TITLE:
Metastatic Lobular Carcinoma of the Breast Presenting with Small Bowel Metastases: Case Report and Literature Review
AUTHORS:
Rodrigo Arrangoiz, María Cristina Ornelas, Janet Pineda-Díaz, Fernando Cordera, David Caba, Eduardo Moreno, Enrique Luque-De-Leon, Manuel Muñoz
KEYWORDS:
Invasive Lobular Carcinoma of the Breast, Metastatic Lobular Carcinoma of the Breast, Metastatic Disease to the Small Bowel from Breast Cancer
JOURNAL NAME:
Advances in Breast Cancer Research,
Vol.9 No.1,
January
15,
2020
ABSTRACT: Introduction: Invasive lobular carcinoma (ILC) is the second most common histologic
type of breast cancer, representing 5% to 15% of invasive tumors. ILC tends to
spread to bones, lungs, central nervous system, reproductive organs, and the
gastrointestinal tract (GI tract). The most commonly affected organs in the GI
tract are the stomach, small intestine, followed by colon and rectum. Case
presentation: A 78-year-old woman who was referred to our institution after having a
bowel obstruction that required a diagnostic laparoscopy where they identified
an obstructing ulcerative lesion in the distal ileum that was managed with a
segmental bowel resection. Pathology report showed an invasive lobular breast carcinoma that occluded 90% of the
bowel lumen. A PET/CT scan revealed a left breast tumor with increased metabolism.
The patient was staged as a clinical cT4b, cN0, cM1 left breast invasive
lobular carcinoma (ER/PgR positive, HER-2 negative). She was managed with
endocrine therapy with Letrozole (an eight-week course). A follow-up PET/CT
showed a peritoneal hypermetabolic nodule adjacent to the previous ileal
anastomosis. The lesion decreased in size and metabolic activity. In a
multidisciplinary fashion, the endocrine therapy was extended
for another three months. Another follow-up PET/CT scan was performed three
months after the identification of the peritoneal implant that showed that the
nodule increased in size and in metabolism. The lesion continued to decrease
significantly in size and became metabolically inactivity. Due to the good
breast response and the possibility that the ileal nodule could be a granuloma,
she underwent an exploratory laparoscopy with excision of the peritoneal nodule,
and a modified left radical mastectomy with immediate breast reconstruction
(complex wound closure). The final pathology report of the nodule was negative
for malignancy. She continued on endocrine therapy and underwent whole breast
irradiation four weeks after the operation. Currently, she is free of disease
with no evidence of local, regional, or distant recurrence, and she is still on
endocrine therapy. Discussion: The time interval between primary breast
cancer and gastrointestinal involvement may range from synchronous presentation
to as long as 30 years. The clinical manifestations in GI lobular breast cancer
metastasis may range from non-specific complaints to acute GI symptoms, such as
a bowel obstruction. There are multiple controversies in the management of ILC.
Systemic treatment should be initiated as soon as possible. Indications for
postmastectomy radiotherapy are also controversial, given the propensity for
multifocal/multicentric tumors and late recurrences, sometimes in atypical
locations. Five years of postoperative adjuvant hormonal therapy is an option
for women with poor prognosis. Remissions are observed in 32% to 53% of
patients. Conclusion: Metastatic lobular carcinoma of the breast has a
wide range of clinical presentations. Patients with a history of breast cancer
who present with new GI tumors should have these lesions evaluated for evidence
of metastasis through histopathologic and immunohistochemical analysis, this
will allow for appropriate management. Currently, breast cancer management
involves a multidisciplinary approach including surgery, radiotherapy, and
systemic medical therapy, and the treatment must be tailored to the patient’s needs.