PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of mcoLink to Publisher's site
 
Mol Clin Oncol. 2017 August; 7(2): 221–224.
Published online 2017 June 13. doi:  10.3892/mco.2017.1292
PMCID: PMC5532703

Metastatic gastric carcinoma to the breast: A case report and review of the Chinese literature

Abstract

Breast metastasis is extremely unusual in gastric cancer patients worldwide. We herein report the case of a 39-year-old female Chinese patient presenting with symptoms of inflammation in the left breast. A biopsy did not reveal any evidence of malignancy. A modified radical mastectomy was performed and the postoperative pathological examination revealed infiltration by signet ring cell gastric carcinoma. A review of the Chinese literature was performed, and a total of 16 patients with breast metastasis from gastric carcinoma have been reported from 1990 onwards. This condition is associated with a poor prognosis, with a survival time of 1 month to 4 years. More studies are required to determine the optimal treatment.

Keywords: breast metastasis, gastric carcinoma, Chinese patients

Introduction

Gastric carcinoma is a common type of cancer in humans. However, metastasis of signet ring cell gastric carcinoma to the breast is extremely rare, with only ~40 cases reported according to the PubMed database (1,2) and only 16 cases reported in the Chinese literature to date. The incidence of metastasis to the breast is ~0.2–1.3% (3), with ovarian cancer being the most common primary site. Systemic therapy is recommended for metastatic breast cancer patients and the survival time is often <1 year (4). Correct diagnosis of primary or metastatic malignant tumor of the breast is extremely important for proper treatment. We herein report the case of a 39-year-old Chinese female patient with metastasis to the breast from signet ring cell gastric carcinoma and perform a review of the relevant literature.

Case report

A 39-year-old female patient presented to the Shanghai General Hospital (Shanghai, China) in March, 2016, complaining of painful swelling of the left breast for 1 week. Physical examination revealed inverted nipple and pitted skin (peau d'orange sign) in the left breast (Fig. 1). A 2×1-cm mass with indistinct borders was identified below the left nipple and several non-fused enlarged lymph nodes were palpated in the ipsilateral axilla. The medical history of the patient included radical resection for poorly differentiated adenocarcinoma of the stomach 18 months prior. Postoperatively, the patient received 6 cycles of chemotherapy treatment as follows: The first course included cisplatin (dose unknown, day 1) + S-1 (40 mg, bid on days 1 and 14); courses 2–6 included oxaliplatin (150 mg, day 1) + S-1 (40 mg, bid on days 1 and 14). Over the last month, the patient underwent radical resection for ovarian metastasis from signet ring cell gastric carcinoma. The patient's father also had a history of gastric cancer.

Figure 1.
Left breast showing inverted nipple and pitted skin (peau d'orange sign).

The ultrasound examination revealed a solid heterogeneous mass in the left breast, suspected to be a malignant tumor, with edema and thickening of the subcutaneous soft tissue of the areola of the left breast (Fig. 2). In addition, two enlarged lymph nodes were palpated in the ipsilateral axilla. Ultrasound angiography revealed a slightly lower enhancement deeper in the left nipple (Fig. 3). A mammogram revealed heterogeneous architectural distortion and increasing uneven density in the left breast (Fig. 4). Enhanced magnetic resonance imaging revealed heterogeneous architectural distortion and skin thickening (Breast Imaging Reporting and Data System type 4) (Fig. 5). A chest computed tomography (CT) confirmed that the epidermis of the left breast was edematous and thickened and several small lymph nodes were detected in the left axilla (Fig. 6). A positron emission tomography/CT raised the suspicion of inflammatory breast cancer and bone metastasis.

Figure 2.
Ultrasonography of the breast revealing a solid heterogeneous mass in the breast, suspected to be a malignant tumor, with edema and thickening of the subcutaneous soft tissue on the left areola.
Figure 3.
Ultrasound angiography of the left breast showing a slightly lower mass enhancement deep in the left nipple (left panel, contrast-enhanced tumor; right panel, appearance of the mass on B-ultrasound).
Figure 4.
Mammogram revealing heterogeneous architectural distortion and increasing uneven density, with changes of the nipple and skin in the left breast (A) Right breast, normal breast tissue. (B) Left breast exhibiting an inverted nipple (arrow a) and heterogeneous ...
Figure 5.
Enhanced magnetic resonance imaging suggesting inflammation or inflammatory breast cancer due to the heterogeneous architectural distortion and skin thickening (Breast Imaging Reporting and Data System type 4).
Figure 6.
Chest computed tomography confirming swelling and thickening of the epidermis of the left breast. A number of small lymph nodes were identified in the left axilla.

Core needle biopsy of the left breast revealed ductal epithelial hyperplasia and infiltration by inflammatory cells, without any evidence of malignancy. The patient received treatment with azithromycin for 6 days. However, the inflammation was not controlled. The patient then underwent modified radical mastectomy. An intraoperative biopsy revealed ductal epithelial hyperplasia without a definitive diagnosis of malignancy. Finally, the postoperative pathological examination revealed signet ring cell carcinoma and metastasis was identified in all 23 retrieved axillary lymph nodes. Immunohistochemical evaluation of the tumor revealed the following: Cytokeratin (CK)7, CK20, villin+, carcinoembryonic antigen+, caudal type homeobox transcription factor 2+, CAM5.2+, Ki-67 (50%), P53+ and CerbB-2.

The patient received chemotherapy for gastric carcinoma with docetaxel (110 mg on day 1) and capecitabine (1.5 g, bid on days 1 and 14) but succumbed to the disease 3 months later. Written informed consent was obtained from the patient and her family regarding the publication of the case details and associated images.

Discussion

Breast metastasis from gastric carcinoma is extremely rare in clinical practice. Previous studies reported that only <0.3% of gastric cancer patients develop breast metastasis, which is far less frequent compared with liver metastasis (4–14%), the most common site of distant metastasis from gastric cancer (5,6). Only 16 cases have been reported in China thus far and are summarized in Table I (719). Of those 16 patients, 12 were diagnosed with signet ring cell carcinoma and 5 had multiple metastases.

Table I.
Patients with breast metastasis from gastric carcinoma in China.

In China, the age at diagnosis of patients with breast metastasis from gastric carcinoma ranges from 26 to 62 years (mean, 40.2 years; median, 38 years). In the international literature (20), the age of the patients developing breast metastasis from gastric carcinoma ranges from 22 to 70 years (mean, 45.5 years; median, 46 years). Due to the occult nature of gastric carcinoma, breast metastasis was the first manifestation of the disease in 43.8% (7/16) of the Chinese patients.

Breast metastasis from gastric carcinoma generally presents as a mass or inflammatory symptoms. The majority (14/16) of the Chinese patients presented with a painless mass in the breast. To the best of our knowledge, our patient is the second reported case in China presenting with symptoms of primary inflammatory breast cancer, which is characterized by erythema and thickening of the skin with pitted skin (peau d'orange sign). The first case was reported in 2013 and only 11 cases of inflammatory breast metastases from gastric cancer have been reported thus far (4).

The treatment for breast metastasis from gastric carcinoma remains controversial. The majority (10/16) of the Chinese patients with breast metastasis from gastric carcinoma underwent modified radical mastectomy, 4 patients received a lumpectomy, and 2 patients only underwent biopsy. Lumpectomy is the current recommendation for the treatment of such patients (19). Qureshi et al (21) reported that radiotherapy is not effective in treating breast metastases, as it cannot prolong patient survival time. Additional investigation is required to determine the optimal treatment. All the patients received chemotherapy for the treatment of primary gastric carcinoma.

The prognosis of breast metastasis from gastric carcinoma is generally poor. The time from surgical treatment of gastric cancer to the diagnosis of breast metastasis varies from 40 days to 60 months in China, whereas 40 days to 72 months was reported by Iesato et al (20). The survival time of Chinese patients with breast metastasis varies from 1 to 48 months. He et al (1) retrieved 38 cases from the international literature and found an overall survival time of 12 days to 18 months. Hadju and Urban (22) reported that >80% of patients with breast metastasis from gastric carcinoma succumbed to the disease within 1 year.

As breast metastasis from gastric carcinoma is rare, increased awareness is necessary and this possible diagnosis should be considered when patients with a history of gastric cancer detect a new breast mass.

References

1. He CL, Chen P, Xia BL, Xiao Q, Cai FL. Breast metastasis of gastric signet-ring cell carcinoma: A case report and literature review. World J Surg Oncol. 2015;13:120. doi: 10.1186/s12957-015-0538-1. [PMC free article] [PubMed] [Cross Ref]
2. Sato T, Muto I, Fushiki M, Hasegawa M, Hasegawa M, Sakai T, Sekiya M. Metastatic breast cancer from gastric and ovarian cancer, mimicking inflammatory breast cancer: Report of two cases. Breast Cancer. 2008;15:315–320. doi: 10.1007/s12282-008-0040-5. [PubMed] [Cross Ref]
3. Alvarado CI, Carrera AM, Perez MD, Tavassoli FA. Metastases to the breast. Eur J Surg Oncol. 2003;29:854–855. doi: 10.1016/S0748-7983(03)00123-9. [PubMed] [Cross Ref]
4. Chaignaud B, Hall TJ, Powers C, Subramony C, Scott-Conner CE. Diagnosis and natural history of extramammary tumors metastatic to the breast. J Am Coll Surg. 1994;179:49–53. [PubMed]
5. Takemura N, Saiura A, Koga R, Arita J, Yoshioka R, Ono Y, Hiki N, Sano T, Yamamoto J, Kokudo N, Yamaguchi T. Long-term outcomes after surgical resection for gastric cancer liver metastasis: An analysis of 64 macroscopically complete resections. Langenbeck's Arch Surg. 2012;397:951–957. doi: 10.1007/s00423-012-0959-z. [PubMed] [Cross Ref]
6. Lee SK, Kim WW, Kim SH, Hur SM, Kim S, Choi JH, Cho EY, Han SY, Hahn BK, Choe JH, et al. Characteristics of metastasis in the breast from extramammary malignancies. J Surg Oncol. 2010;101:137–140. doi: 10.1002/jso.21453. [PubMed] [Cross Ref]
7. Lin RY, Yang YM, Chen HY. 1 case of bilateral breast and axillary lymph node metastasis after operation of gastric cancer. Cancer Res Prevent Treat. 1990;4:218. (In Chinese)
8. Zhu JD, Fang JX. Breast metastasis of gastric cancer in 1 case. Chin J Pract Surg. 1994;14:113. (In Chinese)
9. Li DF, Liang XL, Qi HY. Breast metastasis of gastric cancer in 1 case. Chin J Cancer Prevent Treat. 2001;8:374. (In Chinese)
10. Wei XH. Breast metastasis of gastric cancer in 1 case. Inner Mongol Med J. 2004;36:436. (In Chinese)
11. Zheng YJ, Deng YC, H C. Breast metastasis of gastric cancer in 1 case. Chin J Pract Surg. 2005;25:112. (In Chinese)
12. Wang M, Zhao X, Wu WX. Breast metastasis of gastric cancer in 1 case. Chin J Clin Oncol. 2007;34:5. (In Chinese)
13. Ye CM, Xue MX, Chen B, et al. Breast metastasis of gastric cancer in 1 case. Chi J Gen Surg. 2007;16:569. (In Chinese)
14. Wang ZC, Wu B, Li J. Breast metastasis of gastric cancer in 1 case. Chi J Gen Surg. 2011;9:939. (In Chinese)
15. Weng HY, Zhang B, Lin YL, et al. 1 case of double breast metastasis of gastric cancer. Hainan Med J. 2011;22:132. (In Chinese)
16. Tang F, Jiang GY, Wang NX. Breast metastasis of gastric cancer: A case report and review of literature. Chin J Br Dis. 2012;6:708–712. (In Chinese)
17. Hong YZ, Gao XY. Breast metastasis of gastric cancer in 1 cases. Chin J Gen Surg. 2013;22:939. (In Chinese)
18. Zhu CP, Tang SH. Young gastric cancer and breast metastasis in 1 case. Guangdong Med J. 2013;34:2760. (In Chinese)
19. Tian Q, Zeng J, Tao X, Zhang Z, Zhou X, Wang Y. Clinical pathology of metastatic gastric carcinoma to the breast: A report of two cases and a review of literature. Oncol Lett. 2016;11:3081–3084. [PMC free article] [PubMed]
20. Iesato A, Oba T, Ono M, Hanamura T, Watanabe T, Ito T, Kanai T, Maeno K, Ishizaka K, Kitabatake H, et al. Breast metastases of gastric signet-ring cell carcinoma: A report of two cases and review of the literature. Onco Targets Ther. 2015;8:91–97. [PMC free article] [PubMed]
21. Qureshi SS, Shrikhande SV, Tanuja S, Shukla PJ. Breast metastases of gastric signet ring cell carcinoma: A differential diagnosis with primary breast signet ring cell carcinoma. J Postgrad Med. 2005;51:125–127. [PubMed]
22. Hadju SI, Urban JA. Cancers metastatic to the breast. Cancer. 1972;29:1691–1696. doi: 10.1002/1097-0142(197206)29:6<1691::AID-CNCR2820290637>3.0.CO;2-4. [PubMed] [Cross Ref]

Articles from Molecular and Clinical Oncology are provided here courtesy of Spandidos Publications