Print version ISSN 2237-9363
J. Coloproctol. (Rio J.) vol.32 no.2 Rio de Janeiro Apr./June 2012
Flávia BalsamoI; Rafael Ferreira Correia LimaII; Rodrigo Rocha BatitstaII; Galdino José Sitonio FormigaIII
IAssistant, Service of Coloproctology, Hospital Heliópolis - São Paulo (SP), Brazil. Permanent Member, Sociedade Brasileira de Coloproctologia
IIResident, Service of Coloproctology, Hospital Heliópolis - São Paulo (SP), Brazil
IIIHead of the Service of Coloproctology, Hospital Heliópolis - São Paulo (SP), Brazil; Permanent Member, Sociedade Brasileira de Coloproctologia
Peritoneal carcinomatosis due to breast cancer is rare and gastrointestinal tract involvement is also unusual. Symptoms are unspecific and can begin many years after the primary tumor. Investigation of carcinomatosis origin is mandatory as breast cancer carcinomatosis can relieve partially or totally with chemo and hormonal therapy. A case of colonic obstruction due to carcinomatosis secondary to breast cancer is reported, emphasizing its diagnostic aspects and treatment.
Keywords: intestinal obstruction; /secondary; breast neoplasms; carcinoma; abdomen, acute.
A carcinomatose peritoneal secundária ao câncer de mama é entidade rara e o comprometimento do trato gastrointestinal é pouco frequente. A sintomatologia bastante inespecífica dificulta o diagnóstico e os sintomas podem surgir vários anos após o aparecimento do tumor primário. O diagnóstico da origem da carcinomatose é fundamental, pois quando a doença é secundária à neoplasia de mama, pode ocorrer remissão parcial e até total da doença com quimio e hormonioterapia. Relata-se caso de obstrução colônica devido a carcinomatose peritoneal secundária a neoplasia maligna de mama, com ênfase em seu diagnóstico e tratamento.
Palavras-chave: obstrução intestinal; /secundário; neoplasias da mama; carcinoma; abdome agudo.
Breast cancer is the most frequent malignant tumor in women1-4, but peritoneal carcinomatosis due to breast cancer is rare1, accounting from 6 to 8% of breast adenocarcinoma cases4,5.
Metastatic lesion of breast cancer usually affects lymphatic ganglions, bones, lungs, brain and liver1-3. More rarely, it may also affect the gastrointestinal tract, peritoneum and genital organs1,4.
Its very unspecific symptoms make diagnosis more difficult and they may appear several years after the primary tumor1,3. The investigation of carcinomatosis origin is mandatory, as breast cancer carcinomatosis can relieve partially or totally with proper chemo and hormonal therapy1.
The lobular type of the disease is more associated with metastases in the gastrointestinal tract, genital organs and peritoneum1-4.
The purposes of this report were to describe a case of colonic obstruction due to peritoneal carcinomatosis secondary to malignant breast neoplasm and make a literature review.
A 62-year-old female patient, born in Salto Grande (SP) and living in Santo André (SP), retired, presented for three months changes in the bowel habit - one in three days, associated with distension and abdominal pain like cramps and loss of 20 kilos in the period. The patient presented history of hypothyroidism, treated with Puran T4 100 mcg/day and right mastectomy and hormonal therapy due to malignant breast neoplasm ten years before. The physical examination detected globus and tympanic abdomen, a little distended, no pain at superficial and deep palpation, no palpable mass and bowel sounds were present and normal. The proctologic exam was performed until 20 cm from the anal canal, with normal mucosa. The colonoscopic study was performed until the transverse colon with luminal stenosis and preserved mucosa, blocking the device progression. Biopsies were made with samples from the site, whose histopathological result showed unspecific chronic inflammatory process. Abdominal tomography showed liver without alterations and colonic dilatation, with abrupt interruption at the transverse colon level, as well as greater omentum thickening (Figure 1). Tomography of thorax was normal (Figure 2).
As illustrated in Figure 3, the opaque enema showed free progression of rectal contrast until distal transverse colon, with inadequate filling at this level.
High digestive endoscopy until the second duodenal portion showed mild enanthematous gastritis. The serum level of carcinoembryonic antigen (CEA) was 2.7 ng/dL.
The patient was submitted to exploratory laparotomy, which showed peritoneal carcinomatosis (Figure 4) and involvement of distal transverse colon, with the omentum full of carcinomatosis nodules.
A small portion of the omentum was resected for derivative transversostomy proximally to stenosis. The histopathological analysis of the omentum showed adenocarcinoma infiltrating adipose tissues (Figure 5) and the immunohistochemical analysis showed 90% of the cells positive to markers SP1 (estrogen receptor) and PgR636 (progesterone receptor), as well as presence of positiveness to cytokeratin 7 (CK7), showing primary breast adenocarcinoma (Figure 6).
The patient was submitted to adjuvant chemotherapy with Adriamycin 60 mg/m2 and Paclitaxel 175 mg/m2 and hormonal therapy with Anastrozole (Arimidex®) 1 mg/day, showing improved general conditions and weight gain. Control exams showed absence of omentum thickening, normal liver and unspecific distribution of intestinal loops (Figure 7)
In Figure 8, the opaque enema shows persistent stenosis of transverse colon, with difficult progression of rectal contrast until the colostomy.
The patient was submitted to a new exploratory laparotomy, without evidence of carcinomatosis, which found the cicatricial stenosis of transverse colon, and a segmental colectomy was performed involving the area of stenosis, as well as colostomy with reconstruction of intestinal flow and termino-terminal colonic anastomosis (Figures 9 and 10).
The histopathological study of the specimen showed no evidence of neoplasm, only cicatricial tissue.
The patient presented good progress and was discharged from hospital six days after the surgery. Today, the patient is in 27-month follow-up, without symptoms and free from the disease.
The infrequent occurrence of peritoneal carcinomatosis due to breast adenocarcinoma and its unspecific symptoms make its diagnosis more difficult4.
In the case reported, despite the endoscopic and contrast radiological and tomographic investigations in the preoperative period, it was not possible to diagnose it on this occasion, but only confirm the site with the probable obstruction, which has also been found by other authors1. The definitive diagnosis was only achieved after the histopathological and immunohistochemical analysis of a fragment of the omentum obtained through exploratory laparotomy.
In cases of history of breast neoplasm with any gastrointestinal tract manifestation, the secondary involvement due to breast neoplasm should be considered as one of the hypotheses and, whenever possible, confirm the finding with immunohistochemical exams6. The immunohistochemical markers that can help in this diagnosis are the expression of cytokeratin 7, estrogen and progesterone receptors and negativity to cytokeratin 201,6, also used in this case.
The interval between the primary disease appearance and the peritoneal carcinomatosis may vary from months to 30 years, average interval of 6 years1; in this case, this interval was 10 years.
It was not possible to identify the histological type of breast adenocarcinoma that affected the patient in question and, therefore, we cannot correlate the finding of carcinomatosis to lobular or ductal type.
Surgical interventions are used only to resolve complications, considering that this is a disease with systemic dissemination4, as performed here, with exploratory laparotomy required for intestinal derivation due to partial bowel occlusion and to help achieve the diagnosis.
The patient remains fully asymptomatic, 27 months after the secondary disease diagnosis, as she presented a good response when submitted to chemotherapy and hormonal treatment. This finding agrees with the average survival presented in these cases, which is 24 to 36 months4.
In cases of peritoneal carcinomatosis and history of breast adenocarcinoma, the investigation of the carcinomatosis origin is essential, as good alleviation can be obtained with a specific treatment.
Chemotherapy associated with conservative surgeries can also provide good quality of life.
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2. Araújo LHL, Melo AC, Moreira MML,Gomes CAS, Noronha Jr H, Cunha WML, et al. Metástase gástrica de câncer de mama: relato de caso e revisão de literatura. Rev Bras Cancerol 2007;53(3):365-8. [ Links ]
3. Fillmann LS, Pinho CM, Fillmann HS, Fillmann EEP. Relato de caso: metástase de carcinoma de mama para o intestino grosso. Rev Bras Coloproct 2007;27(4):50-2. [ Links ]
4. McLemore EC, Pockaj BA, Reynolds C, Gray RJ, Hernandez JL, Grant CS, et al. Breast cancer: presentation and intervention in women with gastrointestinal metastasis and carcinomatosis. Ann Surg Oncol 2005;12(11):886-94. [ Links ]
5. Hewitt MJ, Hall GD, Wilkinson N, Perren TJ, Lane G, Spencer JA. Image-guided biopsy in women with breast cancer presenting with peritoneal carcinomatosis. Int J Gynecol Cancer 2006;16 Suppl 1:108-10. [ Links ]
6. Schwartz RE, Klimstra DS, Turnbull ADM. Metastatic breast cancer masquerading as gastrointestinal primary. Am J Gastroenterol 1998;93(1):111-4. [ Links ]
Serviço de Coloproctologia do Hospital Heliópolis
Rua Cônego Xavier, 276 - Vila Heliópolis
CEP: 04231-030 - São Paulo (SP), Brazil
Submitted on: 02/25/2011
Approved on: 08/25/2011
Financial source: none.
Conflict of interest: nothing to declare.
Study carried out at the Service of Coloproctology, Hospital Heliópolis - São Paulo, SP, Brazil.