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  Table of Contents  
LETTER TO THE EDITOR
Year : 2019  |  Volume : 56  |  Issue : 4  |  Page : 370-371
 

Breast metastasis as initial presentation of asymptomatic gastroesophageal carcinoma: A case report


1 Department of Radiodiagnosis, Basavatarakam Indo-American Cancer Hospital and Research Centre, Hyderabad, Telangana, India
2 Department of Pathology and Lab Medicine, Basavatarakam Indo-American Cancer Hospital and Research Centre, Hyderabad, Telangana, India
3 Department of Surgical Oncology, Basavatarakam Indo-American Cancer Hospital and Research Centre, Hyderabad, Telangana, India

Date of Web Publication11-Oct-2019

Correspondence Address:
Rashmi Sudhir
Department of Radiodiagnosis, Basavatarakam Indo-American Cancer Hospital and Research Centre, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijc.IJC_159_19

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How to cite this article:
Sudhir R, Chaudhary VK, Ahmed F, Raju K V. Breast metastasis as initial presentation of asymptomatic gastroesophageal carcinoma: A case report. Indian J Cancer 2019;56:370-1

How to cite this URL:
Sudhir R, Chaudhary VK, Ahmed F, Raju K V. Breast metastasis as initial presentation of asymptomatic gastroesophageal carcinoma: A case report. Indian J Cancer [serial online] 2019 [cited 2019 Nov 21];56:370-1. Available from: http://www.indianjcancer.com/text.asp?2019/56/4/370/268954




Breast cancer is the most common malignancy and remains the leading cause of cancer-related deaths in women.[1] Metastasis to breast from extramammary primary neoplasm is rare, with an incidence of 1.3–2.7%.[2] The common extramammary primary malignancies, which can metastasize to breast are lymphoma, melanoma, rhabdomyosarcoma, lung carcinoma, ovary carcinoma, renal cell carcinoma, thyroid carcinoma, and intestinal carcinoid in descending order of incidence.[3],[4] So far, only one case is reported in the literature of breast metastasis from carcinoma of gastroesophageal (GE) junction in which patient presented with breast metastasis 2 years after the esophagogastrectomy surgery.[5] Here, we report a case of a young woman with asymptomatic squamous cell carcinoma of GE junction presenting with breast metastasis as her initial presentation.

A 33 year old woman presented with complaints of painless right breast mass with gradual increase in size over 3 months. She did not have dysphagia, vomiting, or any other complaints. On examination, she had a small nontender right breast lump without palpable axillary nodes. Ultrasound showed a well-circumscribed hypoechoic mass with posterior enhancement in the right breast [Figure 1]a. Histopathology was suggestive of poorly differentiated invasive carcinoma with a focus of squamous cell differentiation [Figure 1]b. Triple markers (estrogen receptor (ER), progesterone receptor (PR), and Human epidermal growth factor receptor 2-neu (HER2-neu)) assessment on immunohistochemistry (IHC) examination were negative. In absence of any other localizing symptoms or signs to suggest primary malignancy elsewhere, she was planned to be treated for triple negative metaplastic primary breast cancer. On standard protocol of staging work-up for carcinoma breast with basic blood investigations, chest x-ray and ultrasound abdomen, the disease was limited to one breast. Computed tomography (CT) chest or positron emission tomography (PET)/CT was not done as clinically there was no evidence to suggest distant metastasis or primary elsewhere. Hence, she was started on neoadjuvant chemotherapy for primary carcinoma breast. After two cycles of chemotherapy, she complained of significant dysphagia to solids and vomiting and her right breast mass had increased in size. Upper gastrointestinal endoscopy showed an ulceroproliferative growth at the GE junction producing luminal narrowing beyond which endoscope could not be passed. Contrast enhanced computed tomography (CECT) of chest showed a well-circumscribed rounded large heterogeneously enhancing mass in the right breast with skin invasion and a short segment (4 cm) circumferential growth with the epicenter at the GE junction [Figure 2] and [Figure 3]a. Biopsy of the GE junction mass was reported as moderately differentiated squamous cell carcinoma [Figure 3]b. The IHC examination of GE junction mass was positive for CK 5/6 and p63 markers and negative for GATA3 expression. Subsequently, IHC of the breast mass also showed focal positivity for cytokeratin 5 and p63 which are the markers for squamous cell carcinoma [Figure 4]a and [Figure 4]b. Hence, the final diagnosis was primary squamous cell carcinoma of gastroesophageal junction with metastatic breast mass.
Figure 1: (a) Well-circumscribed hypoechoic irregular mass in the breast with posterior acoustic enhancement. (b). Histopathology section (H and E × 40) shows breast parenchyma with neoplastic cells with focal area of squamous differentiation and keratin pearl formation

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Figure 2: Contrast-enhanced CT axial section shows a well-circumscribed heterogeneously enhancing rounded large mass in the right breast with skin invasion

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Figure 3: (a) Contrast-enhanced CT coronal section shows short segment circumferential irregular growth at the gastroesophageal junction (black arrow) causing luminal narrowing. (b) Histopathology section (H and E × 100) suggestive of squamous cell carcinoma

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Figure 4: (a and b) Immunohistochemistry of breast mass showed focal positivity for Cytokeratin (CK) 5 and p63

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Few cases of carcinoma esophagus or stomach, and only one case of carcinoma GE junction with breast metastasis have been described in the literature and all of them were found to have breast metastasis either at the time of diagnosis or later.[5],[6] This is the first case in which patient presented with breast metastasis as initial feature of carcinoma GE junction. Among patients presenting with breast mass alone with malignant features on imaging and pathology, primary breast cancer is always the first diagnostic possibility as metastasis to breast is rare. In this case, biopsy revealed poorly differentiated carcinoma with a focus of squamous cell differentiation which could be either metaplastic primary breast carcinoma or metastasis from elsewhere. Imaging features of metaplastic carcinomas of breast and metastatic breast mass from extra-mammary primary are very similar. Both are rapidly growing, well-circumscribed tumors without microcalcification, architectural distortion, nipple-areolar, or axillary nodal involvement.[3] This patient also showed similar features on imaging which could closely mimic triple-negative subtype of invasive ductal carcinoma; hence, the diagnosis on imaging remains challenging. Malignant breast mass with squamous cell differentiation and absence of carcinoma in situ component on histopathology should always alert the clinician to look for primary malignancy elsewhere in order to avoid mismanagement as occurred in this case, and the diagnosis of metaplastic carcinoma of breast should be considered only after exclusion of metastasis from elsewhere.

In conclusion, this is the first case in English literature of asymptomatic squamous cell carcinoma of gastroesophageal junction presenting with breast metastasis as initial presentation. Rapidly growing well-circumscribed mass in the breast without axillary lymphadenopathy, microcalcification, and ductal carcinoma in-situ (DCIS) component with presence of squamous cell differentiation on histopathology should be further investigated to rule out occult primary elsewhere in the body even if the patient is asymptomatic.

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.



 
  References Top

1.
Siegel RL, Miller KD, Jemal A. Cancer statistics. CA Cancer J Clin 2015;65:5-29.  Back to cited text no. 1
    
2.
Georgiannos SN, Chin J, Goode AW, Sheaff M. Secondary neoplasms of the breast: A survey of the 20th Century. Cancer 2001;92:2259-66.  Back to cited text no. 2
    
3.
Lee SH, Park JM, Kook SH, Han BK, Moon WK. Metastatic tumors to the breast: Mammographic and ultrasonographic findings. J Ultrasound Med 2000;19:257-62.  Back to cited text no. 3
    
4.
McCrea ES, Johnston C, Haney PJ. Metastases to the breast. AJR Am J Roentgenol 1983;141:685-90.  Back to cited text no. 4
    
5.
Jena S, Bhattacharya S, Gupta A, Roy S, Sinha NK. Breast metastasis from esophageal junction cancer: A case report. Case Rep Surg 2014;2014:489427.  Back to cited text no. 5
    
6.
Nielsen M, Andersen JA, Henriksen FW, Kristensen PB, Lorentzen M, Ravn V, et al. Metastases to the breast from extramammary carcinomas. Acta Pathol Microbiol Scand 1981;89:251-6.  Back to cited text no. 6
    


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