Strana 806 VOJNOSANITETSKI PREGLED Vojnosanit Pregl 2012; 69(9): 806–808.

UDC: 616.349-02::618.19-006-033.2
CASE REPORT
DOI: 10.2298/VSP1209806N

Uncommon metastatic site from breast cancer

Retko mesto metastaze karcinoma dojke

Ivan Nikoliü*, Tatjana Ivkoviü-Kapicl†, Biljana Kukiü*, Bogdan Bogdanoviü*,

Tomislav Petroviü‡, Igor Djan§,ŒDragana Smiljeniü

*Clinic for Internal Medicine,†Hystopathology Department, ‡Clinic for Surgical

Oncology, §Radiotherapy Department, Oncology Institute of Vojvodina, Sremska
Kamenica, Serbia, ŒFaculty of Medicine, University of Novi Sad, Novi Sad, Serbia

Abstract Apstrakt

Introduction. Breast cancer is one of the most common
malignancies in women and the main leading cause of can-
cer death. The most frequent sites of metastases from breast
cancer are bones, lungs, the central nervous system, the liver
and soft tissue. Colonic metastases from breast cancer are
rare. Case report. We presented a 70-year-old woman with
bulky obstructing lesion of sigmoid colon. A physician in
charge on our department examined the patient and past
history of breast cancer was found up. Surgery was per-
formed with removal of sigmoid colon and three of six
lymph nodes were positive. Pathological examination, in-
cluding immunohistochemical stains, confirmed the diagno-
sis of metastatic breast cancer to sigmoid colon. The multi-
disciplinary oncology team suggested postoperative che-
motherapy. The patient received four cycles of chemother-
apy with paclitaxel followed by anastrozole. On the first
control visit no disease activity was detected. Conclusion.
In patients with the past history of breast cancer the symp-
toms of hematochezia or anemia may indicate colonic me-
tastases.
Uvod. Karcinom dojke jedan je od najÿešýih karcinoma kod
žena i vodeýi uzrok smrti od malignih bolesti. Karcinom dojke
najÿešýe metastazira u kosti, pluýa, centralni nervni sistem i jet-
ru. Metastaze u debelo crevo su jako retke. Prikaz bolesnika.
Prikazali smo bolesnicu, staru 70 godina, sa dijagnozom ops-
truktivne infiltracije sigmoidnog dela kolona. Lekar koji je pre-
gledao bolesnicu dobio je podatak da je bolesnica operisala
karcinom dojke. Bolesnica je operisana, uraĀena je resekcija
sigmoidnog dela kolona, i od pregledanih šest limfnih ÿvorova
u tri su se nalazila žarišta metastaza. Patološkohistološkim pre-
gledom, ukljuÿujuýi imunohistohemijsku analizu, potvrĀena je
dijagnoza metastatskog karcinoma dojke u sigmoidni kolon.
Multidisciplinarni onkološki tim predložio je postoperativnu
hemioterapiju. Bolesnica je primila ÿetiri ciklusa hemioterapije
sa paklitakselom i nakon toga nastavila terapiju anastrazolom.
Na prvom kontrolnom pregledu nisu viĀeni znaci aktivnosti
maligne bolesti. Zakljuÿak. Kod bolesnica sa ranije postavlje-
nom dijagnozom karcinoma dojke, sa simptomatologijom krvi
u stolici ili prisutnom malokrvnošýu treba misliti i na moguý-
nost pojave metastaza karcinoma dojke u debelo crevo.

Key words: Kljuÿne reÿi:

breast neoplasms; neoplasm metastasis; colonic dojka, neoplazme; neoplazme, metastaze; kolon,
neoplasms; diagnosis, differential. neoplazme; dijagnoza, diferencijalna.

Introduction
Breast cancer is one of the most common malignancies
in women and the main cause of cancer-related deaths 1.
When breast cancer is diagnosed at an early stage, the sur-
vival rate is higher; however, recurrences and metastases are
quite common. Breast cancer usually metastasizes to the
lymph nodes, lung, bone, liver, and brain. There are few re-
ports of breast cancer metastasizing in the gastrointestinal
tract (stomach and small intestine) while colonic metastases
are extremely rare 2, 3. Other unusual locations of breast can-
cer metastases may include eyes, urinary bladder, and skin.
Colonic metastases from breast cancer are rare and their
nonspecific clinical presentation may be easily mistaken as a
second primary colonic carcinoma; it may impair the clinical
diagnosis and delay the treatment resulting in earlier mortal-
ity 4, 5.
Case report
At the beginning of 2010, a 70-year-old woman visited
our Institute complaining of hematochezia. The results of
blood count test and complete check-up were normal and the
result of rectal examination was negative. The findings of

Correspondence to: Ivan Nikoliý, Institute of Oncology of Vojvodina, Institutski put 4, 21204 Sremska Kamenica, Serbia.
Phone: +381 21 4805 569, +381 64 1849860. E-mail: nikolic.ivan@onk.ns.ac.rs
Volumen 69, Broj 9 VOJNOSANITETSKI PREGLED
colonoscopy examination showed circumferential bulky ob-
structing lesion in sigmoid colon. It was not possible for co-
lonoscope to pass through the stenosis. Analysis of the bi-
opsy material confirmed the presence of adenocarcinoma of
the colon (HG3, NG3) (Figure 1). The patient underwent
Fig. 1 – Endoscopic biopsy: metastatic adenocarcinoma in
the specimen of the large intestine mucus (HE, ×40)
surgery and resection of sigmoid colon with end-to-end an-
astomosis. The results of pathological examination including
immunohistochemical staining, confirmed the diagnosis of
metastatic breast cancer to sigmoid colon (CK20-, CK7-,
CK8+, CK18+, ER+, PR+). Six lymph nodes were identified
and three of them were metastatic. These findings were
similar to those of the prior breast cancer specimen (Figures
2 and 3). Cancer cells invaded the whole intestinal wall from
Fig. 2 – Breast cancer metastasis in large intestine wall;
atypical tumor cells abundant in eosonophil cytoplasm and
pleomorphic nuclei arrange in trabecular cluster (HE, ×40)
Fig. 3 – Immunophenotype of metastatic colonic cancer; estrogen
receptor+ (immunohistochemical analysis, B-SA ×200)
mucosa to the serosa and surrounding fat tissue and infil-
trated into the posterior wall of the urinary bladder. The
multidisciplinary oncology team suggested postoperative
Nikoliý I, et al. Vojnosanit Pregl 2012; 69(9): 806–808.
Strana 807
chemotherapy. The patient received four cycles of chemo-
therapy with paclitaxel, followed by anastrozole. The first
control visit showed no disease progression.
The patients past medical history was marked by breast
exulcerated cancer in her left breast without palpable axillar
lymph nodes in 2007. Using core biopsy the following diag-
nosis was established: ductal invasive carcinoma HG 2 with
the invasion of capillaries, lymph ducts, and perineural area.
At that time, the patient was treated with four cycles of
neoadjuvant chemotherapy (5-fluorouracil, adriamycin, cy-
clophosphamide), which resulted in partial clinical response.
Chemotherapy was followed by left mastectomy and ipsilat-
eral axillary lymph node dissection and the excision of infil-
trated region of pectoralis major on June 9, 2008. Histo-
pathological examination of surgical specimen confirmed the
presence of grade II invasive ductal carcinoma (4 cm × 3 cm)
with skin invasion and 10 lymph nodes without metastases
(G2, pT4N0) and the infiltration of muscle and perineural
area. Immunohistochemistry tests for estrogen and proges-
terone receptors showed positive staining for both receptors
(Figure 4). There was no evidence of distant metastases at
the time of surgery. Multidisciplinary oncology team consid-
ered the patient to be at high risk for disease recurrence and
suggested further treatment with radiotherapy (TD 50 Gy in
25 fractions) and adjuvant chemotherapy (cisplatin, cyclo-
phosphamide, methotrexate, and 5-fluorouracil) for six
months, which was followed with tamoxifen therapy until
the beginning of 2010.
Fig. 4 – Primary breast cancer (HE, ×40)
Discussion
Metastatic involvement of the large bowel is rare. The
incidence of metastatic breast cancer involving the colon is
unknown, but an autopsy series reported the frequency of
colonic involvement of metastatic breast cancer to be 8%,
not including serosal implants 6. The disease-free interval
between primary breast cancer and gastrointestinal involve-
ment varies from synchronous presentation up to 30 years,
the median interval between diagnosis and presentation of
metastases is six to eight years 2. The symptoms may vary
from asymptomatic abdominal masses to those mimicking
ulcerative colitis 7. Anorexia, hematochezia, and positive fe-
cal occult blood testing are common presenting symptoms 4.
These non-specific findings often mimic other gastrointesti-
nal diseases such as colorectal cancer, inflammatory bowel
disease, ischemic colitis and, diverticulitis.
Strana 808 VOJNOSANITETSKI PREGLED
Differentiating primary colon cancer from metastatic
breast cancer to the colon may be challenging. In patients with
prior histories of breast cancer, second primaries of the gastro-
intestinal tract are more common than metastatic disease 8. Im-
munohistochemistry has aided in differentiating the tumor site
of origin. Hormone receptors, such as estrogen and progester-
one ones, are utilized to differentiate breast versus gastrointes-
tinal primary cancer 9, but these receptors may be positive in
20% to 28% of primary gastric carcinomas 10. The more com-
mon antigen markers include cytokeratins (CK) 7 and 20 11, 12.
In the presented case, the histological subtype of meta-
static breast cancer was invasive ductal carcinoma (IDC). In-
filtrating lobular carcinoma was found to metastasize more
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Received on April 4, 2011.
Revised on June 6, 2011.
Accepted on June 22, 2011.
Nikoliý I, et al. Vojnosanit Pregl 2012; 69(9): 806–808.