Discussion

Carcinoma breast with oesophageal metastasis is a rare presentation comprising only 0.4%. ^{Reference Borst and Ingold7} Most patients present initially with dysphagia, while other less common symptoms include achalasia ^{Reference Herrera8} and other motility disorders. ^{Reference Isaacs, MacGillivray and Springett9} Lesions most commonly arise in the middle and distal third of thoracic oesophagus, usually seen in post-menopausal women. ^{Reference Rampado, Ruol and Guido2,Reference Wada, Harada and Ohara4} The mean time from mastectomy to the onset of dysphagia was calculated to be 7.1 ± 4.2 years by Anderson and Harell. ^{Reference Anderson and Harell13} In this review of literature, we observed 83% patients presented with complaints of dysphagia after a median of 13 years post-breast surgery, with 72% metastases involving mid-thoracic oesophagus (Table 1). Mechanism of metastases is usually lymphatic, but intramural spread from breast primary is not uncommon. ^{Reference Rampado, Ruol and Guido2}

Table 1. Oesophageal metastases from breast carcinoma in medical literature reviewed for our paper

Mid, middle 1/3^rd oesophagus; Low, lower 1/3^rd oesophagus; GE JN, gastroesophageal junction; NA, not available; Dy, dysphagia; A, achalasia; CA, carcinoma; RT, radiotherapy; C, chemotherapy; sx, surgery; HT, hormonal therapy; D, dilation.

Diagnosis of oesophageal metastases pose a considerable challenge as the metastatic deposition is submucosal with normal mucosal covering. Thus, most cases go undetected during patients’ lifetime, and this explains the aberration seen in the prevalence of 6% in autopsy studies ^{Reference Graham and Goldman10} compared to clinically significant lesions which is less than 1%. While explorative surgeries like thoracoscopy and mediastinal exploration are diagnostic, EUS-FNB and endoscopic mucosal resection (EMR) are safe and effective alternatives. ^{Reference Rampado, Ruol and Guido2,Reference Wada, Harada and Ohara4} In our case, initial biopsy from the oesophageal stricture site was negative for malignancy and EUS-FNB was needed to confirm diagnosis. Histopathological examination (HPE) and IHC studies are necessary to differentiate primary and secondary oesophageal lesions. Oesophageal metastases are usually hormonally receptive owing to their breast origin. In our patient, while HPE revealed adenocarcinomatous lesion, IHC was required to confirm metastatic lesion from breast.

Oesophageal metastases from breast primary usually present after long DFS. ^{Reference Atkins11,Reference Polk, Camp and Walker12} In our case, the interval was 11 years, while the review of literature revealed a median of 13 years and mean of 12 years (Table 1). Breast cancer recurrence as isolated oesophageal lesion is uncommon, and by the time a patient becomes symptomatic for oesophageal lesion, they are already diagnosed with other sites of distant metastases. In our case, the patient presented with breast cancer recurrence involving bone, lung and oesophageal metastases. Thus, a curative treatment is not a legitimate approach to this presentation, and the goal is usually palliation of symptoms. ^{Reference Rampado, Ruol and Guido2,Reference De Palma, di Matteo, Romano, Fimmano, Rondinone and Catanzano6}

Management of secondary oesophageal cancers have undergone considerable change over the years. We reviewed a wide range of publications belonging to even late 20^th century, to get a more holistic picture of evolution of treatment strategies used in his rare condition. Initially treatment included surgery, dilation and stent. Endoscopic dilation has been attempted to relieve symptoms, but evidence suggests that repeated dilation is associated with perforation. ^{Reference Holyoke, Nemoto and Dao5,Reference Nazareno, Taves and Preiksaitis14,Reference Anaya, Yu and Karmy-Jones15} While expandable metal stents are effective in inoperable ^{Reference Borst and Ingold7} and chemoresistant cases, they provide only a temporary palliation of symptoms and associated with a high incidence of oesophageal perforation. ^{Reference Rampado, Ruol and Guido2} Surgical management in oesophageal metastases is ideally not justified due to palliative intent of treatment, but various surgical procedures have been practiced over the years to different outcomes. Adrenalectomy was shown to improve symptoms of dysphagia, especially in post-menopausal women. ^{Reference Holyoke, Nemoto and Dao5} Explorative laparotomy was attempted by Herrera et al, ^{Reference Herrera8} but the patient eventually died due to aspiration pneumonia and sepsis. Some studies have supported an aggressive surgical approach like oesophageal resection as a safe and effective palliation for oesophageal obstruction due to metastatic breast cancer, ^{Reference Shimada, Imamura and Tobe16,Reference Mizobuchi, Tachimori, Kato, Watanabe, Nakanishi and Ochiai17} but preoperative assessment of disease status is necessary for achieving adequate resection. ^{Reference Anaya, Yu and Karmy-Jones15} Surgical placement of Celestin tube was attempted by Simchuk et al, ^{Reference Simchuk and Low18} but patient died due to massive upper gastrointestinal bleeding just 5 months post-surgery.

Recurrent metastatic disease requires systemic treatment, and thus chemotherapy is an effective treatment. Our patient was administered multiple cycles of docetaxel and gemcitabine, while other studies have supported the use of adriamycin, epirubicin and cyclophosphamide. ^{Reference Erman, Karaoğlu, Öksüzoğlu, Aydıngöz, Ayhan and Güler19,Reference Liu, Feng, Chen, Li, Wu, Qian and Yang20} Oesophageal metastases are commonly seen in ER- and PR-positive patients, and thus hormonal therapy have been part of the treatment and are also effective in improving survival. ^{Reference Wada, Harada and Ohara4,Reference Erman, Karaoğlu, Öksüzoğlu, Aydıngöz, Ayhan and Güler19} But some studies have reported exacerbation of dysphagia after years of hormonal therapy, thus warranting a local therapy. ^{Reference Wada, Harada and Ohara4,Reference Miyake, Yamada, Miyake and Endo22} Radiotherapy was actively adopted for treatment only in the 21^st century and practiced only by a handful of clinicians. Importance of local control on survival was emphasised by Miyake et al. ^{Reference Miyake, Yamada, Miyake and Endo22} In our patient, radiotherapy was highly effective in the palliation of symptoms. Improvement of dysphagia after administration of EBRT has also been reported in recent studies. ^{Reference Wada, Harada and Ohara4,Reference Miyake, Yamada, Miyake and Endo22} We also performed ILRT in this patient in addition to the short-course EBRT. The American Brachytherapy Society approves brachytherapy as an effective treatment modality for palliation of dysphagia. Short-course EBRT followed by ILRT, especially in patients with life expectancy >6 months, achieve superior palliation in a shorter duration than the conventional 5-week course EBRT. ^{Reference Gaspar, Nag, Herskovic, Mantravadi and Speiser26}

Therefore, it is principal that treatment should include both systemic therapy and local therapy for effective palliation of symptoms and disease control. At present, systemic chemotherapy with hormonal therapy and local radiotherapy for palliation of symptoms is the best approach for management of secondary oesophageal lesion from breast primary. Also, as oesophageal obstruction is associated with weight loss and cachexia due to decreased oral intake, it is pertinent to ensure adequate nourishment for patients. Ryle’s tube insertion, percutaneous gastrostomy tube and feeding jejunostomy tube have been attempted to aid patient’s nutrition. ^{Reference Wu, Hruban and Fishman21}

Breast cancer with oesophageal obstruction is usually associated with multiple distant metastases, and thus it is difficult to assess the effect of oesophageal metastases on survival. Goldberg et al ^{Reference Goldberg, Rams, Stone and Barkin23} claimed that patients with oesophageal metastases survived only 5 years after dysphagia, but at the same time, oesophageal metastases are not an established prognostic factor. Thus, treatment should be decided by the severity of other metastases and on the degree of stenosis. ^{Reference Miyake, Yamada, Miyake and Endo22} Even though oesophageal cancers are associated with terminal stage of disease, we have observed better survival than expected, which can be attributed to the effectiveness of multimodal treatment. ^{Reference Wada, Harada and Ohara4,Reference Herrera8,Reference Erman, Karaoğlu, Öksüzoğlu, Aydıngöz, Ayhan and Güler19}