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Address correspondence to: Elliot K. Fishman, MD, Department of Radiology, Johns Hopkins Hospital, 601 North Caroline Street, Rm. 3254, Baltimore, MD 21287-0801
Affiliations
From the Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Medical Institutions, Baltimore, Maryland USA
The common sites of metastasis from breast carcinoma include local and distant lymph nodes, lung parenchyma, bone, liver, and brain. While less common, gastrointestinal carcinoma, involving everything from the tip of the tongue to the rectum, secondary to metastatic breast carcinoma have been reported. Many of these lesions occur years after treatment of the primary breast cancer and they can be confused with a second primary. We present a case of breast cancer metastatic to the esophagus which produced symptoms of progressive dysphagia in a woman thirteen years after mastectomy and radiation therapy for breast cancer.
The common sites of metastasis from breast carcinoma include local and distant lymph nodes, lung parenchyma, bone, liver, and brain. While less common, gastrointestinal disorders, involving everything from the tip of the tongue to the rectum, secondary to metastatic breast carcinoma have been reported (
). We present a case of breast cancer metastatic to the esophagus which produced symptoms of progressive dysphagia in a woman 13 years after mastectomy and radiation therapy for breast cancer.
Case Report
An 83-year-old woman, status post right mastectomy and radiation therapy for breast carcinoma 13 years ago, presented with a 3-year history of progressive dysphagia. The patient was afebrile, her blood work including white blood cell count and hematocrit was unremarkable, and her physical exam was within normal limits. The patient had been treated previously with esophageal dilatation for an upper esophageal stricture which was complicated by perforation. Cine esophagopharyngography revealed esophageal narrowing to 7 mm just above the manubrium consistent with stricture. Computed tomography (CT) was then performed and demonstrated moderate bilateral pleural effusions with basilar atelectasis, increased density in the right upper lobe consistent with prior history of radiation therapy, and thickening of the mid-esophagus with blurring of the tissue planes between the esophagus and adjacent aorta (Figure 1). Given the patient’s history of breast cancer, the diagnosis of metastatic breast carcinoma was considered as a possible cause of this esophageal thickening. In addition, a 4.5-cm enhancing and hypervascular lesion, most likely a liver metastasis, was noted in the right hepatic lobe posteriorly.
Figure 1Spiral CT of the chest demonstrates thickening of the mid-esophagus (arrow) with blurring of the tissue planes between the esophagus and adjacent aorta
The patient underwent an esophagoscopy and mediastinal exploration which revealed a very large mass enveloping the esophagus, the brachiocephalic artery, and the trachea at the level of the thoracic inlet. A biopsy of the lesion revealed poorly differentiated infiltrating adenocarcinoma with mucin vacuoles consistent with a breast primary (Figure 2A and B). Esophageal brush cytology showed glandular epithelial cells with marked atypia, suggestive of adenocarcinoma in the background of reactive squamous epithelial cells.
Figure 2(A) Breast cancer metastatic to the esophagus. Islands of epithelial cells (arrows) can be seen infiltrating dense connective tissue stroma. (Magnification × 40). (B) Breast cancer metastatic to the esophagus. Higher magnification (magnification × 400) reveals the characteristics of infiltrating adenocarcinoma including gland formation (arrow) and marked nuclear hyperchromasia and pleomorphism
Figure 2(A) Breast cancer metastatic to the esophagus. Islands of epithelial cells (arrows) can be seen infiltrating dense connective tissue stroma. (Magnification × 40). (B) Breast cancer metastatic to the esophagus. Higher magnification (magnification × 400) reveals the characteristics of infiltrating adenocarcinoma including gland formation (arrow) and marked nuclear hyperchromasia and pleomorphism
A percutaneous gastrostomy tube was placed to aid in the patient’s nutrition. The patient was discharged in good condition, tolerating both tube feedings and clear liquids. She continues to be treated with periodic endoscopic esophageal dilatation and is receiving Tamoxifen with follow-up in both the medical oncology and gastroenterology services.
Discussion
The majority of secondary malignancies of the esophagus arise from neighboring organs such as the larynx, hypopharynx, trachea, bronchus, stomach, or thyroid. Metastases from distant organs are rare (
). Toreson reported a series of 3700 consecutive autopsies in which he discovered 26 secondary malignancies of the esophagus, of which two originated from the breast (
). The majority of cases involving compressive esophageal symptoms secondary to metastatic breast carcinoma are due to tumor infiltration of the periesophageal lymph nodes with or without extension into the esophagus. Breast metastasis to the esophagus itself is uncommon.
Patients with metastatic breast carcinoma to the esophagus often present clinically with an insidious onset of dysphagia. The length of time between treatment of breast cancer and the onset of dysphagia can be several years. Shimada et al., report a mean time of mastectomy to the onset of dysphagia of 7.1 ± 4.2 years with a peak incidence at 4 to 5 years (
Because of the long latency period between the primary disease and onset of dysphagia, a good clinical history and a high index of suspicion are key to establishing the diagnosis. Several imaging modalities can be helpful. Barium swallow typically shows segmental narrowing of the mid-third of the esophagus with an intact mucosa (
). CT can further delineate the anatomical cause and extent of the esophageal thickening and narrowing. However, a definitive diagnosis requires pathologic examination. The reported sensitivity of endoscopic biopsy is low (
Unfortunately, by the time symptoms first appear, the majority of women already have distant metastases. Therefore, treatment has been directed toward palliation, and a variety of options exist. Some have suggested that radiotherapy should be the first-line choice as it is highly effective in relieving symptoms with relatively few immediate risks to the patient (
) have suggested that advances in balloon catheter technology have “virtually eliminated” the risk of rupture or perforation while others contend that the risk with balloon dilatation is higher than generally realized and may be increased with the introduction of newer, larger balloons (
In conclusion, we report a rare case of esophageal thickening presenting with progressive dysphagia due to metastatic breast cancer. The incidence is low, and the interval between treatment of breast cancer and the onset of dysphagia secondary to esophageal metastasis is typically long; thus the diagnosis can be easily overlooked. Radiologists should maintain a high index of suspicion when confronted with segmental esophageal thickening in a woman with a remote history of breast cancer. Because the carcinoma is often well advanced at presentation, treatment is aimed at palliation. Esophageal dilatation remains controversial, and radiation therapy is generally considered the first-line option.
References
Chang S.F.
Burrell M.I.
Brand M.H.
Garsten J.J.
The protean gastrointestinal manifestations of metastatic breast carcinoma.
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