Small bowel obstruction as first presentation of metastatic lobular breast cancer for pilgrim patient

Abstract

Introduction and importance

The most common cancer among females worldwide and in Saudi Arabia is breast cancer. Lobular breast carcinoma is the second most common subtype of breast cancer. There are different patterns of metastasis as ductal breast cancer spreads to the liver, lung, brain, and bone while the lobular subtype metastasizes to the gastrointestinal tract.

Case presentation

A 69-year-old Indian pilgrim presented to the ER complaining of abdominal pain, vomiting, and abdominal distention admitted as a case of intestinal obstruction. CT scan demonstrated intestinal obstruction with transition zone at the terminal ileum. The patient underwent exploratory laparotomy where she was found to have a mass at the terminal ileum. Resection of around 8 cm of small bowel and primary anastomosis were done, histopathology revealed metastatic lobular breast carcinoma.

Clinical discussion

Patients with metastatic breast cancer to the gastrointestinal tract often present with nonspecific symptoms, while acute cases present with complications such as perforation. In a retrospective review of metastatic breast cancer, the majority metastasizes to the colon and rectum, while 19 % to the small bowel. Palliative surgery is considered the first-line treatment of complicated patients, while stable cases are referred to medical oncology.

Conclusion

Breast cancer is the second most common cancer leading to death and lobular subtype has more propensity to metastasize to the gastrointestinal tract compared to ductal breast cancer. Regarding patients presenting to the emergency bay, treating the emergency complaints is the standard management. For immigrant patients, we highly recommend creating a data system for sending histopathology reports to facilitate follow-up in their countries.

Case presentation

A 69-year-old Indian pilgrim patient presented to the ER complaining of abdominal pain for 3 days associated with nausea and vomiting, not passing stool nor flatus was admitted as a case of intestinal obstruction. On examination patient was in pain with tachycardia, abdominal distended with generalized tenderness. Labs revealed metabolic alkalosis with hypokalemia. Abdomen X-ray showed signs of intestinal obstruction with multiple air-fluid levels and dilated small bowel loops. CT scan abdomen and pelvis with IV contrast reported (Figs. 1,2) distended ileum around 5 cm proximal to the transition zone at the terminal ileum with mild free fluid in the abdomen and pelvis. The patient underwent exploratory laparotomy where she was found to have a mass at the terminal ileum with the proximal loop dilated and distal loops collapsed, and further exploration showed enlarged mesenteric lymph nodes. Small bowel resection of around 8 cm and side to side anastomosis was done to relive the intestinal obstruction. Gross pathology showed a solid lesion protruding into the lumen measuring 1.5*1.5*1.5 cm, while the microscopic description consists of small cells with round ovoid nuclei which lack cohesion and appear individually dispersed through a fibrous connective tissue and arranged in single file linear cords that invade the stroma (Fig. 4) concluded as metastatic lobular carcinoma of the breast. Immunohistochemistry reported CK7 + ve, ER + ve, EMA + ve and CKAE1/AE3 + ve. The patient had an uneventful recovery, then she was discharged against medical advice and traveled to her country after two days before the histopathology result and she lost follow-up with us.

Highlights

• •In elderly patients who present with intestinal obstruction, neoplastic etiology must be considered in the top of differential diagnosis.
• •Treatment for emergency cases is the standard of management.
• •Creating an effective data system to communicate with different countries is advisable to detect such cases and address them earlier.

1. Introduction

The most common cancer among females worldwide and in Saudi Arabia is breast cancer [1]. Invasive lobular breast carcinoma is the second most common subtype of breast cancer [2]. Metastatic breast cancer to the gastrointestinal tract is rare and accounts for 8 % to 35 % of cases [3]. Ductal carcinoma spreads to the liver, lung, brain, and bone while lobular metastasizes to the gastrointestinal and gynecological tract [2,3]. The differences in metastatic pattern between invasive ductal and lobular breast cancer are attributed to the loss of expression of the cell-cell adhesion molecule E-cadherin in ILC [2] (Fig. 1). This case has been published in line with the SCARE criteria [11].

Fig. 1.

Sagittal view of CT Abdomen with IV and oral contrast showing mass lesion at ileal loop with upstream dilatation and distal Colonic collapse (yellow arrow).

2. Discussion

Patients with metastatic breast cancer to the gastrointestinal tract often present with nonspecific symptoms including abdominal discomfort or pain, early satiety, nausea, and gastrointestinal bleeding. While acute cases present with perforation and gastrointestinal bleeding, however, intestinal obstruction was reported as the most common clinical presentation [[3], [4], [5]] (Fig. 3). A retrospective review by McLemore et al. found that out of 73 patients diagnosed with metastatic breast cancer, only 23 cases had gastrointestinal metastasis, among these 45 % metastasized to the colon and rectum, 28 % to the stomach, 19 % to the small bowel, and 8 % to the esophagus [6]. Among all metastatic systems the luminal gastrointestinal tract is less common to be involved and it is important to identify the different possible presentations for accurate management [7]. Withington Hospital statistics used clinical and autopsy data showed that invasive lobular carcinoma has more propensity to cause Carcinomatous meningitis and spread to the peritoneal, retroperitoneal, stomach, intestinal wall, and urogenital system more than invasive ductal carcinoma [8] which suggest a different pattern of metastasis for both breast cancer histopathology variants [4,8,9] (Fig. 2).

Fig. 3.

The small intestine lumen with obstructing lesion.

Fig. 2.

Axial view of CT Abdomen with IV and oral contrast showing mass lesion at ileal loop with upstream dilatation and distal Colonic collapse .

In a retrospective review at Memorial Sioan-Kettering Cancer Center of 7 patients with metastatic breast cancer to the gastrointestinal tract, 4 of them had lobular histopathology, 1 had ductal subtype and 2 had mixed lobular and ductal features (4)Immunohistochemistry plays an important role in differentiating between primary GI cancer and breast cancer metastasis. Markers commonly used are estrogen receptors, progesterone receptors, CK7and CK20 [5]. In our patient, ER and CK7 were positive which indicates distant metastasis (Fig. 4). Treatment of metastatic breast cancer to GI depends on the clinical situation of the patient. In emergency cases when a patient presents with obstruction, hemorrhage, or perforation palliative surgery should be the first line of treatment. However, for stable patients with multiple metastases, the mainstay of management is to follow with medical oncology for chemotherapy, radiotherapy, anti-HER2, and hormonal therapy as indicated [5]. Survival is determined by the stage at diagnosis. According to breast cancer statistics for patients diagnosed from 2009 to 2015 in the United States the 5-year survival for stage I was 98 %, for stage II 92 %, 75 % for stage III, and 27 % for stage IV [10].

Fig. 4.

The small intestine wall with lobular carcinoma involving submucosa and invading muscularis propria X40.

3. Conclusion

Breast cancer is the second most common cancer leading to death and the lobular subtype has more propensity to metastasize to the gastrointestinal tract compared to ductal breast cancer. The different presentations of metastatic breast cancer to the bowel make its diagnosis and treatment challenging. For patients who presented in the emergency bay with intestinal obstruction, bleeding, and perforation treating the emergency complaint is the standard of management. For immigrant patients, we highly recommend creating a data system for communicating with them and sending the histopathology reports, with full surgical reports to allow them to follow up appropriately with a surgeon in their countries.

The case has been reported in line with SCARE criteria.

Funding

No grant from funding agencies.

Ethical approval

Ethics clearance was not necessary as patient’s personal data confidentiality was maintained and we reported only the status and pathological condition of the patient as anonymous. The management performed in the treatment of this patient was accordance with the ethical standards of the hospital.

Registration of research studies

Not applicable.

Consent

Consent not obtained from the patient as she was immigrant and travelled to her country, the responsible agency communicate the registered phone number but no reply from the patient or the family.

Author contribution

Dr. Najmah is the main author who collects the case and writes the main manuscript.

Dr. Tala’at the consultant who reviewed the case and participated in the discussion.

Guarantor

The Main author.

Declaration of competing interest

There are no conflicts of interest.