abdominal magnetic resonance imaging (MRI) demonstrated a thickened wall of the right colon and multiple enlarged retroperitoneal and mesenteric lymph nodes. The enhanced computed tomography (CT) scan also showed a marked concentric wall thickening of the whole right colon and multiple lymph node involvement. PET/TC total body showed increase in glucose metabolism in the sacrum, retroperitoneal and mesenteric lymph nodes, and right colon. CEA levels were slightly high (7.6 ng/mL), while CA-15.3, CA125, and CA-19.9 levels were normal. At the time of recovery, bone metastasis was unchanged in size and site. Finally, a colonoscopy demonstrated a massive substenotic lesion involving the whole right colon and terminal ileum covered with hypertrophic and irregular mucous membrane. An endoscopic biopsy demonstrated that the neoplasia was of metastatic nature from “apocrine breast carcinoma.” At the operation, the right colon was affected by the cancer, and its removal was difficult due to the absence of clear cleavage from the retroperitoneal tissue and infiltration of the great gastric curvature, antrum, and duodenum. Large and numerous lymph nodes were present along the ileo-colic artery and the vena cava. A right colectomy with ileocolonic termino-lateral mechanical anastomosis was performed leaving the cancer tissue in the retroperitoneum. Histopathology on the resected specimen showed apocrine breast carcinoma infiltrating all the colonic wall layers involving the serosa and metastasis in 13 of 15 lymph nodes. Immunohistochemical stain showed tumor cells cytokeratin 19 (CK 19) +++, gross cystic disease fluid protein-15
428
(GCFDP-15) +++, and human epidermal growth factor receptor (Her neu) score 3+. During the sixth postoperative day, the patient had a discharge of enteric juice from the drainage, and the day after, she had a massive hemorrhage leading to an emergency operation to repair a lateral duodenal fistula of the third portion of the duodenum and to control venous bleeding from the ileo-colic vein. The long (30 days) postoperative period was characterized by a progressive deterioration of the general condition and cachexia with occurrence of a multiorgan failure. The patient and her relatives then asked a voluntary hospital discharge. Occurrence of GI metastases from breast carcinoma is a rare but possible event, even reported 30 years after mastectomy [2], and among the histotypes of breast cancer, the lobular carcinoma is the most frequently involved in metastasis to unusual sites, including the GI tract, peritoneum, and genital organs. The literature reports nine cases of colorectal breast cancer metastasis: In five patients, it was localized in the rectum and, in the others, like in our case, in the ascending colon. There is no consensus on the management of breast cancer metastasis to the GI tract since surgery in such patients must always be considered as non-curative. In fact, in most of the colon-rectal involvement from breast cancer, the disease was already disseminated. Early diagnosis and differentiation between a primary GI lesion and metastatic breast cancer is sometimes difficult, and although the anamnesis of previous operation for breast cancer and clinical appearance of the colonic involvement could suggest the metastatic origin of this cancer, immunohistochemistry is the only tool for a correct diagnosis. Clinical decision-making, however, should take into consideration the advanced stage of the primary disease which makes an aggressive surgery a useless hazard without
Int J Colorectal Dis (2015) 30:427–428
significant extension of patient survival [3]. In the case described here, for example, surgery could have been limited to a palliative ileocolonic bypass to prevent intestinal occlusion associated with systemic chemotherapy. The true incidence of GI metastases from breast cancer is probably underestimated due to the scarcity of symptoms and the frequent metastatic dissemination in other organs, leading to a rapid deterioration of the health status and death from cachexia. In fact, colonic metastasis detected at the autopsy is reported in 8–15 % of patients dying from disseminated breast cancer [4]. In conclusion, such a rare condition must be taken into consideration in the oncologic follow-up of patients operated from breast cancer, particularly those with the lobular (or mixed lobular) type carcinoma, even after a long disease-free period. Clinical decision-making should be tailored according to the dissemination of the metastatic disease and the risk of intestinal occlusion or bleeding.
References 1. Ambroggi M, Stroppa EM, Mordenti P, Biasini C, Zangrandi A, Michieletti E, Belloni E, Cavanna L (2012) Metastatic breast cancer to the gastrointestinal tract: report of five cases and review of the literature. Int J Breast Cancer 2012:439023. doi:10.1155/2012/439023 2. Benfiguig A, Anciaux ML, Eugene C, Benkémoun G, Etienne JC (1992) Gastric metastasis of breast cancer occurring after a cancer-free interval of 30 years. Ann Gastroentetol Hepatol 28:175–177, PMID: 1444182 3. McLemore EC, Pockaj BA, Reynolds C, Gray RJ, Hernandez JL, Grant CS, Donohue JH (2005) Breast cancer: presentation and intervention in women with gastrointestinal metastasis and carcinomatosis. Ann Surg Oncol 12:886–894, PMID:16177864 4. Cifuentes N, Pickren JW (1979) Metastases from carcinoma of mammary gland: an autopsy study. J Surg Oncol 11:193–205, PMID: 459515
