COLONIC METASTASES OF BREAST CARCINOMA

Case Report & Review of the Literature

Dimitri Koutsomanis,M.D.,PhD (1),Jean-Francois Renier,M.D.(1),Richard Ollivier,MD(1),Angel Moran,MD(2),Abdel-Aziz El-Haite,M.D.(3)

(1)Unité Médico-Chirurgicale Digestive,Centre Hospitalier,76400 Fecamp,France

(2)Service d'Oncologie Médicale,Clinique du Petit Colmoulins,76000 Le Havre,France

(3)Laboratoire d'Anatomie Pathologique,Hôpital Jacques Monod,76000 Le Havre,France

ABSTRACT
Metastasis of breast carcinoma to the colon is a rare occasion.We report here the case of a 65-year old patient who presented a stenosing tumor of breast origin,located in the right colon.Some of the regional lymphnodes were infiltrated but no distant metastasis were detected. The primary breast lesion was a 4cms infiltrating adenocarcinoma,operated four years earlier.Surgical removal of the lesion was followed by Endoxan-Epirubicin & 5-FU chemotherapy and the patient remained disease-free during the 3 years follow-up.We could find only two similar cases reported in the world litterature until now. Profound anemia in a patient with a past history of breast carcinoma may indicate colonic metastasis;treatment should be surgery followed by chemotherapy.

INTRODUCTION
Breast Carcinoma affects up to one in ten women in industrializesd countries.Early detection and surgical removal of the lesion are effective in managing the disease.The dissemination of cells from a primary lesion resulting in the progressive growth of metastatic carcinoma in distant sites,is the most common cause of death in breast cancer patients. Breast cancer metastasis in the gastrointestinal tract is an unusual presentation.We could find only two cases reporting breast cancer metastasis in the colon(1,2)one in the anal canal(3) and one in the stomach(4).Other unusual locations of breast cancer metastasis may include the eyes or the urinary bladder while the breast is the most frequent primary tumour to metastasize to the skin.Cutaneous metastases may take several forms that can mimic various inflammatory skin conditions and misleade final diagnosis. We report here the case of a 64-year-old patient who was referred to us with profound microcytic anemia and had a past medical history of breast carcinoma.

CASE REPORT
On December 13,1996, A.J.,a 64-year-old patient was referred to our department for anemia.On admission hemoglobin was 4,6g/l MCV=63,4 ESR=65/104,FOB-test was negative,BP=13/7cmHg & pulse rate was 100/min.The patient complaint of increased fatigue evoluting over the past month prior to admission. On examination ,a right hypochondric mass was palpable.Her past medical history was marked by a right mammectomy in 1993 followed by therapy with Tamoxifen.At that time histology revealed a hormono-receptor-negative undifferenciated adenocarcinoma (grade III)with extensive carcinomatous lymphangitis.One out of eleven ganglia was metastatic.In June 1993,the patient presented left hemianopsia;an ischemic lesion of the right occipital area was evidenced on a subsequent CT-scanTamoxifen was discontinued and the patient was started on a daily dosis of 0,5g Aspirin.Colonoscopy,performed after transfusion of six units of blood,found a stenosing tumour of the hepatic flexure.Histology was compatible with an undifferenciated adenocarcinoma of mammary origin.This was confirmed on immunohistology.Abdominal CT-scan and 99mTc bone scan failed to show evidence of further metastasis.Right hemicolectomy with end-to-end anastomosis was performed on December 26,1996;all twenty-two ganglia were metastatic.Recovery was uneventful and was followed by chemotherapy associating Endoxan-Epirubicine and 5-FU.The patient has been disease-free during the three-year period of follow-up.

DISCUSSION AND REVIEW OF THE LITERATURE
There are only a few reports of breast cancer metastasis in the gastrointestinal tract(1,2,3,4);only two reports concern the colon. The colon may be the site of metastasis from other carcinomata such as the primary bronchogenic carcinoma(5).Metastasis is not a random event but rather the result of a sequence of selective events.Control of metastasis is molecularly distinct from tumorogenic potential.It was suggested that chromosome 11 encodes a metastasis-suppressor gene for human breast cancer(6).Loss of heterozygosity on the long arm of chromosome 16 in the tumor at the time of operation was significantly correlated with the occurrence of distant metastases 1-13 years after the operation(7).Unusual presentations of breast cancer metastasis may include chilblains(8),Cholecystitis(9),Chrionic diarrhea(10),cutaneous vasculitis(11),bilateral lagopthalmus(12), eyelid metastasis(13),choroidal metastases(14)or metastasis in the urinary bladder(15,16) or submaxillary gland(17).The present case reports a colonic metastasis of breast carcinoma masquerading as a stenosing right-colonic tumour with extensive lymphnode infiltration.Initial presentation was that of a profound microcytic anemia Interestingly,repeated fecal occult blood tests failed to detect bleeding. Surgical removal followed by chemotherapy resulted in a complete remission within the three-years' folllow-up period. To our best knowledge,only two similar cases have been described in the world literature until now,indicating that this is a rare presentation.This is the first report presenting the outcome of combined surgery & chemotherapy for the treatment of this rare metastasis.However rare,we suggest that each patient presenting with profound microcytic anemia and a past medical history of breast cancer,should be endoscopically screened for gastrointestinal metastases of the disease.Surgery combined to chemotherapy may result in long-term remission.

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