Post written by Debdeep Banerjee, Saikiran Raghavapuram, and Benjamin Tharian from the Division of Gastroenterology, Department of Internal Medicine, University of Arkansas for Medical Sciences and the School of Medicine, Texas Tech University Health Sciences Center.

In this video submission, we describe a woman with a past history of breast cancer who had undergone mastectomy and chemotherapy and had been in remission for 9 years. However, she displayed dyspeptic symptoms and a 10-pound weight loss over 1 year. Initial CT scan demonstrated diffuse mild gastric mucosal thickening. EGD was performed and showed thickened, rigid mucosal folds precluding further scope passage into the duodenum. This along with the ‘waffle-like’ appearance throughout the stomach upon scope retroflexion led to the suspicion of linitis plastica. Multiple biopsies demonstrated erosive gastropathy. We opted to perform EUS next, which showed a thickened gastric wall of 16.7 mm, loss of wall-layer definition, and peri-gastric ascites. FNA with a 22G needle was initially performed but proved difficult with poor tissue yield from onsite pathology. A 19G needle was eventually used for FNB, which revealed neoplastic cells in the gastric wall staining positive for estrogen receptors (ER). Finally, PET scan demonstrated widespread metastatic activity and potential peritoneal implants.

Although breast cancer metastasizing to the stomach is not a new phenomenon, it is, nonetheless, very uncommon, especially after so many years of remission. GI metastasis from invasive ductal type breast cancer is rare. In addition, this video provides the viewer a comprehensive workup of such a patient presentation with radiologic and endoscopic diagnostic modalities utilized.

Dyspeptic or upper gastrointestinal symptoms alongside a known history of cancer in patients should prompt alarm, whether the patient is in remission or not. Although multiple negative gastric biopsies may be present, EUS-guided FNB with subsequent immunohistochemistry provides diagnostic confirmation and opportunity for locoregional staging. EGD, CT, and PET provided key adjuncts to establish diagnosis and prognosis. The patient was later seen by oncology and started on letrozole and palbociclib.

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