Gastric metastases originating from occult breast lobular carcinoma: diagnostic and therapeutic problems

Abstract

Background: Breast cancer is the most frequent malignant tumour to metastasize into the gastrointestinal tract in female and is second only to malignant melanoma. Nevertheless gastrointestinal metastases arising from breast cancer are quite rare. The upper gastrointestinal tract is more frequently involved and lobular infiltrating carcinoma has a greater predilection compared to the ductal type.

Case presentation: The authors describe the case of a 70 years old woman with a preoperative diagnosis of gastric undifferentiated medullary--type carcinoma, which was the first manifestation of an occult breast carcinoma. The primary site of carcinoma was identified with the use of a panel of selected immunohistochemical markers.

Conclusion: Our goal in this case report is to increase the awareness of surgeons and clinicians to rule out the possibility of mammary origin in circumstance of gastric cancer occurring in female, even in patients without a previous or concurrent history of breast carcinoma. Although not a particularly common event, it is, nevertheless, reported in the literature. The differentiation between primary gastric carcinoma and metastatic breast carcinoma is essential for planning the correct therapeutic approach, in order to avoid the patient unnecessary surgery.

Figure 1

Photomicrographs of stomach. a)Small monotonous cells arranged in single elements crowed in mucosal layer (Haematoxylin-eosin original magnification 10×). b) Lenities plastic-like invasion of muscular layers (H&E original magnification 20×). c) Neoplastic cells with signet ring-like appearance: presence of an admixture of signet ring cells with single sharply circumscribed vacuoles and multivacuolated forms (hematoxylin-eosin, original magnification 40×). d-e) Neoplastic cells show a strong expression for cytokeratin 7 (original magnification 20×; 40×). f-g) Tumors cells show diffuse and strong nuclear positivity for oestrogenic receptors (original magnification 10×; 20×). h) Focus of Neoplatic cells. i) Cytoplasmatic positivity for gross cystic disease fluid protein 15.

Figure 2

Mammography showed a nodular lesion with irregular margins of 1 cm in diameter, located in the lower outer quarter of the left breast.

Figure 3

Photomicorgraphs of breast. a-b) Lobular carcinoma: small cells arranged in row and in single cells. (H&E, original magnification 20×). c) Lobular carcinoma: neoplastic cells with signet ring like appearance with univacuolated introcytoplasmatic lumina.(H&E, original magnification 40×). d) Lobular carcinoma: estrogen nuclear expression (original expression 40×).