Unusual presentations of primary and secondary esophageal malignancies

A rare recurrence of bilateral breast cancer in the esophagus coincidentally associated with primary gastric cancer: a case report

INTRODUCTION

Cases of esophageal metastasis of breast cancer are extremely rare. We present the case of a patient who developed recurrence as esophageal metastasis following treatment of bilateral breast cancer. Early-stage gastric cancer was also found coincidentally.

CASE PRESENTATION

An 86-year-old Japanese female patient with a history of bilateral breast cancer was found to have a gastric mass on a medical examination. At 72 years of age, she had undergone a total mastectomy with level II axillary lymph node dissection (pT3N0M0 stage II). Left breast cancer was found at the age of 79. A total mastectomy was performed with level II axillary lymph node dissection (pT1N0M0 stage I). At the time of her current admission, our patient complained of dysphagia. A repeat gastrofiberscopy revealed a submucosal lesion in her middle esophagus, located 27cm distal to her incisors, as well as a known type I tumor of the gastric cardia. Computed tomography showed a mass lesion in her middle esophagus that had grown extraluminally and infiltrated the tracheal bifurcation and her left primary bronchus. A boring biopsy of the esophageal lesion was performed under ultrasonic monitoring, and a pathological diagnosis of poorly differentiated adenocarcinoma of the esophagus was obtained. The biopsy of the cardiac lesion revealed moderately differentiated adenocarcinoma of the stomach. The expression status of her hormone receptors indicated that the esophageal lesion reflected metastatic recurrence of her breast cancer with coincidental primary gastric cancer (cT1N0M0 stage IA).

CONCLUSIONS

Esophageal metastasis of breast cancer is extremely rare. An individualized treatment plan combining multimodal approaches should therefore be devised according to the patient's status.

Metastatic breast cancer to the gastrointestinal tract: report of five cases and review of the literature

Luminal gastrointestinal (GI) metastases from breast cancer are rare, reports are fragmentary and poor. The purposes of this study are to assess the gastrointestinal involvement from breast cancer in a retrospective study at a single institution and reviewing the related literature. Between January 2007 and December 2011 a total of 980 patients with breast cancer were treated at our institution, patients' records and report database were analysed. Institutional Review Board approval was obtained for this study. A search of the literature using PubMed, CancerLit, Embase, was performed. Selected for the present review were papers published in English before June 2012. Five of 980 patients (0.5%) showed gastrointestinal metastases from breast cancer, 3 patients had gastric involvement, 1 jejunum, and 1 rectum. Reviewing the literature, 206 patients affected by gastrointestinal metastasis from breast cancer were identified: the most frequent site of metastasis was the stomach (60%). The majority of the patients underwent chemotherapy and endocrine therapy, someone surgery and radiotherapy. GI metastases from breast cancer are rare, but possible, and a very late recurrence can also occur. Cyto-histological diagnosis is mandatory, to differentiate GI metastases from breast cancer to other diseases and to allow an adequate treatment.

Metastatic breast cancer to the gastrointestinal tract: A case series and review of the literature

Metastatic breast cancer involving the hepatobiliary tract or ascites secondary to peritoneal carcinomatosis has been well described. Luminal gastrointestinal tract involvement is less common and recognition of the range of possible presentations is important for early and accurate diagnosis and treatment. We report 6 patients with a variety of presentations of metastatic breast cancer of the luminal gastrointestinal tract. These include oropharyngeal and esophageal involvement presenting as dysphagia with one case of pseudoachalasia, a linitis plastica-like picture with gastric narrowing and thickened folds, small bowel obstruction and multiple strictures mimicking Crohn’s disease, and a colonic neoplasm presenting with obstruction. Lobular carcinoma, representing only 10% of breast cancers is more likely to metastasize to the gastrointestinal tract. These patients presented with gastrointestinal manifestations after an average of 9.5 years and as long as 20 years from initial diagnosis of breast cancer. Given the increased survival of breast cancer patients with current therapeutic regimes, more unusual presentations of metastatic disease, including involvement of the gastrointestinal tract can be anticipated.

Metastatic esophageal tumors from distant primary lesions: report of three esophagectomies and study of 1835 autopsy cases

Three cases of esophagectomy for secondary esophageal carcinoma metastasized from the ovary, breast and lung are reported. Long-term survival, 14 and 4 years, after esophagectomy was achieved in two patients. The intervals between surgery for primary cancer and dysphagia onset in these two patients were 16 and 7 years, respectively. An aggressive surgical approach appears to be the therapeutic procedure of choice for metastatic esophageal carcinoma when the primary tumor growth rate is suspected to be slow. Autopsy data on 1835 cases revealed 112 (6.1%) had metastasis to the esophagus. The lung was the most common primary tumor-bearing organ and the diffusely infiltrative type was the most common esophageal tumor observed macroscopically which corresponded to the findings in our three patients. When an esophageal stricture with normal mucosa is encountered, a metastatic tumor must be taken into consideration.

Does esophagectomy cure a resectable esophageal cancer?

During the years 1978-1990, 401 patients with esophageal cancer were evaluated for curative resection. A retrospective study was undertaken to estimate the efficacy of surgery and select criteria for long-term survival. After investigation, 187 patients (47%) underwent surgery. To evaluate the long-term results, 101 curative esophageal resections classified into stage I (11 patients), II (24 patients), and III, pathological TNM (66 patients), with at least 2 years' follow-up, were considered. Esophagogastrectomy was performed in 91% of the cases and gastric transposition was achieved in 96% of the patients. The anastomoses were intrathoracic (98%) and at the apex of the right thorax for tumors of the middle third of the esophagus. Staplers were used in 76% of sutures. Postoperative hospital mortality was 5.9%. Specific morbidity included strictures 11%, esophagitis 12%, and anastomotic leak 2%. Actuarial 5-year survival was 90.9% in stage I, 52.3% in stage II, and 17.7% in stage III. The overall 5-year survival rate was 34.2%, 64.8% for the N0 patients, and decreased to 17.7% when node involvement was observed. Five- to 8-year survival is also considered. It is concluded from this study that esophagectomy is actually the appropriate treatment in patients with nonmetastatic resectable carcinoma with an overall 34.2% 5-year survival. The operation can be performed with a low morbidity and mortality rate if done in experienced centers.

Esophagectomy for metastatic carcinoma of the esophagus from lung cancer

A patient with metastatic carcinoma of the esophagus from lung cancer is reported. The patient was a 54-year-old woman who underwent a left lower lobectomy for lung cancer 5 years previously. The authors performed a thoracic esophagectomy, dissection of mediastinal lymph nodes, and reconstruction of the esophagus; the surgery was followed by chemotherapy. Because the histologic pattern of the esophageal tumor was similar to that of lung cancer and mucosal involvement was not seen, the esophageal tumor was interpreted to be a metastasis from lung cancer. The patient is well without recurrence of disease 23 months after operation. This is the first report of a successful esophagectomy for metastatic carcinoma of the esophagus from lung cancer.

Enucleation of a secondary esophageal mural tumor

Metastatic tumors to the esophagus have been described as having the imaging characteristics of benign mural tumors such as leiomyomata, but application of enucleation in treating such tumors has not been described. Our report describes long esophageal myotomy and enucleation of tumor for palliation of dysphagia due to a mural tumor originating from a lung primary.

Case report: esophageal metastasis from breast carcinoma presenting as achalasia

Metastatic breast carcinoma to the esophagus most often presents with a mid-esophageal stricture. Involvement of the gastroesophageal junction by breast carcinoma is distinctly unusual. The authors report the case of a 78-year-old woman who presented with clinical and radiologic features of achalasia secondary to breast carcinoma, metastatic to the gastroesophageal junction. Metastatic breast cancer to the gastroesophageal junction should be added to the list of conditions mimicking achalasia.

The occurrence and management of esophageal fistulas resulting from Hodgkin's disease

At their radiation therapy (RT) department, the authors saw a young woman with an esophageal fistula from Hodgkin's disease that was not responsive to chemotherapy; this prompted a review of the literature concerning such patients. Twenty-two patients with Hodgkin's disease and esophageal fistula were found to have been reported previously. Most patients had active disease at the fistula site, and most who were treated with RT or chemotherapy had prompt fistula closure. Fistula formation as a complication of RT for Hodgkin's disease was found to be an extremely unusual occurrence.

Successful esophagectomy for metastatic carcinoma of the esophagus from breast cancer--a case report

A case of progressive dysphagia due to metastatic carcinoma of the esophagus from breast cancer is described herein. The patient was a 55-year-old Japanese woman who had undergone a right radical mastectomy for carcinoma of the right breast 9 years previously. We performed a subtotal esophagectomy and reconstruction, using the stomach. She is now well and working without any further symptoms, five years after surgery. Thus, palliative surgery for the complications caused by metastatic carcinoma of the esophagus may be worthwhile.

Surgery and current management for cancer of the esophagus and cardia

The current status of carcinoma of the esophagus is reviewed, with specific discussions on current problems. These are difficulties in staging the disease, confusion in the classification, surgery vs. radiation therapy, palliative vs. curative resection, transthoracic vs. transhiatal resection for palliation, and stomach vs. colon as an esophageal substitute after resection. The importance of dysphagia as the presenting complaint is stressed, and the etiologic factors for squamous and adenocarcinoma are reviewed, with a focus on Barrett's esophagus. In management, an emphasis is placed on intraoperative staging, the selection of patients for curative resection, the theory and use of en bloc resection, and the effect of tumor localization on the choice of surgical procedure. A description of the operative technique for cervical lesions, and transthoracic, transhiatal, and en bloc resection of thoracic lesions is given. The palliative benefit of bougienage, intubation, surgical bypass, radiotherapy, laser therapy, and electrical coagulation is summarized. The benefits of intubation are stressed. The recent advent of combination therapy, particularly with regard to chemotherapy and surgery, is discussed. Although such therapy is exciting in isolated patients, the results are not sufficiently predictable to be considered as standard therapy. More work needs to be done to identify those patients most apt to benefit from the variety of therapeutic modalities available.

Secondary neoplasms of the esophagus

A review of 62 cases of esophageal involvement by secondary neoplasms is reported. The common routes of esophageal involvement are by direct extension of the tumor from the contiguous or adjacent organs (45.2%), via mediastinal nodes (35.5%), and hematogenous spread from a distant primary (19.3%). In the first 2 modes of esophageal involvement, the diagnosis is usually obvious but hematogenous metastases to the esophagus usually pose a diagnostic challenge. Radiologically, hematogenous metastases show a spectrum of features consisting of a short segment of progressive stricture with normal to minimally irregular mucosa, a submucosal mass with or without ulceration, a polypoid mass or masses, and defects in esophageal motility including secondary achalasia. Since endoscopy and biopsy have limited diagnostic yield, radiologic diagnosis plays a key role in the diagnosis of secondary neoplasms of the esophagus irrespective of their mode of spread to the esophagus.

Dysphagia as the presenting symptom of recurrent breast carcinoma

Esophageal obstruction secondary to recurrent breast carcinoma is not widely recognized. Frequently, the esophageal narrowing is attributed to a benign process, resulting in delays of diagnosis and treatment. Such a case prompted this report and review of the literature.