Autor: Edson Guzmán Calderón 1,2,3,4
A 65-year-old Peruvian woman presented with a 4-month history of recurrent, intermittent, little, and painless rectal bleeding. There was no history of previous abdominal surgery. Three years ago, she underwent a radical right mastectomy with dissection of axillary lymph nodes because of invasive lobular breast cancer.
Immunohistochemical staining was positive for estrogen and progesterone receptors, while HER2 resulted negative. She had been treated with anastrozole all the years subsequent to her mastectomy. On examination, her abdomen was normal. Rectal examination revealed big thrombosed hemorrhoids with signs of recent bleeding.
CT and MRI of thorax, abdomen, and pelvis were requested routinely, and this revealed mucosal thickening involving the whole rectum but with involvement of perirectal fat (Fig. 1). A colonoscopy was subsequently arranged which revealed and showed a hyperemic and nodular lesion of the rectal mucosae suggestive of a neoplastic infiltrate with a rectal stricture, located 8 to 12 cm from the anal verge (Fig. 2). Biopsies revealed no evidence of dysplasia or malignancy. Repeat colonoscopy
and biopsies were performed. The histopathological findings revealed rectal metastatic lesion of the invasive lobular breast cancer (Fig. 3a), and the tumor was estrogen receptor positive (Fig. 3b), progesterone receptor positive, and HER negative.
Edson Guzmán Calderón firstname.lastname@example.org 1. Gastroenterology Unit of the Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru 2. Universidad Peruana de Ciencias Aplicadas (UPC), Lima, Peru 3. Universidad San Martin de Porres (USMP), Lima, Peru 4. Gastroenterology Unit, Clinica Internacional, Lima, Peru
We reported a case of rectal metastasis from lobular breast carcinoma, masquerading as a primary rectal cancer. Lobular breast cancer accounts for only 8–14 % of all breast adenocarcinomas. It is the commonest histological type of breast cancer following ductal cancer . Twenty-four cases have been reported on metastatic lobular carcinoma of the breast to the colorectum . McLemore et al. reported that cases of gastrointestinal metastasis from primary breast cancer were as rare as
73 cases among 12,001 cases . In an autopsy series including 52 cases with GI metastases from BC, the distribution of metastases was as follows: 25 % esophagus, 25 % stomach, 28 % small intestine, 19 % colon, and 4 % rectum . There was no mention of the primary histological subtype in this series.
The metastatic pattern of LC and DC differs. LC has a tendency to metastasize to unusual locations, with metastases to the GIT , gynecological organs, and peritoneum or retroperitoneum being more characteristic of LC. In contrast, DC tends to metastasize to the liver, lung, and brain.
Fig. 1 A MRI of the thorax, abdomen, and pelvis was requested routinely, and this revealed mucosal thickening involving the whole rectum but with involvement of perirectal fat
In the largest retrospective non-autopsy case series from Mayo Clinic, including 73 women with BC metastases to the GIT, McLemore et al.  found most of the metastases in the colon and rectum (45 %) or stomach (28 %). Ten of the patients (24 %) had metastases to two or more GI sites. In this study, GI metastases in patients with invasive lobular BC outnumbered twofold those found in patients with invasive ductal BC . The interval from the primary diagnosis and the presence of GI metastases ranged from several months to 12 years.
Clinical presentation of metastatic disease to the GI tract is diverse, and these symptoms may be nonspecific . In our patient, there were not specific symptoms of rectal involvement; gastrointestinal bleeding was an incidental finding. Rectal metastases from lobular breast carcinoma occur usually 5 to 7 years after primary tumors [3, 8]. The most usual manifestation of rectal metastasis has been diffuse infiltration leading to thickening and rigidity of rectal wall . Patients with rectal metastases commonly present having already developed stenosis and obstruction requiring urgent correction, which usually cannot be achieved by systemic treatment . In this case, our patient showed a circumferential stricture, but this lesion did no cause symptoms of intestinal obstruction.
The method for distinguishing between the two is histology and immunohistochemistry. In some cases such as luminal obstruction, endoscopic examination may not be possible, but when possible will provide; however, a biopsy can be performed and histological and inmunohistochemical analysis must be performed .
Early diagnosis of recurrence depends on screening during follow-up. Screening may involve detailed history and physical examination regularly or may include blood testing, alkaline phosphatase (ALP), liver function tests and tumor markers, bone scans, chest radiographs or CT, CT scans of the abdomen and pelvis, and CT scans or MRI of the brain. It has been documented that the latter extensive screening may detect metastasis before the development of any symptoms and also that patients should have a long-term follow-up . In our patient, the diagnosis was incidental during routine CT scan. The etiology of the rectal bleeding was hemorrhoids.
Surgical excision of metastases in accessible sites, in general, offers significant survival advantage over nonoperative treatment. Surgical excision was the treatment of choice in our case of metastasis to the rectum. However, there are no available survival data regarding the operative treatment of breast cancer metastasis to the rectum. The role of adjuvant therapy has also not been determined yet because of the extreme rarity of reported cases .
Fig. 2 A colonoscopy revealed and showed a hyperemic and nodular lesion of the rectal mucosae suggestive of a neoplastic infiltrate with a rectal stricture, located 8 to 12 cm from the anal verge
Gastrointestinal metastases from breast cancer are a rare entity and rectal involvement is rarer. In patients with lobular breast carcinoma presenting with gastrointestinal symptoms, the possibility of disease recurrence must always be kept in mind. Endoscopic diagnosis may be misleading with pathological diagnosis only being made following surgical resection.
Fig. 3 a H & E stain of rectal mucosa infiltrated by invasive lobular carcinoma, dyshesive neoplastic cells of glandular aspect infiltrating (BIndian file pattern^). b Histology image confirming it to be breast metastasis as estrogen receptor positive
Acknowledgments Dr. Herbert Yabar. Chief of Histopathology Unit of Edgardo Rebagliati Hospital. Lima – Perú
Compliance with Ethical Standards
Conflict of Interest The author declares that he has no conflict of interests.
Author’s Contribution Edson Guzman-Calderón is the corresponding author. He is responsible for the conception and design, acquisition of data, or analysis and interpretation of data, drafting the article or revising it critically for important intellectual content, and final approval of the version to be published.
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