Metastatic breast cancer presenting as a gallstone ileus
A 76-year-old Caucasian woman was admitted with a 2-week history of intermittent colicky lower abdominal pain associated with bilious vomiting and mild abdominal distension. She was previously diagnosed with left breast cancer 18 years ago for which she had undergone an oncological wide local excision, focused external beam radiotherapy and adjuvant treatment with tamoxifen for 5 years. Unfortunately, she developed regional recurrence with bony metastases 17 years following her original diagnosis. She was treated with palliative chemoradiotherapy and had an excellent response to treatment.\nPhysical examination revealed an elderly lady with stable vital signs. The abdomen was mildly distended with tenderness and guarding noted in the peri-umbilical region. Laboratory investigations, including haematological, biochemical, inflammatory and coagulation profiles, were all within normal limits.\nA plain abdominal radiograph was also unrevealing. She proceeded to have computerized tomography (CT) scan of her abdomen and pelvis, which showed dilated small bowel loops consistent with small bowel obstruction. There were two filling defects noted, one in her proximal ileum suspicious for a non-calcified gallstone and the second distally in her terminal ileum (Figs and ). Appearances were suggestive of gallstone ileus. She was adequately resuscitated and underwent a laparotomy. The small bowel was narrowed in two segments: proximally secondary to an impacted gallstone and an area of stricturing noted distally. Both segments were resected with end-to-end anastomosis performed in a two-layer standard hand-sewn fashion. The clinical impression was one of dual pathology including Crohn's disease and gallstone ileus. She did not undergo a cholecystectomy or repair of her cholecystoduodenal fistula. She made an uneventful post-operative recovery and was discharged home well on Day 7.\nHistopathological examination of the resected specimens showed a 3-cm intraluminal gallstone within the proximal ileum, with focal metastatic carcinoma consistent with breast primary present in the adjacent mesenteric adipose tissue (Fig. ), while the more distal, strictured ileal segment revealed mucosal and transmural involvement by metastatic breast carcinoma (Fig. ). The tumour cells were strongly positive for cytokeratin, oestrogen receptor and focal progesterone receptor (<5%), consistent with metastatic breast carcinoma. They also displayed a mixed ductal and lobular differentiation pattern.