A Case of Breast Cancer and GI tract

Authors: Arthur Kabuye, Raymond Boakye MD, Sidhu Harshinder MD, Northwest Hospital
Randallstown MD

Abstract:
Background: Breast cancer is the leading cause of cancer in women, followed by lung cancer. Breast
cancers (cancer.org) can start from the glands and this is referred to as lobular cancers, while others that
start from the ducts are referred to as ductal cancers. As with most cancers, breast cancer has several risk
factors that range from genetic to environmental. About 5-10% of breast cancers are linked to gene
mutations, the most common being BRCA 1 and BRCA 2. (Cancer.org). Breast cancer usually invades
the brain, bones, liver and the lungs. In this case, we report a rarity of breast cancer metastasis to the
gastrointestinal tract.

Case Report:
A 61-year-old woman presented to the hospital for follow up of her recurrent T3N0 stage IIB, estrogen
and progesterone receptor positive, HER2/Neu negative invasive lobular carcinoma of the right breast
metastatic to the bone and a new complaint of intractable nausea and vomiting and inability to have a
bowel movement for the past four days. She denies any fever or chills.

Case Presentation:
A 61-year-old female with a history of hypertension, breast cancer with mastectomy, and a possible
diagnosis of pyloric stenosis, presented to the Emergency Department with weakness, fatigue and
lethargy and frequent vomiting. The duration of current symptoms has been for a week. Patient reports
that the symptoms were fluctuating in intensity and she has been nauseated and vomiting very often. The
vomiting happens usually after a meal. Since she has not been able to hold down food, she has lost
appetite to most of her favorite meals. She also complains of periods of constant belching and hiccupping.
While in the Emergency Department, the patient stated that she felt epigastric discomfort/ burning
sensation after which she proceeded to vomit. At this time an NGT was immediately placed. The patient
stated she felt better and was admitted for further evaluation.

Past Medical History:

Patient past medical history was significant for hypertension, Breast Cancer metastatic to the bone,
Pancreatitis, and Gastric Ulcers

Physical Examination:
VITAL SIGNS: Temp: 37.2C, Pulse: 104 bpm, Respiration Rate 19, SaO2: 90 room air
BP: 89/67
GENERAL: Patient tearful and distressed due to being hungry.
HEENT: Normocephalic/Atraumatic.
SKIN: Warm, dry,
NECK: Supple, no JVD.
CARDIOVASCULAR: Regular rate and rhythm, No murmur, Normal peripheral perfusion.
RESPIRATORY: Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal.
MUSCULOSKELETAL: Normal ROM, no tenderness, no swelling.
ABDOMEN: Mild distention, Normal bowel sounds, Tenderness: Mild, epigastric Pain
NEUROLOGIC: Alert and oriented to person, place, time, and situation. No focal neurological deficit
observed, CN II-XII intact.
PSYCHIATRIC: Cooperative, appropriate mood & affect.
Hospital Course:
Upon admission to the hospital, Physical examination revealed distended stomach and endoscopy
revealed gastric outlet obstruction with pyloric channel ulceration. The patient had through-the-scope
balloon dilation performed and biopsied. Results of the biopsy were negative for H. Pylori and no
evidence of dysplasia. Following the procedure, she was able to tolerate small amounts of solids upon
discharge.

Follow up
Two weeks later the patient was readmitted because of a three-day history of recurrent episodes of nausea
and vomiting. The patient stated that she felt lethargic. She stated she had not been able to progressively
tolerate solids. An EGD was performed which revealed complete pyloric obstruction. The next step in
management was to perform an endoscopic ultrasound-guided stent placement with biopsy. Following the
stent placement, the patient denied any nausea and vomiting and was able to tolerate fluids. Results from
the biopsy showed infiltrative poorly differentiated carcinoma consistent with metastatic breast
carcinoma. Immunostaining was further done and the tumor cells were positive for GATA 3, Estrogen
Receptor and negative for CD20 and CDX2, which is consistent with breast carcinoma.

Discussion:
We present a case report of a patient with a history of breast cancer that metastasized to the bones and the
gastrointestinal tract. Breast cancer can metastasize anywhere in the body, though the most common
primarily metastasis is to the bone, lungs, regional lymph nodes, liver, and brain. In this case, the breast
metastasizes to the GI tract particularly to the junction between the stomach and the duodenum. This
presented as pyloric stenosis, which alone is a rare finding in adulthood.
After three continuous bowel obstructions and persistent vomiting, the biopsy was examined using
immunohistochemical analysis. This would help to differentiate between gastric cancer which can present
in the same way and breast cancer metastasis. When it comes to differentiating between the two, we look
at the cytokines expressed by these tumors.
Immunostaining for ER and PR has been reported to be useful for diagnosing metastatic tumors from
breast cancer, although 32% and 12% of primary gastric cancer are positive for ER and PR respectively
(Koike…et al 2014, Schwarz…et al 1998).
With this in mind, immunostaining for just ER and PR may not be sufficient in ruling out gastric
cancer, though they are used to determine to classify breast cancer. We, therefore, have to look beyond
these markers and consider markers like GATA 3, CD20, CDX2 and pankeratin, as these markers are
more sensitive and specific for cells that are of breast origin. Gastric cancer is positive for CDX2 and
CD20 while metastatic breast cancer is positive GATA 3. Our patient was found to be positive pankeratin,
GATA3 and negative for CD20 and CDX2, hence giving us the diagnosis of breast cancer metastasis to
the Gastrointestinal Tract with obstruction.

Conclusion:
Breast cancer metastasis can be differentiated from other primary source tumors by the use of
immunohistochemistry. Just looking at the endoscopy and presentation of patient symptoms can be
misleading in certain cases or even misdiagnosing the patient, which would turn out to be costly for the
patient. Physicians should consider the possibility of a rarity when treating a refractory condition in a
patient with breast cancer history.

I would like to thank Dr. Sidhu Harshinder of Northwest Hospital, MD

Reference:
“What Is Breast Cancer? | Breast Cancer Definition.” Edited by Stacy Simon, American Cancer
Society, 21 Sept. 2017, www.cancer.org/cancer/breast-cancer/about/what-is-breast-cancer.html.

K. Koike, K. Kitahara, M. Hihaki, M. Urata, F. Yamazaki, and H. Noshiro, “Clinicopathological

features of gastric metastasis from breast cancer in three cases,” Breast Cancer, vol. 21, no. 5,
pp. 629-634, 2014