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Can Metastatic Breast Cancer Spread to the Colon ?
Journal of Cancer Science and Research

Journal of Cancer Science and Research
Open Access

ISSN: 2576-1447

+44 1478 350008

Case Report - (2018) Volume 0, Issue 0

Can Metastatic Breast Cancer Spread to the Colon ?

Muhammad Tahir1*, Atif Sohail2 and Amanpal Singh3
1Internal Medicine, University at Buffalo, New York, USA
2Internal Medicine, University of Health Sciences, Pakistan
3Gastroenterology, Roswell Park Cancer Institute Buffalo, New York, USA
*Corresponding Author: Muhammad Tahir, Internal medicine, University at Buffalo, New York, USA, Tel: 6467645945 Email:

Keywords: Colonic metastasis; Computed Tomography ; immunohistochemistry; palbocilib

Introduction

Breast cancer is the most commonly diagnosed cancer in females and it is very unusual for breast carcinoma to metastasis to the colon. Few cases have been reported in the literature. Here we present a case in which patient presented with colonic metastatic lesion four years after bilateral mastectomies for invasive lobular carcinomas. We will also discuss why sometimes, colonic metastasis of breast cancer is a challenging situation for physicians.

Case Report

A 51 years old, premenopausal female had bilateral mastectomies for invasive lobular carcinomas in April 2013. Both tumors were ER/PR positive HER-2 negative. Extensive work up at that time including CT scan and bone scan did not show any metastasis except for bilateral lymph nodes involvement. She was BRCA 1 and BRCA 2 negative. After receiving radiation therapy, she completed adjuvant chemotherapy with doxorubicin, cyclophosphamide, paclitaxel and she was started on tamoxifen. Four years later, patient presented with intermittent and gradually progressive abdominal pain with relative constipation and was admitted in the hospital for further workup. Her tumor markers continued to rise slowly. Her Carcinoembryonic Antigen level was 16.7(Ref Range: 0-5 mg/ml) and Cancer Antigen 15-3 level was 384.1 (Ref Range: 0-31.3 U/ml). Computed Tomography (CT) scan of the abdomen was done which showed thickening in ascending colon that was absent in previous imaging studies. PET scan showed increased uptake of FDG in right ascending colon. The patient received weekly paclitaxel therapy. Colonoscopy (Figure 1) showed a large partially circumferential mass in ascending colon 5 cm distal to cecum. Histology (Figure 2a and 2b) and immunohistochemistry of the biopsy were consistent with ER positive, PR negative and HER-2 negative lobular breast carcinoma for which she was managed conservatively.

cancer-science-and-research-proximal-ascending

Figure 1: A partially circumferential mass at proximal ascending colon around 4-5 cm distal to the cecum.

cancer-science-and-research-breast-invading

Figure 2a: H and E stained slide at 400X demonstrating sheets, single file and single malignant cells from metastatic lobular carcinoma of the breast invading around benign colorectal glands.

cancer-science-and-research-breast-ducts

Figure 2b: H and E stained slides at 400X and demonstrates single file and single malignant cells from lobular carcinoma of the breast invading around benign breast ducts.

During further follow up screening, she was found to have new metastatic bone lesions in spine. Biopsy confirmed bone lesions as ER positive, PR negative and HER-2 negative breast cancer metastasis. Tamoxifen was discontinued and she was treated with letrozole, palbocilib and monthly denosumab. She developed pancytopenia so letrozole and palbocilib were stopped. In April 2014, her re-staging scans showed many new and progressing old bone lesions. Patient was managed conservatively.

Discussion

Breast cancer is the most common cancer and one of the leading causes of death in women [1]. It most commonly metastasizes to lymph nodes, bones, lungs and brain but It is rare for breast cancer to cause extra-hepatic GI metastases[2]. In 1993, Borst et al. analyzed 2605 breast cancer patients over a period of 18 years and reported only 17 had GI metastasis [3] and also reported that the frequency of the lobular breast carcinoma to metastasize to GI tract was very small in amount i.e. 4% [3]. It is because lobular carcinoma shows distinct histological and biological features, such as inactivation of E-Cadherin [4] that leads to lack of cohesiveness between cells and typically has slow growing behavior due to HER2-negativity [5]. The clinical presentation of colonic metastases is very nonspecific and ranges from abdominal pain, intestinal obstruction to rarely as inflammatory diarrhea [6,7].

GI metastasis of breast carcinoma is a challenging situation for the physician. First, almost all the metastatic colonic lesions present like primary GI tumors on radiography and endoscopy. They can present as poorly differentiated, lintis plastica type GI lesion and can be misdiagnosed as primary GI carcinoma [8]. Calafat et al. and Easter et al reported metastasis of lobular breast carcinoma that presented as Crohn’s disease [7,9]. The most common mode of spread is diffuse infiltration of colon[2] but it can also present as a colonic polyp [10]. In our patient a circumferential mass was found in ascending colon, on colonoscopy. The standard method of analysis is immunohistochemistry. Metastatic breast cancers are positive for CK7, ER, PR, GCDFP-15 and Cytikine20 negative but the GI carcinomas are almost always positive for Cytokine20 [11]. Staining for p53 and Erb2/NEU are usually negative in primary colon carcinomas.

The other problem is the unusual long and unpredictable time interval between primary breast carcinoma and GI metastases [12]. The median interval between breast cancer and GI metastases is 6 or 7 years [8]. In many patients the history of primary breast cancer is known but Harsløf et al. reported a case of colon metastasis compatible with lobular carcinoma of the breast although the primary breast cancer was never identified [13]. GI metastases can even be the initial presentation of the breast carcinoma [14].

The interesting thing about our patient was that no metastases were found beyond axillary lymph nodes, when she underwent bilateral mastectomies for ER/PR positive and HER-2 negative invasive lobular carcinoma. The colonic mass presented four years after that and on immunohistochemistry it turned out to be metastases from lobular breast cancer and was ER positive and PR negative.

Treatment depends on clinical presentation and extent of the disease. Early chemotherapy and/or hormonal therapy improves prognosis vs. surgical treatment. Surgical resection should be reserved for palliation of intestinal obstruction or bleeding. Abdominal obstruction due to stenosis should be corrected with surgery [12]. The median survival after diagnosis of GI metastasis is 1 year [2].

References

  1. Bamias A, Baltayiannis G, Kamina S, Fatouros M, Lymperopoulos E, et al. (2001) Rectal metastases from lobular carcinoma of the breast: report of a case and literature review. Annals of oncology12: 715-718.
  2. Taal BG, den Hartog Jager FC, Steinmetz R, Peterse H (1992) The spectrum of gastrointestinal metastases of breast carcinoma: II. The colon and rectum. Gastrointestinal endoscopy 38:136-141.
  3. Borst MJ, Ingold JA (1993) Metastatic patterns of invasive lobular versus invasive ductal carcinoma of the breast. Surgery 114:637-641.
  4. Winston CB, Hadar O, Teitcher JB, Caravelli JF, Sklarin NT, et al. (2000) Metastatic lobular carcinoma of the breast: patterns of spread in the chest, abdomen, and pelvis on CT. American journal of roentgenology 175:795-800.
  5. Venanzi FM, Soverchia L, Felicetti P, Mennecozzi M, Concetti A (2002) HER-2/neu oncogene sequence revisited. Journal of the National Cancer Institute 94:1808-1809.
  6. Gifaldi AS, Petros JG, Wolfe GR (1992) Metastatic breast carcinoma presenting as persistent diarrhea. Journal of surgical oncology 51:211-215.
  7. Easter DW, Jamshidipour R, McQuaid K (1995) Laparoscopy to correctly diagnose and stage metastatic breast cancer mimicking Crohn's disease. Surgical endoscopy 9:820-823.
  8. Matsuda I, Matsubara N, Aoyama N, Hamanaka M, Yamagishi D, et al. (2012) Metastatic lobular carcinoma of the breast masquerading as a primary rectal cancer. World journal of surgical oncology 10:231.
  9. Calafat P, de Diller AB, Sanchez C (1999) Breast carcinoma metastasis in ileum-colon and gallbladder simulating inflammatory diseases. Revista de la Facultad de Ciencias Medicas 56:123-127.
  10. Villa Guzman JC, Espinosa J, Cervera R, Delgado M, Paton R, et al. (2017) Gastric and colon metastasis from breast cancer: case report, review of the literature, and possible underlying mechanisms. Breast cancer 9:1-7.
  11. Kim HW, Moon DH (2015) Sigmoid colon metastasis from metaplastic breast carcinoma mimicking primary sigmoid colon cancer. Revista espanola de medicina nuclear e imagen molecular 34:211-212.
  12. Amin AA, Reddy A, Jha M, Prasad K (2011) Rectal metastasis from breast cancer: an interval of 17 years. BMJ case reports 2011.
  13. Harslof SS, Andersen LM, Hoyer U, Christiansen JJ (2010) Breast cancer metastasis to the colon. Ugeskrift for laeger 172:2309-2310.
  14. Calo PG, Fanni D, Ionta MT, Medas F, Faa G, et al. (2012) Jejunal obstruction caused by metastasis from an undiagnosed breast cancer: a case report. Tumori98:89e-91e.
Citation: Tahir M, Sohail A, Singh S (2017) Can Metastatic Breast Cancer Spread to the Colon?. J Can Sci Res 3: 14.

Copyright: © 2017 Tahir M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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