Bo Jin ＊,Yan-ping Liu ,Hai-jiang Wang ,and Qi-shan Wang

1Department of Gastroenteropathy Surgery,2ICU,Third Affiliated Hospital (Xinjiang Tumor Hospital),Xinjiang Medical University,Urumchi 830011,China

METASTATIC gastric tumors are clinically uncommon,and metastatic gastric cancer from breast cancer was rarely reported.Here we report a case of gastric metastasis of atypical medullary carcinoma from breast.

CASE DESCRIPTION

A 59-year-old woman presented to our hospital on Febuary 13th,2009 for evaluation of a gastric mass with a normal serum carcinoembryonic antigen (CEA) level(2.080 μg/L).Two years previously,she had undergone a modified radical mastectomy of left breast cancer with a pathological diagnosis of atypical medullary carcinoma(Fig.1),and an immunohistochemistrical result of estrogen receptor (ER) (-),C-erbB2 (-),thymidylate synthase (TS)(-),myeloid differentiation protein receptor (MDR) (-),progesterone receptor (PR) (-),Ki-67 (+),nm23 (+),and lung resistance related protein (LRP) (-).After the surgery,she was given six cycles of adjuvant docetaxel plus epirubicin chemotherapy.

Upon review,she complained abdominal discomfort,acid reflux,but denied melena,hematemesis,and hematochezia.The family history of gastric tumor was denied.Subsequent endoscopic examination was performed and showed a 1.0 cm×0.8 cm sized ulcer at the antrum (Fig.2).Histopathologic examination revealed poorly differentiated adenocarcinoma (Fig.3).Abdominal CT showed thickened gastric wall at the antrum,with enlarged lymph nodes along the lesser curvature of the stomach (Fig.4).

Figure 1.Pathological diagnosis of atypical medullary carcinoma of breast.HE staining ×100

Figure 2.Endoscopic examination reveals a 1.0 cm×0.8 cm sized ulcer at the antrum (A),with white fur covered and bleeding after touched (B).

Misdiagnosed as primary gastric cancer,the patient was given two cycles of neoadjuvant etoposide+oxaliplatin+tegafur chemotherapy,with the effect assessment as partial remission.Then she received a radical distal gastrectomy,with a histopathological diagnosis of atypical medullary carcinoma (Fig.5),consistent with the primary lesion of breast cancer.The results of immunohistochemistry were∶ER(-),PR(-),epidermal growth factor receptor (EGFR) (-),vascular endothelial growth factor(VEGF) (+),human epidermal growth factor receptor-2(HER-2) (-).

Figure 3.A diagnosis of poorly differentiated adenocarcinoma was made by endoscopic pathology.HE staining×100

Figure 4.Plain (A) and contrast CT scans (B) of the abdomen show thickened gastric wall at the antrum(↑),with enlarged lymph nodes along the lesser curvature of the stomach (▲).

Figure 5.Pathological diagnosis of gastric metastasis.HE staining ×100

Concerning with the specificity of atypical medullary carcinoma and the partial remission effect of neoadjuvant etoposide+oxaliplatin+tegafur chemotherapy on the gastric metastasis,the same protocol was chosen for postoperative adjuvant chemotherapy.Neither relapse nor metastasis was detected in nearly 2 years after surgery,and the patient maintained a satisfactory life quality.

DISCUSSION

Gastric metastatic carcinoma,namely secondary gastric carcinoma,means the carcinoma cells that attack the stomach and grow there through blood vessel,lymph vessel,and other pathway,consistent with the primary carcinoma in phenotype.The canceration of ectopic tissue such as ectopic pancreas,however,does not belong to gastric metastatic carcinoma,because of its primary characteristic.

It is not uncommon for the stomach to be directly attacked by the carcinoma of organ close to the stomach such as hepatic cancer,cholangiocarcinoma,pancreatic cancer,colon cancer,etc.It was reported that among patients who died of tumor,1.28%-1.7% was accompanied by gastric metastatic tumor,1among which distant metastasis is worth researching.The involvement of the stomach by distant metastases is clinically unusual,with the most common reported primaries including melanoma and carcinomas of the breast and lung.2,3

There is not a significant difference on clinical and histopathological characteristic between the primary and secondary gastric cancer.4-7Up to half of individuals harbouring such metastases are symptomatic,most commonly with bleeding,pain,vomiting,and anorexia.8The diagnosis of gastric metastatic cancer depends on the primary tumor history and histopathological examination.9-11The phenotype of gastric metastatic cancer should be consistent with the primary tumor.The recognition of such metastases to the stomach outside of findings at autopsy is rare.12Higgins13found 64 cases of metastatic carcinoma in the stomach among 31 541 autopsied cases,while Davis and Zollinger14reported 67 metastatic tumours in the stomach among 23 109 autopsied cases.Preoperative histological diagnosis can be very difficult,because endoscopic biopsies are in many cases superficial and may lead to false negative results,that is why endoscopic biopsy findings are normal in up to 50% of patients with secondary gastric cancer.15Distant metastasis to the stomach seems to usually happen after systematic treatment such as chemotherapy to the primary tumor.16To choose an effective scheme is difficult,especially for neoadjuvant chemotherapy,so surgery should be made a priority for consideration.

Breast cancer is the most frequent malignant tumor to metastasize into the gastrointestinal tract (mainly the stomach17-19,in 4%-18% of patients20) in female and is second only to malignant melanoma,and lobular infiltrating carcinoma has a greater predilection compared to the ductal type.21Medullary carcinoma is a kind of tumor with clear boundaries,poor differentiation,flake arrangement,no adenoid structure,little interstition,and obvious lymph plasma cell infiltration.For its strict diagnosis standard,medullary carcinoma accounts for only 1%-7% of breast cancer.22,23Anatomically,there is no definite relationship between stomach and breast on vascular or lymph drainage,and six cases of metastasis deposit to breast from gastric carcinoma has been reported since 1999,24without one case of atypical medullary carcinoma of breast as the primary lesion.There has been rare report clarifying gastric metastasis from breast cancer hematogenously,though the stomach receives a rich blood supply.Gastric cancer and breast metastasis share almost the same clinical,endoscopic,and radiological features that do not help much in specifying whether the carcinoma is primary or secondary.It is reported that the prognosis of gastric metastasis from breast cancer is poor with a median survival rate of two years following the diagnosis of gastric lesions.19

In summary,gastric metastatic carcinoma possesses a highly low incidence,but it should not be overlooked,especially when a primary tumor history is known.Endoscopic examination plus autopsy is necessary for diagnosis,though misdiagnosis usually happens.Surgery works as a prior choice for treatment.

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