An 87-year-old woman with a previous history of breast carcinoma presented with gastric symptoms due to metastasis to the stomach. Common sites of breast cancer metastases include the lungs, bones, and the liver. Although gastric metastases are not common, it accounts for 5.9% of all GI metastasis from breast cancers. It is of the utmost importance that the clinician be familiar with this pathologic entity, as the treatment for metastatic breast cancer presenting as linitis plastica is drastically different from that used to treat primary gastric cancer.

We present an 87-year-old Caucasian woman with a history of invasive lobular carcinoma of the breast. Approximately 15 years prior to presentation, the patient underwent a left sided lumpectomy, axillary lymph node dissection, followed by radiotherapy. She presented with chief complaints of a recurrent left sided breast mass and anorexia. She also complained of occasional nausea and vomiting after oral intake and a 20 pound weight loss over a three month period. On physical examination, there was a firm mass in the superolateral portion of the left breast roughly measuring 6 x 6 cm. Skin thickening with erythematous excoriations was also present. Work up included core needle biopsies of the breast lesion, as well as, an upper endoscopy. The gastroscopy revealed characteristics of linitis plastica including diffuse gastric wall thickening with large folds and patchy inflamed ulcerations.

The core biopsies of the breast showed non-cohesive malignant cells in single files (“Indian files”) penetrating between normal mammary epithelial elements (Figure 1). The cells appeared plasmacytoid with pleomorphic nuclei, consistentwithinfiltratinglobularcarcinoma(Figure1). The stomach biopsies revealed tumor cells diffusely expanding within the lamina propria of the gastric mucosa (Figure 2). The cellular morphology was similar to that seen in the breast biopsy with a plasmacytoid appearance and abnormal mitotic figures, confirming that the tumor was of breast origin. Immunohistochemically, there was an absence E-cadherin expression accounting for the non-cohesive nature of the malignant cells. Both the primary breast and the metastatic gastric tumor were positive for estrogen receptors, further assisting an exclusion of a primary gastric adenocarcinoma.

Figure 1: Core needle biopsy.

Linitis plastica secondary to metastatic carcinoma of the breast is uncommon. The usual sites of metastasis include the bone,lung,liverandbrain. Aschetal,performedanautopsy series with 337 patients with metastatic breast carcinoma, and identified that 16.4% had metastases to the gastrointestinal system, of which 5.9% had metastasized to the stomach 1. Although uncommon, there is a growing body of literature, composed mostly of case reports and small retrospective chart reviews, which describe gastric metastasis from breast carcinoma.

Linitis plastica is a term that describes a stomach with diffuse infiltration of a malignancy resulting in a rigid, thickened, “leather bottle” appearance. Taal et al, described three patterns of endoscopic features in a retrospective review of 51 patients with gastric metastases from breast carcinoma 2. Most patients, 57%, had diffuse involvement of the stomach, either as multiple erosions, gastritis, or linitis plastica with enlarged and thickened folds. We found 18% to have localized lesions such as a large ulcer or a polypoid mass. The last group was found to have stenosis from external compression and local infiltration of the gastric wall, of which 12% had stenosis at the esophagogastric junction and 14% had stenosis at the pylorus.

Figure 2: Gastric biopsy.

Interestingly, invasive lobular carcinoma and invasive ductal carcinoma of the breast differ in predilection for metastatic sites. Borst et al, performed a retrospective review over an 18-year period and discovered that invasive lobular carcinoma is more likely to involve the gastrointestinal system, gynecologic organs, and peritoneum/retroperitoneum 3. In regards to the gastrointestinal system, fifty percent of the gastrointestinal metastases were to the small bowel (8/16) with only 3 out of 16 cases involving the stomach. Other metastatic sites in the gastrointestinal system included the sigmoid and rectum (2/16), esophagus (1/16), cecum (1/16), and pancreas (1/16). On the other hand, invasive ductal carcinoma metastasized more often to the lung and pleura. Although rare, when invasive ductal carcinoma metastasizes to the stomach, they present in a discrete nodular pattern, as opposed to linitis plastic 4.

The differentiation of primary gastric carcinoma from metastatic carcinoma of breast origin is vital for treatment and management. Although both entities are associated with poor prognosis, gastric metastatic disease of breast origin is amenable to chemotherapeutic and hormonal treatment. Cormier et al, observed a significant improvement in survival in patients with metastatic breast cancer who received chemotherapeutic and hormonal treatment 5. Of 31 patients, nearly 1/3 of the patients were able to survive more than 2 years despite extensive metastases. Cormier et al, also observed temporary resolution of gastric outlet obstruction, allowing for the removal of jejunostomies and resumption of oral intake for several patients 5. In another retrospective review, Taal et al observed a palliative effect with partial remission amongst patients treated with hormonal therapy (tamoxifen or aminogluthetimide), chemotherapy (cyclophosphamide, methotrexate plus 5-FU or cyclophosphamide, adriamycin plus 5-FU), or a combination of chemotherapy and hormonal treatments 2. Of whom 5/14 treated with hormonal therapy, 6/8 treated with chemotherapy, and 6/8 treated with combination of chemotherapy and hormonal treatment responded favorably. The overall response rate was 46% and the median duration of response was 10 months with a 2-year survival rate of 23%.

McLemore et al, performed a retrospective chart review with 47 patients that revealed that palliative surgical intervention did not affect overall survival (28 vs. 26 months)6. Obviously, intervention may play a role in palliative care and relief of symptoms. The decision to intervene with surgery should be based upon the individual’s clinical presentation and an honest discussion regarding quality of life.

Gastric metastasis of breast origin is an uncommon occurrence; however, there is a growing body of literature documenting this predilection. It is important for clinicians to be aware of the potential for breast carcinoma to metastasize to the stomach, as gastrointestinal symptoms may serve as an indicator of metastatic breast carcinoma.

1. Asch MJ, Wiedel PD, Habif DV. Gastrointestinal Mestastases: autopsy study and 18 cases. Arch Surg 1968, Vol. 96, pp. 840-843.
2. Taal BG, Peterse H, Boot H. Clinical presentation, endoscopic features, and treatment of gastric metastases from breast carcinoma. Cancer, vol. 89, no. 11, pp.2214-2221.
3. Borst MJ, Ingold JA. Metastatic patterns of invasive lobular versus invasive ductal carcinoma of the breast. Surgery, vol. 114, no. 4, pp. 637-641.
4. Whitty LA, Crawford DL, Woodland JH, Patel JC, Nattier B, Thomas CR. Metastatic breast cancer presenting as linitis plastica of the stomach. Gastric Cancer 2005, 8: 193-197.
5. Cormier WJ, Gaffey TA, Welch JM, et al. Linitis plastica caused by metastatic lobular carcinoma of the breast. Mayo Clin Proc 1980; 55: 747-53.
6. McLemore EC, Pockaj BA, Reynolds C, Gray RJ, Hernandez JL, Grant CS, Donohue JH. Breast cancer: presentation and intervention in women with gastrointestinal metastasis and carcinomatosis. Annals of Surgical Oncology 2005, vol 12, no 11, pp. 886-894.