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Histological and immunohistochemical features of rectal biopsy. (A) Diffuse carcinomatous infiltration of the rectal wall, mostly in the basal layer of mucosa and superficial submucosa. (B) Immunohistochemistry depicted strong immunoreactivity to gross cystic disease fluid protein 15 antigen (Immunohistochemical stain, ×100).
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Figure 4: Histological and immunohistochemical features of rectal biopsy. (A) Diffuse carcinomatous infiltration of the rectal wall, mostly in the basal layer of mucosa and superficial submucosa. (B) Immunohistochemistry depicted strong immunoreactivity to gross cystic disease fluid protein 15 antigen (Immunohistochemical stain, ×100).

Mentions: After six years of disease-free period, the patient was admitted to our hospital for the second time because of prolonged constipation, early satiety, and weight loss. Rectosigmoidoscopy revealed thickening and rigidity of the rectal wall, with stenosis of the lumen 10 cm above the anal verge. Further examination with abdominal and pelvic magnetic resonance imaging (MRI) showed a stage 3 rectal tumor, with extension of tumor tissue through the muscle layer and obliteration of the interface between the muscle and perirectal fat (Figure 2). In order to determine the presence of distant metastases, the patient underwent a positron-emission tomography examination, which demonstrated a high uptake of fluorine18-fluoro-deoxy-glucose (18F-FDG) in the rectal wall, with an standardized uptake value (SUVmax) of 9.8 (Figure 3). Histopathological analysis of biopsy specimens taken during rectosigmoidoscopy showed diffuse infiltration of tumor cells along the rectal wall, some of them with the presentation of the "signet-ring cell" type (Figure 4A). Immunohistochemistry revealed that the tumor cells were reactive for CK7, GCDFP-15, CA 15-3, and ER (Figure 4B). On the basis of these findings, a diagnosis of rectal metastasis from lobular breast carcinoma was made. Clinical and mammography examination of the breasts excluded loco-regional relapse or second primary cancer in the contralateral breast. Since our patient had already developed stenosis and serious obstruction, rectal metastatic involvement was treated surgically with a colo-ano "pull-through" anastomosis, and subsequent operation after five months for closing a colostomy. In addition, daily treatment with aromatase inhibitor (anastrozole, 1 mg/day) was administered. After a one year follow-up period, the patient was asymptomatic and regular US and CT examinations have not shown a relapse of the disease. The clinical course of the disease has been depicted in Figure 5.

Invasive Lobular Breast Cancer Presenting an Unusual Metastatic Pattern in the Form of Peritoneal and Rectal Metastases: A Case Report

Saranovic D, Kovac JD, Knezevic S, Susnjar S, Stefanovic AD, Saranovic DS, Artiko V, Obradovic V, Masulovic D, Micev M, Pesko P - J Breast Cancer (2011)

Bottom Line: Peritoneal and rectal metastases are very rare and only rarely occur as the first manifestation of disease.We herein report the case of a 47-year-old woman who presented with abdominal carcinomatosis as a first sign of invasive lobular breast carcinoma (ILC).After a six year disease-free period, relapse occurred with severe obstruction due to rectal metastasis from lobular breast carcinoma.

Affiliation: Department of Radiology and Magnetic Resonance Imaging, University Clinical Center of Serbia, Belgrade, School of Medicine, University of Belgrade, Belgrade, Serbia.

ABSTRACT
Gastrointestinal metastases from invasive lobular breast cancer are uncommon with the stomach and small intestines being the most common metastatic sites. Peritoneal and rectal metastases are very rare and only rarely occur as the first manifestation of disease. We herein report the case of a 47-year-old woman who presented with abdominal carcinomatosis as a first sign of invasive lobular breast carcinoma (ILC). Identifying the most important immunohistochemical markers for ILC: gross cystic disease fluid protein 15, estrogen and progesterone receptors enabled a correct diagnosis. After a six year disease-free period, relapse occurred with severe obstruction due to rectal metastasis from lobular breast carcinoma. Since there was no widespread metastatic disease, surgery with concomitant hormonal therapy was performed.

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