Metastatic lobular breast carcinoma to the pancreas: a case report

Metastatic lobular breast carcinoma to the pancreas: a case report We report a case of a 72-year-old female, with an extensive breast cancer history, who presented with abdominal pain to her general practitioner. Cross-sectional imaging demonstrated a lesion in the head of pancreas, which was not amenable to curative resection. Percutaneous biopsy was obtained, which demonstrated metastatic lobular breast cancer. This rare case highlights how previous medical histories may assist in final pathological diagnosis. invasive lobular breast carcinoma with extra-nodal extension. INTRODUCTION Oestrogen receptor status was positive, progesterone receptor We report a rare case of metastatic breast cancer spreading to negative and HER-2 receptor negative. Post-operatively, repeat the pancreas, which provides a lesson in how thorough history imaging once again failed to demonstrate a primary lesion. taking may assist in the final pathological diagnosis. Staging CT scans of her chest, abdomen and pelvis were clear for metastatic disease. She was subsequently treated with exe- mestane and had regular surgical and medical oncology follow CASE REPORT up, with no evidence of loco-regional recurrence. When she now presented with generalized abdominal pain, A 72-year-old female patient presented to her general practi- a CT scan of the abdomen was performed, revealing a lesion in tioner with several months of generalized abdominal pain on the head of the pancreas measuring 7 × 4cm . This mass the background of a breast cancer history. Nineteen years prior extended into the porta hepatis and towards the left lobe of the to presentation, she was diagnosed with a 9 mm ductal carcin- liver, opacification of the splenic vein and superior mesenteric oma of the left breast, which was treated with a wide local exci- veins was absent, and the confluence of the portal vein could sion (original imaging unavailable). It was oestrogen receptor also not be visualized (Fig. 1). Total bilirubin was 13 μmol/L positive. A level II axillary clearance revealed no involved (normal <20), raised ALT at 127 U/L (normal <34) and AST at nodes. Post-operatively she received tamoxifen, which was 69 U/L (normal <31). ALP and GGT were also mildly raised at ceased after 6 months due to side effects. Fourteen years later 135 U/L for ALP (normal 30–110) and 219 U/L for GGT (normal (5 years prior to this presentation) she represented with palp- <38). Carcinoembryonic antigen and CA19.9, both markers of able left axillary lymphadenopathy. A core biopsy was suggest- pancreatic cancer, were not raised. She was referred to a hepa- ive of invasive breast carcinoma, however, no primary breast tobiliary surgeon for consideration of a pancreaticoduodenect- lesion was identifiable on bilateral mammogram, ultrasound omy, with the assumption of a primary pancreatic lesion. Due and MRI scans. Completion level II axillary clearance was per- to suspected vascular involvement and potential peritoneal formed that demonstrated 7/7 positive lymph nodes for Received: February 14, 2018. Accepted: May 6, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy111/5017813 by Ed 'DeepDyve' Gillespie user on 21 June 2018 2 A. Zammit et al. Figure 1: Axial slice of portal-venous phase CT scan demonstrating lesion in the head of pancreas. Figure 3: The poorly differentiated carcinoma shows nuclear positivity for GATA3 (IPX). GATA3 is commonly mutated in breast carcinoma and has been reported as indicative of metastatic breast carcinoma [9, 10]. Figure 2: H and E stain demonstrating poorly differentiated carcinoma with perineural invasion. Figure 4: The poorly differentiated carcinoma shows nuclear positivity for oestrogen receptor (IPX). disease seen on the CT, she was regarded as an unsuitable can- didate for a pancreaticoduodenectomy. To consider the use of palliative chemotherapy, a percutaneous biopsy for tissue diag- of invasive breast carcinoma metastasizing to the pancreas [4]. nosis was performed. Histology demonstrated a poorly differ- The literature also demonstrates the difficulty diagnosing entiated tumour, surrounded by benign pancreatic tissue with metastatic spread of breast cancer to the pancreas. There are focal areas of perineural invasion by GATA3 positive epithelial several reports of patients undergoing a pancreaticoduodenect- cells. These cells also stained positive for ER, K19 and CEA, but omy and only subsequent operative histology revealing meta- negative for PR, B72.3, E-cadherin and HER2. The final diagnosis static breast carcinoma [4]. Some authors have suggested that was poorly differentiated lobular breast carcinoma. surgical resection may be appropriate for both symptom con- Unfortunately, we were unable to compare the expression pro- trol and formal diagnosis [ 5, 6]. files between the pathology from the axillary dissection and In this patient’s case, the hepatobiliary department felt that the metastatic disease (Figs 2–4). in the absence of obstructive jaundice, and the possibility of tumour vascular involvement, a pancreaticoduodenectomy DISCUSSION would not improve her quality of life nor provide a survival During 2017 the projected incidence for breast cancer in advantage. Should there had been no vascular involvement, surgical resection may have been of benefit[6–8]. Australia is 17 000, representing one of the most prevalent can- cer diagnoses [1]. In Western populations lobular breast carcin- Whilst metastatic disease to the pancreas is uncommon, we would suggest that with the discovery of pancreatic lesions, oma accounts for ~10% of all breast cancer diagnoses, and overall has a poorer prognosis than that of ductal breast carcin- metastatic disease always be considered, especially with a his- tory of previous malignancy. A thorough history and the avail- oma [2, 3]. Following this patient’s diagnosis, we investigated how frequently lobular breast carcinoma metastasizes to the ability of previous pathology reports, may assist in final pathological diagnosis. pancreas. From the literature we identified only 12 other cases Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy111/5017813 by Ed 'DeepDyve' Gillespie user on 21 June 2018 Metastatic lobular breast carcinoma to the pancreas 3 5. Tohnosu N, Narushima K, Sunouchi K, Saito T, Shimizu T, CONFLICT OF INTEREST STATEMENT Tanaka H, et al. A case of breast cancer metastatic to the None declared. tail of the pancreas. Breast Cancer 2006;13:225–9. 6. Molino C, Mocerino C, Braucci A, Riccardi F, TrunfioM,Carrillo G, et al. Pancreatic solitary and synchronous metastasis from REFERENCES breast cancer: a case report and systematic review of contro- versies in diagnosis and treatment. World J Surg Oncol 2014;12:2. 1. Australian Institute of Health and Welfare. Cancer in 7. Pappo I, Feigin E, Uziely B, Amir G. Biliary and pancreatic Australia 2017. Canberra: AIHW, 2017. metastases of breast carcinoma: is surgical palliation indi- 2. Dossus L, Benusiglio PR. Lobular breast cancer: incidence cated? J Surg Oncol 1991;46:211–4. and genetic and non-genetic risk factors. Breast Cancer Res 8. Jyoti B, Bharat C, Ravi T, Subhash RK, Asawari P, Sudeep G. 2015;17:37. Billiary obstruction in a metastatic tumor of the pancreas 3. Arpino G, Bardou VJ, Clark GM, Elledge RM. Infiltrating lobu- from breast cancer. South Asian J Cancer 2017;6:10. lar carcinoma of the breast: tumor characteristics and clin- 9. Shield PW, Papadimos DJ, Walsh MD. GATA3: a promising ical outcome. Breast Cancer Res 2004;6:R149–56. marker for metastatic breast carcinoma in serous effusion 4. Bonapasta SA, Gregori M, Lanza R, Sangiorgi E, Menghi A, specimens. Cancer Cytopathol 2014;122:307–12. Scarpini M, et al. Metastasis to the pancreas from breast 10. Cancer Genome Atlas N. Comprehensive molecular por- cancer: difficulties in diagnosis and controversies in treat- traits of human breast tumours. Nature 2012;490:61–70. ment. Breast Care 2010;5:170–3. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy111/5017813 by Ed 'DeepDyve' Gillespie user on 21 June 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Metastatic lobular breast carcinoma to the pancreas: a case report

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Abstract

We report a case of a 72-year-old female, with an extensive breast cancer history, who presented with abdominal pain to her general practitioner. Cross-sectional imaging demonstrated a lesion in the head of pancreas, which was not amenable to curative resection. Percutaneous biopsy was obtained, which demonstrated metastatic lobular breast cancer. This rare case highlights how previous medical histories may assist in final pathological diagnosis. invasive lobular breast carcinoma with extra-nodal extension. INTRODUCTION Oestrogen receptor status was positive, progesterone receptor We report a rare case of metastatic breast cancer spreading to negative and HER-2 receptor negative. Post-operatively, repeat the pancreas, which provides a lesson in how thorough history imaging once again failed to demonstrate a primary lesion. taking may assist in the final pathological diagnosis. Staging CT scans of her chest, abdomen and pelvis were clear for metastatic disease. She was subsequently treated with exe- mestane and had regular surgical and medical oncology follow CASE REPORT up, with no evidence of loco-regional recurrence. When she now presented with generalized abdominal pain, A 72-year-old female patient presented to her general practi- a CT scan of the abdomen was performed, revealing a lesion in tioner with several months of generalized abdominal pain on the head of the pancreas measuring 7 × 4cm . This mass the background of a breast cancer history. Nineteen years prior extended into the porta hepatis and towards the left lobe of the to presentation, she was diagnosed with a 9 mm ductal carcin- liver, opacification of the splenic vein and superior mesenteric oma of the left breast, which was treated with a wide local exci- veins was absent, and the confluence of the portal vein could sion (original imaging unavailable). It was oestrogen receptor also not be visualized (Fig. 1). Total bilirubin was 13 μmol/L positive. A level II axillary clearance revealed no involved (normal <20), raised ALT at 127 U/L (normal <34) and AST at nodes. Post-operatively she received tamoxifen, which was 69 U/L (normal <31). ALP and GGT were also mildly raised at ceased after 6 months due to side effects. Fourteen years later 135 U/L for ALP (normal 30–110) and 219 U/L for GGT (normal (5 years prior to this presentation) she represented with palp- <38). Carcinoembryonic antigen and CA19.9, both markers of able left axillary lymphadenopathy. A core biopsy was suggest- pancreatic cancer, were not raised. She was referred to a hepa- ive of invasive breast carcinoma, however, no primary breast tobiliary surgeon for consideration of a pancreaticoduodenect- lesion was identifiable on bilateral mammogram, ultrasound omy, with the assumption of a primary pancreatic lesion. Due and MRI scans. Completion level II axillary clearance was per- to suspected vascular involvement and potential peritoneal formed that demonstrated 7/7 positive lymph nodes for Received: February 14, 2018. Accepted: May 6, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy111/5017813 by Ed 'DeepDyve' Gillespie user on 21 June 2018 2 A. Zammit et al. Figure 1: Axial slice of portal-venous phase CT scan demonstrating lesion in the head of pancreas. Figure 3: The poorly differentiated carcinoma shows nuclear positivity for GATA3 (IPX). GATA3 is commonly mutated in breast carcinoma and has been reported as indicative of metastatic breast carcinoma [9, 10]. Figure 2: H and E stain demonstrating poorly differentiated carcinoma with perineural invasion. Figure 4: The poorly differentiated carcinoma shows nuclear positivity for oestrogen receptor (IPX). disease seen on the CT, she was regarded as an unsuitable can- didate for a pancreaticoduodenectomy. To consider the use of palliative chemotherapy, a percutaneous biopsy for tissue diag- of invasive breast carcinoma metastasizing to the pancreas [4]. nosis was performed. Histology demonstrated a poorly differ- The literature also demonstrates the difficulty diagnosing entiated tumour, surrounded by benign pancreatic tissue with metastatic spread of breast cancer to the pancreas. There are focal areas of perineural invasion by GATA3 positive epithelial several reports of patients undergoing a pancreaticoduodenect- cells. These cells also stained positive for ER, K19 and CEA, but omy and only subsequent operative histology revealing meta- negative for PR, B72.3, E-cadherin and HER2. The final diagnosis static breast carcinoma [4]. Some authors have suggested that was poorly differentiated lobular breast carcinoma. surgical resection may be appropriate for both symptom con- Unfortunately, we were unable to compare the expression pro- trol and formal diagnosis [ 5, 6]. files between the pathology from the axillary dissection and In this patient’s case, the hepatobiliary department felt that the metastatic disease (Figs 2–4). in the absence of obstructive jaundice, and the possibility of tumour vascular involvement, a pancreaticoduodenectomy DISCUSSION would not improve her quality of life nor provide a survival During 2017 the projected incidence for breast cancer in advantage. Should there had been no vascular involvement, surgical resection may have been of benefit[6–8]. Australia is 17 000, representing one of the most prevalent can- cer diagnoses [1]. In Western populations lobular breast carcin- Whilst metastatic disease to the pancreas is uncommon, we would suggest that with the discovery of pancreatic lesions, oma accounts for ~10% of all breast cancer diagnoses, and overall has a poorer prognosis than that of ductal breast carcin- metastatic disease always be considered, especially with a his- tory of previous malignancy. A thorough history and the avail- oma [2, 3]. Following this patient’s diagnosis, we investigated how frequently lobular breast carcinoma metastasizes to the ability of previous pathology reports, may assist in final pathological diagnosis. pancreas. From the literature we identified only 12 other cases Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy111/5017813 by Ed 'DeepDyve' Gillespie user on 21 June 2018 Metastatic lobular breast carcinoma to the pancreas 3 5. Tohnosu N, Narushima K, Sunouchi K, Saito T, Shimizu T, CONFLICT OF INTEREST STATEMENT Tanaka H, et al. A case of breast cancer metastatic to the None declared. tail of the pancreas. Breast Cancer 2006;13:225–9. 6. Molino C, Mocerino C, Braucci A, Riccardi F, TrunfioM,Carrillo G, et al. Pancreatic solitary and synchronous metastasis from REFERENCES breast cancer: a case report and systematic review of contro- versies in diagnosis and treatment. World J Surg Oncol 2014;12:2. 1. Australian Institute of Health and Welfare. Cancer in 7. Pappo I, Feigin E, Uziely B, Amir G. Biliary and pancreatic Australia 2017. Canberra: AIHW, 2017. metastases of breast carcinoma: is surgical palliation indi- 2. Dossus L, Benusiglio PR. Lobular breast cancer: incidence cated? J Surg Oncol 1991;46:211–4. and genetic and non-genetic risk factors. Breast Cancer Res 8. Jyoti B, Bharat C, Ravi T, Subhash RK, Asawari P, Sudeep G. 2015;17:37. Billiary obstruction in a metastatic tumor of the pancreas 3. Arpino G, Bardou VJ, Clark GM, Elledge RM. Infiltrating lobu- from breast cancer. South Asian J Cancer 2017;6:10. lar carcinoma of the breast: tumor characteristics and clin- 9. Shield PW, Papadimos DJ, Walsh MD. GATA3: a promising ical outcome. Breast Cancer Res 2004;6:R149–56. marker for metastatic breast carcinoma in serous effusion 4. Bonapasta SA, Gregori M, Lanza R, Sangiorgi E, Menghi A, specimens. Cancer Cytopathol 2014;122:307–12. Scarpini M, et al. Metastasis to the pancreas from breast 10. Cancer Genome Atlas N. Comprehensive molecular por- cancer: difficulties in diagnosis and controversies in treat- traits of human breast tumours. Nature 2012;490:61–70. ment. Breast Care 2010;5:170–3. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy111/5017813 by Ed 'DeepDyve' Gillespie user on 21 June 2018

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Journal of Surgical Case ReportsOxford University Press

Published: May 29, 2018

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