A CASE OF BREAST

CANCER METASTASIS TO
GI TRACT
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Case Presentation:
A 61-year-old female with a history of hypertension, breast cancer with mastectomy, and a
possible diagnosis of pyloric stenosis, presented to the emergency Department with weakness,
fatigue, and frequent non-bilious vomiting. The duration of her current symptoms has been for a
week. Patient reports that the symptoms were fluctuating in intensity and she has been nauseated
and vomiting frequently. The vomiting happens usually after a meal. Since she has not been able
to hold down food, she has lost her appetite to most of her favorite food. She also complains of
periods of constant belching and hiccups. She stated that she has not had a bowel movement for
the past five days.
Upon presenting to the Emergency Department, the patient stated that she felt epigastric
discomfort described as a burning sensation after which she proceeded to vomit.

The Diagnosis:
Upon admission to the hospital, physical examination revealed a distended stomach, and
endoscopy revealed gastric outlet obstruction with pyloric channel ulceration. The patient had
through-the-scope balloon dilation performed and biopsied. Results of biopsy were negative for
H. Pylori and no evidence of dysplasia. Following the procedure, she was able to tolerate small
amounts of solids upon discharge.
Two weeks later, the patient was readmitted because of a three-day history of recurrent episodes
of nausea and vomiting. The patient stated that she felt lethargic. She stated she had not been
able to progressively tolerate solids. An EGD was performed which revealed stenotic gastro-
outlet. A CT-scan with biopsy was performed. Results from the biopsy showed infiltrative poorly
differentiated carcinoma consistent with metastatic breast carcinoma. Immunostaining was
further done and the tumor cells were positive for GATA 3, Estrogen Receptor and negative for
CD20 and CDX2, which is consistent with breast carcinoma.

Discussion:
We present a case report of a patient with a history of breast cancer that metastasized to the
bones and the gastrointestinal tract. Breast cancer can metastasize anywhere in the body, though
the most common primary metastasis is to the bone, lungs, regional lymph nodes, liver, and
brain. In this case, the breast metastasized to the GI tract particularly to the junction between the
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stomach and the duodenum. This presented as pyloric stenosis, which alone is a rare finding in
adulthood.
After three continuous bowel obstructions and persistent vomiting, the biopsy was examined
using immunohistochemical analysis. This would help to differentiate between gastric cancer
which can present in the same way and breast cancer metastasis. When it comes to differentiating
between the two, we look at the cytokines expressed by these tumors.
Immunostaining for ER and PR has been reported to be useful for diagnosing metastatic tumors
from the breast cancer, although 32% and 12% of primary gastric cancer are positive for ER and
PR respectively (Koike…et al 2014, Schwarz…et al 1998).
With this in mind, immunostaining for just ER and PR may not be sufficient in ruling out gastric
cancer, though they are used to classify breast cancer. We, therefore, have to look beyond these
markers and consider markers like GATA 3, CD20, CDX2 and pankeratin, as these markers are
more sensitive and specific for cells that are of breast origin. Gastric cancer is positive for CDX2
and CD20 while metastatic breast cancer is positive GATA 3. Our patient was found to be
positive pankeratin, GATA3 and negative for CD20 and CDX2, hence giving us the diagnosis of
breast cancer metastasis to the Gastrointestinal Tract with obstruction.

The Takeaway:
Breast cancer metastasis can be differentiated from other primary source tumors by the use of
immunohistochemistry. Just looking at the endoscopic findings and presentation of patient
symptoms can be misleading in certain cases or even lead to misdiagnosis the patient, which
would turn out to be costly for the patient. Physicians should consider the possibility of a rarity
when treating a refractory condition in a patient with a breast cancer history.
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Reference:
“What Is Breast Cancer? | Breast Cancer Definition.” Edited by Stacy Simon, American Cancer
Society, 21 Sept. 2017, www.cancer.org/cancer/breast-cancer/about/what-is-breast-cancer.html.

K. Koike, K. Kitahara, M. Hihaki, M. Urata, F. Yamazaki, and H. Noshiro, “Clinicopathological

features of gastric metastasis from breast cancer in three cases,” Breast Cancer, vol. 21, no. 5, pp.
629-634, 2014

Schwartz RE, Klimstra DS and Turnbull AD: Metastatic breast cancer masquerading as
gastrointestinal primary. Am J Gastroenterol 93: 111-114. 19