Rectal metastases from lobular carcinoma of the breast: Report of a case and literature review

Rectal metastases from lobular carcinoma of the breast: Report of a case and literature review

Annals of Oncology 12 715-718, 2001. © 2001 KluHer Academic Publishers. Primed in the Netherlands Clinical case Rectal metastases from lobular carcin...

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Annals of Oncology 12 715-718, 2001. © 2001 KluHer Academic Publishers. Primed in the Netherlands

Clinical case Rectal metastases from lobular carcinoma of the breast: Report of a case and literature review A. Bamias,1 G. Baltayiannis,2 S. Kamina, 3 M. Fatouros,4 E. Lymperopoulos,1 N. Agnanti,3 E. Tsianos2 & N. Pavlidis1 Departments of 'Medical Oncology. 2Gastroenterology. 'Histopathology, 4 Surgery. Ioannina University Hospital, loannina, Greece

Summary Metastatic involvement of the gastrointestinal (GI) tract secondary to breast cancer is rare. Reported herein is the case of a 74-year-old woman with metastatic lobular breast carcinoma to the rectum presenting with obstruction. The breast tumour was diagnosed nine years prior to the presentation of rectal metastases. Endoscopy was repeated twice until a diagnosis was established. Examination of endoscopy material revealed infiltration of the rectum by malignant signet ring cells identi-


Breast cancer is the most frequent malignancy in the female population and a significant cause of morbidity and mortality. Distant metastases are present in about 60% of the patients at the time of diagnosis, while 30%80% will develop metastatic disease following surgery and/or chemotherapy, radiotherapy or endocrine therapy [1]. Breast carcinoma usually metastasizes to lymph nodes, lung, bone, liver or brain, but GI involvement is rare [2]. The most frequent sites of the GI tract involved are the stomach and the small intestine [3-6], while colonic and rectal metastases are extremely rare. Especially rectal involvement has been mostly reported as single cases, with only one serie of seven cases published [2, 4, 7-11]. Nevertheless, recognition of this rare entity is important, because presentation resembles that of primary rectal carcinoma and different therapeutic modalities may be appropriate. We herein report the case of a patient with breast cancer metastases to the rectum presenting with obstruction along with a review of English published literature.

Case report A 74-year-old woman had undergone right modified radical mastectomy and axillary lymph node dissection in 1991 due to a breast adenocarcinoma. Histopathological examination revealed a 6 cm infiltrating lobular adenocarcinoma of histological grade 2, with all 10 reDownloaded from by guest on 27 March 2018

cal to those of the primary breast tumour. The patient did not respond to chemotherapy and underwent laparotomy with a defunctioning colostomy. Literature review revealed only a few more cases of metastatic breast carcinoma to the rectum. Awareness of this condition may lead to accurate diagnosis and early initiation of systemic treatment, thus avoiding surgical intervention.

Key words: breast cancer, lobular carcinoma, rectal metastases

sected lymph nodes infiltrated by tumour cells (Figure la). Immunohistochemistry for oestrogen and progesterone receptors showed weak staining of 20% of cancer cells for both receptors. There was no evidence of distant metastases at the time of diagnosis. The patient received six cycles of adjuvant chemotherapy (cyclophosphamide, mitoxantrone, 5-fluorouracil). Two years after the operation, she was started on tamoxifen (20 mg daily) due to the development of bone metastases. Four years later, there was progression of bone disease with pain in the pelvis and lumbar spine. The radiographic examination revealed several osteolytic and osteoblastic lesions in the sacrum. She received second-line hormone treatment with methoxyprogesterone (160 mg daily) and radiation therapy at the sacrum (3000 cGy), resulting in significant remission of her symptoms. One year later, she complained of progressively worsening constipation with tenesmus. An abdominal computerised tomography (CT) scan showed thickness of the rectal wall and abnormalities of the area between the rectum and the sacrum consistent with radiation changes. She underwent rectosigmoidoscopy, which revealed a diffuse inflammatory area of the lower rectum. Biopsies were negative for malignant cells. A diagnosis of postradiation colitis was made and the patient received cortisone enemas. Because of clinical deterioration and markedly elevated CA 15-3, a second endoscopy was performed a year later. At that time, there was an ulcerated area with stenosis of the lumen 7 cm above the anal verge, just below the lower limit of the radiation field.

716 She received radiotherapy and pamidronate with symptomatic improvement. She remains alive six months after the operation. Discussion Metastatic tumors of the GI tract are unusual but probably more common than clinically suspected as shown by autopsy series [4, 5]. Breast cancer is amongst the commonest primaries metastasising to the GI tract, along with melanoma, ovary and bladder [4, 8]. Metastases to the stomach and small intestine from breast cancer have been more frequently reported [2-4, 9-11] compared to colonic and rectal involvement. Especially metastases to the rectum are extremely rare and account for only a minority of large bowel metastases [2, 3, 1116]. We only found two small series and a few case reports, summarised in Table 1. Lobular carcinoma represents the commonest breast cancer metastasising to colon and rectum [2-4], although it comprises only 10% of breast adenocarcinomas [1]. The reasons for this have not been clarified. The more common ductal carcinoma has only been reported as the most frequent primary in one autopsy serie [4], indicating that metastases from lobular carcinoma possibly become clinically evident more often or earlier in the course of (b) the disease. Figure 1. (a) Infiltrating lobular carcinoma of the breast with a few Clinical presentation of metastatic disease to the 'signet-ring'cells (H+E x 400). (b) Metastases of the same carcinoma GI tract is diverse. Symptoms may be non-specific or to the rectum with 'signet-ring' morphology. There are no dysplastic strikingly similar to that of primary GI malignancies [3, changes in the overlying epithelium or the glands (H + E x 230). 8, 14,15, 17] as it happened in our case. This in combination with the usually long interval after the initial diagThe new biopsy revealed infiltration from malignant nosis [2—4, 8, 11] makes the differential diagnosis between cells of the signet ring type. Review of the specimen a primary tumour and metastases from a known breast from the primary lesion confirmed the diagnosis of a carcinoma difficult. The diagnosis of a metastatic lesion metastatic breast carcinoma to the rectum (Figure lb). to the GI tract becomes even more unlikely on the rare Immunohistochemical staining for oestrogen and pro- occasion when it represents the first manifestation of gesterone receptors showed similar results to those of breast cancer [12]. In most series reporting metastases the primary tumour. Staging investigations revealed no from breast carcinoma to GI tract the median interval other visceral metastases but a CTscan of her abdomen between diagnosis and presentation of metastases is five to six years [2^4-]. The interval of 8.5 years in our report revealed mild bilateral hydronephrosis. The patient was initially treated with chemotherapy is one of the longest in the literature, although 10 years consisting of mitomycin-C, mitoxantrone and metho- or more have rarely been reported [2-4, 11]. trexate, while medroxyprogesterone was stopped. After Although in many cases biopsy obtained during the first cycle constipation worsened with significant endoscopy will not reveal malignant cells, endoscopy faecal impaction and pseudo-diarrhea. Due to impend- should be performed in order to accurately detect the ing obstruction the patient underwent exploratory site of the lesion and because endoscopic appearance laparotomy. There were several seedings in the pelvic of metastatic lesions may differ from that of a primary peritoneum, uterus and bladder wall and bilateral carcinoma. Our literature review showed that metastases hydronephrosis. The bowel wall below the peritoneal to the GI tract may appear as diffuse thickening and reflection was diffusely thickened. Histopathological rigidity of the colonic wall mimicking plastic linitis, examination of biopsy specimens from the uterus and Crohn's-like appearance and ulcerated or nodular areas the right ureter revealed infiltration by malignant cells rather than solitary, discrete masses [2, 3, 9, 12,15, 16]. The identical to those found by endoscopy. A right ureter- fact that a second endoscopy was required to confirm ostomy and sigmoid colostomy were performed. The the diagnosis in our case may indicate that follow-up patient declined any further chemotherapy and she re- endoscopies of such lesions might increase the sensitivity mained well for four months after the operation, when of this method. Since surgical resection remains the only she developed pain of her left femur due to osteolysis. other means of establishing a diagnosis, repeated endos-

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717 Table 1. Rectal metastases from breast carcinoma. Author [reference]

Number of patients



Taal et al. [2]


60" (median)

Lobular* 15 Ductal" 1 NR" 1

Asch ct al. [5]


58 75 NR


Klein and Sherlock [11]


68 77

Lobular NR

Time from diagnosis (months) 53* (median)

78 18 NR 56 276

Haubrich [7]





Present report







Resection+systemic" 3 Radiotherapy" 2 Systemic treatment" 12

Median survival 16 months"

Colostomy Colostomy NR

Died (2 months) Died postoperatively

Radiotherapy Radiotherapy + hypophysectomy

Died shortly after diagnosis Alive ( > 1 year)


Died(l month)

Chemotherapy Resection

Alive (4 months)

Abbreviation. NR - not reported ° Data of colonic and rectal metastases together (17 patients).

copies might prevent unnecessary surgical procedures in many of these patients. Histologically, metastases often do not form glands or tubular structures but infiltrate as small nests and strands of tumour cells, which are usually of the signet ring type. Histopathological diagnosis can be difficult, particularly for pathologists who are unaware of the patient's history. In addition, the 'signet-ring' morphology of lobular carcinoma may mimic other primary tumours, i.e., gastric carcinoma. The lack of dysplasia or atypia of the rectal epithelium and the glands surrounding the malignant cells is often helpful in the differential diagnosis between a primary and a metastatic lesion. Immunohistochemistry may also be useful in reaching the correct diagnosis. The most informative markers are gross cystic disease fluid protein-15 (GCDFP-15) and oestrogen (ER) and progesterone (PgR) receptors. Metastatic breast carcinomas are usually positive for GCDFP-15 and often for ER and/or PgR, in contrast to most colorectal or gastric carcinomas, which are negative [18-20]. Systemic treatment (chemotherapy, endocrine treatment or both) is usually employed in patients with metastases to the GI tract, since patients usually present with involvement of multiple organs [2, 3]. Results are variable and improvement in more than 50% of the patients was reported in the only series, where results of treatment were analysed in detail [2]. Survival after diagnosis of GI metastases is poor with few patients surviving beyond two years [2, 3], although survival up to nine years has also been reported [21]. We also used chemotherapy as the initial treatment for our patient. Nevertheless, progression of stenosis prompted surgical removal of the tumour. Patients with rectal metastases commonly present having already developed stenosis and obstruction requiring urgent correction, which usually cannot be achieved by systemic treatment. This underlines the importance of early diagnosis, which would Downloaded from by guest on 27 March 2018

enable prompt initiation of systemic treatment, thus avoiding surgical intervention. Not surprisingly, laparotomy revealed more extensive disease than shown by preoperative investigations. In most cases reported, colorectal metastases are part of widespread metastatic disease [2, 11] and this should be taken into account in management decisions.

Conclusion Rectal metastases from breast carcinoma are very rare and represent the least frequent metastatic site in the GI tract. Nevertheless, in patients with lobular carcinoma this possibility should be suspected in the case of symptoms suggesting a rectal lesion. Endoscopy can be helpful but will not confirm the diagnosis in a significant percentage of cases. A high level of suspicion for metastatic breast cancer, a detailed pathological analysis and repetition of endoscopy are necessary for early diagnosis, which might help to avoid surgical treatment.

Acknowledgement The authors are grateful to Dr A. Skopelitou (Histopathology Department, loannina University Hospital) for the preparation of the figures.

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Received 28 July 2000; accepted 10 November 2000. Correspondence to: Dr A. Bamias Oncology Department Ioannina University Hospital Ioannina 45110, Greece E-mail: [email protected]