Gynecology & Obstetrics
Open Access

Invasive Ductal Carcinoma of the Breast Presenting as Small Bowel Obstruction and Ruptured Appendix: A Rare Case Report and Review

Leela S Pillarisetty^*, Subhash Nagalla, Meridyth Buschardt and Sumanth Kumar Bandaru ^*Correspondence: Leela S Pillarisetty, Department of Health Sciences, Texas Tech University, Permian Basin, Texas, United States, Tel: 432 934-6918, Email:

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Introduction

Breast Cancer is the most common cancer among women across the world and is also the leading cause of death from cancer in women [1]. In the United States, breast cancer is the most commonly diagnosed cancer in women and is the second leading cause of death from cancer in women.

Breast cancer diagnosis and treatment is a multidisciplinary approach and involves breast surgeon, medical oncologist, radiation oncologist, social worker, psychiatrist, and it has been proven to be active and reduces mortality and morbidity. Early diagnosis from appropriate and timely workup results in better patient outcomes and reduces morbidity and mortality [2].

Breast cancer is usually suspected in a patient with palpable breast mass with lymphadenopathy and is confirmed by biopsy. Immunohistochemical stains are used to identify the type of breast cancer, and to select appropriate treatment and determine prognosis [3]. Imaging studies like CT scan of the chest, Bone scan and ultrasound of the abdomen may be used to evaluate for metastatic disease.

The usual sites of breast cancer metastasis are lungs, chest wall and liver, very rarely breast cancer metastasizes to the gastrointestinal tract [4]. In this case report, we are presenting a patient with Breast cancer metastasizing to the appendix with perforation and causing small bowel obstruction.

With the advent of novel diagnostic techniques, breast cancer presenting as an acutely ruptured appendix is very rare [5]. Invasive lobular carcinomas more commonly metastasize to the GI tract whereas invasive Ductal carcinoma frequently metastasizes to lungs, bone, and liver [4]. The common pathogenesis for this presentation is that the breast cancer metastasizes to the appendix where it tends to obstruct the lumen causing rupture [6].

Case Report

We present here a case of a 52-year-old female patient who was diagnosed with breast cancer metastasizing to the appendix. Her course was complicated by perforation and small bowel obstruction. Initially, she presented to the emergency department with a three-day history of abdominal pain, nausea, vomiting, and fever. Physical exam revealed diffuse abdominal tenderness without rebound tenderness or guarding. Labs showed leukocytosis. CT scan revealed possible partial or early completes small bowel obstruction, secondary to inflammation. A 1.8 × 1.3 cm irregular soft-tissue attenuation nodule of the inferior right breast was also identified Figures 1-4. Biopsy of the breast lesion offered; however, the patient declined. She decided to wait to follow up until after her GI condition is stabilized.

Figure 1: CT Abdomen and Pelvis (series 2 image 47) Revealed thickening of the distal portion of the small bowel, as well as, stranding. Suggestive of inflammatory/infectious colitis.

Figure 2: CT Abdomen and Pelvis (series 2 image 36) showed dilation of the small bowel (mid and proximal), likely from early complete/ partial SBO. “String of Pearls” sign noted in the jejunum indicating increased fluid content in the bowel.

Figure 3: CT Abdomen and Pelvis w/o Contrast showing an irregular nodule of the inferior aspect of right breast, measuring 1.8 × 1.3 cm (series 2, image 7). Differential scarring vs. carcinoma.

Figure 4: CT Abdomen and Pelvis w/o Contrast (Series 2, image 11), showing bilateral breast implants, suspect lesion lay just distal on the right side.

A provisional diagnosis of small bowel obstruction secondary to inflammatory or infectious enteritis with luminal narrowing was made. Conservative management was initially pursued, with an expected resolution of the obstruction with time. Intravenous fluids and antibiotics were started. She was made NPO, and a nasogastric tube was placed. Initial improvement of her leukocytosis and abdominal pain was seen; however, within 24 hours she began to experience worsening abdominal pain, nausea, and vomiting. She underwent emergent laparotomy, which revealed significant inflammation of the distal small bowel loops and an intra-abdominal abscess, sealed off by small bowel loops.

A thorough surgical examination revealed a tumor at the base of the appendix, with associated ischemia and rupture at the tip of the appendix. The appendiceal rupture was determined to be the source of the abscess. The abscess was drained and appendectomy, including a thin rim of the caecum, was performed. A nodule was also found in the iliac mesentery. The appendix specimen and iliac mesenteric nodule were both sent for frozen section.

The preliminary pathology report showed a carcinoid tumor of the appendix, with positive margins. The ileal mesenteric node was also positive for carcinoid tumor. The patient underwent right hemicolectomy and extended small terminal resection. Her postoperative course was uneventful, and she recovered without complications. An oncologist saw the patient in the postoperative period and was discharged to be followed up by the oncologist in the outpatient clinic.

The final pathology report described the appendix and mesenteric nodule specimen as Metastatic ductal carcinoma of the breast, which stained strongly positive for estrogen, progesterone receptors, GATA-3, GCDFP-15 and E-Cadherin (Figure 5A-5H). Four serosal lymph nodes from the right hemicolectomy specimen were also positive for cancer (Figure 5G).

Figure 5: (A): Tumor in appendiceal serosa and wall; (B): Gata stain positive; (C): E-Cadherin stain positive and; (D): Estrogen receptorpositive. (E): Tumor infiltrating appendiceal mucosa; (F): Progesterone receptor positive; (G): lymph node metastasis and; (H): Garza S 100 stain negative.

Discussion

Metastatic tumors to the appendix are usually rare. Over 23 years reviewing about 8699 appendectomy specimens only about 15 cases of secondary appendiceal tumors were identified [7]. Breast cancer presenting as a ruptured appendix has a poor prognosis and the median survival after a diagnosis of secondary appendiceal tumors was 22.6 months [8,9]. Some studies have also recommended prophylactic appendectomy along with salpingo-oophorectomy in patients with BRCA mutations [10]. Invasive lobular carcinomas more commonly metastasize to the GI tract whereas invasive Ductal carcinoma frequently metastasizes to lungs, bone, and liver [4].

Estrogen receptor (ER) positive tumors usually metastasize to bones whereas ER-negative tumors metastasize to viscera [11]. The main aim of metastatic breast cancer is to improve the quality of life. Systemic chemotherapy with endocrine and biologic therapies is the mainstay of treatment.

The selection of treatment depends on hormone status and HER-2 expression. Estrogen and progesterone receptor(ER, PR) positive tumors are treated with endocrine therapy, HER2 positive tumors are treated with trastuzumab, and Chemotherapy is used in Hormone Receptor (HR) negative disease [12]. Endocrine therapy mainly targets to reduce the effect of estrogen on the tumor either by depleting estrogen or by acting on the estrogen receptors. Aromatase inhibitors such as anastrozole and letrozole decrease the production of estrogen. Selective Estrogen Receptor Modulators (SERM) such as Tamoxifen has opposing effects on breast tissue and has an agonistic effect on bone and endometrial tissue [13]. Fulvestrant, a Selective Estrogen Receptor Down regulator (SERD) downregulates the estrogen receptors, and recent studies have shown it to have superior efficacy over 3rd generation aromatase inhibitors in the Hormone receptor-positive metastatic breast cancer [14]. CDK 4/6 inhibitors such as palbociclib, ribociclib have shown efficacy and synergy when used with endocrine therapy in ER-positive metastatic breast cancers[15].

The first line of treatment in a postmenopausal patient with De novo metastatic breast cancer is a combination of CDK 4/6 Inhibitor and an aromatase inhibitor [13]. Palbociclib in combination with letrozole has shown longer progression-free survival and objective response rates when compared with letrozole alone [13,16]. Other combinations such as ribociclib plus letrozole and abemaciclib with letrozole have also shown better efficacy than monotherapy [17,18]. The most common reported adverse effects included Neutropenia, leukopenia, fatigue and Nausea [16-18].

Alternative regimens include fulvestrant alone or in combination with CDK 4/6 Inhibitor and monotherapy with aromatase inhibitors [13,15]. Visceral metastasis of Breast cancer carries a poor prognosis with a median survival of fewer than 22 months while Non-Visceral metastasis has a median survival of more than 33 months. Survival is shown to be better in patients with HR-positive tumors when compared to HR-negative tumors. Younger Age at initial diagnosis has a worse prognosis because of aggressive disease [19]. Post Menopause, Lymphovascular invasion is poor independent prognostic factors [20].

Conclusion

Invasive Ductal carcinomas of the breast very rarely metastasize to the GI tract, Invasive lobular carcinomas more commonly metastasize to the GI tract whereas invasive Ductal carcinoma metastasizes to lungs and liver. Over a period of 23 years reviewing about 8699 appendectomy specimens only about 15 cases of secondary appendiceal tumors were identified.

Young age at diagnosis of Breast cancer with visceral metastasis and lymphovascular invasion carries a very poor prognosis. Breast cancer diagnosis and treatment is a multidisciplinary approach and involves breast surgeon, medical oncologist, radiation oncologist, social worker, and a psychiatrist, and it has been proven to be effective and reduces mortality and morbidity. The first line of treatment in a postmenopausal patient with De novo metastatic breast cancer is a combination of CDK 4/6 Inhibitor and an aromatase inhibitor.

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