Ann Thorac Surg 2006;81:1136-1138
© 2006 The Society of Thoracic Surgeons
Case report
Esophageal Perforation in a Patient With Metastatic Breast Cancer to Esophagus
Daniel A. Anaya, MD
a
,
Mujun Yu, MD
b
,
Riyad Karmy-Jones, MD
a
,
*
a Division of Thoracic and Trauma Surgery, Harborview Medical Center, University of Washington, Seattle, Washington
b Department of Pathology, Harborview Medical Center, University of Washington, Seattle, Washington
Accepted for publication January 18, 2005.
* Address correspondence to Dr Karmy-Jones, University of Washington, Harborview Medical Center, 325 Ninth Ave, Box 359796, Seattle, Washington 98104-2499 (Email: karmy{at}u.washington.edu).
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Abstract
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Esophageal metastasis from breast cancer is rare and can present after a long latency period. The middle and distal third of the esophagus are the most common sites and dysphagia (with or without stricture) is the most common presentation. Because of predominantly submucosal involvement, diagnosis is often difficult to establish until significant complications arise. We present the case of a patient with esophageal perforation due to dilatation treatments for dysphagia secondary to a distal stricture, later proven to be caused by esophageal metastasis from a breast cancer treated 19 years earlier.
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Introduction
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Distant metastasis to the esophagus is rare, but it has been described from malignant melanoma, breast, cervix, and lung cancers. Borst and Ingold [1] followed 2,246 patients with diagnoses of breast cancer over an 18-year period and noted metastasis to the esophagus in 0.4% of patients. However, others have shown that of those patients who die from breast cancer, 4% to 5% have esophageal metastasis [2]. We present a case of esophageal perforation after multiple dilatation treatments for an esophageal stricture in a patient who had breast cancer treated 19 years earlier and was now proven to have esophageal metastasis from her initial breast cancer.
A 67-year-old woman was referred after presentation of chest pain, nausea and vomiting, and fevers approximately 4 hours after having an esophageal dilatation for a distal esophageal stricture at an outside institution. She had presented with dysphagia as her primary symptom 6 months earlier and had undergone at least 10 esophageal dilatations as well as biopsies of her esophageal mucosa, all negative for malignancy. On arrival to our institution she was found to be mildly tachycardic with a white blood cell count of 16,000 and an outside computed tomographic scan that showed pneumomediastinum. An esophagram revealed an esophageal perforation at the gastro-esophageal junction with free leakage of contrast into the mediastinum but no obvious stricture (Fig 1).
The patient had a history of having had a lumpectomy with axillary node dissection and postoperative radiation therapy for a right inferomedial breast cancer 19 years prior. The lesion was a 15-mm infiltrating ductal carcinoma with positive estrogen and progesterone (PR) receptors, and all lymph nodes were negative (11 of 11). She received postoperative radiation at the surgical site to a dose of 6,100 cGy and had follow-up examinations and mammograms every year for the next 19 years. All surveillance work-up had remained negative.
Endoscopy was performed in the operating room, and no obvious stricture was noted. However, at left thoracotomy, the site of perforation was found to be dense, thickened, and firm, and the esophagus could not easily be mobilized to approach the perforation. In addition, a pulmonary nodule in the left lower lobe was discovered, and a wedge resection was done. Because of the question of mass, and multiple dilations, an esophagectomy through an Ivor-Lewis approach was performed. Pathology revealed an infiltrating lobular carcinoma of breast origin, present at the site of perforation (Fig 2). The lung lesion was also metastatic breast cancer. Both lesions were positive for estrogen and progesterone and intermediate for Ki-67. No new lesions have been found in either breast. The patient left the hospital in stable condition and was started on aromatase inhibitor therapy. At 6 months follow-up the patient is doing well with no evidence of recurrence.
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Fig 2. Microscopic findings of the esophageal lesion (using an estrogen stain) showing infiltrating lobular carcinoma of breast origin.
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Comment
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Although rare, breast metastasis to the esophagus has been previously reported. It typically presents with a long interval between the primary breast tumor diagnosis and treatment and its recurrence with esophageal involvement. Anderson and Harell [3] reported a mean time from mastectomy to onset of dysphagia of 7.1 ± 4.2 years. It usually affects postmenopausal women with a history of successfully treated breast cancer, typically located in the inner quadrants. Most reports have described esophageal involvement localized to the middle third and less frequently to the distal third of the esophagus. Histologic diagnosis is often difficult to establish if the lesion is papillary. However, having the pathology slides from the initial primary tumor may be a key to establishing this diagnosis because other tumors that can theoretically metastasize to the esophagus can be positive for estrogen receptors, including lung, endometrium, and pancreas. This was subsequently confirmed with immunohistochemical studies. In this case, the lobular appearance was characteristic. It is not uncommon for papillary breast cancer to have occult lobular components, and given the absence of a new breast primary, this is still consistent with the lesions being late metastases.
Dysphagia is the most common symptom in these patients and is usually present in as much as 90% to 95%. Other symptoms previously reported include weight loss, dysphonia, acute perforation, achalasia, and bleeding [4, 5]. The esophageal involvement is usually submucosal, thus biopsies may not make the diagnosis [4, 6]. Transesophageal endoscopic ultrasound may have helped make the diagnosis earlier.
Given its rarity, the prognosis of patients with esophageal metastasis from breast primary after a long latency period is difficult to establish. However, most of these recurrences have been estrogen and progesterone positive and disease-free survival for as much as 5 years has been reported with anti-hormonal therapy [6, 7]. Esophagectomy has also been described with good results, although preoperative diagnosis is the key to achieving complete resection [6].
In summary, breast cancer can metastasize to the esophagus, even up to 19 years after the primary tumor has been diagnosed and "fully" treated. Patients with a history of breast cancer (particularly remote) with persistent stricture without definable cause may benefit from having an endoscopic ultrasound. Esophagectomy may be appropriate in combination with chemotherapy, particularly if there are no widespread metastases.
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References
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- Borst MJ, Ingold JA. Metastatic patterns of invasive lobular versus invasive ductal carcinoma of the breast Surgery 1993;114(4):637-641.[Medline]
- Abrams HL, Spiro R, Goldstein N. Metastases in carcinoma; analysis of 1000 autopsied cases Cancer 1950;3(1):74-85.[Medline]
- Anderson MF, Harell GS. Secondary esophageal tumors AJR 1980;135:1243-1246.[Abstract]
- Herrera JL. Case reportesophageal metastasis from breast carcinoma presenting as achalasia. Am J Med Sci 1992;303(5):321-323.[Medline]
- Hastier P, Francois E, Delmont JP, Harris AG, Barthel HR, Namer M. Esophageal metastases from breast cancer detected by hematemesis Am J Gastroenterol 1994;89(2):289-290.[Medline]
- Shimada Y, Imamura M, Tobe T. Successful esophagectomy for metastatic carcinoma of the esophagus from breast cancera case report. Jpn J Surg 1989;19(1):82-85.[Medline]
- Erman M, Karaoglu A, Oksuzoglu B, Aydingoz U, Ayhan A, Guler N. Solitary esophageal metastasis of breast cancer after 11 yearsa case report. Med Oncol 2002;19(3):171-175.[Medline]
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Abstract
Introduction
