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Strana 806 VOJNOSANITETSKI PREGLED Vojnosanit Pregl 2012; 69(9): 806–808.

UDC: 616.349-02::618.19-006-033.2
CASE REPORT
DOI: 10.2298/VSP1209806N

Uncommon metastatic site from breast cancer


Retko mesto metastaze karcinoma dojke

Ivan Nikoliü*, Tatjana Ivkoviü-Kapicl†, Biljana Kukiü*, Bogdan Bogdanoviü*,


Tomislav Petroviü‡, Igor Djan§,ŒDragana Smiljeniü

*Clinic for Internal Medicine,†Hystopathology Department, ‡Clinic for Surgical


Oncology, §Radiotherapy Department, Oncology Institute of Vojvodina, Sremska
Kamenica, Serbia, ŒFaculty of Medicine, University of Novi Sad, Novi Sad, Serbia

Abstract Apstrakt

Introduction. Breast cancer is one of the most common Uvod. Karcinom dojke jedan je od najÿešýih karcinoma kod
malignancies in women and the main leading cause of can- žena i vodeýi uzrok smrti od malignih bolesti. Karcinom dojke
cer death. The most frequent sites of metastases from breast najÿešýe metastazira u kosti, pluýa, centralni nervni sistem i jet-
cancer are bones, lungs, the central nervous system, the liver ru. Metastaze u debelo crevo su jako retke. Prikaz bolesnika.
and soft tissue. Colonic metastases from breast cancer are Prikazali smo bolesnicu, staru 70 godina, sa dijagnozom ops-
rare. Case report. We presented a 70-year-old woman with truktivne infiltracije sigmoidnog dela kolona. Lekar koji je pre-
bulky obstructing lesion of sigmoid colon. A physician in gledao bolesnicu dobio je podatak da je bolesnica operisala
charge on our department examined the patient and past karcinom dojke. Bolesnica je operisana, uraĀena je resekcija
history of breast cancer was found up. Surgery was per- sigmoidnog dela kolona, i od pregledanih šest limfnih ÿvorova
formed with removal of sigmoid colon and three of six u tri su se nalazila žarišta metastaza. Patološkohistološkim pre-
lymph nodes were positive. Pathological examination, in- gledom, ukljuÿujuýi imunohistohemijsku analizu, potvrĀena je
cluding immunohistochemical stains, confirmed the diagno- dijagnoza metastatskog karcinoma dojke u sigmoidni kolon.
sis of metastatic breast cancer to sigmoid colon. The multi- Multidisciplinarni onkološki tim predložio je postoperativnu
disciplinary oncology team suggested postoperative che- hemioterapiju. Bolesnica je primila ÿetiri ciklusa hemioterapije
motherapy. The patient received four cycles of chemother- sa paklitakselom i nakon toga nastavila terapiju anastrazolom.
apy with paclitaxel followed by anastrozole. On the first Na prvom kontrolnom pregledu nisu viĀeni znaci aktivnosti
control visit no disease activity was detected. Conclusion. maligne bolesti. Zakljuÿak. Kod bolesnica sa ranije postavlje-
In patients with the past history of breast cancer the symp- nom dijagnozom karcinoma dojke, sa simptomatologijom krvi
toms of hematochezia or anemia may indicate colonic me- u stolici ili prisutnom malokrvnošýu treba misliti i na moguý-
tastases. nost pojave metastaza karcinoma dojke u debelo crevo.

Key words: Kljuÿne reÿi:


breast neoplasms; neoplasm metastasis; colonic dojka, neoplazme; neoplazme, metastaze; kolon,
neoplasms; diagnosis, differential. neoplazme; dijagnoza, diferencijalna.

Introduction Colonic metastases from breast cancer are rare and their
nonspecific clinical presentation may be easily mistaken as a
Breast cancer is one of the most common malignancies second primary colonic carcinoma; it may impair the clinical
in women and the main cause of cancer-related deaths 1. diagnosis and delay the treatment resulting in earlier mortal-
When breast cancer is diagnosed at an early stage, the sur- ity 4, 5.
vival rate is higher; however, recurrences and metastases are
quite common. Breast cancer usually metastasizes to the Case report
lymph nodes, lung, bone, liver, and brain. There are few re-
ports of breast cancer metastasizing in the gastrointestinal At the beginning of 2010, a 70-year-old woman visited
tract (stomach and small intestine) while colonic metastases our Institute complaining of hematochezia. The results of
are extremely rare 2, 3. Other unusual locations of breast can- blood count test and complete check-up were normal and the
cer metastases may include eyes, urinary bladder, and skin. result of rectal examination was negative. The findings of

Correspondence to: Ivan Nikoliý, Institute of Oncology of Vojvodina, Institutski put 4, 21204 Sremska Kamenica, Serbia.
Phone: +381 21 4805 569, +381 64 1849860. E-mail: nikolic.ivan@onk.ns.ac.rs
Volumen 69, Broj 9 VOJNOSANITETSKI PREGLED Strana 807

colonoscopy examination showed circumferential bulky ob- chemotherapy. The patient received four cycles of chemo-
structing lesion in sigmoid colon. It was not possible for co- therapy with paclitaxel, followed by anastrozole. The first
lonoscope to pass through the stenosis. Analysis of the bi- control visit showed no disease progression.
opsy material confirmed the presence of adenocarcinoma of The patients past medical history was marked by breast
the colon (HG3, NG3) (Figure 1). The patient underwent exulcerated cancer in her left breast without palpable axillar
lymph nodes in 2007. Using core biopsy the following diag-
nosis was established: ductal invasive carcinoma HG 2 with
the invasion of capillaries, lymph ducts, and perineural area.
At that time, the patient was treated with four cycles of
neoadjuvant chemotherapy (5-fluorouracil, adriamycin, cy-
clophosphamide), which resulted in partial clinical response.
Chemotherapy was followed by left mastectomy and ipsilat-
eral axillary lymph node dissection and the excision of infil-
trated region of pectoralis major on June 9, 2008. Histo-
pathological examination of surgical specimen confirmed the
Fig. 1 – Endoscopic biopsy: metastatic adenocarcinoma in
presence of grade II invasive ductal carcinoma (4 cm × 3 cm)
the specimen of the large intestine mucus (HE, ×40) with skin invasion and 10 lymph nodes without metastases
(G2, pT4N0) and the infiltration of muscle and perineural
area. Immunohistochemistry tests for estrogen and proges-
surgery and resection of sigmoid colon with end-to-end an- terone receptors showed positive staining for both receptors
astomosis. The results of pathological examination including (Figure 4). There was no evidence of distant metastases at
immunohistochemical staining, confirmed the diagnosis of the time of surgery. Multidisciplinary oncology team consid-
metastatic breast cancer to sigmoid colon (CK20-, CK7-, ered the patient to be at high risk for disease recurrence and
CK8+, CK18+, ER+, PR+). Six lymph nodes were identified suggested further treatment with radiotherapy (TD 50 Gy in
and three of them were metastatic. These findings were 25 fractions) and adjuvant chemotherapy (cisplatin, cyclo-
similar to those of the prior breast cancer specimen (Figures phosphamide, methotrexate, and 5-fluorouracil) for six
2 and 3). Cancer cells invaded the whole intestinal wall from months, which was followed with tamoxifen therapy until
the beginning of 2010.

Fig. 2 – Breast cancer metastasis in large intestine wall;


atypical tumor cells abundant in eosonophil cytoplasm and Fig. 4 – Primary breast cancer (HE, ×40)
pleomorphic nuclei arrange in trabecular cluster (HE, ×40)

Discussion

Metastatic involvement of the large bowel is rare. The


incidence of metastatic breast cancer involving the colon is
unknown, but an autopsy series reported the frequency of
colonic involvement of metastatic breast cancer to be 8%,
not including serosal implants 6. The disease-free interval
between primary breast cancer and gastrointestinal involve-
ment varies from synchronous presentation up to 30 years,
the median interval between diagnosis and presentation of
metastases is six to eight years 2. The symptoms may vary
Fig. 3 – Immunophenotype of metastatic colonic cancer; estrogen from asymptomatic abdominal masses to those mimicking
receptor+ (immunohistochemical analysis, B-SA ×200) ulcerative colitis 7. Anorexia, hematochezia, and positive fe-
cal occult blood testing are common presenting symptoms 4.
mucosa to the serosa and surrounding fat tissue and infil- These non-specific findings often mimic other gastrointesti-
trated into the posterior wall of the urinary bladder. The nal diseases such as colorectal cancer, inflammatory bowel
multidisciplinary oncology team suggested postoperative disease, ischemic colitis and, diverticulitis.

Nikoliý I, et al. Vojnosanit Pregl 2012; 69(9): 806–808.


Strana 808 VOJNOSANITETSKI PREGLED Volumen 69, Broj 9

Differentiating primary colon cancer from metastatic frequently to the gastrointestinal tract, peritoneum, and ret-
breast cancer to the colon may be challenging. In patients with roperitoneum than the IDC 13. Metastatic disease involving
prior histories of breast cancer, second primaries of the gastro- the colon may be viewed as a systemic visceral disease,
intestinal tract are more common than metastatic disease 8. Im- which should be treated with chemotherapy. Pathological
munohistochemistry has aided in differentiating the tumor site analysis and repetition of endoscopy are necessary for the
of origin. Hormone receptors, such as estrogen and progester- early and accurate diagnosis 14.
one ones, are utilized to differentiate breast versus gastrointes-
tinal primary cancer 9, but these receptors may be positive in Conclusion
20% to 28% of primary gastric carcinomas 10. The more com-
mon antigen markers include cytokeratins (CK) 7 and 20 11, 12. Radiologists and endoscopists should pay a special at-
In the presented case, the histological subtype of meta- tention to patients with the history of lobular breast cancer
static breast cancer was invasive ductal carcinoma (IDC). In- and newly identified GI malignancies that may, among other
filtrating lobular carcinoma was found to metastasize more diseases, be the metastases from breast cancer.

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Nikoliý I, et al. Vojnosanit Pregl 2012; 69(9): 806–808.