Widespread metastatic breast cancer to the bowel: an unexpected finding during colonoscopy

Abstract

Metastatic neoplasms to the gastrointestinal (GI) tract are an uncommon entity and in extremely rare cases originate from the breast. The clinical manifestations of metastatic breast cancer into the GI tract are frequently non-specific, and the interval between the diagnosis of lobular carcinoma and GI metastasis can often delay up to 30 years. Here, we present a 73-year-old female with an unusual colonoscopy that revealed a submucosa nodular infiltrate throughout all the colon with a cobblestone-like appearance, which was later confirmed to be metastatic lobular carcinoma of the breast that was surgically removed 15 years early. A couple of months later, she developed malignant small bowel obstruction and laparotomy revealed extended small bowel and colonic metastatic involvement.

A 73-year-old female with a past medical history of breast cancer that was treated with bilateral mastectomy and adjuvant chemotherapy 15 years ago, after treatment there was no evidence of metastatic disease, she presented to the clinic with symptoms consistent with chronic colitis. A colonoscopy was performed and revealed a submucosa nodular infiltrate throughout all the colon with a cobblestone-like appearance (Fig. 1a), colonic biopsies showed diffuse metastatic lobular breast cancer with positive estrogen receptors, negative progesterone receptors and negative for HER2 overexpression (Fig. 1b and c). After discussing medical treatment options (i.e. chemotherapy or hormonal therapy), the patient decided to forgo treatment. A couple of months later, she arrived to the emergency department with a proximal small bowel obstruction and surgical management was required, laparotomy revealed seven areas within the small bowel with either complete or partial malignant obstruction and infiltration of the ascending, transverse and descending colon. A proximal small bowel resection of the complete obstruction with a palliative ileostomy and mucous fistula was performed. No postoperative complications were reported.

Figure 1:

(A) Colonoscopy showing submucosal nodular infiltrate with a cobblestone-like appearance throughout all the circumference of the colon. (B) Microscopy of the colonic biopsies showing metastatic carcinoma infiltrating colonic mucosa with scattered residual glands. (C) Immunohistochemistry showing metastatic tumor cells with nuclear positivity for estrogen receptor

Metastatic neoplasms to the gastrointestinal (GI) tract are rare that usually originate from skin, lung, kidney, prostate, ovary, stomach or hepatobiliary system and in extremely rare cases from the breast. Lobular carcinoma is the most common histopathological subtype of metastatic breast cancer that invades the GI tract [1, 2]. The interval between the diagnosis of lobular carcinoma and GI metastasis can be up to 30 years. Colonoscopy may reveal an abnormal lumen appearance with multiple polypoid lesion with a cobblestone-like appearance that might cause intraluminal obstruction. Diagnosis is made through histopathological examination. Although the majority of reports of metastatic breast cancer involves a single colonic segment, this is an abnormal presentation of metastatic breast cancer to the GI tract due to the extended involvement of several colonic segments and multiple regions of the small bowel, without evidence of extraintestinal metastasis [1, 3].

CONFLICT OF INTEREST STATEMENT

Authors declare no conflict of interest related to the publication of this article.

FUNDING

There is no funding for this article.

ETHICAL APPROVAL

All ethical requirements have been fulfilled for this publication.

CONSENT

Patient provides written informed consent for the publication of this article and any accompanying images. A copy of the written consent form is available for review by the Editor-in-Chief of this journal.

GUARANTOR

Ruben Blachman-Braun, MD, MSc.