Biliary and pancreatic metastases of breast carcinoma: is surgical palliation indicated?

Invasive lobular carcinoma metastasis to pancreas mimicking pancreatic signet ring cell carcinoma: A case report and systematic review of the literature

Metastasis to the gastrointestinal tract is a rare instance in the natural history of breast cancer, usually in association with lobular histology and widespread dissemination of disease. We report the case of a 74-year-old woman with a history of invasive lobular carcinoma presenting with a pancreatic metastasis mimicking a primary pancreatic adenocarcinoma; we also present a systematic review of the relevant literature. The presentation of pancreatic metastasis in the setting of breast cancer is unspecific, and histology is of paramount importance for a correct diagnosis; surgical metastasectomy could be of some benefit in the correct clinical setting.

Endoscopic drainage with a metallic stent for obstructive jaundice caused by bile duct metastasis of breast cancer: A case report

Key Clinical Message

Bile duct metastasis of breast cancer is rare. It often causes obstructive jaundice which makes the patient interrupt state of treatment. Endoscopic drainage for obstructive jaundice is effective and less invasive treatment option also in this case.

Abstract

A 66-year-old breast ductal carcinoma patient developed obstructive jaundice, presenting with epigastric discomfort and dark-colored urine. Computed tomography and endoscopic retrograde cholangiopancreatography revealed bile duct stenosis. Brushing cytology and tissue biopsy confirmed bile duct metastasis, a self-expandable metallic stent was placed/replaced endoscopically, and chemotherapy was continued, extending the patient's life.

Metastatic Lobular Carcinoma of the Male Breast Masquerading as a Pancreatic Head Mass, a Diagnostic Dilemma—Rare Case and Literature Review

Male breast cancer comprises of 1% of all and invasive lobular carcinomas (ILC) are even rarer in males. ILC are known to have unusual metastatic sites. We report a case of a 51-year-old male diagnosed with breast cancer, who presented with a recurrent chest wall nodule and icterus after 24 months of disease-free interval. On further investigations, he was found to have pancreatic head mass associated with conjugated hyperbilirubinemia suggestive of obstructive jaundice and a left parasternal soft tissue recurrence. A self-expandable metallic stent was inserted for recurrent cholangitis. Biopsy from the chest wall nodule was recurrence of ILC and pancreatic head mass was suspected to be either a second primary or an isolated pancreatic head metastasis of ILC on imaging. In either case surgical resection if operable and localized was planned. However, on staging laparoscopy, the patient was found to have mild ascites and multiple peritoneal nodules, which on biopsy proved to be metastases from ILC. Patient was treated with second-line hormonal therapy with luteinizing hormone-releasing hormone agonist and an aromatase inhibitor. ILC may present with unusual sites of metastasis leading to diagnostic dilemma. A high index of suspicion of metastases and appropriate biopsies can help one embark upon the most appropriate plan.

Rare common bile duct metastasis of breast cancer: A case report and literature review

BACKGROUND

Breast cancer is the most common tumor in women, and about one-third of cases develop metastatic disease. However, metastatic breast cancer rarely invades the common bile duct (CBD) directly without involving the liver, and involvement of the gastrointestinal tract is rare. Cases of such metastases pose a particular diagnostic challenge.

CASE SUMMARY

A 55-year-old female presented to the Department of Gastroenterology with complaint of a 2 mo history of right upper abdominal pain accompanied by pain in the right back, aggravated after eating greasy diet. The patient had received a diagnosis of breast cancer 3 years prior. Physical examination showed obvious superficial protuberant erythema on the left neck and chest skin, with slight tenderness and burning sensation. Endoscopic retrograde cholangiopancre-atography showed an obstruction at the end of the CBD. Histopathology of the CBD and symptomatic skin biopsies showed positivity for cytokeratin 7 and trans-acting T-cell-specific transcription factor breast cancer biomarkers. A cancer embolus was also found in the skin vasculature. Accordingly, the diagnosis of breast cancer metastases to the skin and biliary ducts was made. A plastic biliary sent was placed, which relieved the right upper abdominal pain and protected against unnecessary hepatectomy surgery.

CONCLUSION

Although rare, biliary metastasis should be considered in patients with bile duct stenosis and a history of breast cancer.

Palliative Surgical Treatment for Liver Metastases Arising From Breast Cancer

Introduction

Patients with liver metastases arising from breast cancer presenting with jaundice have poor prognoses; most patients are not treated aggressively. However, we report an improvement in the quality of life (QOL) of the patient by inserting a biliary stent as palliative surgical treatment.

Case presentation

The patient was a 63-year-old woman. She had left breast cancer and had undergone total mastectomy and axillar lymph node dissection approximately 20 years ago. Thereafter, chemotherapy and hormonal therapy were continued for approximately 5 years. Sixteen years after surgery, the patient presented with hepatic failure; furthermore, total bilirubin (T-Bil) levels had increased to 5.5 mg/dL. Imaging revealed multiple liver metastases and dilatation of the intrahepatic bile duct. A biliary stent was placed, and treatment for obstructive jaundice was administered. After 3 months, the patient was able to maintain QOL without any increase in T-Bil levels.

Conclusion

Palliative surgical treatment via biliary stenting for the onset of obstructive jaundice caused by liver metastases arising from breast cancer can be useful for maintaining patient QOL.

Pancreatic Mass of Unusual Etiology: Case Report of Metastatic Disease after a Prolonged Lag Phase

Although not a typical site, the pancreas does occasionally harbor metastatic disease. Management of these metastases differs from the management of conventional primary cancers. Our case is one of an 85-year-old female presenting with obstructive jaundice and whose workup revealed a pancreatic mass. Her past medical history included a mastectomy 14 years previous for invasive lobular carcinoma. She underwent celiotomy, and an intraoperative diagnosis of metastatic lobular carcinoma of the breast was made based on frozen section. Due to pulmonary metastasis and vascular infiltration, which precluded pancreatoduodenectomy, the patient underwent palliative bypass and fared well postoperatively. With more aggressive management of primary breast cancers in the past decade, isolated metastatic disease is of increasing concern and raises questions about surgical strategies to be implemented with these patients. For instance, should palliative treatment be considered or should a radical intention to cure procedure be performed despite the metastatic disease? Factors favoring radical procedures include prolonged lag phase between the primary and the recurrence; presence of well-differentiated tumors; and isolated metastatic disease. Primary lung and renal cancers metastasize more frequently than breast cancers do to the pancreas. Hence, existing literature has not clearly defined indications for radical treatment of metastatic breast cancers to the pancreas. Based on experiences with metastatic renal and lung cancers, one can reasonably infer that radical procedures performed on selected cases could possibly achieve a cure or prolonged disease-free survival. The key factor in determining whether the patient undergoes palliative versus radical treatment is a slow growth pattern of the tumor, characterized by a prolonged lag phase between the primary and the metastatic disease.

Solitary pancreatic metastasis from breast cancer: case report and review of literature

CONTEXT

Pancreatic metastases from primary malignant tumors at other sites are rare, constituting about 2% of the neoplasms that affect the pancreas. Pancreatic metastasis from breast cancer is extremely rare and difficult to diagnose, because its clinical and radiological presentation is similar to that of a primary pancreatic tumor.

CASE REPORT

A 64-year-old female developed a lesion in the pancreatic tail 24 months after neoadjuvant therapy, surgery and adjuvant radiation therapy for right-side breast cancer (ductal carcinoma). She underwent distal pancreatectomy with splenectomy and left adrenalectomy, and presented an uneventful outcome. The immunohistochemical analysis on the surgical specimen suggested that the lesion originated from the breast.

CONCLUSION

In cases of pancreatic lesions detected in patients with a previous history of breast neoplasm, the possibility of pancreatic metastasis should be carefully considered.

Metastatic lobular breast carcinoma to the pancreas: a case report

We report a case of a 72-year-old female, with an extensive breast cancer history, who presented with abdominal pain to her general practitioner. Cross-sectional imaging demonstrated a lesion in the head of pancreas, which was not amenable to curative resection. Percutaneous biopsy was obtained, which demonstrated metastatic lobular breast cancer. This rare case highlights how previous medical histories may assist in final pathological diagnosis.

Duodenal Obstruction from Isolated Breast Cancer Metastasis a Case Report

Metastatic involvement of the upper gastrointestinal tract from breast cancer has been reported in autopsy series as occurring in more than 15% of patients, usually associated with extensive systemic spread; clinical manifestations from such metastases have been described in less than 1% of cases. Lobular infiltrating carcinoma seems to have a different metastatic pattern than the ductal type, with an apparent predilection for the gastrointestinal tract. Metastatic presentation as an isolated intestinal obstruction without other signs of metastatic spread is extremely rare. We present a case of isolated duodenal metastasis from breast cancer, associated with intestinal obstruction, as the first sign of metastatic spread.

Ampullary Metastasis From Breast Cancer: A Rare Cause of Obstructive Jaundice

Breast cancer is the most common tumor in women and the first cause of death for malignancy in the female. Bile ducts are not among the common sites of metastasis from breast cancer. Few cases of obstructive jaundice due to metastatic breast cancer have been described in the literature and they mostly resulted from widespread liver metastases that eventually involved the bile ducts. We report an exceptional case of ampullary metastasis in the absence of liver metastases. Sporadic reports have been published about the involvement of the ampulla by breast cancer metastasis. This case emphasizes the need to consider this diagnosis in women presenting with obstructive jaundice, especially when there is a clinical possibility of breast cancer.

Concomitant endometrial and gallbladder metastasis in advanced multiple metastatic invasive lobular carcinoma of the breast: A rare case report

INTRODUCTION

At time of presentation, fewer than 10% of patients have metastatic breast cancer. The most common sites of metastasis in order of frequency are bone, lung, pleura, soft tissue, and liver. Breast cancer metastasis to the uterus or gallbladder is rare and has infrequently been reported in the English literature.

PRESENTATION OF CASE

A 47 year old female with a recent history of thrombocytopenia presented with abnormal vaginal bleeding. Pelvic ultrasound revealed multiple uterine fibroids and endometrial curettings revealed cells consistent with lobular carcinoma of the breast. Breast examination revealed edema and induration of the lower half of the right breast. Biopsy of the right breast revealed invasive lobular carcinoma. Bone marrow aspiration obtained at a previous outpatient visit revealed extensive involvement by metastatic breast carcinoma. Shortly after discharge, the patient presented with acute cholecystitis and underwent cholecystectomy. Microscopic examination of the gallbladder revealed metastatic infiltrating lobular carcinoma. The final diagnosis was invasive lobular carcinoma of the right breast with metastasis to the bone marrow, endometrium, gallbladder, regional lymph nodes, and peritoneum.

DISCUSSION

The growth pattern of invasive lobular carcinoma of the breast is unique and poses a challenge in diagnosing the cancer at an early stage. Unlike other types of breast cancer, it tends to metastasize more to the peritoneum, ovary, and gastrointestinal tract. Metastasis to the endometrium or gallbladder is rare.

CONCLUSION

Metastatic spread should be considered in the differential diagnosis of patients with invasive lobular breast carcinoma presenting with abnormal vaginal bleeding or acute cholecystitis.

Obstructive Jaundice as an Uncommon Manifestation of Metastatic Breast Cancer

Invasive ductal carcinoma is the most common type of breast cancer and accounts for about 70-85% of all invasive breast carcinomas. It primarily metastasizes to the bone, lungs, regional lymph nodes, liver and brain. Most of breast cancer recurrence occurs within the first 5 years of diagnosis, particularly for ER negative disease. Gastrointestinal tract involvement is very rare and is detected in only 10% of all the cases, and it usually derives from lobular breast cancer rather than the much more common cell type of ductal breast cancer. Early diagnosis is very important because it enables prompt and adequate choice of treatment and improves patient’s long-term prognosis. In this report we describe an unusual case of obstructive jaundice caused by metastases from invasive ductal breast cancer to the lymph nodes of the hepatoduodenal ligament with extramural compression of the distal common bile duct and tumor invasion to the lumen of the duct. Our goal is to emphasize possible diagnostic pitfalls and increase the clinical awareness and the importance of intensive follow-up in patients with breast cancer, even years after the initial diagnosis.

Metastatic breast cancer mimicking a hilar cholangiocarcinoma: case report and review of the literature

BACKGROUND/AIMS

Breast cancer is the most common tumor in women and the first cause of death for malignancy in the female population. Bile ducts are not among the common sites of metastasis from breast cancer; few cases of obstructive jaundice due to metastatic breast cancer have been described in the literature and they mostly resulted from widespread liver metastases that eventually involved the bile ducts. We report an exceptional case of metastatic infiltration of the extrahepatic bile ducts in absence of liver metastases.

CASE PRESENTATION

A 56-year-old woman who had undergone a right mastectomy 13 years earlier due to infiltrating ductal breast cancer and had remained tumor free, presented at a follow-up examination with obstructive jaundice.Imaging (computed tomography, magnetic resonance and endoscopic retrograde cholangiopancreatography) scans showed features that were suggestive of a primary tumor of the extrahepatic bile duct. At surgery, the intraoperative findings were also those of a tumor of the bile duct, however, an histological examination showed no evidence of malignancy in the mucosa, but did shown an infiltration of the external wall from adenocarcinoma. Immunohistochemistry analysis demonstrated that the tumor was metastatic breast cancer.

CONCLUSIONS

Indeterminate stenosis of the extrahepatic bile ducts should be examined with suspicion in women with a history of breast cancer, and bile duct metastases are to be considered among the possible diagnoses. A differential diagnosis from cholangiocarcinoma is of paramount importance and mainly relies on pathology.

Pancreatic solitary and synchronous metastasis from breast cancer: a case report and systematic review of controversies in diagnosis and treatment

Background

Metastases from breast cancer cause the frequent involvement of lung, bone, liver, and brain, while the occurrence of metastases to the gastrointestinal tract is rare, and more frequently discovered after a primary diagnosis of breast cancer. Solitary pancreatic metastases from breast cancer, without widespread disease, are actually unusual, and only 19 cases have been previously described; truly exceptional is a solitary pancreatic metastasis becoming evident together with the primary breast cancer.

Case presentation

A 68-year-old woman reported general fatigue, lethargy, and jaundice. Abdominal ultrasound (US) and magnetic resonance imaging (MRI) showed an ampulloma of Vater’s papilla; moreover, a neoplastic nodule in the left breast was diagnosed. She underwent surgery for both breast cancer and ampulloma of Vater’s papilla. Pathological examination of pancreatic specimen, however, did not confirm primary carcinoma of the duodenal papilla, but showed a metastatic involvement of pancreas from lobular breast cancer. Immunohistochemistry has been essential to confirm the origin of the malignancy: hormone receptors and mammaglobin were expressed in both the primary breast tumor and the pancreatic metastasis.

Conclusions

This is one of the few reported cases in literature of an isolated and synchronous pancreatic metastasis from breast cancer, where the definitive diagnosis was obtained only after surgery. We discuss the controversies in this diagnosis and the choice of correct treatment. The surgical resection of solitary metastases can be performed in the absence of disseminated disease.

Breast cancer metastases to the pancreas

INTRODUCTION

The pancreas can serve as the destination for metastatic spread of malignancies from multiple organ sites. Breast cancer metastases to the pancreas are part of this spectrum and surgeons evaluate such patients as part of their practice. Uniform clinical guidelines for these cases do not exist and care is primarily driven by the personal experience of the treating surgeon.

DISCUSSION

We present two patients with breast cancer metastases to their pancreas and review their workup and clinical management in light of our experience and the existing published literature. We propose that metastatic disease to the pancreas has to remain in the differential diagnosis for any patient with a new pancreatic mass and prior cancer history. Surgical resection is a viable treatment option for patients with isolated metastatic disease to the pancreas if the underlying biology of the metastatic tumor is favorable.

Renal cell carcinoma with metastases to the gallbladder: four cases from the National Cancer Institute (NCI) and review of the literature

OBJECTIVE

We evaluate presentation and outcome of patients with metastatic RCC to the gallbladder from our institution and published literature.

METHODS

Patients with a history of gallbladder metastasis from RCC were selected from our institution's prospective database. A systematic PubMed search was performed to identify articles describing patients with metastatic RCC to the gallbladder. The final cohort included 33 patients: 4 from our institution and 29 from 28 previously published cases. Survival analysis was conducted using log-rank Kaplan-Meier analysis.

RESULTS

Median patient age was 63 years and the majority of patients were male. Most patients were asymptomatic and diagnosed with gallbladder metastasis on imaging performed for surveillance or staging. The median time to gallbladder metastasis following nephrectomy was 4 years. Metastasis to the gallbladder occurred both synchronously (33%) and metachronously (67%). Of the patients with available histology, all had clear cell RCC (n = 28). Of all patients, 13 (39%) had metastasis only to the gallbladder, while 20 (61%) had additional sites of metastasis. The most common sites of additional metastasis were contralateral kidney (30%), pancreas (21%), lung (18%), adrenal (18%), and lymph nodes (9%). All patients underwent cholecystectomy. At a median follow up time of 1.5 years after cholecystectomy, 54% of patients had no evidence of disease, 14% were alive with metastasis, 23% had died from metastatic RCC, and 9% died from causes unrelated to their cancer.

CONCLUSION

Gallbladder metastasis from RCC is a rare event that may occur synchronously or metachronously with most patients being asymptomatic. Clear cell carcinoma appears to be the primary pathology associated with gallbladder metastasis. High rates of bilateral RCC and pancreatic metastasis suggest novel associations in patients with RCC and gallbladder metastasis.

Indications and recommended approach for surgical intervention of metastatic disease to the gallbladder

Metastatic disease to the gallbladder is unusual. The most common malignancy metastatic to the gallbladder is melanoma, followed by renal cell carcinoma (RCC) and breast cancer. Due to the unusual nature of the disease, there are no trials available for review. Thus, the management for these patients has been based on institutional experience and review of case series. The indications for surgical intervention for melanoma are metastatic disease discrete to the gallbladder and biliary symptoms, which are uncommon for melanoma, but might occur due to cystic duct obstruction culminating in cholecystitis. Laparoscopic cholecystectomy without a lymphadenectomy is emerging as the preferred approach for this metastatic deposit. The vast majority of patients with metastases to the gallbladder from RCC carry a good prognosis and a laparoscopic cholecystectomy should be considered. Patients with metastases to the gallbladder from the breast classically present with biliary symptoms and commonly undergo a laparoscopic cholecystectomy, which invariably demonstrates a deposit in the gallbladder from lobular breast cancer. In the present report, we review the indications for surgical intervention from various malignancies metastatic to the gallbladder and the current consensus for the laparoscopic approach from the diverse metastatic deposits to the gallbladder.

Value of pancreatic resection for cancer metastatic to the pancreas

BACKGROUND

Cancer metastatic to the pancreas from other primary sites is uncommon, and it has been treated with an aggressive surgical approach in fit patients when the primary tumor is controlled and the pancreas is the only site of metastatic disease. The value of pancreatic resection in this setting is unclear. The purpose of this study was to review cases of cancer metastatic to the pancreas.

METHODS

We reviewed our experience with cancer metastatic to the pancreas and the literature regarding resection of pancreatic metastases. Patient and tumor characteristics were summarized using descriptive statistics.

RESULTS

A total of 220 patients with pancreatic metastasis were analyzed. Three patients were selected from our own experience, and 217 were selected from a literature review. In the 127 patients whose symptoms were recorded at the time of presentation, the most common presenting symptoms were jaundice (n = 32, 25.2%) and abdominal pain (n = 25, 19.7%). In the 189 patients for whom the location of the metastasis in the pancreas was revealed, the most common location was the head of the pancreas (n = 79, 41.8%). The primary tumor site was most commonly kidney (n = 155, 70.5%). Surgical resection was attempted in 177 of 220 patients; 135 patients suffering from RCC metastasis also underwent pancreatic resection. In the latter group, a median survival of 70 months was seen, as well as 78% and 65% 2- and 5-year survival rates, respectively.

CONCLUSION

Survival after resection of RCC with isolated metastasis to the pancreas is favorable. However, a more detailed analysis considering outcomes without surgery for each primary tumor site is needed before the value of this aggressive surgical approach can be completely assessed in the general occurrence of pancreatic metastasis.

Ruptured gallbladder as the first presentation of breast cancer

Background

Perforation of the gall bladder as a first presentation of breast cancer has not been reported.

Case presentation

Here we present a case of an elderly lady with acute abdomen with evidence of possible perforation of gall bladder on CT scan. Histopathology of the cholecystectomy specimen revealed invasive lobular breast cancer.

Her metastatic breast cancer with right sided primary discovered subsequent to her presentation with acute abdomen is managed successfully with Anastrozole.

Conclusion

We present a rare case of gall bladder perforation from metastatic breast cancer.

A rare cause of distal bile duct stenosis

INTRODUCTION

In a patient with a distal bile duct stenosis a definite diagnosis could not be made preoperatively.

DISCUSSION

The histologic evaluation of the surgical resection specimen revealed infiltration of the pancreatic head and the distal bile duct by breast tumor cells.

CONCLUSION

The metastasis was the only tumor manifestation after mastectomy 12 years ago.

Value of pancreatic resection for cancer metastatic to the pancreas

BACKGROUND

Cancer metastatic to the pancreas from other primary sites is uncommon, and it has been treated with an aggressive surgical approach in fit patients when the primary tumor is controlled and the pancreas is the only site of metastatic disease. The value of pancreatic resection in this setting is unclear. The purpose of this study was to review cases of cancer metastatic to the pancreas.

METHODS

We reviewed our experience with cancer metastatic to the pancreas and the literature regarding resection of pancreatic metastases. Patient and tumor characteristics were summarized using descriptive statistics.

RESULTS

A total of 220 patients with pancreatic metastasis were analyzed. Three patients were selected from our own experience, and 217 were selected from a literature review. In the 127 patients whose symptoms were recorded at the time of presentation, the most common presenting symptoms were jaundice (n=32, 25.2%) and abdominal pain (n=25, 19.7%). In the 189 patients for whom the location of the metastasis in the pancreas was revealed, the most common location was the head of the pancreas (n=79, 41.8%). The primary tumor site was most commonly kidney (n=155, 70.5%). Surgical resection was attempted in 177 of 220 patients; 135 patients suffering from renal cell carcinoma (RCC) metastasis also underwent pancreatic resection. In the latter group, a median survival of 70 mo was seen, as well as 78% and 65% 2- and 5 y survival rates, respectively.

CONCLUSION

Survival after resection of RCC with isolated metastasis to the pancreas is favorable. However, a more detailed analysis considering outcomes without surgery for each primary tumor site is needed before the value of this aggressive surgical approach can be completely assessed in the general occurrence of pancreatic metastasis.

Metastatic disease to the pancreas and spleen

Isolated metastases to the pancreas and spleen are a rare occurrence. When they are diagnosed, pancreatic metastases are most often from renal cell carcinoma, lung cancer, and breast cancer. The most common source of splenic metastases is gynecological in origin; the overwhelming majority is ovarian. If extensive staging studies reveal these metastases to be isolated, then curative resection may be warranted. This review will demonstrate that long-term survival may be achieved in patients with isolated metastases and a prolonged disease-free interval.

Breast signet-ring cell lobular carcinoma presenting with duodenal obstruction and acute pancreatitis

We report here an extremely rare case of breast signet-ring cell carcinoma (SRCC) initially manifesting as duodenal metastasis and acute pancreatitis. A 62-year-old female presented with duodenal obstruction and swollen head of the pancreas, and the diagnosis of acute pancreatitis was initially made. Upper gastrointestinal endoscopy revealed duodenal stenosis with erosive mucosa, with signet-ring cells infiltrating the submucosal layer, suggesting duodenal metastasis of SRCC. Despite absence of a palpable mass in both breasts, computed tomography revealed diffuse enhancement of the left breast in addition to left axillary lymphadenopathy. Histological examination of mammary needle biopsy samples revealed SRCC with a non-invasive lobular carcinoma component. Primary breast SRCC with duodenal metastasis was therefore diagnosed. The patient underwent palliative surgery twice for intestinal obstruction due to peritoneal dissemination. She has remained alive without bowel obstruction for 18 months while being treated with cytotoxic chemotherapies.

Bilateral synchronous breast carcinomas followed by a metastasis to the gallbladder: a case report

Background

Breast cancer is usually associated with metastases to lungs, bones and liver. Breast carcinoma metastasizing to the gallbladder is very rare.

Case presentation

A 59-year-old woman presented with bilateral synchronous breast lesions. A palpable, retroareolar solid lesion of diameter equal to 5 cm was present in the right breast, and a newly developed, non-palpable lesion with microcalcifications (diameter equal to 0.7 cm) was present in the upper outer quadrant of the left breast. Modified radical mastectomy was performed on the right breast and lumpectomy after hook-wire localization was performed on the left breast, combined with lymph node dissection in both sides. The pathological examination revealed invasive lobular carcinoma grade II in the right breast and invasive ductal carcinoma grade I in the left breast. Chemotherapy, radiation therapy, trastuzumab and letrozole were appropriately administered. At her 18-month follow-up, the patient was free of symptoms; the imaging tests (chest CT, abdominal U/S, bone scan), biochemical tests, blood cell count and tumor markers were also normal. At the 20th month after surgery however, the patient developed symptoms of cholecystitis and underwent cholecystectomy. The histopathological examination revealed metastasis of the lobular carcinoma to the gallbladder.

Conclusion

This extremely rare case confirms on a single patient the results of large series having demonstrated the preferential metastasis of lobular breast cancer to the gallbladder. Symptoms of cholecystitis should not be neglected in such patients, as they might indicate metastasis to the gallbladder.

A case of breast cancer metastatic to the tail of the pancreas

Breast cancer metastasis to pancreas is rarely seen. There have been only 6 cases described in the literature. We present the seventh case of a 54-year-old woman with breast cancer that metastasized to the tail of the pancreas 4 years and 4 months after radical mastectomy. Although the serum levels of CA15-3 and TPA had gradually increased without symptoms, it was difficult to establish the diagnosis before contrast-enhanced abdominal CT scan was performed. Immunohistochemical staining using E-cadherin was positive, proving that the breast cancer was ductal rather than lobular in origin. CA15-3 immunohistochemically stained positive in the resected pancreas lesion. Positive monoclonal staining by GCDFP-15 (gross cystic disease fluid protein-15) in the pancreas tumor also confirmed it breast cancer origin. Investigation of chemokine/chemokine receptors may clarify a new mechanism of metastasis to the pancreas from breast cancer.

Diagnosis of nonprimary pancreatic neoplasms by endoscopic ultrasound-guided fine-needle aspiration

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is a proven modality for the diagnosis of primary pancreatic neoplasms. We describe our experience in diagnosing nonprimary pancreatic tumors by EUS-FNA. Cytology files were searched for all EUS-FNA of the pancreas for the period 2000-2002. All cases diagnosed as neoplasms were selected and those diagnosed as nonprimary pancreatic tumors were reviewed and analyzed. One hundred ninety-one of 468 cases were diagnosed as neoplasms. Eleven of these cases were diagnosed as nonprimary pancreatic tumors (2.4% of all diagnoses and 5.7% of all neoplasms). The diagnoses were supported by clinical history (n = 7), cytological findings (n = 11), cell block histology (n = 11), cell block immunohistochemistry (n = 6), and flow cytometry (n = 1). EUS-FNA is a safe and minimally invasive method for the diagnosis of nonprimary pancreatic neoplasms. Evaluation of clinical history, cytomorphology, and ancillary techniques, especially those applied to cell block material, are essential for accurate diagnoses.

A case of invasive lobular carcinoma of the breast first manifesting with duodenal obstruction

Lobular carcinoma of the breast presents with various clinical manifestations. Lobular carcinoma comprises about one fifth of cases of ductal carcinoma. Intestinal metastasis is dominant in cases of lobular carcinoma. Without a prior diagnosis of lobular carcinoma of the breast, the diagnosis of intestinal metastasis from breast cancer is difficult. A 52-year-old women underwent duodenogastrectomy for duodenal cancer. About 18 months later, she underwent mastectomy for lobular carcinoma of the breast. The duodenal cancer consisted mainly of malignant cells invading the submucosa that were identical to those in the breast. Immunohistochemical assays for estrogen receptor also confirmed breast cancer metastasis. Duodenal obstruction was the first sign of isolated metastatic lobular carcinoma of the breast in this case. The characteristic metastatic pattern of lobular carcinoma, which differs from that of ductal carcinoma, should be kept in mind to ensue proper diagnosis. Preceding breast surgery for lobular carcinoma should prompt investigation based on the typical metastatic pattern.

Pancreatic metastases: observations of three cases and review of the literature

BACKGROUND

The aim of the study is to analyze pancreatic metastases and their clinical, radiological, therapeutic and prognostic features.

METHODS

Three cases of pancreatic metastases observed and a world literature review of 333 cases were recorded.

RESULTS

Pancreatic metastases are due more frequently to renal cell carcinoma; they are usually metachronous and characterized by a long period of time between the resection of the primary tumor and their detection. The differential diagnosis with other pancreatic masses is difficult, but an accurate anamnesis, some peculiar findings of imaging techniques and percutaneous fine needle aspiration could allow preoperative diagnosis. Pancreatic resections are the treatment of choice allowing the better palliation and improving survival. 150/234 pancreatic metastases underwent pancreatic resections (resectability index = 64.1%); 88/132 patients are alive with a mean follow-up of 27.1 months; of the 44 dead patients the mean survival time was 21.3 months. Among pancreatic metastases the primary tumor with better prognosis is renal cell carcinoma.

CONCLUSION

Pancreatic metastases are rare; their preoperative diagnosis is difficult but useful and possible. Surgical resection is suggested because the patient still may have a prolonged survival.

Secondary tumors of the pancreas: an analysis of a surgical and autopsy database and review of the literature

The vast majority of pancreatic carcinomas are primary, and, among these, more than 90% are of ductal origin. However, a variety of extrapancreatic tumors may involve the pancreas secondarily and may manifest different clinicopathological characteristics and outcomes. In this study, pathology material from 973 surgical specimens and 4955 adult autopsy cases was reviewed to identify the tumors metastatic to or secondarily involving the pancreas. Biliary and periampullary neoplasms and tumors confined to peripancreatic soft tissue were excluded. In the autopsy series, the pancreas was involved by tumor in 190 cases, and 81 of these were secondary tumors. These were predominantly of epithelial origin, most commonly from lung (34), followed by GI tract (20), kidney (4), breast (3), liver (2), ovary (1), and urinary bladder (1). In addition, there were six tumors of hematopoietic origin, two melanomas, two sarcomas, and two mesotheliomas. Among the 973 surgical specimens, 38 cases contained metastatic tumors to the pancreas. Of these, 11 were lymphomas, and the others were carcinomas of stomach (7), kidney (6), lung (2), liver, prostate, ovary, uterus (1 case of each), and a Merkel cell carcinoma. In addition, there were three malignant gastrointestinal stromal tumors and one retroperitoneal leiomyosarcoma. In conclusion, lung cancer is the most common source of metastasis to pancreas, followed by gastrointestinal carcinomas and lymphomas. These tumors are usually seen in patients with disseminated disease and are detected mainly in autopsies. Secondary tumors constitute about 4% of pancreatic specimens in the authors' surgical database. Approximately one-third of them are clinically mistaken as primary tumors of the pancreas. These are predominantly hematopoietic malignancies or carcinomas of renal or gastric origin. Secondary tumors should be entertained in both the clinical and pathological differential diagnosis of pancreatic neoplasia.

A case of breast cancer metastasizing to cervix after resection of pancreatic metastasis

A case of breast cancer that metastasized to the cervix 10 years and 8 months after mastectomy is reported. The patient had undergone pancreaticoduodenectomy due to solitary metastasis to the head of the pancreas 4 years previously. The cervical metastasis was associated with abnormal genital bleeding. After pancreaticoduodenectomy the serum levels of CEA, CA15-3 and NCC-ST-439, which are markers of breast cancer, were within normal limits, but the serum level of CA15-3 had increased month by month. The patient had abnormal genital bleeding and presented to the department of gynecology at our hospital. The tumor was in the cervix, bled easily and 2.5x2.0 cm in size on ultrasonography. It was thought to be carcinoma of the cervix, but biopsy revealed the tumor to be an adenocarcinoma pathologically and CA15-3 was immunohistochemically demonstrated in the resected specimen, similar to lobular carcinoma of the breast. Abdominal CT scan revealed involvement of the ovaries and uterus, prompting hysterectomy with bilateral oophorectomy. After discharge, she received chemoendocrine therapy. However, she subsequently died due to peritoneal carcinomatosis.

Breast cancer metastatic to abdomen and pelvis: role of surgical resection

OBJECTIVE

The purpose of this study was to describe the characteristics and outcome of women with metastatic breast cancer to the abdomen and pelvis, and to assess the role of surgical resection of abdominal and pelvic metastasis in this disease.

METHODS

We retrospectively reviewed the medical records of 59 women with documented metastatic breast cancer to the abdomen or pelvis who had exploratory surgery by the Gynecology Service between 1986 and 2001.

RESULTS

Exploratory surgery was performed a median of 5 years (range, 0-25 years) after initial diagnosis of breast cancer. Median survival from diagnosis of abdominal disease was 23 months, and 5-year survival was 24%. Survival was 36 months for optimally debulked patients (<2 cm of residual disease) and 20 months for suboptimally debulked patients (P = 0.07). Patients diagnosed 5 or more years after initial breast cancer diagnosis had a median survival of 36 months versus 17 months if diagnosed earlier (P < 0.01). On multivariate analysis the time to recurrence of breast cancer in the abdomen and optimal debulking were both significant variables. Hazard ratio for dying of disease if recurring before 5 years was 2.7 (CI 1.45-5.03) [P < 0.01]. Hazard ratio for dying of disease if suboptimal debulking was achieved was 2.14 (CI 1.13-4.02) [P = 0.02].

CONCLUSIONS

The disease pattern of metastatic breast carcinoma to the abdomen and pelvis does not appear to effect survival. Survival in patients where optimal debulking is achieved and in those recurring late is improved. Surgical resection of metachronous metastatic breast cancer to the abdomen and pelvis may be an important component of the management of this disease and should be considered in candidate patients.

Bowel obstruction due to extrinsic compression by metastatic lobular carcinoma of the breast

The commonest sites for breast cancer metastases are the bones, lungs, liver, pleura, adrenals and central nervous system. However, although other sites have been reported, solitary metastases to the gastrointestinal tract are extremely uncommon. Widely disseminated gastrointestinal metastases may be found in up to 20% of patients. Although only 15% of patients with breast cancer will have the lobular variety, these make up the majority of patients with solitary gastrointestinal metastases. Here we present three cases where solitary lobular breast cancer metastases have been demonstrated to be the cause of bowel obstruction. In two cases of duodenal obstruction was demonstrated and in the third colonic obstruction. In all cases a focal extrinsic compression was found.

A Case of Breast Cancer Metastatic to the Head of the Pancrea

A case of breast cancer that metastasized to the head of the pancreas 6 yearsand 8 months after mastectomy is reported. The pancreas head metastasis was associated with general fatigue and obstructive jaundice. The serum levels of CEA, CA15-3 and NCC-ST-439, tumor markers of breast cancer, were within normal limits, but CA15-3 was immunohistochemically demonstrated in the resected metastatic lesion, in a manner similar to lobular carcinoma of the breast.

Fine-needle aspiration cytology of metastatic clear-cell renal carcinoma presenting as a solitary mass in the head of the pancreas

In nearly 25% of patients with primary renal-cell carcinoma, metastasis is not uncommon and usually does not give rise to difficulties in diagnosis. However, its presentation as a mass in the head of the pancreas following an elapse of several years after the initial diagnosis of renal carcinoma is not only uncommon but may be confused clinicoradiologically with a primary pancreatic adenocarcinoma. The case presented here illustrates such an example with an emphasis on the usefulness of fine-needle aspiration cytology (FNAC) in the diagnosis.

Pancreatic metastases from breast cancer: an unusual cause of biliary obstruction

Metastatic tumour deposition within the pancreas is a rare cause of biliary obstruction. We present a case in which obstructive jaundice was the first sign of dissemination of a breast cancer, the cause being intrapancreatic obstruction to the biliary tree by tumour.

Utilization of fine-needle aspiration biopsy in the diagnosis of metastatic tumors to the pancreas

There is relatively little information concerning the use of fine-needle aspiration biopsy (FNAB) to diagnose a mass in the pancreas that is secondary to metastatic tumor. This study reviews the incidence and types of neoplasms which metastasize to the pancreas and assesses the contribution FNAB can make in their diagnosis. Of 117 radiologically guided FNABs of the pancreas, 11% (n = 13) showed metastatic malignancy. Nine patients had a previous history of malignancy while four patients presented with a pancreatic mass and were subsequently found to have wide-spread malignant disease. The majority of metastatic lesions were epithelial (77%, n = 10). Patient outcomes were generally poor (mean survival 2.8 mo). Metastases to the pancreas occur from a variety of primary sites and should be considered in patients with a pancreatic mass and a history of prior malignancy. FNAB is useful in diagnosing these metastases and this is clinically important because of their poor prognosis.