Metastatic Lobular Carcinoma of the Breast Mimicking Barrettʼs Esophagus

Abstract

A 63 year-old female with a past medical history of lobular carcinoma of the breast who underwent mastectomy 5 years ago, hypertension, and hypothyroidism presents with a 4 year history of gastroesophageal reflux symptoms including post prandial epigastric abdominal pain, bloating, and burning sensation in the epigastric area non refractory to several trials of proton pump inhibitors. The patient was a non smoker with no alcohol use. Physical exam was unremarkable. EGD was conducted which demonstrated findings consistent with Barrett's esophagus extending 33 cm to 35 cm from the incisors. Round lesions were also noted consistent with peri-esophgeal lymph nodes at 28 cm from the incisors. One measuring 4x5 mm and the other larger lesion measured 5x13 mm. Under Doppler guidance, a 25 G FNA was used to obtain 4 passes of the larger lymph node. A biopsy of the tissue was obtained and VLE was performed on the mucosa. Endoscopic en bloc resection of the nodule was conducted utilizing hot snare technique. Pathology of the resected tissue demonstrated poorly differentiated adenocarcinoma that was estrogen receptor positive, progesterone and HER2neu negative consistent with metastatic lobular carcinoma of the breast. The patient was referred to oncology for further management and follow up. Among the population of adults in the United States it is estimated that approximately 5.6% have Barrett's esophagus, a serious complication of gastroesophageal reflux disease in which the normal tissue lining of the esophagus undergoes a metaplastic process replacing damaged squamous mucosa with metaplastic columnar mucosa. Diagnosis is typically made through endoscopic visualization and biopsy that demonstrates columnar mucosa extending above the GE junction. Metastasis of breast cancer to the esophagus is a known but rare occurrence often made difficult to diagnose because they are often located in the submucosa and are covered with normal appearing esophageal mucosa. The mechanism of esophageal spread from breast cancer is controversial with involvement of peri-esophageal lymph nodes through intra-mammary lymphatic channels has been suggested as the most likely origin. This case reinforces the importance of biopsy for neoplastic appearing masses of the esophagus especially in the context of unusual esophageal presentations and a known history of metastatic disease.Figure: Endoscopic imaging of the esophagus proximal to the GE junction demonstrating mucosa with irregular surface, loss of layered architecture and presence of glandular mucosa with irregular cribiform glands.Figure: H&E stain of GE junction demonstrating poorly differentiated carcinoma. The squamous epithelium shows reactive changes, and the rest of the glandular epithelium is inflamed showing mild acute and chronic inflammation.Figure: Immunohistochemical stains demonstrate estrogen receptor positive, progesterone receptor negative, and Her2 negative poorly differentiated metastatic adenocarcinoma of the breast.