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Letters to the Editor  |   March 2011
Case Report of Mesenteric Metastases From Lobular Breast Carcinoma
Author Affiliations
  • Roy R. Danks, DO
    Kansas City University of Medicine and Biosciences College of Osteopathic Medicine, Missouri
    Saint Luke's Medical Group-Cushing Care Specialists, Leavenworth, Kansas
Article Information
Gastroenterology
Letters to the Editor   |   March 2011
Case Report of Mesenteric Metastases From Lobular Breast Carcinoma
The Journal of the American Osteopathic Association, March 2011, Vol. 111, 180-182. doi:10.7556/jaoa.2011.111.3.180
The Journal of the American Osteopathic Association, March 2011, Vol. 111, 180-182. doi:10.7556/jaoa.2011.111.3.180
To the Editor:  
Breast cancer is the most common type of malignancy and the second most common cause of cancer-related mortality among women in the United States.1 Invasive lobular carcinoma (ILC) is the second most common type of primary breast cancer, after ductal carcinoma (DC), and accounts for 8% to 14% of breast cancer cases.2,3 
Invasive lobular carcinoma can be difficult to detect in clinical and radiologic examinations because of its diffuse infiltration and the absence of well-defined margins.4,5 Noncohesive cells and tendency for infiltration could be linked to a higher probability of ILC recurrence and metastatic disease.6 The most common sites of breast cancer metastasis are the lungs, liver, bone, and central nervous system. Although the spread of cancer to these sites is common in both ILC and DC, ILC has been found to metastasize to the gastrointestinal tract, peritoneum-retroperitoneum, and genitourinary organs.2,6,7 
In the present letter, we describe a case of an unusual metastatic spread of ILC. This case highlights the need for a high index of suspicion when a patient with breast cancer presents with non-specific gastrointestinal symptoms. 
Report of Case
In our case, an 85-year-old woman underwent treatment for breast carcinoma 15 years before her present hospital admission. The histopathologic mechanisms of this patient's cancer were not known at the time of admission. The cancer stage and lymph node status were also not known. Her treatment for the breast carcinoma consisted of excision of the cancerous tissue. The patient was then followed routinely by her oncologist. 
Approximately 3 months prior to the present hospital admission, a solitary pulmonary nodule was discovered on a chest computed tomography (CT) scan. The patient then underwent a CT-guided biopsy of the lung nodule; results of this biopsy were negative for malignancy. However, a pneumothorax developed after the biopsy procedure. Drainage was performed, and the pneumothorax was resolved. 
One month prior to hospital admission, the patient underwent a positron emission tomography (PET) scan. Results of this test were reportedly normal according to the patient. 
The patient was admitted to the hospital immediately after presentation for decreased appetite, weight loss, malaise, and abdominal pain in the right lower quadrant. She reported progressive weight loss (approximately 26 pounds over 6 months) with worsening fatigue over the past few weeks. She reported at least 1 episode of bloody stools and constipation. The patient attributed the constipation to recent use of acetaminophen and hydrocodone for back pain. 
On physical examination after hospital admission, the patient was found to have obvious weight loss, and she appeared fatigued. Her lungs were clear bilaterally with good excursion and minimal effort. Cardiovascular examination revealed slight irregularity in heart rate and rhythm. Breast examination revealed a round, mobile, nontender, mass, 6 to 8 cm in diameter, in the left breast. According to the patient, this mass had been present since surgery on the breast 15 years previously and was a noncancerous “cyst.” She reported that her oncologist regularly monitored the condition of the mass. 
The patient's abdomen had normoactive bowel sounds and was soft with no organomegally or masses. The abdomen was minimally tender to palpation in the right lower quadrant at the iliac crest and at the junction of the right costal margin. No guarding and no abdominal wall defects were noted. 
Laboratory testing revealed positive results for fecal occult blood. Urinalysis was notable for a protein level of 30 mg/dL, positive leukocyte esterase results, and 10 to 20 white blood cells per high-power field. The white blood cell count was 19,700 × 109/L. Neutrophil granulocytes made up 72% of the white blood cell count, with an elevated level of 15.1 × 109/L. The hemoglobin level was stable at 13.9 g/dL, with a hematocrit volume of 41%. Results of chest radiograph and kidney-ureter-bladder tests were negative. 
A CT scan performed after admission showed free fluid around the liver and below the diaphragm in the paracolic gutters. Diffuse atherosclerotic disease of the arterial vasculature of the abdomen was noted. No bowel wall thickening and no free air were noted. 
The patient underwent a colonoscopy, in which an iatrogenic perforation of the sigmoid colon occurred during advancement of the colonoscope. She was then taken to the operating room for an emergency exploratory laparotomy. A sigmoidectomy was performed without complications. During the operation, the entire abdomen was examined. A minimal amount of ascitic fluid was discovered. No palpable lesions of the colon were identified. In approximately the midpoint of the jejunum, the mesentery was found to be extremely thick and indurated with what appeared to be lymphadenopathy. Because of the suspicious appearance of the mesentery, a biopsy of the mesenteric tissue was taken. No gross abnormalities of the small bowel were noted. 
The histologic examination of the mesenteric biopsy revealed atypical, discohesive infiltrate throughout the mesentery, involving 3 of 3 lymph nodes with extracapsular extension. Immunohistochemical stains were performed, and the infiltrating cells were found to be positive for OSCAR cytokeratin, mammaglobin, and GCDFP-15 (gross cystic disease fluid protein of 15 kiladaltons) and negative for LCA (leukocyte common antigen), CD34, and CD117. The immunophenotype and morphologic characteristics were most consistent with metastatic lobular carcinoma. 
The patient was offered palliative chemotherapy for stage-IV breast carcinoma, but she declined this treatment. 
Comment
The metastatic spread of breast carcinoma to the gastrointestinal system, peritoneum-retroperitoneum, and gynecologic organs is much more prevalent in ILC than in DC. One series of 2605 patients, comparing rates of metastasis from ILC and DC, revealed statistically significant differences (P<.05) for metastases of the gastrointestinal tract (4.5% ILC vs 0.2% DC), peritoneum-retroperitoneum (3.1% ILC vs 0.6% DC), and gynecologic organs (4.5% ILC vs 0.8% DC).2 The reasons for this distinct metastatic pattern are unclear. It has been suggested that the loss of expression of the cell-to-cell adhesion protein E-cadherin in ILC—a loss that is not observed in DC—may contribute to this type of infiltration.3,5,6 
Although metastases to the gastrointestinal tract are infrequent in ILC, patients with breast carcinoma presenting with nonspecific gastrointestinal symptoms need to be thoroughly evaluated to rule out metastatic disease. Cases have been reported of ILC metastases to the esophagus, stomach, and small and large intestines.2 Esophageal disease has been shown to present with progressive dysphagia and dysarthria.8 Gastric involvement has a variety of symptoms, including early satiety, vomiting, epigastric discomfort, melena, and dyspepsia. Because of nonspecific symptoms and imaging results, gastric metastases from breast carcinoma can be difficult to distinguish from primary stomach cancer and benign disease processes.8,9 
Small bowel metastases can present with symptoms of bowel obstruction, obstructive jaundice, diarrhea, abdominal cramps, and vomiting.8,10 Small bowel obstruction has many etiologic mechanisms—adhesions being the most common—making diagnosis of metastatic disease difficult.11 Several cases of rectal involvement have been described with presentations of constipation, tenesmus, heme-positive stool, and abdominal mass.5,9,12 Metastases of breast carcinoma to the omentum and mesentary has been reported, with the presence of ascites that are compatible with peritoneal carcinomatosis.13 
The patient in our case demonstrated nonspecific symptoms of weight loss, decreased appetite, abdominal pain, and ascites 15 years after her initial diagnosis and treatment for breast carcinoma. Recognizing the range of clinical presentations for metastatic ILC to the gastrointestinal tract is imperative for early diagnosis and treatment. 
Our case also highlights the potential limitations of imaging tests for diagnosing metastatic breast carcinoma. The patient's recent CT and PET scans did not demonstrate any mesenteric or lymph node involvement. Known limitations of PET scans include the inability to recognize small masses or to differentiate between scar tissue and active tumors.14 The diffusely infiltrative nature of ILC and the absence of a well-defined margin may have contributed to the negative results of the PET and CT scans in our case. 
Metastatic breast carcinoma in the gastrointestinal tract can produce a variety of radiologic and clinical presentations. As our case demonstrates, the absence of positive findings in imaging studies should not exclude the possibility of metastasis. Clinician knowledge of the atypical metastatic pattern of invasive lobular breast carcinoma is imperative when patients with a history of ILC present with nonspecific gastrointestinal symptoms. Early recognition of mesenteric metastases is key for initiation of appropriate antineoplastic therapy. 
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