Stomach in Chest and Chest in Stomach.

Case Report

A 76-year-old woman presented with hypotension noted to be atrial fibrillation. Her medical history was significant for diabetes mellitus, hypertension, morbid obesity, end-stage renal disease, and gastroesophageal reflux disease with known large hiatal hernia. After presentation, she developed nausea, vomiting, and vague epigastric pain. Chest computed tomography (CT) demonstrated an intrathoracic stomach with superior displacement of the greater curvature, suggesting volvulus (Figure 1). Upper gastrointestinal series demonstrated an organoaxial volvulus (Figure 2). Esophagogastroduodenoscopy (EGD) to rule out ischemia revealed a largely intrathoracic stomach with suggestion of a twist, and a friable, erythematous raised lesion was noted in the fundus (Figure 3). Pathology of the lesion revealed a metastatic carcinoma, consistent with primary breast cancer (Figure 4). Immunohistochemical staining revealed that the tumor cells were estrogen-receptor positive, focally progesterone-receptor positive, and negative for HER2 protien (Figure 4). Unfortunately, the patient soon developed sepsis and died before repeat EGD could be performed for detorsion and gastropexy.

Figure 1

Chest CT showing intrathorasic stomach in the (A) sagittal and (B) transverse views.

Figure 2

Upper gastrointestinal series showing organoaxial volvulus.

Figure 3

EGD showing (A) a twist in gastric body and (B) a metastatic implant in the fundus.

Figure 4

(A and B) Pathology showing metastatic carcinoma, consistent with primary breast cancer. (C) Immunohistochemical staining showing estrogen-receptor positive tumor cells.

Metastatic breast cancern is highly uncommon in the gastrointestinal tract. Gastric metastatic neoplasms from sources outside the primary gastrointestinal tract are also uncommon.1 Most reported cases of gastric metastatic breast cancer include a previous diagnosis of breast cancer.2 To our knowledge, this is the first report of metastatic breast cancer in a cancer-naïve patient diagnosed via examination of nausea and retching secondary to intrathoracic gastric volvulus. Among previously reported cases of hiatal hernia associated with malignancy, only 6 mentioned an additional association with gastric volvulus.1

Disclosures

Author contributions: KR Badipatla wrote the manuscript and obtained the figures. I. Harnik edited the manuscript, and is the article guarantor. JT John and A. Guo reviewed the manuscript.

Financial disclosure: None to report.

Informed consent was obtained for this case report.