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Gastric linitis plastica due to tnetastatic lobular breast carcinotna

H UGH J FREEMAN, MD, URVE KUUSK, MD, JENNIFER DAVIS, MD

HJ FREEMAN, U KUUSK, J DAVIS. Gastric linitis plastica due to metastatic lobular breast carcinoma. Can J Gastroenterol 1993;7(1):55-57. A 35-yearold female with previously diagnosed lobular breast carcinoma presented with clinical radiographic and endoscopic features of a diffuse gastric infiltrative process. Multiple gastric biopsies revealed characteristic histological features of a metastatic lobular breast carcinoma. In patients with a history of breast carcinoma, distinction between primary and secondary gastric malignancy is important as treatment options may differ substantially. Recognition that the scirrhous changes in the stomach are due to metastatic breast carcinoma, particularly of the lobular histological type, may lead to further palliative pharm.acologic therapy that could benefit the patient and improve survival.

Key Words: Cancer of che s comach, Chemotherapy, Gastric cancer, Linitis p/ascica, Lobular breast carcinoma, Signet ring cell

Linite plastique gastrique attribuable au cancer lobulaire metastatique du sein

RESUME: Une femme de 35 ans, chez qui un cancer lobulaire du sein avait deja ete diagnostique, se presence avec des signes cliniques, radiologiques et endoscopiques d'un processus infiltrant diffus au niveau de l'estomac. De nombeuses biopsies gascriqucs ont revele des caracteristiques hiscologiques typiques du cancer lobulaire metastatique du sein. Chez les patiences qui one des antecedents de cancer du sein, la distinction entre cancer de l'estomac primaire et secondaire est importance, puisquc les choix therapeutiques en dependent considerablemenc. L'identification d'un changement squirrheux au niveau de l'estomac est du a la presence d'w1 cancer du sein metatastique particulieremenc de type histologique lobulaire ct peut permcttre un traitement pharmacologique palliatif qui beneficierait a la patience et ameliorcrait ainsi ses chances de survie.

Departments of Medicine (Gascroemerology), Surgery and Pathology, University Hospital and University of British Columbia, Vancouver, British Columbia

Correspondence and reprints: Dr Hugh Freeman , Head, Gascroemerology, AC U F-13 7, University Hospital (UBC Site), 2211 Wesbrook Mall, Vancouver, British Columbia V6T 1W5. Telephone (604) 822-7216 or 822-7235

Received for publication January 9, 1992. Accepted July 15. 1992

CAN J GASTROENTEROL VOL 7 No I JANUARY/FEBRUARY 1993

BREAST CARCINOMA IS THE MOST

common malignancy in women and metastases occur frequently, particularly to lymph nodes, bones, lung, liver and hrain. Although previously considered to be rare ( 1) gastric metastasis from breast carcinoma has been increasingly recorded (2-7). Radiologic and pathological patterns of gastric metastatic disease include: microscopic or macroscopic disease without detectable radiographic change; solitary or multiple nodules, often with ulceration, that may appear as a radiographic filling defect; and diffuse gastric infiltration that simulates more typical linitis plastica of the stomach. In these patients, the characteristic histologic features of lobular carcinoma may be present (8). Recognition of this hi:.tologic subgroup and its ability to mimic primary gastric linitis plastica may be important because of the recent developments in the role of palliative chemotherapy and hormonal treatment in improving quality of life and survival of patients with metastatic breast carcinoma.

CASE PRESENTATION A 35-year-old female was referred in

March L 991 for investigation of a seven-month history of progressive nausea, vomiting anJ a 16 kg weight

55

FREEMAN et al

Figure 1) Section of breast carcinoma obtained at mastectomy in 1988. Cords of infiltratingneoplascic cells are observed . (Hemataxylin and cosin XI 15)

Figure 2) Section of breast carcinoma in FiKtLre I sliowing poorly differenciated breast carcinoma celL1 arranged in smgle file forrnanon. (Hematoxylin and eosin x290)

Figure 3) Section from chest wall obtained in March 1991 . Cords of infiltrating neoplastic cells arranged in single file formation are evidenc. (Hcmawxylin and eosin x320)

Figure 4) Secrion from gastric mucosa obtained by endosco/)lc biopsy m March 1991. Infiltrating neoJ>lastic breast carcinoma cells arranged m single file formation are />resent in the lamina propria. ( Hemawxylm and eosin x320)

los~. S he complained of dysphagia, particularly for solids, anJ emesis of v ir

tually undigested food almost immediately following a meal. Recent invcscigalions done in a community hospital prior to referral included chest radiographs, abdominal ultrasound, upper gastrointestinal barium and endoscopic studies; all were reported to

be normal. Past history included a modified radical mastecwrny in 1988 for a lobular carcinoma of the left breast (Figures J ,2); al that time, lymph nodes were negative for metastases. Reconstructive breast surgery, was completed in May 1989; however, localized recurrence of breast carcinoma was detec ted in December 1989 and was lreated with rad iotherapy.

56

Examination at referral in March l 991 revealed a cachectic woman with a left mastectomy scar and a left breast prosthesis but no lymphadenopathy. Abdominal examination was normal. An erythematous area on the left chest wall was biopsied and showed infiltrating lobular breast carcinoma (Figure 3 ). Laboratory studies including hcmogram, multichannel blood chemistry analysis and abdominal ultrasound were normal. Abdominal computerized tomography suggested enlarged paraaortic lymph nodes and possible gastric wall thickening. Upper gastrointestinal endoscopy revealed narrowing and rigidity of the gastrocsophageal junction; the patient experienced discomfon with air insuffiation of the

stomach. Gastric fundic, body and antral mucosa were abnormally thickened, typical of a diffuse infiltrating process. Multiple endoscopic gastric mucosa[ biopsies revealed the lamina propria to be expanded hy an infiltrate composed of malignant cells with histo logic characteristics similar to the previously defined lobular infiltrating breast carc inoma (Figure 4 ); the gastnc epiLhelium was normal and intestinal metaplasia was not present. A barium swallow revealed a thickened and rigid stomach characte ristic of the l ypical radiologic features of gastric linitis plastica (Figure 5). A feeding jejunostomy was inserted because of her inability to

cat and a course of chemotherapy was initiated using 5-fluorouracil , doxoru-

CAN J 0ASTROENTEROL VOL 7 No l JANUARY/FEBRUARY 1993

b1cm and cyclophosphamiJe. She had a good c lm1cal response with a IO kg increase in weight and resolution of chest wall Jbease. By July 199 l, she was able co tolerate a nl)rmal J1ct anJ her jeJunosromy tube was removed. She comple ted her e ighth and tinal course of c hemotherapy in August 1991. She has been able to mamta in her origmal wcighr on a normal die t s ince that time anJ repeat banum radiographic stuJics in December l 99 1 revealed evidence for improved gastm. wall d1stcns1bility (Figure 6). At this rnnc, she 1s clmically well on tamox1fcn alone.

DISCUSSION Breast carc inoma i5 thl.· most com

mon malignancy m women and metastatic involvement of distant si res -cspcc1a lly lymph m1des, hone, liver, lung anJ bram - 1s frequent. Prl.'\'IOU~ reports, however, have abl1 regularly documented the occasional pauent with hreast carcmoma and gastric meta~ras~ ( 1-8). Although some autopsy scric~ (5,6) have rcponeJ an incidence as high rn, 15%, J efintttve premortem d iagnosis of metasLattc breast carcinoma with gasrroscop1c mucosa! biopsy ts much le:..'> common. This may reflect limited clmical recognition that ~>astnc lmitis plasncn m a fema le, especia lly with a previously diagnosed breast carcinoma, can be Jue to metastatic hrcast carcmoma. In addition, Jistinct hisrological features of ~rcast carcinoma may be difficult to define, especia lly if the charactensttc 'single file' adenocarcmoma cclb of the lobular variety of brea.-;t carcinoma arc difficult to reco,1.,rn1:c (8); this ii. nllt a typical m1croscop1c feature of gastric cancer. In aJJition, ,mailer biopsies obtained at the tune of endo,cllptc evalua-

REFERENCES I. W.irren S, W1Lh,11n EM. Studie, on

tumor mcta,ras1s 2 The d1,1ributl(ln nf meta~rnse, m cancer of the hreast. Surg Gynccol Ob,tet 1933;57:81-5.

Z. Asd1 MJ, W1cdel PD, Habif DV. Gu~tmmtc~tmal meta,ta.,c., from carcmnma nf the hrca,t: Auwpsy swdy anJ 18 C.hcs requiring l>peracivc inrervenrl(ln Arch '-,urg I 968;96:840-3.

3. Chrn SH, Sheehan A{, P11:krcn JW. Mct,\Stattt: involvcnll'nt of the

Figure 5) Barium rad1ographic mid" done in Mar(h J 99 / ,hoU'mg thickened and rigid gastric fold.1 characteristic of the c:v/>ical radiologzt jeaturcs de5crih<!d for gmmc lm111s pkt1uw

non may not permit d1fferent1at1nn of a primary gastric carc111oma from a mctustauc lcstnn. Spectftc J1agnos1s, huwever, may bl· crit ical as e\'aluatilln for che1rn1thcrnpy anJ/or hormonal treatment may he Wllrthwhilc particularly it metastatic breast carc111omn 1s present. Diagnosis of mctastattL ll1bular care monrn of the breast may be a ided by dcfinitton of hormonal receptnrs, breast specifk ant igen s or other marker,, such as cywplasmtc globule, (9).

A lthough a number of repmts have Jescribed linttts plastiLa Jue to metastatic carcmoma of the breast, the histolog1c subtype has been only {1ccas1onally dcrntleJ. Choi er al (3) Jcscribcd rhe pt imary histological fcarurL·s 111 »ix cases as "poorly differentiated rows of small anaplastic cells" anJ the diffuse mvolvement 111 these cases as distinguished from "medium diffcrcnrnncd carcinomas" with nodular or ulcerative gastric 11wolvcment.

sh>mad1 by breast canl.cr. C.mccr l 964; l 7:791 7.

4. C1fu.:nrc, N, Pickren JW. Mcrnstast·, from Larcinrnn.1 nf mammary glancl: An autnpsy study. J Surg Oncol 1979,11:191-205.

5. (~raham WP Ill, Goldman L. Gastn,mtcsunal mct,1srasc~ from Larci r1\lma of the hrcast. Ann Surg 1964; 59:4 77 -80.

6. Hartmann WP, Sherlock P. (hstroduodenal metastases frnm can.: inoma of the brc,1st· An .1Jrenal steroid-induced

C/\N J GA:-.TRl)ENTEWI Vm 7 Nu I J J\NUARY/FEBRLARY 1993

Linitis plastlca and breast cancer

Figure 6) Barium radingra[>liic swd)' done December 1991 5/icm 'Ill~ nn/mwd dmen.s1hi/11v of gam1c folds f oUowmR cliemmliern/ry

Cmm1er ct al (8) described 31 pattems with lohular breast carcmoma and linitts plastt<.a Jue to metastases seen dunng a 30-ycar interval at the Mayo Cltn1L; il these, 14 haJ gastric mvolvcment alone or concurrent with other metastases, similar to the current patient, pro\'1Jing evidence of tumour dissemination. lmius plastica due to gastnc metastases from primary ducral carcinoma w,1s mll observed; this type of breast care inoma metastases appears to cause d1~crctc nnJules 111 the stomach, sometimes with mucosa[ ulceration or serosal unplants as the dommant feature (8). As chcmothcrapeuuc and hormonal t reatmcnt reg 1, mens have stgniftc,mtly 11nproved surv ival 111 patients with metastatic breast carcinoma, recognition and accurate d 1agnos1s of the protc:rn prescnrattons nf disseminated disease, particularly in the gastr01nre,t1n,1I traLt, may be critical to successfu l management.

phenomenon. Cmcer 1961; 14:426-31. 7. Menuck LS, Amhcrg JR. Mcw,wic

d1,ca,c in\'olving the ,wmach. Am J Dig Dis I 975;20:903-11.

8. Ct1rm1er WJ, Gaffey TA, Welch JM, Welch JS, Edmon,on JI I Lm111, plast1ca cmN:d by mern,1a1ic lohul,1r carcinoma of the hrea,c M,1yo Clm1c Pmc 1980:55:747-53.

9. Andcr.,cn JA, Vcndclhoc ML. Cycopla~m1L mucou, g1'1hulcs 111

lobular carcinoma m ,itu. Am J Surg Pmhol 1981 ;5:251-5.

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