Young woman with ductal breast cancer and bleeding gastric metastases

What happened, in summary

A 31-year-old woman had node-positive invasive ductal cancer of the right breast that was oestrogen-receptor positive, progesterone-receptor negative and HER2 negative. She underwent right mastectomy, followed by three cycles of fluorouracil, epirubicin and cyclophosphamide and four weekly cycles of nab-paclitaxel. Seven months later, surveillance CT showed bulky right axillary lymph nodes without other visible distant disease. Complete axillary dissection found cancer in all 12 removed nodes. A repeat scan 1 month later showed new metastases in the pancreas, liver and kidney. She then received radiation to the right chest wall and lymph nodes, with endocrine therapy planned. Soon afterward, she developed 2 days of severe nausea, vomiting and an episode of frank haematemesis, accompanied by a substantial fall in haemoglobin. Endoscopy found multiple hard nodules with central ulceration across the upper stomach. Biopsy showed poorly differentiated adenocarcinoma with CK7, GATA3 and oestrogen-receptor positivity, consistent with metastatic ductal breast cancer rather than a new gastric primary. Endoscopic clips could not be placed because the nodules were firm, so haemostatic powder was used to reduce rebleeding. Endocrine therapy was attempted but poorly tolerated. With extensive disease and rapid clinical decline, she chose palliative care and died 1 month after the gastrointestinal bleeding presentation.