|Year : 2015 | Volume
| Issue : 3 | Page : 660
Gastric metastases from breast cancer: A report of two cases and review of literature
KS Rachan Shetty1, Vasu Reddy Challa2, KC Lakshmaiah1, G Champaka3, K Govind Babu1
1 Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
2 Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
3 Department of Pathology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka, India
|Date of Web Publication||9-Oct-2015|
Vasu Reddy Challa
Department of Surgical Oncology, Kidwai Memorial Institute of Oncology, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
Though breast cancer is a common cancer it rarely metastasizes to stomach. Lobular carcinoma is the most common histological type which presents with gastric metastases. The most common presentation is linitis plastica. Here, we would like to report two cases of invasive ductal breast cancer who presented with gastric metastases. One case presented as linitis plastica and the other as nodular growth. Both were given palliative chemotherapy and both responded partially. One patient was succumbed to death in 6 months and the other patient is surviving 7 months after diagnosis of gastric metastases. In conclusion, gastric metastases from breast cancer are rare and are associated with poor prognosis. We would like to add these cases to the literature due to its rarity.
Keywords: Breast cancer, gastric metastases, invasive ductal cancer, stomach metastases
|How to cite this article:|
Rachan Shetty K S, Challa VR, Lakshmaiah K C, Champaka G, Babu K G. Gastric metastases from breast cancer: A report of two cases and review of literature. J Can Res Ther 2015;11:660
|How to cite this URL:|
Rachan Shetty K S, Challa VR, Lakshmaiah K C, Champaka G, Babu K G. Gastric metastases from breast cancer: A report of two cases and review of literature. J Can Res Ther [serial online] 2015 [cited 2019 Nov 17];11:660. Available from: http://www.cancerjournal.net/text.asp?2015/11/3/660/139523
| > Introduction|| |
Breast cancer is one of the most common cancers in women in world. It commonly metastasizes to lung, liver, bone and brain. Invasive ductal carcinoma is the most common histological type followed by lobular carcinoma which accounts for 10-14% of cases. , Nearly, 50% of patients with breast cancer develop metastases in their life time. , Gastrointestinal metastases of breast cancer are rare and autopsy series had an incidence of 8-35% of gastrointestinal metastases. , They may be asymptomatic or present with nausea, vomiting and abdominal pain. These symptoms may be attributed to treatment, peritoneal carcinomatosis or coincidental gastrointestinal diseases leading to underdiagnosis of this condition.
As gastric metastases form breast cancer is rare, only case reports or case series were reported. Most common histological type is lobular carcinoma. Here we would like to report two cases of invasive ductal carcinoma who presented with gastric metastases.
| > Case reports|| |
The present case report is about a 56-year-old female patient who underwent breast conservation therapy in 2009 for invasive ductal carcinoma pT2N2M0 stage. The histopathological examination revealed invasive ductal carcinoma grade III, estrogen receptor (ER) positive, progesterone receptor (PR) negative and Her 2 positive. She was treated with adjuvant therapy with docetaxel, adriamycin and cyclophosphamide for 6 cycles followed by trastuzumab 3 weekly for 1 year. She was later continued with anastrazole. In July 2011, she developed multiple skeletal and supraclavicular lymph node metastases. She was later treated with 13 cycles of Trastuzumab, exemestane and zoledronic acid. She developed cardiac dysfunction and hence Trastuzumab was discontinued and was continued with exemestane alone. In January 2013, she presented with epigastric discomfort and non-bilious vomiting. She underwent upper gastrointestinal endoscopy (UGIE), which showed diffuse nodular lesions involving whole of the stomach with decreased distensability. A biopsy was taken which showed infiltration of lamina propria and mucosa diffusely with small round cells as sheets and single neoplastic cells with surrounding normal glands. Immunohistochemistry (IHC) showed the tumor to be positive for gross cystic disease fluid protein (GCDFP-15), mammaglobin and human epidermal growth factor receptor 2/neu. A contrast enhanced computer tomography (CECT) scan showed diffuse thickening of gastric wall from esophagogastric junction until the pylorus with sclerotic lesion in left iliac bone [Figure 1]a. The right breast showed seroma which did not show an increased fluoro-deoxyglucose (FDG) uptake, whereas there was an increased FDG uptake of the stomach lesion [Figure 1]c and d. She was started with paclitaxel and anastrazole. She is doing well after 3 cycles of chemotherapy with partial response and she improved clinically.
|Figure 1: (a-d) A contrast enhanced computer tomography scan showing diffuse thickening with linitis plastic appearance (a) and nodular growth (b) Smooth walled swelling with no enhancement in right breast suggestive of seroma (c) A fluoro-deoxyglucose positron emission tomography scan showing an uptake in the stomach (arrow) (d)|
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This was another case report of a 61-year-old female patient who diagnosed with invasive ductal carcinoma in March 2010, underwent modified radical mastectomy of left breast. Histopathologcial examination revealed a pT3N1 disease and triple negative breast cancer. Patient was administered 5-fluorouracil, epirubicin and cyclophosphamide regimen and adjuvant radiotherapy. In august 2012, she presented with abdominal pain, melena and abdominal distension. A CECT scan showed a nodular growth with gastric wall thickening involving the body of the stomach [Figure 1]b. An UGIE showed a nodular growth involving the body and pylorus of stomach. Biopsy was taken which showed neoplastic cells infiltrating the stomach wall with normal mucosal glands in between [Figure 2]a-c. IHC showed the specimen to be positive for GCDFP-15 [Figure 2]d. Patient was considered for palliative chemotherapy with paclitaxel, but was succumbed to death after 6 months.
|Figure 2: (a-d) Gastric mucosa and lamina propria infiltrated by invasive breast cancer with small discohesive tumor cells located between normal gastric glands (a-c); Immunohistochemical staining showing sheets of cells and single neoplastic cells with surrounding normal glands positive for gross cystic disease fluid protein-15|
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| > Discussion|| |
Breast cancer rarely metastasizes to gastrointestinal tract (GIT). In an autopsy series of 1010 cancer patients, the incidence of gastric metastases was 1.7% with melanoma as the most common malignancy followed by breast cancer to cause gastric metastases.  Autopsy series of breast cancer patients alone showed the incidence of gastric metastases in 2-18% of cases.  In another report by Taal et al., the morbidity of breast cancer metastases to stomach was 0.3%.  In the GIT, stomach is the most common site of metastases (60%) from breast cancer followed by esophagus (12%), colon (11%) and rectum (7%).  Lobular carcinoma spreads more commonly to GIT rather than ductal carcinoma. The incidence of invasive lobular carcinoma is around 15% and it has increased propensity to spread to GIT, gynecologic organs, peritoneal surface and retroperitoneum.  The exact reason is not known, but may be due to tissue tropism of lobular cells to the GIT.
Gastric metastases can present as linitis plastica, obstruction, nodule, ulcer, pain, bleeding and dyspepsia.  The most common presentation is the linitis plastic appearance due to diffuse infiltration of the gastric wall by the neoplastic cells leading to narrowed gastric lumen and decreased distensability of stomach as in our case. It can be characteristically diagnosed by CECT scan or barium meal. The definitive diagnosis requires histopathological examination with IHC. Metastatic lobular carcinoma appears similar to diffuse gastric cancer with small round cells arranged as linear cords between the normal appearing glands. It can be differentiated from intestinal type of gastric cancer as it forms glands and occurs in a patient with intestinal metaplasia and e-cadherin overexpression. However it is difficult to differentiate from diffuse signet ring cell adenocarcinoma and other conditions such as lymphoma, macrophages and xanthomas, which need to be ruled out by performing keratins study before deriving a conclusion.  It is difficult at times to differentiate metastatic lobular carcinoma from signet ring cell carcinoma and may require IHC to differentiate lobular carcinoma from gastric cancer.
Various IHC markers were used to diagnose breast cancer from gastric cancer such as ER-alpha, PR, GCDFP-15, cytokeratins 7, cytokeratins 20 and mammaglobin.  Her 2 positivity is detected in 5% of patients with ILC and 20% of patients with gastric cancer.  The treatment for gastric metastases is mainly hormonal or chemotherapy. Surgery is considered for palliation in presence of obstruction, severe bleeding or perforation. The overall 2 year survival rate varied from 25% to 53% respectively. 
| > Conclusion|| |
Gastric metastases from breast cancer are rare and patient needs to be worked-up in presence of gastrointestinal symptoms though they present many years after the primary therapy. They may need endoscopy with biopsy, CECT scan and IHC to diagnose and initiate an appropriate treatment. Metastatic breast carcinoma may need additional investigations like IHC to differentiate it from signet ring cell carcinoma.
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[Figure 1], [Figure 2]