Surg Endosc (1995) 9:820-823
Surgical
Laparoscopy to correctly diagnose and stage metastatic breast cancer
mimicking Crohn's disease
D. W. Easter ~, R. Jamshidipour ~, K. McQuaid 2
1 Department of Surgery, University of California in San Diego, La Jolla, CA 92037, USA
2 Section of Endoscopy, Department of Medicine, Veterans Affairs Medical Center, University of California in San Francisco, San
Francisco, CA 94122, USA
Received: 22 September 1993/Accepted: 29 December 1994
Abstract. We report a case of metastatic lobular
breast carcinoma with extrahepatic gastrointestinal
disease. On the basis of clinical findings, radiologic
investigations, computerized axial tomography, gas-
trointestinal endoscopy, and gastric biopsy, the diag-
nosis of gastric and ileal Crohn's disease was made.
The correct diagnosis of peritoneal carcinomatosis
was made at laparoscopy. This case exemplifies the
utility of laparoscopy in establishing the diagnosis and
staging for abdominal disease of uncertain etiology.
Key words: Breast cancer - - Crohn's disease - - Lob-
ular c a r c i n o m a - Laparoscopy
Laparoscopy has been available to general surgeons to
assist in the diagnosis of obscure conditions of the
abdomen for over 90 years. However, significant en-
thusiasm for this diagnostic modality postdated the re-
cent laparoscopic cholecystectomy "revolution" of
1989-1990.
We have routinely employed diagnostic laparosco-
py when conventional, less-invasive procedures fail to
resolve clinical questions involving abdominal viscera
[6]. The utility of this approach is exemplified by the
following case report.
Case report
A 68-year-old white female was referred to the UCSD Surgical On-
cology Clinic in January 1991. In 1986 she was diagnosed with
"early" breast cancer. Biopsy at that time showed infiltrating lob-
ular carcinoma with features of the signet ring variant. She refused
further staging or surgery and elected to have alternative treatment
Correspondence to: D. W. Easter, UCSD Medical Center, 225
Dickinson Street, San Diego, CA 92013, USA
Endoscopy
© Spfinger-VerlagNew York Inc. 1995
in Mexico, including radiation treatment and tamoxifen. She
stopped taking tamoxifen without medical advice in 1989. Her past
medical history was notable for the diagnosis of "irritable bowel
syndrome" from the age of 19.
She remained asymptomatic until early 1990 when she developed
dysphagia, heartburn, abdominal distension, and bloating. Upper
gastrointestinal endoscopy showed a hiatal hernia, erosive esopha-
gitis, and hyperemia of the gastric folds. Because of these findings,
she was placed on omeprazole in February of 1990.
In April of 1990, the patient was admitted to hospital with an
episode of small-bowel obstruction. She responded to conservative
management. Small-bowel series showed delayed transit with an
irregular segment at the terminal ileum. Repeat gastroscopy and
biopsy of esophagus, stomach, and small bowel were negative for
malignancy.
The patient was empirically placed on oral steroids for suspected
Crohn's disease. Her symptoms improved over the next 6 months.
Colonoscopy in June 1990 showed "narrowing" at the hepatic flex-
ure, with nodularity and edema of the ascending colon. A C T scan
at that time showed thickening of the gastric antrum and ascending
colon. An upper gastrointestinal series in December showed a di-
lated distal esophagus with smooth, tapered narrowing at the gas-
troesophageal junction consistent with a benign stricture. "Cob-
blestoning" of the gastric antrum and multiple aphthous ulcers were
also noted (Fig. 1). These changes were also thought to be a mani-
festation of Crohn's disease.
She had an acute exacerbation of her symptoms in January 1991
and underwent repeat gastroscopy. This showed a normal gastro-
esophageal junction, "nodular cobblestoning," scattered superficial
erosions in the cardia and fundus, and pseudopolyps in the antrum.
Biopsies of the antrum showed acute and chronic inflammatory
changes which were thought to be consistent with Crohn's disease.
Gastric biopsies showed "suspicious" cells but did not reveal the
presence of malignancy.
The patient was referred in January of 1991 for diagnostic lapa-
roscopy. Findings at laparoscopy included diffuse peritoneal carci-
nomatosis involving the stomach, right and transverse colon, and
right hemidiaphragm (Fig. 2). Adhesive bands were observed from
the cecum to the peritoneal side wall. The terminal ileum and cecum
were also involved (Fig. 3). Biopsies of the parietal peritoneum and
the serosal surface of the stomach showed diffuse infiltration by
malignant cells. Histopathology (Fig. 4) was consistent with meta-
static infiltrating lobular carcinoma of the breast. The patient made
an uneventful recovery from her diagnostic laparoscopy.
With further advice, she resumed oral tamoxifen but initially
declined systemic chemotherapy. In March 1991, the patient had
demonstrated bony metastatic disease as well as carcinoma erupting

Fig. 1. Upper gastrointestinal series showing "cobblestoning" of the gastric antrum with multiple aphthous ulcers. These findings were
misinterpreted as Crohn's disease.
Fig. 2. Laparoscopic findings showing diffuse peritoneal carcinomatosis throughout the abdominal cavity, including the right hemidiaphragm
A and the serosal surface of the stomach B.
Fig. 3. Laparoscopic view of the terminal ileum showing infiltration by metastatic tumor and "creeping fat." (See text.)
from the umbilical trocar site, By May 1991 she had developed
marked ascites and radiologic evidence of metastases to the pelvis
and retroperitoneum (Fig. 5). Despite megestrol and two cycles of
intraperitoneal chemotherapy, she died from progressive disease in
July 1991. Autopsy findings included invasive lobular breast carci-
noma involving both breasts, the stomach, small intestine, colon,
spleen, gallbladder, uterus, ovaries, lungs, bones, perirenal fat,
adrenals, and the cerebellum. Of note, she had no metastases to lung
or liver.
Discussion
Breast cancer is the m o s t c o m m o n site of cancer and
the second-most-frequent cause of cancer deaths for
w o m e n in the United States [1]. E x t r a h e p a t i c gastro-
intestinal m e t a s t a s e s f r o m breast cancer, although not
c o m m o n , are b y no m e a n s rare. Such m e t a s t a s e s
present as lesions involving the stomach, small intes-
tine, and colon [5, 7, 10]. T h e clinical picture m a y be
indistinguishable f r o m C r o h n ' s disease or ulcerative
colitis unless p r o p e r tissue biopsies are taken [10--12].
The exact incidence of gastrointestinal metastases
821
arising from breast primaries is not known. In a u t o p s y
series, the incidence is reported as high as 15-18% in
patients dying of breast cancer [2, 3, 9]. H o w e v e r , the
clinical incidence in patients is substantially l e s s - -
m a n y patients with such lesions must remain a s y m p -
tomatic or are not correctly diagnosed. Clavien reports
an incidence of 3.9% in a series of 1192 patients With
breast cancer [4].
Recent reports indicate that this pattern of spread
is often associated with invasive lobular c a r c i n o m a but
it can also o c c u r with ductal c a r c i n o m a [13, 14].
Whereas ductal c a r c i n o m a is usually unilateral and has
a tendency to metastasize to the lungs and the liver,
invasive lobular carcinoma of the breast tends to be
bilateral, with metastases to bone, peritoneum, and
the gastrointestinal tract [8]. Gastric and small-bowel
lesions are m o r e c o m m o n than colonic and rectal le-
sions [3].
S y m p t o m s a s s o c i a t e d with g a s t r o i n t e s t i n a l me-
tastases are non-specific. T h e s e s y m p t o m s m a y , as in
our case, respond to misdirected m a n a g e m e n t . The
radiographic findings m a y r e s e m b l e those of C r o h n ' s
822

Fig. 4. Biopsies obtained at laparoscopy showing metastatic infiltrating

lobular carcinoma of the breast, involving the abdominal wall A, and the
pelvic wall B (hematoxillin & eosin, ×200).
Fig. 5. Computerized axial tomography of abdomen with contrast,
showing advanced widespread disease; there is marked ascites and tu-
mor involvement of the retroperitoneum as well as the umbilical trocar
site.

disease [10]. The absence of lung or liver metastases in
lobular carcinoma can easily confound findings of
computed tomography. Since the metastases are sero-
sal-based, tissue biopsies at endoscopy often lead to
false-negative results. Taal reports only a 60% success
rate in correct interpretation of upper gastrointestinal
endoscopic findings and a disappointing 65% true-
positive rate for deep-tissue biopsies [13]. At colonos-
copy, success rates of 70% for correct endoscopic in-
terpretation and 60% for positive biopsy rates apply
[14]. The median survival from the time of diagnosis in
patients with upper and lower gastrointestinal me-
tastases in the two largest reported series was 12 and
16 months [13, 14], with some patients surviving up to
7 years [4].
To our knowledge, this is the first report of a case
of disseminated breast cancer with gastrointestinal
metastases diagnosed by laparoscopy. The potential
advantages of laparoscopy include (1) accurate patho-
logic staging, (2) safety, (3) capability for large and
multiple biopsies, (4) exact hemostatis following biop-
sies, and (5) patient acceptance [6].
The role of diagnostic laparoscopy in general sur-
gery is expanding. As surgeons become more comfort-
able with minimal-access surgery, it will quite likely
become an important tool not only for the diagnosis
but also for the treatment of many intraabdominal dis-
orders. Laparoscopy may entirely obviate the need for
an exploratory laparotomy in many cases. In patients
with limited life expectancy, this approach can reduce
postoperative discomfort and hospital stay as well as
allow for the rapid initiation of adjuvant therapies.
Acknowledgment. The authors wish to thank Dr. Nissi Varki for
help with the preparation and interpretation of the histopathology
photographs. We would also like to thank Ms. Tracy Templeton for
her excellent assistance in the preparation of the manuscript.
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