8/8/2019 Fulltextlaparosctopy on Breast

1/4

S u r g E n d o s c ( 1 9 9 5 ) 9 : 8 2 0 - 8 2 3 SurgicalEndoscopy Spfinger-VerlagNew York Inc. 1995

Laparoscopy to correc t ly d iagnose and s tage metas ta t ic breas t cancermi mi c k i ng C r o hn ' s d i s e a s eD . W . E a s t e r ~ , R . J a m s h i d i p o u r ~ , K . M c Q u a i d 21 D e p a r t m e n t o f S u r g e r y , U n i v e r s i t y o f C a l i f o r n i a i n S a n D i e g o , L a J o l l a , C A 9 2 0 37 , U S A2 S e c t i o n o f E n d o s c o p y , D e p a r t m e n t o f M e d i c i n e , V e t e r a n s A f f ai r s M e d i c al C e n t e r , U n i v e r s i t y o f C a l i fo r n i a in S a n F r a n c i s c o , S a nF r a n c i s c o , C A 9 4 1 2 2, U S AR e c e i v e d : 2 2 S e p t e m b e r 1 9 9 3 / A c c e p t e d : 2 9 D e c e m b e r 1 9 9 4

A b s t r a c t . W e r e p o r t a c a s e o f m e t a s t a t i c l o b u l a rb r e a s t c a r c i n o m a w i t h e x t r a h e p a t i c g a s t r o i n t e s t i n a ld i se a se . On the ba s i s o f c l in i c a l f i nd ings , r a d io log ici n v e s t i g a t i o n s , c o m p u t e r i z e d a x i a l t o m o g r a p h y , g a s -t r o in t e s t ina l e ndosc opy , a nd ga s t r i c b iopsy , t he d i a g -nos i s o f ga s t r i c a nd i l ea l C r o hn ' s d i se a se wa s m a de .T h e c o r r e c t d i a g n o s is o f p e r i to n e a l c a r c i n o m a t o s i sw a s m a d e a t l a p a r o s c o p y . T h i s c a s e e x e m p l i f i e s t h eu t i l it y o f l a pa r o sc op y in e s t a b l i sh ing the d i a gnos i s a n ds t a g ing f o r a bdom ina l d i se a se o f unc e r t a in e t io logy .K e y w o r d s : B r e a s t c a n c e r - - C r o h n ' s d i s e a se - - L o b -u la r c a r c i n o m a - L a p ar o sc o p y

L a p a r o s c o p y h a s b e e n a v a i la b l e to g e n e r a l s u r g e o n s t oa s s i s t in t he d i a gnos i s o f obsc u r e c o nd i t ions o f t hea b d o m e n f o r o v e r 9 0 y e a r s . H o w e v e r , s i g ni f ic a n t e n -t h u s i a s m f o r t h i s d i a g n o s t i c m o d a l i t y p o s t d a t e d t h e r e -c e n t la p a r o sc o p i c c h o l e c y s t e c t o m y " r e v o l u t i o n " o f1989-1990.W e h a v e r o u t i n e l y e m p l o y e d d i a g n o s ti c l a p a ro s c o -p y w h e n c o n v e n t i o n a l , l e s s - in v a s i v e p r o c e d u r e s f a il t or e so lve c l in i c a l que s t ions invo lv ing a bdom ina l v i sc e r a[ 6 ] . The u t i l i t y o f t h i s a pp r oa c h i s e xe m pl i f i e d by thef o l lowing c a se r e po r t .

C a s e r e p o r tA 6 8 - y e a r - o l d w h i t e f e m a l e w a s r e f e r r e d t o t h e U C S D S u r g i c a l O n -c o l o g y C l i n i c i n J a n u a r y 1 9 91 . I n 1 9 8 6 s h e w a s d i a g n o s e d w i t h" e a r l y " b r e a s t c a n c e r . B i o p s y a t t h a t t i m e s h o w e d i n f i lt r at i n g l o b -u l a r c a r c i n o m a w i t h f e a t u r e s o f t h e s i g n e t r i n g v a r i a n t . S h e r e f u s e df u r t h e r s t ag i n g o r s u r g e r y a n d e l e c t ed t o h a v e a l t e r n at i v e t r e a t m e n t

Correspondence to: D . W . E a s t e r , U C S D M e d i c a l C e n t e r , 22 5D i c k i n s o n S t r e e t , S a n D i e g o , C A 9 2 0 1 3 , U S A

i n M e x i co , i n c l u d i n g r a d i a ti o n t r e a t m e n t a n d t a m o x i f e n . S h es t o p p e d t a k i n g t a m o x i f e n w i t h o u t m e d i c a l a d v i c e i n 1 9 8 9. H e r p a s tm e d i c a l h i s t o r y w a s n o t a b l e f o r t h e d i a g n o s i s o f " i r r i t a b l e b o w e ls y n d r o m e " f r o m t h e a g e o f 1 9.S h e r e m a i n e d a s y m p t o m a t i c u n t i l e a r ly 1 99 0 w h e n s h e d e v e l o p e dd y s p h a g i a , h e a r t b u r n , a b d o m i n a l d i s t e n s i o n , a n d b l o a t in g . U p p e rg a s t r o i n t e s t i n a l e n d o s c o p y s h o w e d a h i a t a l h e r n i a , e r o s i v e e s o p h a -g i t is , a n d h y p e r e m i a o f t h e g a s t r i c f o l d s. B e c a u s e o f t h e s e f i n d i n g s ,s h e w a s p l a c e d o n o m e p r a z o l e i n F e b r u a r y o f 1 9 9 0 .I n A p r i l o f 1 9 9 0 , t h e p a t i e n t w a s a d m i t t e d t o h o s p i t a l w i t h a ne p i s o d e o f s m a l l -b o w e l o b s t r u c ti o n . S h e r e s p o n d e d t o c o n s e r v a t i v em a n a g e m e n t . S m a l l - b o w e l s e r i e s s h o w e d d e l a y e d t r a n s i t w i t h a ni r r e g u l a r se g m e n t a t t h e t e r m i n a l i l eu m . R e p e a t g a s t r o s c o p y a n db i o p s y o f e s o p h a g u s , s t o m a c h , a n d s m a l l b o w e l w e r e n e g a t i v e fo r

m a l i g n a n c y .T h e p a t i e n t w a s e m p i r i c a l l y p l a c e d o n o r a l s t e r o i d s f o r s u s p e c t e dC r o h n ' s d i s ea s e . H e r s y m p t o m s i m p r o v e d o v e r t h e n e x t 6 m o n t h s .C o l o n o s c o p y i n J u n e 1 9 90 s h o w e d " n a r r o w i n g " a t t h e h e p a t i c f l ex -u r e , w i t h n o d u la r i ty a n d e d e m a o f t h e a sc e n d i n g c o lo n . A C T s c a na t t h a t t i m e s h o w e d t h i c k e n in g o f t h e g a s t ri c a n t r u m a n d a s c e n d i n gc o l o n . A n u p p e r g a s t r o i n t e s t i n a l s e ri e s i n D e c e m b e r s h o w e d a d i-l a t e d d i s t a l e s o p h a g u s w i t h s m o o t h , t a p e r e d n a r r o w i n g a t t h e g a s -t r o e s o p h a g e a l j u n c t i o n c o n s i s t e n t w i t h a b e n i g n s t r ic t u r e. " C o b -b l e s t o n i n g " o f t h e g a s t r i c a n t r u m a n d m u l t i p le a p h t h o u s u l c e r s w e r ea l s o n o t e d ( F i g . 1 ) . T h e s e c h a n g e s w e r e a l s o t h o u g h t to b e a m a n i -f e s t a t i o n o f C r o h n ' s d i s e a s e .S h e h a d a n a c u t e e x a c e r b a t io n o f h e r s y m p t o m s i n J a n u a r y 1 99 1a n d u n d e r w e n t r e p e a t g a s t r o s c o p y . T h i s s h o w e d a n o r m a l g a s t r o -e s o p h a g e a l j u n c t i o n , " n o d u l a r c o b b l e s t o n i n g , " s c a t t e r ed s u p e rf i c ia le r o s i o n s in t h e c a r d i a a n d f u n d u s , a n d p s e u d o p o l y p s i n t h e a n t r u m .B i o p s i e s o f t h e a n t r u m s h o w e d a c u t e a n d c h r o n i c i n f l a m m a t o r yc h a n g e s w h i c h w e r e t h o u g h t t o b e c o n s i s t e n t w i t h C r o h n ' s d i s e a se .G a s t r i c b i o p s i es s h o w e d " s u s p i c i o u s " c e ll s b u t d i d n o t r e v e a l t h ep r e s e n c e o f m a l i g n a n cy .T h e p a t i e n t w a s r e f e r r e d i n J a n u a r y o f 1 9 9 1 f o r d i a g n o s t i c l a p a -r o s c o p y . F i n d i n g s a t l a p a r o s c o p y i n c l u d e d d i f f u s e p e r i t o n e a l c a r c i -n o m a t o s i s i n v o l v i n g th e s t o m a c h , r i g h t a n d t r a n s v e r s e c o l o n , a n dr i g h t h e m i d i a p h r a g m ( F i g. 2 ) . A d h e s i v e b a n d s w e r e o b s e r v e d f r o mt h e c e c u m t o t h e p e r i t o n e a l s i d e w a l l . T h e t e r m i n a l i l eu m a n d c e c u mw e r e a l s o i n v o l v e d ( F i g . 3 ). B i o p s i e s o f t h e p a r i e t a l p e r i t o n e u m a n dt h e s e r o s a l s u r f a c e o f t h e s t o m a c h s h o w e d d i f f u s e i n f il t r a t i o n b ym a l i g n a n t c e l ls . H i s t o p a t h o l o g y ( F i g . 4 ) w a s c o n s i s t e n t w i t h m e t a -s t a t i c i n f i l t ra t i n g l o b u l a r c a r c i n o m a o f t h e b r e a s t . T h e p a t i e n t m a d ea n u n e v e n t f u l r e c o v e r y f r o m h e r d i a g n o s t i c l a p a r o sc o p y .W i t h f u r t h e r a d v i c e , s h e r e s u m e d o r a l t a m o x i f e n b u t i n i t i al l yd e c l i n e d s y s t e m i c c h e m o t h e r a p y . I n M a r c h 1 9 91 , t h e p a t i e n t h a dd e m o n s t r a t e d b o n y m e t a s t a ti c d i s e a s e a s w e l l a s c a r c i n o m a e r u p t i n g

8/8/2019 Fulltextlaparosctopy on Breast

2/4

821

Fig. 1. U pper gastrointestinal series showing "cobblestoning" of the gastric antrum with multiple aphthous ulcers. These findings weremisinterpreted as C rohn 's disease.Fig. 2. Laparosco pic find ings showing diffuse peritoneal carcino matosis through out the abdominal cavity, including the right hemidiap hragmA and the serosal surface of the stomach B.Fig. 3. Laparoscopic v iew of the terminal ileum showing infiltration by m etastatic tumor and "creeping fa t." (See text.)

from the umbilical trocar site, By May 1991 she had developedmarked ascites and radiologic evidence of metastases to the pelvisand retroperitoneum (Fig. 5). Despite megestrol and two cycles ofintraperitoneal chemotherapy, she died from progressive disease inJuly 1991. Autopsy findings included invasive lobular breast carci-nom a involving both breasts, the stomach, sma ll intestine, colon,spleen, gallbladder, uterus, ovaries, lungs, bones, perirenal fat,adrenals, and the cerebellum. Of note, she had no m etastases to lungor liver.

Discus s ion

B r e a s t c a n c e r i s t he m o s t c o m m o n s it e o f c a n c e r a n dt h e s e c o n d - m o s t - f r e q u e n t c a u s e o f c a n c e r d e a th s f o rw o m e n i n th e U n i t e d S t a t e s [ 1]. E x t r a h e p a t i c g a s t ro -i n t es t in a l m e t a s t a s e s f r o m b r e a s t c a n c e r , a l t h o u g h n o tc o m m o n , a r e b y n o m e a n s r a r e . S u c h m e t a s t a s e sp r e s e n t a s l e s i o n s i n v o l v i n g th e s t o m a c h , s m a l l i n t e s -t ine , and co lon [5 , 7 , 10] . Th e c l in ica l p ic tu re m ay bei n d i st i n g ui s h a b le f r o m C r o h n ' s d i s e a s e o r u l c e r a t iv ec o l it i s u n l e s s p r o p e r t i s s u e b i o p s i e s a r e t a k e n [ 10 -- 12 ].T h e e x a c t i n c i d e n c e o f g a s t r o i n te s t i n a l m e t a s t a s e s

a r is i ng f r o m b r e a s t p r i m a r i e s i s n o t k n o w n . I n a u t o p s ys e r i e s , t h e i n c i d e n c e i s r e p o r t e d a s h i g h a s 1 5 - 1 8 % i np a t i e n t s d y i n g o f b r e a s t c a n c e r [ 2, 3, 9] . H o w e v e r , t h ec l i n ic a l i n c i d e n c e i n p a t i e n t s i s s u b s t a n t i a l l y l e s s - -m a n y p a t i e n ts w i t h s u c h le s i o ns m u s t r e m a i n a s y m p -t o m a t i c o r a r e n o t c o r r e c t l y d i a g n o s ed . C l a v i e n r e p o r t san inc iden ce o f 3 .9% in a s e r i es of 1192 pa t i en t s Wi thb r e a s t c a n c e r [ 4 ] .

R e c e n t r e p o r t s i n d i c a t e t h a t t h is p a t t e r n o f s p r e a di s o f t e n a s s o c i a t e d w i t h i n v a s i v e l o b u l ar c a r c i n o m a b u ti t c a n a l s o o c c u r w i t h d u c t a l c a r c i n o m a [ 1 3 , 1 4] .W h e r e a s d u c t a l c a r c i n o m a is u s u a l l y u n i l a t e r a l a n d h a sa t e n d e n c y t o m e t a s t a s i z e t o t h e l u n g s a n d t h e l i v e r ,i n v a s i v e l o bu l a r c a r c i n o m a o f t h e b r e a s t t e n d s t o b eb i l a t e r a l , w i t h m e t a s t a s e s t o b o n e , p e r i t o n e u m , a n dt h e g a s t r o i n t e s t i n a l t r a c t [ 8 ] . G a s t r i c a n d s m a l l - b o w e ll e s i o n s a r e m o r e c o m m o n t h a n c o l o n i c a n d r e c t a l l e -s ions [3] .

S y m p t o m s a s s o c i a t e d w i t h g a s t r o i n t e s t i n a l m e -t a s t a s e s a r e n o n - s p e c i f i c . T h e s e s y m p t o m s m a y , a s i no u r c a se , r e s p o n d t o m i s d i r e c t e d m a n a g e m e n t . T h er a d i o g r a p h ic f i n d in g s m a y r e s e m b l e t h o s e o f C r o h n ' s

8/8/2019 Fulltextlaparosctopy on Breast

3/4

822

Fig. 4. Biopsies obtained at laparo scop y showing metas tat ic infi l t rat inglobul a r ca rc inoma of t he b reas t , i nvo lv ing t he abdomina l wal l A , and t hepelvic wal l B (hematoxi l l in & eosin, 200).F ig . 5 . Computer i zed ax i a l t omography of abdomen wi th con t ras t ,showing advanced widespread d i sease ; t here i s marked asc i t es and t u -mor i nvo lvem ent o f t he re t roper i t oneum as wel l as t he umbi l ica l t rocarsite.

disease [10] . The abse nce of lung or l iver metas tase s inlobu l a r c a r c inoma c a n e a s i l y c onf ound f i nd ings o fcomputed tomography. S ince the metas tases a re se ro-sa l -based, t i ssue biops ies a t endoscopy of ten lead tofa lse -nega tive resul t s. Taa l r epor ts only a 60% successra te in cor rec t in te rpre ta t ion of upper gas t rointes tina lendoscopic f indings and a disappoint ing 65% t rue-pos i t ive ra te for deep- t i ssue biop s ies [13] . At colonos-copy, success ra tes of 70% for cor rec t en dosco pic in-te rpre ta t ion and 60% for pos i t ive biopsy ra tes apply[14]. The me dian survival f rom th e t ime of diagnosis inpa t ients wi th upper and lower gas t rointes t ina l me-tas tases in the two la rges t r epor ted se r ies was 12 and16 mo nths [13, 14] , with s om e patients surviving up to7 years [4].To ou r knowled ge , th is i s the f i rs t r epor t of a caseof dissem ina ted bre as t canc er wi th gas t rointes t ina lmetas tases diagnosed by laparoscopy. The potent ia ladvantages of laparoscop y inc lude (1) accura te pa tho-logic staging, (2) safety, (3) capabil i ty for large andmul t ip le biops ies , (4) exac t hem osta t i s fo l lowing biop-sies, and (5) patient acceptance [6] .The role of d iagnost ic laparosco py in genera l sur -gery i s expanding. As su rgeons beco me mo re comfor t -able with minimal-access surgery, i t wil l quite l ikelybecome an impor tant tool not only for the diagnosisbut a l so for the t r ea tmen t o f man y int raabdomina l d is-o r de rs . L a pa r o sc opy ma y e n t i r ely obv i a t e t he ne e d fo r

an explora tory laparotomy in many cases . In pa t ientswi th l imi ted li f e expec tancy, th is approach can redu cepostopera t ive discomfor t and hospi ta l s tay as wel l asallow for the rapid init iation o f adjuv ant th erapies.Acknowledgment. The au thors w i sh t o t hank Dr . N i ss i Vark i fo rhe lp w i th t he p repara t i on and i n t e rpre t a t i on o f t he h i s t opa tho logyphotographs . W e would a l so li ke t o t hank Ms. Trac y Tem ple ton fo rher exce l l en t ass i s t ance i n t he p repara t i on o f t he manuscr ip t .

References1 . Amer i can Cancer Soc i e ty (1994) Cancer fac t s and f i gures .CA A cancer j ourna l fo r phys i c i ans 44 :7 -262. Asch MJ, W eidel PD, Hab if DV (1968) Gast ro intest in al me-t as t ases f rom carc inoma of t he b reas t . Arch Surg 96 :840-8433 . C i fuen t es N , P i ckren JW (1979) Metas t ases f rom ca rc inoma ofmammary g l and : an au topsy s t udy . J Surg Oncol 11 :193-2054 . C l av i en PA, Laffe r U , Torhos t J , Harder F (1990) Gas t ro -intest inal metastases as fi rst cl inical manifestat ion of the dis-semina t i on o f a b reas t cancer . Eur J Surg Oncol 16 :121-1265 . Cormier WJ, Gaffey TA, Welch JM, Ed mon son JE (1980) L ini -t i s p l a s t i c a c a u s e d b y m e t a s t a t i c l o b u l a r c a r c i n o m a o f t h ebreas t . Mayo Cl in Proc 55 :747-7536 . Eas t e r DW, Cusch i e r i A , Nathanson LK, Lave l l e -Jones M(1992) The ut i l i ty of diagnost ic laparoscopy for abdominal dis-o rders . Audi t o f 120 pa t i en t s . Arch Surg 127 :379-3837 . Graham WP, Goldma n L (1964) Gas t ro in t es t i na l met as t asesf rom carc inoma of t he b reas t . Ann Surg 158 :477-4808 . Harr i s M, Howel l A , Chr i ssohou M, Swinde ll RIC , H udson M ,Sel lwood RA (1980) A compar i son of t he metas t a t i c pa t t e rn o f

8/8/2019 Fulltextlaparosctopy on Breast

4/4

82 3in f i l t r a t i ng lobu la r ca r c inoma and in f i l t r a t i ng duc ta l ca r c inomao f th e b r e a s t . B r J C a n c e r 5 0 : 2 3 - 3 09 . H a r t m a n n W H , S h e r l o c k P (1 9 61 ) M e t a s t a s e s f r o m c a r c i n o m ao f th e b r e a s t. C a n c e r 1 4 : 4 2 61 0. K o o s L , F i e l d R E ( 1 9 80 ) M e t a s t a t ic c a r c i n o m a o f b r e a s t s i m u -l a t in g C r o h n ' s d i s e a s e . I n t S u r g 6 5 : 3 5 % 3 6 211. M ad eya S , B or s ch G ( 1989) Di f f e r en t i a l d i agnos i s o f C r o hn ' sd i s eas e : s egm enta l i n t es t ina l metas t as i s o f b r eas t and s tom achc a n c e r . L e b e r M a g e n D a r m 1 9 : 1 4 0 - 1 5 2

1 2. M e l n i c k G S , R o s e n h o l t z M ( 1 96 1 ) M e t a s t a t i c b r e a s t c a r c i n o m as i m u la t i n g u l c e r a ti v e c o l i ti s . A m J R o e n t g e n o l 8 6 : 7 0 2 - 7 0 61 3. T a a l B G , D e n H a r t o g J a g e r F C , S t e i n m e t z R , P e t e r s e H ( 19 9 2)T h e s p e c t r u m o f g a st r o in t e s t in a l m e t a s t a s e s f r o m b r e a s t c a r c i -n o m a : I . S t o m a c h . G a s t r o i n t e s t E n d o s c 3 8 : 1 3 0 - 1 3 514. T aa l B G, den Har to g J ager FC , S t e inm etz R , Pe t e r s e H ( 1992)T h e s p e c t r u m o f g a st r o i n te s t i n a l m e t a s t a s e s o f b r e a s t c a r c i -n o m a : I I . T h e c o l o n a n d r e c t u m . G a s t r o i n t e s t E n d o s c 3 8 : 1 3 6 -141