Abstract

Introduction: Breast cancer is the most common cancer in women, it is well known to metastasize to lymph nodes, lungs, liver, brain, and bones. However, luminal gastrointestinal metastasis is rare, especially to the appendix. Herein, we report a case where the cancer metastasized to the ileum and appendix causing acute appendicitis and small bowel obstruction. Case summary: A 44-year-old female with a history of stage IV metastatic breast cancer to bones, lungs and ovaries, presented with acute abdominal pain for one day. She was diagnosed 3 years prior to presentation with right invasive lobular carcinoma (estrogen and progesterone positive, HER-2 negative), she had right mastectomy and was started on tamoxifen. One year later she had metastasis to the left breast and lungs, so she was started on Exemestane and Everolimus with stability in disease till her current presentation. On the current presentation her pain was generalized and associated with nausea, vomiting and constipation. Her abdomen was soft, distended with generalized tenderness. A Computed tomography of the abdomen and pelvis showed partial small bowel obstruction and swollen appendix but did not meet the diagnostic criteria of acute appendicitis (Figure 1-2). Her symptoms worsened despite conservative treatment, so she was taken to the operating room for exploratory laparotomy where she was found to have a markedly dilated ileum with peritoneal implants, in addition to an inflamed and edematous appendix surrounded by a foul-smelling fluid collection, so she underwent ileocecectomy, appendectomy, and lysis of adhesions. Pathology showed metastatic breast cancer in the mesentery, appendix and small intestines with findings consistent of acute appendicitis. Her post-operative course was uncomplicated, and she was discharged home with follow up with surgery and oncology.Conclusion: Small intestinal and appendiceal metastases of breast cancer are very rare, though it should be considered in the differential diagnosis in cancer patients presenting with acute abdominal pain.2486_A Figure 1. A CT scan of the abdomen (cross section) showing a fluid-filled loop of the small bowel suspicious for transitional segment of obstruction.2486_B Figure 2. A CT scan of the abdomen and pelvis (coronal section) where part “A” is showing a dilated bowel lobes suggesting intestinal obstruction, and part “B: is showing a swollen appendix.

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