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Special Feature |

Image of the Month—Diagnosis FREE

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Section Editor: Carl E. Bredenberg, MD

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Arch Surg. 2009;144(10):973-974. doi:10.1001/archsurg.2009.172-b.
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Published online

ANSWER: SMALL-BOWEL METASTASIS FROM INFILTRATING LOBULAR BREAST CANCER

Abdominal computed tomography (Figure 1) shows partial small-bowel obstruction at the midjejunal level with proximal dilated loops and distal collapsed small bowel.

Place holder to copy figure label and caption
Figure 1.

Transition zone between proximal dilated small bowels (large arrow) and distal collapsed ones (small arrow).

Graphic Jump Location

The pathology of the small bowel (Figure 2) revealed evidence of metastatic lobular breast cancer as the cause of the transition zone and bowel obstruction. The Tru-cut needle biopsy of the right breast mass was diagnostic for invasive lobular carcinoma of the breast. The patient's breast cancer was found to be estrogen- and progesterone-receptor positive and human epidermal growth factor 2 negative. There was no evidence of further metastatic disease on an extent-of-disease evaluation of the patient.

Place holder to copy figure label and caption
Figure 2.

Image shows metastatic lobular carcinoma cells (double-headed arrow) infiltrating the mucosa and submucosa of the small bowel. Residual crypts with Paneth cells (long arrow) and goblet cells (short arrow) are also seen.

Graphic Jump Location

The patient was treated with Anastrozole, an antiestrogen therapy. The patient underwent a prophylactic toilet mastectomy of the right breast 2 months after her abdominal surgery. She was alive 1 year after her diagnosis with metastatic lobular breast carcinoma at the time of submission of this article.

Approximately 10% of all breast cancer is invasive lobular cancer (ILC),13which has a predilection to spread to the gastrointestinal tract.1,46Forty percent of patients who die of ILC have metastatic spreading to the bowel.4Symptomatic bowel metastases often manifest with signs of obstruction.7

Invasive lobular cancer gastrointestinal metastases can be challenging to identify with imaging because they often present as diffuse thickening or stricture rather than a solitary mass.4Microscopically, infiltration of ILC is characterized by single-file cell invasion known as Indian filing.

Initial management in this case of stage 4 ILC included resection of the metastatic lesion to release the bowel obstruction. Simple mastectomy is appropriate when the primary site has ulcerated or progressed to the extent that it interferes with chemotherapy. Endocrine therapy is usually recommended for a minimum of 5 years for endocrine-responsive tumors, or chemotherapy only for non–endocrine-responsive tumors.8Overall, the 5-year survival rate for patients with ILC is 94%.9The prognosis of ILC is still controversial, with most studies documenting a prognosis comparable with that of stage-matched and grade-matched invasive ductal carcinomas.10

The connection between ILC and bowel metastasis is important to remember. When a patient presents with 2 different symptoms, the etiology can often be traced back to a common origin. Patients with bowel obstruction and risk factors for breast cancer warrant a careful historical and physical evaluation, especially a breast examination. Patients with ILC should receive vigilant attention to abdominal symptoms and follow-up study.

Return to Quiz Case.

Correspondence:Emad Kandil, MD, Division of Endocrine and Oncologic Surgery, Tulane Medical School, 560 First Ave, New York, NY 10016 (ekandil@tulane.edu).

Accepted for Publication:January 14, 2009.

Author Contributions:Study concept and design: Kandil and King. Acquisition of data: Kandil and Moroz. Analysis and interpretation of data: Kandil, King, Alabbas, Moroz, and Wright. Drafting of the manuscript: King, Alabbas, and Moroz. Critical revision of the manuscript for important intellectual content: Kandil and Wright. Administrative, technical, and material support: Alabbas. Study supervision: Kandil, Moroz, and Wright.

Financial Disclosure:None reported.

Arpino  GBardou  VJClark  GMElledge  RM Infiltrating lobular carcinoma of the breast: tumor characteristics and clinical outcome. Breast Cancer Res 2004;6 (3) R149- R156
PubMed Link to Article
Martinez  VAzzopardi  JG Invasive lobular carcinoma of the breast: incidence and variants. Histopathology 1979;3 (6) 467- 488
PubMed Link to Article
Li  CIAnderson  BODaling  JRMoe  RE Changing incidence of lobular carcinoma in situ of the breast. Breast Cancer Res Treat 2002;75 (3) 259- 268
PubMed Link to Article
Lamovec  JBracko  M Metastatic pattern of infiltrating lobular carcinoma of the breast: an autopsy study. J Surg Oncol 1991;48 (1) 28- 33
PubMed Link to Article
Kumar  VFausto  NAbbas  A Robbins and Cotran Pathologic Basis of Disease.  Philadelphia, PA Elsevier Saunders2005;
Kobayashi  TShibata  KMatsuda  YTominaga  SKomoike  YAdachi  S A case of invasive lobular carcinoma of the breast first manifesting with duodenal obstruction. Breast Cancer 2004;11 (3) 306- 308
PubMed Link to Article
Asch  MJWiedel  PDHabif  DV Gastrointestinal metastases from carcinoma of the breast: autopsy study and 18 cases requiring operative intervention. Arch Surg 1968;96 (5) 840- 843
PubMed Link to Article
Orvieto  EMaiorano  EBottiglieri  L  et al.  Clinicopathologic characteristics of invasive lobular carcinoma of the breast: results of an analysis of 530 cases from a single institution. Cancer 2008;113 (7) 1511- 1520
PubMed Link to Article
Mersin  HYildirim  EGülben  KBerberoğlu  U Is invasive lobular carcinoma different from invasive ductal carcinoma? Eur J Surg Oncol 2003;29 (4) 390- 395
PubMed Link to Article
Molland  JGDonnellan  MJanu  NCCarmalt  HLKennedy  CWGillett  DJ Infiltrating lobular carcinoma: a comparison of diagnosis, management and outcome with infiltrating duct carcinoma. Breast 2004;13 (5) 389- 396
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Transition zone between proximal dilated small bowels (large arrow) and distal collapsed ones (small arrow).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Image shows metastatic lobular carcinoma cells (double-headed arrow) infiltrating the mucosa and submucosa of the small bowel. Residual crypts with Paneth cells (long arrow) and goblet cells (short arrow) are also seen.

Graphic Jump Location

Tables

References

Arpino  GBardou  VJClark  GMElledge  RM Infiltrating lobular carcinoma of the breast: tumor characteristics and clinical outcome. Breast Cancer Res 2004;6 (3) R149- R156
PubMed Link to Article
Martinez  VAzzopardi  JG Invasive lobular carcinoma of the breast: incidence and variants. Histopathology 1979;3 (6) 467- 488
PubMed Link to Article
Li  CIAnderson  BODaling  JRMoe  RE Changing incidence of lobular carcinoma in situ of the breast. Breast Cancer Res Treat 2002;75 (3) 259- 268
PubMed Link to Article
Lamovec  JBracko  M Metastatic pattern of infiltrating lobular carcinoma of the breast: an autopsy study. J Surg Oncol 1991;48 (1) 28- 33
PubMed Link to Article
Kumar  VFausto  NAbbas  A Robbins and Cotran Pathologic Basis of Disease.  Philadelphia, PA Elsevier Saunders2005;
Kobayashi  TShibata  KMatsuda  YTominaga  SKomoike  YAdachi  S A case of invasive lobular carcinoma of the breast first manifesting with duodenal obstruction. Breast Cancer 2004;11 (3) 306- 308
PubMed Link to Article
Asch  MJWiedel  PDHabif  DV Gastrointestinal metastases from carcinoma of the breast: autopsy study and 18 cases requiring operative intervention. Arch Surg 1968;96 (5) 840- 843
PubMed Link to Article
Orvieto  EMaiorano  EBottiglieri  L  et al.  Clinicopathologic characteristics of invasive lobular carcinoma of the breast: results of an analysis of 530 cases from a single institution. Cancer 2008;113 (7) 1511- 1520
PubMed Link to Article
Mersin  HYildirim  EGülben  KBerberoğlu  U Is invasive lobular carcinoma different from invasive ductal carcinoma? Eur J Surg Oncol 2003;29 (4) 390- 395
PubMed Link to Article
Molland  JGDonnellan  MJanu  NCCarmalt  HLKennedy  CWGillett  DJ Infiltrating lobular carcinoma: a comparison of diagnosis, management and outcome with infiltrating duct carcinoma. Breast 2004;13 (5) 389- 396
PubMed Link to Article

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