2013, Volume 29, Number 3, Page(s) 231-234
Bilateral Breast Metastasis from Mucinous Adenocarcinoma of the Rectum: A Case Report and Review of the Literature
Rumana MAKHDOOMI, Farhat MUSTAFA, Rayees AHMAD, Suhail MALIK, Sheema SHEIKH, Khalil Mohammad BABA
Department of Pathology, Sheri-Kashmir Institute of Medical Sciences (SKIMS), SRINAGAR, INDIA
Keywords: Breast, Metastasis, Rectum, Adenocarcinoma
Metastatic breast carcinoma is rarely seen in clinical practice. It has
been reported that lymphoma-leukemia, melanoma and sarcomas
can metastasize to the breast. Bilateral metastases to the breast
are rare and commonly have been seen to originate from ovarian
carcinoma. Adenocarcinoma of rectum metastasizing to breast is an
extremely rare clinico-pathological situation. We report a 28-year-old
female who presented with bilateral breast metastasis 9 months after
abdomino-perineal resection and total meso-rectal excision for a
locally advanced mucinous adenocarcinoma of the rectum. A few
case reports of a mucinous adenocarcinoma of rectum presenting
with bilateral breast metastasis have been seen in the world literature
and we hereby report this case who till now is the youngest patient
Metastatic lesions to the breast are rare1
leukemias, melanomas and sarcomas are the commonest
malignancies that can metastasize to breast2
to the breast from rectal carcinoma is very rare, bilateral
breast metastasis being an extremely rare clinicopathological
. A few cases of bilateral breast
metastasis in the literature have been found to arise from
. We hereby report bilateral breast metastasis in
a 28-year-old female who had been operated 9 months back
for mucinous adenocarcinoma of the rectum. This is a rare
case of bilateral breast metastasis from adenocarcinoma
of the rectum and the youngest case reported so far. An
accurate diagnosis of breast metastasis is important because
the treatment and outcome of primary and metastasis to
the breast from gastrointestinal primaries is different.
A 28-year-old, married female presented to us at the FNAC
(Fine needle aspiration cytology) clinic with a history of
bilateral breast masses for one month. On general physical
examination, the patient was emaciated, pale with slight
icterus, with no lymphadenopathy – cervical or axillary.
Breast examination revealed multiple discrete masses in
both breasts, largest on measuring 3x2 cm and smallest
one measuring 2x1 cm. FNAC was done from the largest
masses of both breasts. Microscopy showed mucin pools
with a few cells showing pleomorphism and a signet ring
like morphology (Figures 1
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|Figure 1: FNAC breast showing mucous pools with occasional
pleomorphic cells. MGG (May-Grunwald Giemsa x20).
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|Figure 2: FNAC breast showing pleomorphic cells (PAP x40),
with one of the cells showing nucleus pushed to one side (signet
Mammography of both breasts was done three months
back. It revealed prominent fibro-glandular tissue with
no definite soft tissue nodule. There was no evidence of interstitial distortion and no micro-calcification was seen.
Bilateral nipples and retro-alveolar areas appeared normal.
In her past history, nine months back the patient had
presented with a history of pain in the lower abdomen
and constipation for 5 months. She had also complained
of bleeding per rectum for one month. Proctoscopy done
revealed a constricting growth, circumferential 3-4 cms
from the anal verge. Colonoscopy had revealed a polypoidal
growth on the right lateral wall of the rectum.
Routine blood investigations were normal except for a
raised level of carcino-embryonic antigen (CEA) level of
9.6 ng/ml. Contrast enhanced computerized tomography
(CECT) of abdomen and pelvis revealed a thick-walled
ano-rectal region with small paracentral nodes. Patient underwent
an abdomino-perineal resection. Intraoperatively
circumferential growth was seen in the rectum, 4 cm from
the anal verge. Growth was free, anteriorly, posteriorly and
laterally. Liver was free and no iliac nodes were felt. Postoperative
recovery period was uneventful with decrease
in CEA levels to 2.3 ng/ml. Histopathology of the resected
specimen revealed mucus secreting adenocarcinoma with
signet-ring differentiation (Figure 3), dissecting the muscle
bundles and extending up to the serosa. Five lymph nodes
were infiltrated by malignant cells. Both proximal and distal
resection margins were free of tumour.
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|Figure 3: Mucin pools with signet ring cells infiltrating colon
In view of the history and characteristic mucin pools
and signet ring cells, the diagnosis of metastatic
mucinous adenocarcinoma of the breast was made.
Immunohistochemistry done for breast markers like ER
(Estrogen receptor), PR (Progesterone receptor) and Her
2 were negative. The patient is on adjuvant chemotherapy
and is doing well after 2 months of follow-up.
Metastases to the breast are relatively uncommon but
virtually any malignancy may metastasize to the breast.
Most breast metastases originate from the contralateral
. However, lymphomas, leukemias, melanomas,
sarcomas, carcinomas from lung, stomach, esophagus,
ovary, oropharynx may be associated with metastasis to
. Bilateral breast metastases are very rare and have been seen in a few cases of ovarian carcinoma2
Breast secondaries from a colorectal neoplasm are rare
till date and only 19 such cases have been reported, two
of them being in men4-12
. However, bilateral breast
metastasis from adenocarcinoma of the rectum is very
rare, ours being the fourth case in the world literatüre6
Based on the review of 19 cases of colorectal carcinoma
metastasizing to the breast, Schaekelford et al. reported a
majority of cases (55%) to the left breast with 30% to the
right breast and only 3 cases with bilateral breast metastasis6
. Also, Schaekelford reported non-breast metastasis at
the time of diagnosed breast metastasis in 15 cases (75%).
In our case, however, metastasis to other organs was absent
after a thorough scanning.
Solitary discrete lesions in the breast are the most common
form of presentation7. Multiple well-defined lesions
and diffuse involvement are less common1. Our case
presented with bilateral multiple breast masses varying in
size from 0.5 to 3cm. The lesions were located superficially
in both breasts with no nipple retraction. Axillary lymph
node involvement is known7 but it was not seen in our
case. Breast metastases may be the first manifestation of the
Our patient was a 28-year-old female, and the average age
of patients with metastatic breast cancer is 43.3 years1.
Breast metastases are usually seen in the reproductive age
group (30-45 years)5. Bilateral breast metastasis from
ovarian cancer show a mean age of 46 years with a mean
interval of 22 months and a mean survival of 12 months2.
Colorectal metastases to breast average 3.5 cm in size and
range in size from 1 to11 cms6. The three patients reported
with bilateral breast metastasis from adenocarcinoma of
colon were aged 74 years, 43 years and 35 years making our
patient the youngest patient reported so far4,6. The first
two patients had been operated for colorectal carcinoma
two years and two months back respectively, both patients
having Duke's stage (C) rectal carcinoma.
The imaging features were not helpful in our case whereas
the other two (Ist two) cases mimicked a multifocal primary
breast carcinoma owing to the speculated, irregular soft
tissue density mammographic appearances8. The high
content of mucin within a tumor may be responsible for
some of the atypical imaging features4. Colorectal
carcinoma metastases to breast most often appear as masses
without calcifications on mammography; in series of 9 cases
with reported mammographic findings 2 (22%) exhibited
Radiologic studies of the breast may therefore be misleading
as metastasis may be associated with calcifications and may
not present as multiple bilateral masses and may mimic a
primary mammary carcinoma4. Metastatic neoplasms
to the breast may be diagnosed by fine needle aspiration
cytology12 and in clear-cut cases the need for biopsy may
not be there.
Mucinous differentiation of colorectal cancer is known
to be associated with a poor outcome13. In our patient,
the rectal tumor showed histological features of mucinous
differentiation. The features displayed were not typical
enough to sub-categorize this into signet ring cell subtype.
The metastatic cells showed pools of mucous with a few
signet rings. Metastatic breast cancer from rectum has been
reported earlier in a patient who defaulted from oncological
treatment3. However our patient was on a regular followup
and doing well.
Colorectal carcinoma (CRC) metastasizing to breast needs
to be distinguished from primary mucinous carcinoma of
the breast, and the histo-morphologic clues of a metastatic
CRC such as the presence of ῾dirty' necrosis can be helpful.
Metastatic CRC can morphologically mimic a primary
poorly differentiated ductal carcinoma of the breast.
Histopathological clues of metastases include lack of an
in-situ component, prominent lympho-vascular space
invasion and a ῾triple-negative' phenotype.
Immunohistochemistry in a vast majority of cases identifies
the phenotype of carcinoma, CRC is positive for cytokeratin
20, CDX2 and negative for breast markers cytokeratin-7,
mammaglobin and ER and PR in greater than 90% of cases5. Immunohistochemistry done for breast markers i.e,
ER, PR, Her 2 was negative in the primary adenocarcinoma
of rectum. The likelihood of a primary breast cancer metastasizing
to the colon was therefore ruled out in our case. In
our patient, the mode of spread was likely hematogenous.
The low rate of metastasis of gastrointestinal cancers to
breast can be explained by the fact that gastrointestinal malignancies
commonly metastasize by way of the portal route14.
The reason why this tumor metastasized to both breasts
and not other organs is not clear. Only further studies will
tell whether this is part of a syndrome in which there was
a similar tumor arising from both breasts and also from
the rectum or the breasts in this patient were genetically
predisposed to receive metastatic deposits from rectum.
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