A Rare Site of Spread of a Common Cancer

Abstract

A 46-year-old Native American woman was evaluated in the emergency department with the new onset of tonic–clonic seizures and altered mental status. Computed tomography (CT) and magnetic resonance imaging (MRI) of her brain revealed a cerebral infarct in the right middle cerebral artery (MCA) distribution. The patient was admitted to the neurology intensive care unit for further evaluation and care. She had a pertinent medical history of type 2 diabetes mellitus, tobacco and methamphetamine use, and ductal type, hormone receptor-negative breast carcinoma diagnosed 7 years prior, for which she underwent right mastectomy. She was undergoing chemotherapy with capecitabine and had been recently diagnosed with metastases to the bones and spine. During hospital admission, her mentation declined and she developed severe oropharyngeal dysphagia. The gastroenterology service was consulted to provide enteral access for nutrition. An esophago-gastro-duodenal (EGD) endoscopy revealed diffuse granular, congested, and friable mucosa throughout the stomach (Fig. 1). A percutaneous gastrostomy (PEG) tube was placed, and biopsies of the stomach were taken. A CT scan of the abdomen with contrast showed diffuse thickening of the gastric wall (Fig. 2). Results of pathologic examination of the gastric biopsies showed diffuse-type invasive adenocarcinoma (Fig. 3a). Due to the previous history of breast malignancy, immunohistochemical analysis revealed neoplastic cells strongly positive for cytokeratin AE1/AE3, GATA binding protein 3, and e-cadherin, indicating metastasis from primary breast cancer as opposed to a new primary gastric adenocarcinoma (Fig. 3b). Stains for chromogranin and synaptophysin were negative. Stains for estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor (HER)2 were negative. Given the severity of clinical problem, on the basis of a meeting with the family and the gastroenterology, primary, and palliative care services, the patient and family decided to pursue only comfort measures. Unfortunately, the patient passed away a few days later.