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| CASE REPORT |
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| Year : 2020 | Volume
: 18
| Issue : 1 | Page : 55-58 |
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Metastasis of carcinoma rectum to the breast: A rare entity
Royson Dsouza1, Gigi Varghese1, Shawn Thomas2, Deepak Abraham2
1 Department of Surgery, General Surgery Unit, Vellore, Tamil Nadu, India
2 Department of Endocrine Surgery, Christian Medical College, Vellore, Tamil Nadu, India
| Date of Submission | 18-Oct-2019 |
| Date of Decision | 28-Nov-2019 |
| Date of Acceptance | 13-Nov-2019 |
| Date of Web Publication | 03-Feb-2020 |
Correspondence Address:
Dr. Gigi Varghese
Department of Surgery, General Surgery Unit, Christian Medical College, Vellore, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/cmi.cmi_45_19
A 28-year-old female presented to the endocrine surgery clinic with complaints of the right breast lump for 3 months. Clinical examination revealed a 3 cm × 2 cm hard lump in the upper outer quadrant, suspicious of carcinoma breast with clinical staging of T2N0M0. Three years before this, she was diagnosed to have adenocarcinoma of the rectum and had undergone treatment. On serial follow-up, there was no evidence of locoregional recurrence of the disease. Ultrasound imaging of the right breast was suggestive of BI-RADS V lesion, highly suspicious of primary breast malignancy. However, the core biopsy was reported to be mucinous adenocarcinoma with immunohistochemical markers suggestive of a colorectal primary. Metastasis to the breast from a primary colorectal carcinoma is an exceedingly rare clinical entity. The imaging findings may not yield any characteristic differences between primary breast cancer and breast cancer due to metastasis from other cancerous primary. Biopsy of the lesion with relevant immunohistochemical markers remains the mainstay of the diagnosis. The overall prognosis is poor, and the treatment comprises oral capecitabine as a palliative agent with or without wide local excision of the metastatic breast lesion.
Keywords: Breast cancer, carcinoma rectum, metastasis of carcinoma rectum, secondary neoplasm of the breast
How to cite this article:
Dsouza R, Varghese G, Thomas S, Abraham D. Metastasis of carcinoma rectum to the breast: A rare entity. Curr Med Issues 2020;18:55-8 |
| Introduction | |  |
Cancers in the breast almost always originate from the mammary tissue and are seldom metastatic from other primaries. The most common malignancy to metastasis to the breast is the contralateral breast carcinoma.[1] Colorectal cancers often spread to the lymph nodes, liver, lungs, and bones, and metastasis to the breast is an exceedingly rare clinical entity.[2] The evaluation of suspected breast cancer consists of a triple assessment, which includes history and clinical examination, breast imaging, and histopathology.[3] A core biopsy is crucial to establish the diagnosis of metastatic breast cancer, which may be otherwise treated as primary breast cancer. This can aid in the diagnosis of primary cancer, which can be either an occult primary or even a resected tumor. In the current report, we present the case of a 28-year-old female who was diagnosed to have adenocarcinoma of the rectum had undergone curative therapy and on follow-up presented with a breast lump, which was subsequently diagnosed to be a metastasis from a colorectal primary. Her clinical presentation, evaluation, treatment, and outcome have been discussed with a relevant review of the literature.
| Case Report | | |
A 28-year-old homemaker presented with a history of the right breast lump for 3 months which was insidious, painless, and gradually progressing in size. There was no nipple discharge, retraction, or skin change. The opposite breast and axilla were normal. There was no history suggestive of metastatic disease. She did not have any family history of breast cancer.
She was diagnosed to have adenocarcinoma of the rectum 3 years before current presentation, which on magnetic resonance imaging was staged as T3c N2 with circumferential resection margin (CRM) involvement and without any evidence of extramural vascular invasion [Figure 1]. Mucosal biopsy was reported as poorly differentiated adenocarcinoma with signet ring-cell morphology. Her case was discussed in the multidisciplinary team meeting and she underwent neo-adjuvant long-course chemoradiation therapy (50.4 Grays in 28 fractions) with concurrent capecitabine followed by laparoscopic ultralow anterior resection. Surgical histopathology had shown postchemotherapeutic changes and no viable tumor in the resected rectal specimen or in the mesorectal lymph nodes indicating pathological complete response. She was rediscussed in the multidisciplinary team meeting after which she received six cycles of adjuvant chemotherapy with CAPOX regimen considering the young age of onset and due to signet ring-cell histology and poor differentiation of rectal adenocarcinoma. She was asymptomatic and doing well on follow-up. Her annual computed tomography (CT) [Figure 2] tests and carcinoembryonic antigen levels had not shown any evidence of local or systemic failure. | Figure 1: Magnetic resonance imaging of the pelvis showing circumferential thickening of the high and midrectum with perirectal fat stranding. Hyperintense signal intensity shows no restricted diffusion. The lesion extends from S3 to S5, measuring approximately 52 mm with an extramural spread of 7 mm and involvement of circumferential resection margin by the node at 5 o' clock position. There is no infiltration of puborectalis/anal sphincter complex. There are more than four mesorectal nodes. No significant paraaortic, internal-iliac, external-iliac, or inguinal lymphadenopathy. Magnetic resonance T3cN2 stage
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 | Figure 2: Computed tomography scan of the abdomen and pelvis showing postoperative changes are seen in the pelvis. There are no features of pelvic disease recurrence. There are no focal lesions in the liver. The gall bladder, pancreas, adrenal glands, and kidneys are normal
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On examination, she was moderately built and nourished with a body mass index (BMI) of 23. Her general physical examination was unremarkable. On local examination, both breasts were symmetric in size, and nipples were at the same levels. There was a lump in the right breast in the upper outer quadrant measuring 3 cm × 2 cm, which was hard in consistency and fixed to the breast tissue. There was no involvement of the skin or the chest wall. The right axillary nodes were not palpable. The contralateral breast and axilla were normal. Her abdominal and digital rectal examination was normal.
Investigations
Her routine blood tests were within the normal limits. Ultrasonography of the breast revealed an ill-defined hypoechoic wider than taller lesion with irregular margins of BIRADS V type and no significant axillary nodes [Figure 3]. Following this, a core biopsy was done which showed tumor cell nests with abundant extracellular mucin. Upon immunohistochemistry, the tumor cells were positive for CK20 and CDX2, the markers for colonic mucinous neoplasms. The cells were negative for GCDFP, GATA3, estrogen receptor (ER), and mammoglobin. The overall features were conclusive of a metastatic colonic tumor. For further metastatic workup, a CT scan of the thorax and abdomen was done which did not reveal any other abnormality apart from the breast lesion [Figure 4] and [Figure 5]. A positron emission tomography scan was deferred in view of mucinous type of tumor with low tracer uptake. Routine surveillance colonoscopy as per the standard follow-up practice guidelines of our institution was reported as normal. | Figure 3: Ultrasonogram of the breast and axilla showing an ill-defined hypoechoic wider than taller lesion at 12 o' clock position measuring 3.2 cm × 2.2 cm with irregular margins in the right breast. There are no significant axillary lymph nodes in the right side
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 | Figure 4: Computed tomography of the thorax showing soft-tissue density lesion seen in the right breast in the upper-outer quadrant measuring 28 mm × 22 mm with irregular margins. There are no intralesional calcifications. There is no invasion of pectoralis muscle or overlying skin. There is no architectural distortion. There is no significant axillary or internal mammary lymphadenopathy
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 | Figure 5: Computed tomography of the thorax and abdomen showing no evidence of pulmonary, liver, or bony metastasis and no significant lymphadenopathy
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Treatment
Primary breast carcinoma was the first differential that was considered in our patient as she had completed treatment for carcinoma rectum 3 years ago and was disease-free. The diagnosis of a metastatic breast lesion of colorectal primary was confirmed only after the core biopsy of breast lesion.
The patient went through a multidisciplinary team-based meeting consisting of endocrine and colorectal surgeons, medical and radiation oncologists, oncopathologist, and radiologists. As the metastasis was unifocal without any axillary nodal involvement, she underwent a wide local excision. Intraoperatively, there was a tumor measuring 3 cm × 2 cm, which was well circumscribed and not involving the skin or underlying muscle. Her postoperative recovery was uneventful, and she was discharged the following day.
Outcome and follow up
Right breast wide local excision specimen histopathology was consistent with mucinous adenocarcinoma with free margins and without perineural or lymphovascular invasion. The immune profile (positive for CK20 and CDX2) was in keeping with a colorectal primary. She received adjuvant chemotherapy with capecitabine, and on 3 months follow-up, there was no disease recurrence.
| Discussion | | |
Primary breast carcinoma is the most common cancer in women and is the second-leading cause of cancer death overall.[4] The most common metastasis to the breast is from a contralateral breast carcinoma, followed by leukemia, melanoma, lymphoma, ovary, lung, and gastric cancer.[1] The first case of extramammary breast metastasis to be ever reported was in 1903.[5] The largest collective review of metastatic breast cancers was published by Williams et al. from the MD Anderson Cancer Centre, Houston where primary tumor being the gastrointestinal tract ranked fourth (12/169). However, the authors did not specify which part of the gastrointestinal tract was the primary site.[6]
Colorectal cancer is the third most common cancer with a lifetime risk of about 1 in 22 for men and 1 in 24 for women. Till date, there are only over 22 reported cases of colorectal cancer metastasis to the breast which either appeared benign on mammography or with suspicious features of primary breast malignancy.[1],[7],[8],[9] These lesions can be either synchronous or metachronous. On an average, metastatic breast lesions appear 21 months after the diagnosis of colorectal cancer; majority were reported to be in the left side measuring 1–11 cm and had mucinous or signet ring-cell features on histopathology.[10] Our patient had metastasis to the right breast and was diagnosed almost 40 months after the initial diagnosis of carcinoma rectum.
History of colorectal malignancy in a patient presenting with a breast lump is important and the same has to be conveyed to the radiologist and the pathologist. Although mammographic finding in breast metastasis is that of a rounded and well-circumscribed mass without any spiculation, microcalcifications, or skin thickening, it can often mimic benign or a primary breast neoplasm.[1] The accurate diagnosis of a metastatic breast lump is made on a histopathological examination.[11] Majority of breast tumors are CK7 positive and CK20 negative, whereas the colorectal malignancies are CK7 negative and CK20 positive. If the immunohistochemistry shows the breast tumor to be negative for all breast markers such as ER, progesterone receptor, Her2nu, CK7, GCDP15, and basal cell adenocarcinoma with positivity for CK20 and CDX2, metastasis from a colorectal primary can be confirmed[12] if there is a past history of treated colorectal cancer.
As both breast and colorectal primaries are common, two separate primaries are more likely than metastases to the breast. In this scenario, with early disease, the intent of treatment is curative and not palliative. On the other hand, the prognosis of metastatic breast cancer from a colorectal primary is poor, with a median survival of 8–10 months.[6] Hence, the management is more of palliative intent. The biology of the underlying primary, disease-free interval, and effectiveness of systemic therapies determine the prognosis of the metastatic breast lesions. The majority of the histopathology would be signet ring or mucinous neoplasms with a poor prognosis. However, some nonsignet ring-cell colorectal cancers with oligometastatic disease can have favorable outcomes. Surgical excision is not often indicated in view of short life expectancy and risk of seeding to the skin.[2] However, there is limited information regarding the same in the literature and most breast lumps have been excised having been mistaken for primary neoplasm. Oral capecitabine is added either after the excision or as the sole agent for palliative chemotherapy, which might slow down the growth of the lump.[13] Our patient after having undergone a wide local excision followed by oral capecitabine therapy did well and did not show any recurrence at 3 months follow-up.
| Conclusion | | |
Metastasis to the breast from a primary colorectal carcinoma is an exceedingly rare clinical entity and can present at any time frame, even after several years following curative treatment of colorectal cancer. The ultrasound and mammographic findings may not yield any characteristic differences between primary breast cancer and breast cancer due to metastasis from other cancerous primary. Core biopsy of the breast lump with relevant immunohistochemical markers remains the mainstay of the diagnosis and differentiation between primary breast cancer and breast metastasis with primary of colorectal origin. The overall prognosis is poor and the treatment comprises oral capecitabine as a palliative agent with or without wide local excision of the metastatic breast lesion.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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