A Case of Esophageal Stricture Due to Metastatic Breast Cancer
Diagnosed by Endoscopic Mucosal Resection
Fumiko Sunada1, Hironori Yamamoto1, Hiroto Kita1, Kazunobu Hanatsuka1, Hironari Ajibe1, Mamiko Masuda1,
Tomosuke Hirasawa1, Hiroyuki Osawa1, Kiichi Sato1, Yasuo Hozumi2and Kentaro Sugano1
1Department of Gastroenterology and2Department of Surgery, Jichi Medical School, Kawachi-gun, Tochigi, Japan
Received February 15, 2005; accepted May 15, 2005; published online July 8, 2005
Metastasis of breast cancer to the esophagus has been reported but is rare. It is often difficult to
diagnose metastases of breast cancer to the esophagus because they are often located in the
submucosa and covered with normal mucosa. Although several methods have been reported in
order to obtain specimens for pathological diagnosis, the adverse effects including bleeding and
perforation were considerable problems. We report a case of a patient with esophageal stricture
due to metastatic breast cancer to the esophagus. Pathological diagnosis was successfully
obtained using endoscopic mucosal resection of the esophagus.
Key words: tumor metastasis to esophagus – metastatic breast cancer – endoscopic mucosal resection
Tumor metastasis to the esophagus is a rare occurrence, and
breast cancer is its most frequent origin (1–3). Diagnosis of
esophageal stricture resulting from metastatic breast cancer is
often difficult, and most cases were diagnosed on autopsy and
endoscopic biopsy confirmed metastatic breast cancer of the
We present here a case of a patient with esophageal stricture
due to metastatic breast cancer of the esophagus, in whom
pathological diagnosis was successfully established using
endoscopic mucosal resection (EMR) of the esophagus.
A 68-year-old woman was admitted to our hospital because of
increasing symptoms of dysphagia lasting several years. She
had had a mastectomy due to breast cancer when she was
45 years old. Upper endoscopy showed a severe stricture in
the mid-esophagus where the endoscope could not pass
through (Fig. 1). Repeated biopsy from the stricture was neg-
thickening of the wall of the esophagus around the stricture
(Fig. 2). Endoscopic ultrasound (EUS) of the stricture revealed
thickening of the fourth layer around the esophagus (Fig. 3).
Laboratory data revealed a normal level of CEA (3.2 U/ml),
and an elevated level of CA15-3 (52 U/ml). After receiving
informed consent, the stricture was dilated endoscopically
using a balloon dilator. The esophageal mucosa covering
the lumen of the stricture after the dilation was smooth and
neoplasm was not detected by another repeated biopsy. We
could not obtain the diagnosis for the stricture even after the
dilation therapy, and the patients was carefully observed
because her symptoms had disappeared and also she did not
want further study at that time. However, she had dysphagia
6 months later and was again admitted to our hospital.
Esophagoscopy on admission demonstrated a similar esopha-
geal stricture at the same location. In order to make a patho-
logical diagnosis, EMR was carried out for the stricture lesion
using a cap method after the injection of 20 ml of saline
underneath the mucosa (Fig. 4) (11). There were no complica-
tions including perforation and bleeding after EMR. The
For reprints and all correspondence: Hiroto Kita, Department of
Gastroenterology, Jichi Medical School, 3311-1 Yakushiji, Minamikawachi,
Kawachi, Tochigi 329-0498, Japan. E-mail: firstname.lastname@example.org
on the stricture appeared normal.
Jpn J Clin Oncol 2005;35(8)483–486
#2005 Foundation for Promotion of Cancer Research
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pathological diagnosis was adenocarcinoma (Fig. 5). Immun-
ostaining of the resected sample was positive for Her-2, ER,
PgR, GCDFP and CAM 5.2. Although detailed information on
the original breast cancer was not available because the opera-
tion had been done >20 years previously, these results strongly
indicate that the stricture was due to metastasis from the
breast cancer. After the diagnosis, she was treated with
hormone therapy. She gained weight after 6 months of treat-
ment, and she had no symptoms during the 8 months of
Since the first reported case of metastatic esophageal carcin-
esophageal tumors have been reported from various organs,
including breast, larynx, thyroid, hypopharynx and stomach
(7,13,14). Breast carcinoma represents one of the most
frequent origins of metastasis in the esophagus (1–3). Dia-
gnosis of breast cancer metastasis to the esophagus is difficult,
and esophageal involvement can occur without clinical symp-
toms in a considerable number of patients with breast cancer.
Abrahms et al. reported seven patients with esophageal meta-
stases on autopsy among 167 patients who died of breast
cancer (15). Asch et al. also performed an autopsy series of
337 patients who died of breast cancer and found 20 patients
with esophageal metastases, although dysphagia was present in
only two of them (16). Graham et al. suggested a prevalence of
up to 6% of metastases in the esophagus for breast cancer,
although clinically symptomatic cases would not be as numer-
ous (17). The mechanism of esophageal spread from breast
cancer has been controversial. Involvement of periesophageal
lymph nodes through intra-mammary lymphatic channels was
Figure 4. Macroscopic view of the resected specimen. The mass lesion was
observed from the bottom.
Figure 3. Endoscopicultrasound of the stricture revealed the thickening of the
fourth layer around the esophagus.
Figure 2. Chest computed tomography revealed thickening of the esophageal
wall at the carina.
484 Esophageal stricture from breast cancer
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suggested to cause esophageal obstruction usually at the level
of the carina (18,19).
Dysphagia is one of the most common clinical presentations
associated with esophageal metastasis from breast cancer. The
mean period between the diagnosis of cancer and the onset
of symptoms due to esophageal metastases was reported to be
?8 years, including the previously recorded longest time inter-
val of 22 years (17). In our case, ?20 years had passed to the
onset of dysphagia due to esophageal metastases after the first
diagnosis of breast cancer was made.
Metastatic esophageal carcinoma is a diagnostic challenge
because of the difficulty of obtaining adequate specimens
for pathological diagnosis. It is also difficult to differentiate
it from primary esophageal carcinoma. In our case, esophago-
scopy exhibited a stricture with normal mucosa, which was a
typical macroscopic feature of the metastatic esophageal car-
cinoma. Biopsy from the stricture is often negative. Anderson
et al. reported 15 cases of secondary esophageal tumor dia-
gnosed from an autopsy and surgical pathology, including
seven cases of lung cancer, four cases of breast cancer and
single cases of kidney, pancreas and cervical cancers (20).
Laforet et al. reported that biopsy was performed endoscop-
ically in seven patients with esophageal strictures due to sec-
ondary esophageal tumor and accompanied with three
perforations, while diagnostic tissue was recovered in three
cases (21). Varanasi et al. reported that of three cases of breast
carcinoma metastatic to the esophagus, diagnosis was made by
surgery in two cases and by lymph node biopsy in one case (4).
Esophageal obstructionwas alsoobservedinmediastinal meta-
stasis from breast cancer (10,22).
Several techniques have been introduced for the diagnoses
of strictures with possible involvement of either primary or
metastatic neoplasms. Wiersema et al. and Giovannini et al.
separately described the combination of EUS and EUS-guided
fine-needle aspiration as a diagnostic method to treat sub-
mucosal tumor (SMT) (23,24). However, the relatively small
specimens obtained with this method make it difficult to dif-
ferentiate benign from malignant tumors. Normal findings also
do not exclude the possibility of malignancy, (25,26). The
guillotine needle biopsy technique described by Caletti et al.
is safe, but up to three consecutive procedures are required for
histological confirmation (27). Large forces in conjunction
with a tunneling technique can be used to obtain sufficient
samples. However, bleeding may be troublesome as a com-
plication of this technique (28,29).
EMR is a widespread technique of cutting mucosal lesions
through the submucosa (30). EMR is also applicable to treat
SMT in the esophagus and stomach, although indications
for endoscopic treatment of SMT have not been established
(31,32). Several EMR techniques have been developed for the
diagnosis of SMT. Takahashi et al. and Yu et al. separately
reported that EMR is a safe method for obtaining tissues
for histological diagnosis (18,19). Kawamoto et al. found
that endoscopic submucosal tumorectomy was useful, but
this technique should be restricted to the lesions limited to
the submucosa (33). In this patient, we have applied the
EMR technique for the diagnosis of the occupying lesion in
the esophagus presumably located in the submucosa. The dia-
gnosis was of clinical importance because metastasis from
breast cancer can be treated by chemotherapy, radiotherapy
and/or hormone therapy.
1. Herrera JL. Benign and metastatic tumors of the esophagus. Gastroenterol
Clin North Am 1991;20:775–89.
2. Holyoke ED, Nemoto T, Dao TL. Esophageal metastases and dysphagia in
patients with carcinoma of the breast. J Surg Oncol 1969;1:97–107.
3. Nussbaum M, Grossman M. Metastases to the esophagus causing
gastrointestinal bleeding. Am J Gastroenterol 1976;66:467–72.
metastatic to the esophagus: clinicopathological and management
features of four cases, and literature review. Am J Gastroenterol 1995;
5. Boccardo F, Merlano M, Canobbio L, Rosso R, Aste H. Esophageal
6. Isaacs P, MacGillivray N, Springett P. Late recurrence of breast cancer
presenting with esophageal dysmotility. J Clin Gastroenterol 1989;
7. Atkins JP. Metastatic carcinoma to the esophagus. Endoscopic
considerations with special reference to carcinoma of the breast. Ann
Otol Rhinol Laryngol 1966;75:356–67.
metastasis from breast carcinoma associated with pseudoepitheliomatous
hyperplasia: an unusual endoscopic diagnosis. J Surg Oncol 1989;41:
report and review of the literature. Pathol Int 1997;47:614–7.
to the cervical esophagus. Laryngoscope 1982;92:999–1000.
11. Inoue H, Endo M, Takeshita K, Yoshino K, Muraoka Y, Yoneshima H.
A new simplified technique of endoscopic esophageal mucosal resection
using a cap-fitted panendoscope (EMRC). Surg Endosc 1992;6:264–5.
12. GrossP,FreedmanLJ. Obstructingsecondarycarcinomaoftheesophagus.
Arch Pathol 1942;33:361–4.
13. Toreson WE. Secondary carcinoma of the esophagus as a cause of
dysphagia. Arch Pathol 1942;38:82–4.
14. Fisher MS. Metastasis to the esophagus. Gastrointest Radiol 1976;1:
15. Abrahms HL, Spiro R, Goldstein N. Metastases in carcinoma: analysis of
1000 autopsied cases. Cancer 1950;3:74–85.
16. Asch MJ, Wiedel PD, Habif DV. Gastrointestinal metastases from
carcinoma of the breast. Autopsy study and 18 cases requiring operative
intervention. Arch Surg 1968;96:840–3.
Ann Surg 1964;159:477–80.
18. Takahashi H, Fujita R. Endoscopic diathermic resection of gastric
submucosal tumors (in Japanese with English abstract). Gastroenterol
19. Yu JP, Luo HS, Wang XZ. Endoscopic treatment of submucosal lesions
of the gastrointestinal tract. Endoscopy 1992;24:190–3.
20. Anderson MF, Harell GS. Secondary esophageal tumors. AJR Am J
21. Laforet EG, Kondi ES. Postmastectomy dysphagia. Am J Surg 1971;
22. Vansant JR, Davis RK. Esophageal obstruction secondary to mediastinal
metastasis from breast carcinoma. Chest 1971;60:93–5.
23. Wiersema MJ, Wiersema LM, Khusro Q, Cramer HM, Tao LC. Combined
endosonography and fine-needle aspiration cytology in the evaluation of
gastrointestinal lesions. Gastrointest Endosc 1994;40:199–206.
24. Giovannini M, Seitz JF, Monges G, Perrier H, Rabbia I. Fine-needle
aspiration cytology guided by endoscopic ultrasonography: results in
141 patients. Endoscopy 1995;27:171–7.
25. Giovannini M, Seitz JF, Monges G, Perrier H, Castellani P. Guided
puncture-cytology under electronic sectorial ultrasound endoscopy.
Results in 26 patients. Gastroenterol Clin Biol 1993;17:465–70.
Jpn J Clin Oncol 2005;35(8) 485
by guest on June 6, 2013
26. WiersemaMJ,HawesRH,TaoLC,WiersemaLM,KopeckyKK,RexDK, Download full-text
et al. Endoscopic ultrasonography as an adjunct to fine needle aspiration
cytology of the upper and lower gastrointestinal tract. Gastrointest Endosc
27. Caletti GC, Brocchi E, Ferrari A, Bonora G, Santini D, Mazzoleni G,
et al. Guillotine needle biopsy as a supplement to endosonography
in the diagnosis of gastric submucosal tumors. Endoscopy 1991;23:
28. Benya RV, Metz DC, Hijazi YJ, Fishbeyn VA, Pisegna JR, Jensen RT.
Fine needle aspiration cytology of submucosal nodules in patients with
Zollinger–Ellison syndrome. Am J Gastroenterol 1993;88:258–65.
29. Kochman ML, Hawes RH. Endosonographic Evaluation of Submucosal
Lesions of the Gastrointestinal Tract. New York: Raven Press; 1994.
30. Lightdale CJ. Endoscopic mucosal resection: this is our turf. Endoscopy
resection of a large leiomyoma of the esophagus. Gastrointest Endosc
enucleation of upper-GI submucosal tumors by using an insulated-tip
electrosurgical knife. Gastrointest Endosc 2004;59:409–15.
33. Kawamoto K, Yamada Y, Furukawa N, Utsunomiya T, Haraguchi Y,
MizuguchiM,et al. Endoscopic
gastrointestinal submucosal tumors restricted to the submucosa: a
new form of endoscopic minimal surgery. Gastrointest Endosc
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