S2370 A Unique Case of Ampulla of Vater Metastasis From Breast Cancer Without Hepatic/Pancreatic Involvement

Abstract

INTRODUCTION: Breast cancer is a leading cause of malignancy and death in women worldwide. It usually metastasizes to the brain, bones, lymph nodes, lungs, and liver but may rarely involve the GI tract (in 10%). Bile duct involvement from breast cancer without liver involvement is uncommon. We report an exceptionally uncommon case of ampullary metastasis from breast cancer without liver metastases who presented with nausea and vomiting. CASE DESCRIPTION/METHODS: A 59-year-old female with PMH of ER-/PR-Her2+ breast cancer (invasive ductal carcinoma-diagnosed in 2007) s/p lumpectomy, adjuvant chemoradiotherapy followed by local in-breast recurrence in 2013 with a metastasis to CNS/pleura s/p chemoradiotherapy presented from a rehabilitation center with persistent nausea, vomiting, RUQ pain, clay-colored stools and dark urine. Physical examination revealed RUQ abdominal tenderness. Routine laboratory tests were significant for abnormal liver blood tests (Tbil 2.9, ALP 462, AST 598, ALT 931, Lipase 558). She was resuscitated with iv fluids and was started on antibiotics and antiemetic. RUQ US showed dilatation of CBD and intrahepatic ducts. CT abdomen/pelvis with IV contrast confirmed US findings and the pancreas was unremarkable. Subsequent ERCP showed erythematous major papilla with severe and diffuse dilatation of the common bile duct, left main hepatic duct and right main hepatic duct with friable major papillary mucosa. Cells for cytology were obtained by brushing lower biliary and ampullary areas. A 10 Fr x 7 cm plastic biliary stent was placed 6 cm into the common bile duct. Her symptoms improved after the stenting and she started tolerating food. Liver blood tests also improved(Tbil 0.8, ALP 388, AST 80, ALT 558, Lipase 76). The pathology from the biopsy of the ampullary area showed poorly differentiated carcinoma consistent with metastasis of the patient's metastatic breast cancer which was ER/PR/HER2 +ve. She was discharged from the hospital back to the rehabilitation center, however, she succumbed to breast cancer. DISCUSSION: Biliary tract involvement by metastatic cancer is uncommon in general, colon cancer being the most common. Metastasis to the biliary tract and ampulla of Vater from isolated breast cancer without liver involvement is rare. Clinically, it is important to recognize this group of patients as relief of biliary obstruction using surgical bypass or biliary stenting may extend survival to over 1 year, in comparison to those with liver metastasis, whose mean survival is usually 1 month.Figure 1.: Area of Papilla in the 2nd Portion of the Duodenum showing erythematous major papilla, Congested major papilla.Figure 2.: Fluoroscopy image of stent placement.Figure 3.: Poorly differentiated carcinoma cells in intestinal mucosa with positive GATA-3 staining consistent with metastasis from breast primary.