Breast Metastases

Breast metastases to the gastrointestinal tract result in a different pattern. Autopsy series record an incidence of breast metastases to the gastrointestinal tract as high as 8.2%246 to 16.4%.233 The need for surgical intervention for an abdominal complication of the metastasis is not

234 233

uncommon. Asch and associates collected a group of 18 cases of metastatic breast lesions requiring surgery, often many years after a mastectomy.

Fig. 4-209. Metastatic melanoma to small bowel.

Numerous submucosal masses are scattered throughout the small intestine. Their varying sizes indicate probable embolic metastatic showers at different times. (Reproduced from Meyers and McSweeney.1)

Fig. 4-209. Metastatic melanoma to small bowel.

Numerous submucosal masses are scattered throughout the small intestine. Their varying sizes indicate probable embolic metastatic showers at different times. (Reproduced from Meyers and McSweeney.1)

Talis Lesion

Fig. 4-210. Metastatic melanoma to small bowel.

Multiple submucosal masses of approximately equal size confined to one segment of small bowel indicate embolic metastases within a discrete arterial distribution.

Fig. 4-210. Metastatic melanoma to small bowel.

Multiple submucosal masses of approximately equal size confined to one segment of small bowel indicate embolic metastases within a discrete arterial distribution.

Fig. 4-211. Metastatic melanoma to the ascending colon.

Its embolic nature is revealed by the two large submucosal masses of approximately equal size on the antimesenteric border in the field of distribution of the right colic artery. (Reproduced from Meyers and McSweeney.1)

Fig. 4-211. Metastatic melanoma to the ascending colon.

Its embolic nature is revealed by the two large submucosal masses of approximately equal size on the antimesenteric border in the field of distribution of the right colic artery. (Reproduced from Meyers and McSweeney.1)

The type that gives rise to gastrointestinal metastases and symptoms most often is the poorly differentiated breast cancer that grows in rows of small anaplastic cells.246 No significant desmoplastic response accompanies the highly cellular secondary deposits. Infiltrating lobular carcinoma, while considerably less common than infiltrating ductal carcinoma, metastasizes significantly more often to the gastrointestinal tract.247-249 Although all layers of the bowel wall may be diffusely infiltrated, most of the embolic deposits reside in the submucosa,234 where they are more readily subject to radiologic identification.

While widespread peritoneal metastases may be present, a linitis plastica appearance often dominates the radiologic findings, commonly in the stomach 1,250-254

(Figs. 4-215 and 4-216). Although no desmoplastic response is elicted by breast metastases, the highly cellular submucosal deposits may narrow and deform the lumen, presenting a scirrhous appearance. Rigidity and thickening with markedly diminished or absent peristalsis are associated with spiculation and angulation of the folds. Pseudoulcerations are produced by buckling or redundancy of the mucosa. The changes may be diffuse or localized but are more common and prominent in the distal two-thirds of the stomach. Despite the occasional severe circumferential narrowing of the antrum, some degree of luminal patency is maintained so that gastric outlet obstruction is not a characteristic feature. The linitis plastica appearance produced is indistinguishable from that of a primary scirrhous carcinoma or lymphoma. Osteoblastic metastases, however, are frequently

Spiculation Small Bowel

Fig. 4-212. Metastatic melanoma to small bowel.

There is a nonobstructing submucosal mass with a large ulcerated excavation in a distal jejunal loop. The hematogenous metastasis is distinctly localized to the antimesenteric border of the loop.

(Reproduced from Meyers and McSweeney.1)

Fig. 4-213. Metastatic melanoma to small bowel.

A prominent submucosal metastasis is present on the antimesenteric border of the ileum (arrow). (Reproduced from Gourtsoyiannis and Nolan.80)

Fig. 4-213. Metastatic melanoma to small bowel.

A prominent submucosal metastasis is present on the antimesenteric border of the ileum (arrow). (Reproduced from Gourtsoyiannis and Nolan.80)

present1,255 (Fig. 4-215a). Secondary ulceration may be encountered as a prominent feature236,253 (Fig. 4-217).

Breast metastases to the small bowel may result in a focal stricture (Fig. 4-218) alternating areas of narrowing with interval dilatations (Fig. 4-219), or, rarely, a localized submucosal mass (Fig. 4-220).

Carcinoma of the breast is the most common source of hematogenous spread to the colon. In a series of 337 autopsies in patients with breast carcinoma, Asch and associates233 observed metastases to the colon in 4.5%. Of a group of 75 patients with advanced breast carcinoma who had laparotomy or autopsy, Graham234 noted that 16% demonstrated colonic metastases. These may present clinically many years after a radical mastectomy.44 The spread to the large intestine may be easily mistaken for primary inflammatory processes, such as granulo-matous or ulcerative colitis, both clinically and radio-logically.44 Diarrhea may be a conspicuous clinical presentation, occasionally of several years' duration, and perhaps associated with some blood and mucus. Characteristic radiologic findings (Figs. 4-221 through 4227), include mucosal thickening, nodular masses, multiple and eccentric strictures, asymmetric involvement, pseudosacculations, spiculations of contour, and frequent associated terminal ileal involvement.44 The findings may be limited to the right colon (Figs. 4-221 and 4-222), diffuse (Figs. 4-223 through 4-226), or rarely confined to the rectum256,257 (Fig. 4-227). It is apparent that these changes share many common features with inflammatory colitis, particularly Crohn's disease. Deep biopsy and cytologic analysis of any ascitic fluid may be confirmatory.

Fig. 4-214. Metastatic melanoma to small bowel.

CT demonstrates a large submucosal mass (M) in the antimesenteric wall of a jejunal loop. Another loop shows a smaller metastasis (arrowhead).

(Courtesy of Michiel Feldberg, M.D., Ph.D., University of Utrecht, The Netherlands.)

Fig. 4-214. Metastatic melanoma to small bowel.

CT demonstrates a large submucosal mass (M) in the antimesenteric wall of a jejunal loop. Another loop shows a smaller metastasis (arrowhead).

(Courtesy of Michiel Feldberg, M.D., Ph.D., University of Utrecht, The Netherlands.)

Baby Sleeping

Baby Sleeping

Everything You Need To Know About Baby Sleeping. Your baby is going to be sleeping a lot. During the first few months, your baby will sleep for most of theday. You may not get any real interaction, or reactions other than sleep and crying.

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