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Balázs Á, Vass T, Baranyai Z. Esophageal Strictures due to Mediastinal Metastases from Breast Cancer. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03369-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
AbstractMediastinal metastases represent an infrequent recurrence of breast carcinoma. Esophageal involvement by metastatic tissue is extremely rare. The situation means an unusual diagnostic and therapeutic challenge. Dignity of esophageal stricture is difficult to ascertain; endoscopy and picture giving methods might be conflicting. This study aimed to analyze the clinical characteristics and the therapeutic possibilities of the condition. A retrospective analysis of malignant esophageal stricture cases was performed from a prospectively collected database between 1984 and 2020. Out of 3996 cases with esophageal malignancy, 17 esophageal strictures were confirmed to be related to breast cancer metastasis. Surgical resection was feasible in 3 cases; endoprosthesis insertion was performed for palliation in 7 cases, and in 7 cases, only supportive care was available. Our incidence rate was 0.43%. Dysphagia indicating an affected esophagus presented on average 10.5 years after the primary tumor surgery. Mean duration between onset of symptoms achieving appropriate diagnosis was 6.4 months. Dignity of the malignancy was confirmed only retrospectively in one case. Morphologic findings showed an external esophageal compression in 52.9%, while in 35.3%, a destructive tumor growth affecting the mucosal layer could be found. Overall, survival was 7.6 months referring to 15 cases. The possible occurrence of mediastinal metastases involving the esophagus should be seriously considered in patients with previous breast cancer history. Biopsies obtained from the intact mucosal surface of the stenotic esophagus are often inefficient and misleading; therefore, repeated biopsies are necessary. Options for radical surgery are highly limited.
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Alfian Sulai DD, Krishnasamy T, Nik Mahmood NRK. Diagnostic challenge in silent metastatic invasive breast carcinoma: dysphagia as the only symptom. BMJ Case Rep 2021; 14:14/7/e239997. [PMID: 34290001 DOI: 10.1136/bcr-2020-239997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Metastatic cancer to the oesophagus is rare. Most cases are diagnosed at autopsy or surgery. The breast is the most common organ bearing a primary tumour. Metastatic oesophageal tumours are nearly always located in the submucosal layer with normal benign-looking mucosa, rendering tissue diagnosis difficult. In the absence of breast-related symptoms, the diagnosis of oesophageal metastasis from breast primary would be very challenging. We report a case of a 50 year-old woman, who was referred to our centre for a second opinion after she was offered an esophagectomy for a suspected oesophageal carcinoma. She presented solely with dysphagia and weight loss. Multiple investigations were performed to investigate her dysphagia which eventually led to the diagnosis of metastatic breast cancer with oesophageal involvement. She underwent excision of right breast invasive lobular carcinoma with axillary dissection. She completed her adjuvant chemoradiotherapy and currently on daily dose of tamoxifen, whereby her dysphagia has dramatically improved.
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Affiliation(s)
| | - Theevashini Krishnasamy
- Department of Surgery, Universiti Teknologi MARA Fakulti Perubatan Kampus Sungai Buloh, Sungai Buloh, Malaysia
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Miyake M, Yamada A, Miyake K, Endo I. Esophageal metastasis of breast cancer during endocrine therapy for pleural dissemination 21 years after breast surgery: a case report. Surg Case Rep 2019; 5:22. [PMID: 30771195 PMCID: PMC6377688 DOI: 10.1186/s40792-019-0585-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 02/06/2019] [Indexed: 12/19/2022] Open
Abstract
Background The esophageal metastasis of breast cancer is rare. Moreover, it is extremely unusual for patients to experience the symptoms of esophageal metastasis during their lifetimes. We present a case of dysphagia caused by esophageal metastasis after a long interval following a primary mastectomy. Case presentation A 77-year-old woman with a history of heterochronous bilateral breast cancer and under treatment for pleural dissemination recurrence originating from right breast cancer complained of dysphagia. At the age of 56, she had undergone a right radical mastectomy for right breast cancer. The histopathological findings revealed invasive ductal carcinoma, pT3N1M0, which was estrogen receptor (ER)- and progesterone receptor (PgR)-positive. At the age of 73, she underwent a second operation, a left modified radical mastectomy. The histopathological examination revealed invasive ductal carcinoma, pT1N0M0, which was negative for ER, PgR, and human epidermal growth factor receptor 2 (HER2). Four years after completion of adjuvant therapy for the left breast cancer, pleural effusion on her left side was observed and histopathological examination of a sample revealed pleural dissemination resulting from the right breast cancer. After initiation of therapy for recurrence, she developed dysphagia and, therefore, underwent an upper gastrointestinal tract endoscopic examination. The examination revealed whole circumferential stenosis and a band unstained by Lugol’s solution located 30 cm from her incisors. Examination of a biopsy specimen revealed a subepithelial luminal structure and dysplastic cells. Immunostaining was positive for CK7 and negative for CK20; furthermore, the sample was ER and PgR-positive. Considering the pathological findings, the patient was diagnosed with esophageal metastasis of her right breast cancer. Conclusions Metastatic lesions in the esophagus are often located in the submucosa; therefore, they may not be definitively diagnosed by histopathological examination of mucosal biopsy specimens. Esophageal metastasis originating from breast cancer often occurs as a part of multiple organ metastases; however, esophageal metastasis is usually not considered a prognostic factor for patients. Therefore, treatment should be determined according to the severity of the other metastatic sites and the degree of esophageal stenosis.
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Affiliation(s)
- Masuyo Miyake
- Department of Breast Surgery, Chigasaki Municipal Hospital, Honson 3-5-1, Chigasaki, Kanagawa, 253-0042, Japan.,Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Fukuura 3-9, Kanazawa, Yokohama, Kanagawa, 236-0004, Japan
| | - Akimitsu Yamada
- Department of Breast Surgery, Chigasaki Municipal Hospital, Honson 3-5-1, Chigasaki, Kanagawa, 253-0042, Japan. .,Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Fukuura 3-9, Kanazawa, Yokohama, Kanagawa, 236-0004, Japan.
| | - Kentaro Miyake
- Department of Breast Surgery, Chigasaki Municipal Hospital, Honson 3-5-1, Chigasaki, Kanagawa, 253-0042, Japan.,Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Fukuura 3-9, Kanazawa, Yokohama, Kanagawa, 236-0004, Japan
| | - Itaru Endo
- Department of Gastroenterological Surgery, Yokohama City University School of Medicine, Fukuura 3-9, Kanazawa, Yokohama, Kanagawa, 236-0004, Japan
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Liu A, Feng Y, Chen B, Li L, Wu D, Qian J, Yang A. A case report of metastatic breast cancer initially presenting with esophageal dysphagia. Medicine (Baltimore) 2018; 97:e13184. [PMID: 30407355 PMCID: PMC6250498 DOI: 10.1097/md.0000000000013184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
RATIONALE Breast cancer metastasis to the esophagus is uncommon. To our knowledge, the present case is the first report of breast cancer with dysphagia as the initial symptom. PATIENT CONCERNS A 62-year-old woman was admitted to our hospital for progressive dysphagia. DIAGNOSES Endoscopic ultrasound-guided fine needle biopsy of the esophageal lesion found poorly differentiated carcinoma, and surgical resection of the breast nodule revealed invasive ductal carcinoma. INTERVENTIONS The patient underwent an esophagectomy, and the immunohistochemistry of surgical specimen was identified as metastatic breast cancer. Then patient was treated with chemotherapy and hormone therapy. OUTCOMES The patient remained symptom-free during 5 months of follow-up examinations. LESSONS This case indicates that metastatic breast cancer to the esophagus should be considered as a cause of esophageal stricture in older women.
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Affiliation(s)
| | | | | | - Li Li
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Han SH, Yang MA, Lee JU, Park MS, Lee YJ, Kim JW, Ju MJ, Cho JW. A Case of Esophageal Stricture Due to Metastatic Breast Cancer Diagnosed by Using Endoscopic Ultrasound Guided Fine Needle Biopsy. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2015. [DOI: 10.7704/kjhugr.2015.15.2.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Shang Hoon Han
- Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Seonam University College of Medicine, Jeonju, Korea
| | - Min A Yang
- Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Seonam University College of Medicine, Jeonju, Korea
| | - Jae Un Lee
- Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Seonam University College of Medicine, Jeonju, Korea
| | - Moon Sik Park
- Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Seonam University College of Medicine, Jeonju, Korea
| | - Young Jae Lee
- Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Seonam University College of Medicine, Jeonju, Korea
| | - Ji Woong Kim
- Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Seonam University College of Medicine, Jeonju, Korea
| | - Myoung Jin Ju
- Department of Pathology, Presbyterian Medical Center, Seonam University College of Medicine, Jeonju, Korea
| | - Jin Woong Cho
- Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, Seonam University College of Medicine, Jeonju, Korea
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Kashiwagi S, Onoda N, Asano Y, Noda S, Kawajiri H, Takashima T, Ishikawa T, Hirakawa K. A rare recurrence of bilateral breast cancer in the esophagus coincidentally associated with primary gastric cancer: a case report. J Med Case Rep 2014; 8:58. [PMID: 24533645 PMCID: PMC3930013 DOI: 10.1186/1752-1947-8-58] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 12/23/2013] [Indexed: 12/31/2022] Open
Abstract
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.
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Affiliation(s)
- Shinichiro Kashiwagi
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
| | - Naoyoshi Onoda
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
| | - Yuka Asano
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
| | - Satoru Noda
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
| | - Hidemi Kawajiri
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
| | - Tsutomu Takashima
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
| | - Tetsuro Ishikawa
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
| | - Kosei Hirakawa
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, Japan
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Lahbabi M, Ihssane M, Sidi Adil I, Dafr Allah B. Pseudoachalasia secondary to metastatic breast carcinoma mimicking radiation stenosis. Clin Res Hepatol Gastroenterol 2012; 36:e117-21. [PMID: 22766147 DOI: 10.1016/j.clinre.2012.05.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2012] [Revised: 05/16/2012] [Accepted: 05/23/2012] [Indexed: 02/04/2023]
Abstract
We reported on a rare case of pseudoachalasia secondary to metastatic breast carcinoma mimicking radiation stenosis. A 65-year-old woman was admitted to our department complaining of progressive dysphagia to solids and liquids. Her medical history revealed a surgery for left breast tumour, which had been performed 11 years, previously, with adjuvant treatment based on hormonal therapy and radiotherapy. The presenting symptoms had started 1 year before her admission, with progressive paradoxical medio chest dysphagia. The patient had lost 7 kg in weight without prominent anorexia. The endoscopic, radiological, histological and manometric appearance was in favor pseudoachalasia associated with stenosis of the esophagus. The esophageal mucosa covering the lumen of the stricture after the dilation was smooth and neoplasm was not detected by another repeated biopsy. We could not obtain the diagnosis for the stricture. The most likely diagnosis was a pseudoachalasia associated with esophagus stenosis complicating probably radiotherapy. The patient had received four pneumatic dilatations with several normal biopsies. At the last one (4 months later), pathological examination of the biopsy specimen revealed infiltrating lobular breast carcinoma. The final diagnosis was pseudoachalasia secondary to metastatic breast carcinoma mimicking radiation stenosis. Treatment was based mainly on tamoxifen.
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Affiliation(s)
- Mounia Lahbabi
- Department of hepato-gastroenterology, Hassan II university hospital Fes, Fes, Morocco.
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Vashi PG, Gupta D, Tan B. Colon carcinoma with unusual metastasis to the esophagus manifesting as multiple nodules and Dysphagia: management with systemic chemotherapy. Case Rep Gastroenterol 2012; 6:484-8. [PMID: 22855665 PMCID: PMC3409515 DOI: 10.1159/000341587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We present here the rare clinical case of a 44-year-old gentleman with metastasis from colon carcinoma to the esophagus presenting with multiple nodules and dysphagia, which was successfully managed with systemic chemotherapy. The patient presented at our institution with 3-month history of dysphagia almost 4 years after being operated for stage III carcinoma in the sigmoid colon. Endoscopic findings showed multiple nodules at the gastroesophageal junction and mid esophagus. Histological features and immunostains confirmed the diagnosis of metastatic colon carcinoma. Because of evidence of extensive metastatic disease in the spine and liver requiring systemic therapy, the patient was treated with chemotherapy with irinotecan and cetuximab, with subsequent improvement in tumor markers, liver metastasis and symptoms of dysphagia. Even though repeat endoscopy showed no improvement in esophageal nodules, the overall response to chemotherapy was positive. In conclusion, we present a very rare, previously unreported case of metastases from colon cancer to the esophagus presenting as non-obstructive nodules and dysphagia that responded to systemic chemotherapy.
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Affiliation(s)
- Pankaj G Vashi
- Cancer Treatment Centers of America at Midwestern Regional Medical Center, Zion, Ill., USA
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Wada Y, Harada N, Ohara K, Kawata H, Iwasaki H, Kawamura Y, Gomi T, Ohtoshi M, Nakashima Y. Esophageal metastasis of breast carcinoma. Breast Cancer 2008; 16:151-6. [PMID: 18762863 DOI: 10.1007/s12282-008-0068-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2008] [Accepted: 07/22/2008] [Indexed: 01/27/2023]
Abstract
Esophageal metastasis from primary breast cancer is an unusual manifestation. We recently treated a patient with dysphagia, whose breast cancer had been treated in the distant past. A 70-year-old woman had been followed regularly in our outpatient clinic for 14 years after her primary breast cancer treatment, with no apparent tumor recurrence. After 2 years absence, she consulted our clinic with progressive dysphagia. Contrast esophagography and endoscopic examination with ultrasonography revealed a protruding submucosal tumor that was histopathologically diagnosed as esophageal metastasis of breast cancer. Radiation therapy involving a total of 60 Gy in combination with aromatase inhibitor was given. The patient's dysphagia was greatly relieved, concomitant with marked improvement of the stenotic lesion on imaging. Since treatment for recurrent breast cancer is generally palliative, systemic (chemo- and/or endocrine-) therapy in combination with radiotherapy is the first-line option for esophageal metastasis of breast cancer.
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Affiliation(s)
- Yasuo Wada
- Department of Surgery, NHO Himeji Medical Center, 68 Honmachi, Himeji, Hyogo, 670-8520, Japan.
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Abstract
Metastasis to the oesophagus is most frequently described in association with lung or breast cancer. Diagnosis is frequently complicated as often only normal tissue is present in endoscopic biopsy specimens. Although oesophagectomy for metastasis has been described, few patients are suitable for curative resection. We report the case of a 62-year-old man who developed an oesophageal metastasis from colorectal cancer and review the available literature.
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Affiliation(s)
- Sarah C Thomasset
- Department of Hepatobiliary and Pancreatic Surgery, Leicester General Hospital, Leicester, UK
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Rampado S, Ruol A, Guido M, Zaninotto G, Battaglia G, Costantini M, Portale G, Amico A, Ancona E. Mediastinal carcinosis involving the esophagus in breast cancer: the "breast-esophagus" syndrome: report on 25 cases and guidelines for diagnosis and treatment. Ann Surg 2007; 246:316-22. [PMID: 17667512 PMCID: PMC1933553 DOI: 10.1097/01.sla.0000263507.11053.26] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Breast metastases of mucosal/submucosal layers of the esophagus are extremely rare: esophageal involvement is usually part of a mediastinal carcinosis. AIM We report the largest series to date of 25 cases of metastatic esophageal involvement from breast cancer, discussing both diagnostic techniques and treatment options. MATERIALS AND METHODS Twenty-five female patients with a history of breast cancer referred for secondary esophageal involvement (1980-2006) were studied. RESULTS All patients presented with worsening dysphagia. Twenty-four had undergone surgery for breast cancer a median of 10 years earlier: 1 had received chemoradiotherapy, and 17 had adjuvant radiotherapy/telecobalt therapy following breast surgery. Endoscopic biopsy/cytology were negative for cancer in 17 of 19 patients; in 9 patients, the diagnosis was made with thoracoscopy/laparoscopy. Immunohistochemical staining was done in 10 patients (ER and/or PrR positive). Fifteen patients presented with distant metastatic involvement. Therapy was directed toward dysphagia relief, mostly with endoscopic dilations/prostheses. Complications (4 perforations) occurred only in those 15 patients who had endoscopic dilations/prostheses. Fifteen patients had cytoreductive therapy. Nine of 25 patients are still alive. The median overall survival was 7 months; 1-, 3-, and 5-year survival rates were 44%, 16%, and 8%, respectively. CONCLUSIONS A "breast-esophagus" syndrome can be defined: it is often diagnosed only after excluding other diseases or after relief of dysphagia with adequate therapy. The presence of distant metastases helps the diagnosis of esophageal involvement from mediastinal carcinosis, while diagnosis is a problem in case of mediastinal/pleural disease only: in this case, exploratory thoracoscopy is mandatory for a final diagnosis. Given the high related risk of perforation from endoscopic procedures (dilations/prostheses), the treatments of choice are currently hormone therapy or chemotherapy/radiotherapy.
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Aurello P, D'Angelo F, Cosenza G, Petrocca S, Stoppacciaro A, Ramacciato G, Ziparo V. Gastric Metastasis 14 Years after Mastectomy for Breast Lobular Carcinoma: Case Report and Literature Review. Am Surg 2006. [DOI: 10.1177/000313480607200518] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
In planning treatment of a gastric neoplasm in a patient previously treated for lobular breast carcinoma, it is important to differentiate a primary gastrointestinal tract tumor from a metastatic form. We report a case of a breast lobular carcinoma metastatic to the stomach. The patient underwent a subtotal gastrectomy for symptomatic disease. Although gastric symptoms appeared 14 years after the breast carcinoma, immunohistochemical analysis of the surgical specimen helped to establish that the gastric lesion, thought to be primary, was effectively a metastatic repetition of the breast neoplasm. To better define treatment in a gastric neoplasm patient previously treated for breast carcinoma, the preoperative diagnosis should rule out a metastatic disease. The patient described received an adjuvant chemotherapy according to breast cancer protocol after gastric resection for symptomatic disease. The patient is still alive and undergoing chemotherapy for peritoneal carcinosis.
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Affiliation(s)
| | | | | | - Sergio Petrocca
- Pathology, II School of Medicine, University of Rome “La Sapienza,” Azienda Ospedaliera Sant'Andrea, Rome, Italy
| | - Antonella Stoppacciaro
- Pathology, II School of Medicine, University of Rome “La Sapienza,” Azienda Ospedaliera Sant'Andrea, Rome, Italy
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