|LETTER TO EDITOR
|Year : 2020 | Volume
| Issue : 3 | Page : 627-629
Rectal cancer with breast metastasis: A case report with review of literature
Sandip Ganguly1, Sheena Alphones2, Priya Ghosh3, Divyas Midha2, Joydeep Ghosh1, Bivas Biswas1
1 Department of Medical Oncology, Tata Medical Center, Kolkata, West Bengal, India
2 Department of Pathology, Tata Medical Center, Kolkata, West Bengal, India
3 Department of Radiology, Tata Medical Center, Kolkata, West Bengal, India
|Date of Submission||26-Apr-2020|
|Date of Decision||13-May-2020|
|Date of Acceptance||29-May-2020|
|Date of Web Publication||19-Sep-2020|
Department of Medical Oncology, Tata Medical Center, 14 Mar EW Arterial Road, Newtown, Kolkata - 700 160, West Bengal
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ganguly S, Alphones S, Ghosh P, Midha D, Ghosh J, Biswas B. Rectal cancer with breast metastasis: A case report with review of literature. Cancer Res Stat Treat 2020;3:627-9
|How to cite this URL:|
Ganguly S, Alphones S, Ghosh P, Midha D, Ghosh J, Biswas B. Rectal cancer with breast metastasis: A case report with review of literature. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Oct 31];3:627-9. Available from: https://www.crstonline.com/text.asp?2020/3/3/627/295527
Most of the tumors in the breast metastasize from the contralateral breast, lungs, lymphomas, and melanomas. The incidence of breast metastasis from the extramammary sites has been reported to be around 3%. Cases of rectal cancers metastasizing to the breast are very rare. Here, we report a case of rectal cancer with metastasis to the breast and have performed a systematic review of the available literature on the same.
A 32-year-old female patient was diagnosed with mucinous adenocarcinoma of the rectum in March 2019. After proper staging and workup, the disease was found to be locally advanced. She was started on neoadjuvant radiotherapy (50 Gy/25 fractions) along with oral capecitabine (825 mg/m2 twice a day). She completed the chemoradiotherapy in June 2019 and was scheduled for elective surgery. Unfortunately, she defaulted and did not undergo the surgery.
Two months later, in September 2019, she presented to our hospital. The evaluation revealed lung metastases along with a lesion in the right breast. Mammography with ultrasonography (USG) of the breast lesion showed a Breast Imaging-Reporting and Data System (BI-RADS) 4B lesion 1.2 cm × 1.1 cm in size [Figure 1]. A USG-guided biopsy of the lesion revealed a mucinous adenocarcinoma that had metastasized from the primary rectal tumor. An immunohistochemistry (IHC) examination revealed that the lesion was positive for CK20, CDX2, and SATB and negative for GATA3 [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d, [Figure 2]e, [Figure 2]f. The patient was started on systemic chemotherapy with a combination of capecitabine and oxaliplatin, and an interim response assessment showed stable disease. The timeline of the clinical events is shown in [Table 1].
|Figure 1: Lobulated high-density lesion with partially obscured margins in the inferomedial quadrant of the right breast abutting the chest wall. Ultrasonography screening reveals lobulated hypoechoic lesion at the 5 O' clock position at the periphery of the right breast- breast imaging-reporting and data system 4B|
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|Figure 2: (a) Four cores of breast biopsy tissue showing the typical morphology of a mucinous carcinoma (H and E, ×4 and × 40). (b) Microscopy shows tumor cells arranged in a solid and acinar pattern floating in a sea of lightly staining amorphous mucin. (c) Immunohistochemistry shows tumor cells to be strongly and diffusely positive for the special AT-rich sequence binding protein 2. (d) Immunohistochemistry shows tumor cells to be strongly and diffusely positive for cytokeratin 20. (e) Immunohistochemistry shows tumor cells to be strongly and diffusely positive for the caudal-related homeobox gene 2. (f) Immunohistochemistry shows tumor cells to be negative for GATA3 binding protein, while the remnant breast tissue was positive for GATA3|
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As per the latest GLOBOCAN data, the incidence of rectal cancers is around 2.1% in India. Compared to colon cancer, rectal cancer has a greater extent of systemic spread beyond the liver because of its communication with the inferior vena cava through the inferior hemorrhoidal plexus. Therefore, unlike colon cancer, rectal malignancies spread more to the lungs and less to the peritoneum. There are reports of metastasis from the rectal primary to distant sites., Reports of breast metastasis from the rectal primary are scarce in the available literature.
A total of 17 cases have been reported in the literature where rectal cancers have metastasized to the breasts [Table 2]. The median age of the patients in these reports is 42 years, which is more than that of our patient. Only one male patient has been reported, whereas the rest are females. In these reports, 47% of the patients showed metastasis only to the breast, and 35% showed metastases to more than one organ other than the breast. Our patient showed metastasis to both, the lung as well as the breast. In 47% of the cases, metastasis was observed only in the right breast, as seen in our case, while in 18% of the cases, it was seen in both the breasts. In all the reports, the diagnosis of the primary and metastatic disease was based on the use of standard imaging and diagnostic modalities. The onset of metastases has not been reported consistently but ranges from as early as 2.5 months to as late as 7 years. In our patient, metastasis was diagnosed within 6 months from the time of diagnosis of the rectal primary.
Young women may have breast masses that can be detected by a clinical examination. Mammography along with USG can be helpful in differentiating the benign breast masses from the malignant ones. However, in borderline cases, a biopsy is essential to distinguish between the two. Even in patients with a history of non-breast cancer, it is essential to perform a biopsy of the breast mass found on imaging/examination to rule out a second primary tumor. IHC studies play a crucial role in differentiating metastatic lesions from second primary tumors, as they may have some overlapping morphological features. For instance, rectal carcinomas are characterized by CK20, CDX2, and SATB 2 positivity, whereas the breast tumors are characterized by CK7 and GATA3 positivity.
Proper clinical, imaging and histological examinations should be performed to correctly stage a patient with rectal cancer, as the intent of treatment changes based on the extent of the disease.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]