An extremely rare cause of gastric outlet: breast lobular carcinoma metastases to stomach.

Abstract

A 47-year-old female was admitted with complaints of epigastric abdominal pain, nausea, vomiting, and weight loss that started 3 months ago. Gastroscopy evaluation revealed gastric outlet obstruction due to chronic ulceration in the pyloric region. Endoscopic biopsy samples reported chronic active inflammation. Her physical examination revealed a mobile and solid mass about 2 9 2 cm in size on the upper-outer quadrant of the left breast, and a palpable lymph node of 1.5 cm in diameter on the left axilla. Computerized contrast tomographic imaging revealed a focal density area over the upper-middle of the left breast, about 2.5 cm in diameter, and lymph nodes in the left axilla. Circumferential wall thickening at the pyloric level with distention was observed in abdominopelvic computerized tomography. Patient was operated with antrectomy-truncal vagotomy-gastroenterostomy procedure. A pathologic evaluation reported massive tumoral mass at the distal gastric localization with infiltration to periserosal adipose tissue (T3) and the local invasion pattern was similar to gastric carcinoma with primary neuroendocrine differentiation. Immunohistochemistry showed that carcinoma cells were positive for CK7, ER, PR, GCDFP-15 and Ecadherin was negative (Fig. 1). The patient underwent mastectomy operation in the same hospitalization period after she had clinically stabilized from the first operation. Modified radical mastectomy operation was performed. Pathologic evaluation demonstrated a 3 9 2 9 1.2 cm mass, which histopathologic findings correlated as lobular carcinoma. Immunohistochemical staining was positive for ER, PR, GCDFP-15, and negative for E-cadherin and cerbB2 (Fig. 2). Thirty-one metastatic lymph nodes and one benign lymph node were obtained on axillary dissection. Postoperative follow-ups were all normal and the patient was discharged at the end of the first month. Surgical oncology council opted for the patient to take chemotherapy and hormonotherapy in the postoperative period. Gastrointestinal metastases generally emerge after several years in patients with breast cancers. This period ranged from 5 to 20 years and even 30 years, after the diagnosis of primary breast cancer (26). Symptoms are generally nonspecific in patients with gastric metastasis. Metastases of lobular breast carcinoma are generally characterized by diffuse infiltration of stomach, and radiologic imaging studies may reveal linitis plastica pattern (12,13,14). Metastatic infiltration of the stomach is generally limited to the submucosa or seromuscular layer. Because of this, histopathologic diagnosis must include deep biopsies. Immunohistochemical staining of metastatic breast carcinomas is generally CK7-, GCDFP-15-, CEA-, estrogen receptor (ER)and progesterone receptor (PR)-positive, and CK-20-negative. Among gastrointestinal malignancies, only those of the gastric, colorectal, pancreatic, and transitional cell carcinomas are CK-20 positive, unlike breast carcinomas, which are all are CK-20-positive (17). Survival rates for gastrointestinal metastases of the breast are generally lower than 2 years in most patients (26). The survival rate was better in patients after Address correspondence and reprint requests to: Pinar Sarkut, MD, Department of General Surgery, Uludag University School of Medicine, 16059 Gorukle, Bursa, Turkey, or e-mail: pinartasar@gmail.com