The “Reverse Breast-Esophagus Syndrome”: Metastatic Carcinosis of Breast in Treated Esophagus Cancer

The “Reverse Breast-Esophagus Syndrome”: Metastatic Carcinosis of Breast in Treated Esophagus Cancer

A 62 year old female patient presented to us in October 2015 with a painful left breast lump which had grown progressively in size over the past 8 months. She had undergone a surgical resection for a mid-thoracic esophagus carcinoma in 2013. At that time, she had complaints of dysphagia, retrosternal pain and weight loss, and her barium swallow had revealed a stricture with marked irregularity in mid-thoracic part of esophagus distal to the carina. Upper GI endoscopy found a 6 cm mass, associated with mucosal irregularity and a narrowing of the esophageal lumen, 25cm from the incisor teeth. Endoscopic punch biopsy confirmed the lesion to be a squamous cell esophageal cancer. The patient was taken up for esophagectomy with a gastric pull-through operation. The resected specimen was histologically found to be an invasive, moderately differentiated, squamous cell carcinoma punctuated with areas of poor differentiation. The resection was followed by 4 cycles of chemotherapy with 5- Fluorouracil and Cisplatin. Follow-up barium swallow was normal. Since her recovery, the patient did well until she developed a lump in her left breast. On examination, this was a firm 3 cm × 2 cm mass just beneath the nipple, which was tender and immobile. Axillary lymph nodes were impalpable bilaterally. We put her first through mammography, a basic screening test in a late middle age female with a breast mass. At mammography, the patient had a retroareolar, hyperdense, irregular mass lesion which had indistinct margins, associated with surrounding architectural distortion. On breast ultrasound, the lesion was hypoechoic; measured approximately 2.5 cm × 2.3 cm × 1.7cm , had an irregular shape, angulated margins, demonstrated macrocalcification and was abutting the pectoralis major, but not infiltrating it. The mass did not reveal any posterior acoustic shadowing. The skin, nipple-areola complex and underlying muscle were not involved and thus we categorized the lesion as BI-RADS 4C (50-95% suspicion of malignancy) putting the possibility of a second primary malignancy in breast and metastasis from the prior esophagus cancer as the two differential diagnoses, the former being the more common scenario. On color Doppler, the mass had internal vascularity. Both axillae were normal. On strain elastography (SE), the mass had a Tsukuba elasticity score of 4 and strain ratio of 5.33, indicative of malignancy. We performed a magnetic resonance imaging (MRI) of bilateral breasts of the patient for complete evaluation of the lesion, to exclude any multifocal, multicentric disease and for comprehensive evaluation of axilla. T1-weighted pre-contrast scan showed an irregular, hypointense mass lesion on left breast in retroareolar position. It was heterogeneously hypointense on T2-weighted and STIR images. Dynamic contrast enhanced (DCE) MRI revealed an irregular lesion with heterogenous enhancement on post-contrast T1-weighted imaging and type 2 curve (plateau or indeterminate

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