Esophageal metastasis from breast cancer after two decades of remission: a case report

Introduction

Breast cancer is the most common malignancy in women and the second leading cause of cancer-related death in the world. It commonly metastasizes to the bones, liver, lungs, and brain. Gastrointestinal involvement is rare, with the esophagus being the least frequently involved site (1,2). Diagnosis is often delayed due to the nonspecific nature of presenting symptoms. Notably, the literature describing very late esophageal metastasis from breast cancer is particularly scarce, and reporting such cases is essential to improving understanding of their pathophysiology, clinical presentation, and management.

We present a case of a 55-year-old woman with a remote history of invasive ductal breast cancer who developed dysphagia after a very long disease-free status (20 years) and was found to have esophageal metastasis from breast cancer. We present this article in accordance with the CARE reporting checklist (available at https://aoe.amegroups.com/article/view/10.21037/aoe-25-25/rc).

Case presentation

A 55-year-old woman with a BRCA-2 mutation was diagnosed in 2005 with stage IIB (T2N1M0), estrogen receptor (ER)/progesterone receptor (PR)-positive, human epidermal growth factor receptor 2 (HER2)-negative invasive ductal breast carcinoma. She completed neoadjuvant chemotherapy in March 2005, followed by bilateral mastectomy with bilateral salpingo-oophorectomy in November 2005, and received adjuvant anastrozole from June 2005 to June 2015. She remained in complete remission for 20 years.

In April 2025, she presented with a one-month history of progressive dysphagia to solids, nausea, vomiting, and unintentional weight loss. She had no risk factors for esophageal disease, including smoking and alcohol use, and no family history of esophageal cancer. A swallow study demonstrated delayed esophageal clearance, mild proximal dilation, and a mid-esophageal stricture. Upper endoscopy revealed a partially obstructive mid-esophageal mass (Figure 1A-1D). Biopsies showed poorly differentiated carcinoma. Immunohistochemistry was positive for pankeratin, GATA3, TRPS1, and ER, and negative for mammaglobin and E-cadherin. This immunoprofile, in conjunction with the patient’s clinical history of breast cancer, supports a diagnosis of metastatic breast carcinoma (3).

Figure 1 Endoscopic evaluation of the esophagus demonstrates a partially obstructive, circumferential submucosal mass in the middle third of the esophagus. (A) Endoscopic image showing a partially obstructive, circumferential mass in the mid-esophagus; (B) closer endoscopic view revealing the esophageal mass; (C) endoscopic image showing an intact thickened mucosal surface consistent with submucosal spread; (D) endoscopic image showing an intact thickened mucosal surface consistent with submucosal spread.

A contrast-enhanced computed tomography (CT) scan of the chest demonstrated a 3.5 cm × 5.4 cm heterogeneously enhancing posterior mediastinal mass encasing the main bronchi and abutting the aorta and pulmonary artery (Figure 2A,2B). Positron emission tomography (PET) imaging showed hypermetabolism in the subcarinal region involving the esophagus [standardized uptake value (SUV) 13.25] with extension into the right mainstem bronchus and associated carinal lymphadenopathy, consistent with malignancy. Otherwise, no additional sites of abnormal uptake were identified on the PET scan, indicating the absence of other detectable metastatic disease (Figure 2C,2D). She was subsequently started on letrozole 2.5 mg and ribociclib 600 mg.

Figure 2 Cross-sectional imaging demonstrates the mediastinal involvement of the esophageal lesion. (A) Transverse view of the CT chest with contrast. Arrow indicates a heterogeneously enhancing mass in the posterior mediastinum associated with mild narrowing of the right main bronchus, suspicious for malignant etiology. (B) Coronal view of the CT chest with contrast. Arrow indicates a heterogeneously enhancing mass in the posterior mediastinum. (C) Transverse images of a PET scan of the chest. Arrow indicates the abnormal uptake involving the esophagus and right mainstem bronchus. (D) Coronal PET/CT image. Arrow indicates abnormal uptake in the esophagus extending into the right mainstem bronchus. CT, computed tomography; PET, positron emission tomography.

In July 2025, she presented with cough, dyspnea, and worsening dysphagia. CT of the chest and esophagram revealed complete esophageal obstruction with a tracheoesophageal fistula. Repeat endoscopy showed near-complete obstruction, and an esophageal stent was placed. Bronchoscopy identified airway involvement requiring right bronchial stenting, later exchanged to a bifurcated tracheobronchial stent due to migration. Due to the lack of clinical response, despite adequate tolerance, letrozole and ribociclib were discontinued, and she was transitioned to trastuzumab deruxtecan 5.4 mg/kg every 3 weeks (Figure 3). At her most recent follow-up in October 2025, she reported symptomatic improvement, including better swallowing and stabilization of weight. She is scheduled for central venous access placement in preparation for systemic chemotherapy initiation.

Figure 3 Timeline summarizing the patient’s course of disease, diagnoses, and management. ER, estrogen receptor; HER2, human epidermal growth factor receptor 2; PR, progesterone receptor.

Ethics

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Publication of this case report and accompanying images was waived from patient consent according to the University of Miami ethics committee/institutional review board. The nature of the incident being reported does not make it possible for the subject to be identified and does not include any photographs or images, nor does it involve a rare disease. Furthermore, the patient’s details were kept anonymous.

Discussion

The most common primary cancers that metastasize to the gastrointestinal tract are melanoma, followed by ovarian, bladder, breast, and lung cancer (4). Esophageal metastasis from breast cancer is rare and often difficult to diagnose. Presenting symptoms—including dysphagia, nausea, and vomiting—are nonspecific and may mimic common benign gastrointestinal conditions (5). Prior case reports have described esophageal metastases as occurring more frequently in patients with invasive lobular carcinoma compared with other histologic subtypes (6). In a review of 64 reported cases of breast cancer metastatic to the esophagus, the middle third of the esophagus was involved most commonly, consistent with our findings. Unlike our case, which represents an isolated esophageal metastasis, most reported cases demonstrated multiple distant metastatic sites. Only eight cases documented a remission period of 20–25 years, indicating that such late recurrence with esophageal involvement is exceedingly uncommon (7).

In early-stage, ER-positive breast cancer, late recurrence remains a well-recognized challenge. Adjuvant endocrine therapy, particularly with aromatase inhibitors, has been established to reduce this risk and further delay recurrence. The average interval between initial breast cancer diagnosis and the development of esophageal metastasis is approximately 10 years (8). In our case, the latency period was notably prolonged, approaching 20 years. Loss of E-cadherin expression is common in invasive lobular carcinoma; however, reduced or absent expression may also occur in high-grade ductal tumors, with reported rates around 38%. Reduced/loss of E-cadherin function has been linked to aggressive tumor behavior and was found to occur late in the carcinogenesis process, driven by genomic instability (9). Mammaglobin expression is variable, and a negative result does not exclude breast cancer, limiting its diagnostic specificity (10).

Metastatic cells may spread to periesophageal lymph nodes and infiltrate intramurally, ultimately causing esophageal obstruction. Endoscopic examination often reveals normal-appearing mucosa overlying the area of narrowing, while mucosal abnormalities such as erythema, edema, erosions, or visible masses are uncommon (11). Standard mucosal biopsies may yield false-negative results due to submucosal tumor spread, making deeper tissue sampling—such as endoscopic ultrasound–guided fine-needle biopsy—essential for diagnostic confirmation (12). This case report has several limitations. First, the patient’s original histopathology from 2005 was unavailable, limiting our ability to perform a direct comparative analysis between the initial breast tumor and the current metastatic esophageal lesion, which would have strengthened diagnostic certainty. Second, the follow-up period after initiation of the patient’s current therapy remains short, restricting our ability to fully assess treatment response and long-term clinical outcomes.

Conclusions

This case describes a rare occurrence of esophageal metastasis from breast cancer after a significantly long period of remission (20 years). This emphasizes the importance of long-term follow-up in breast cancer survivors. Physicians should consider metastatic disease among the differential diagnoses in patients with new, nonspecific esophageal symptoms, even decades after initial breast cancer diagnosis. Prompt, thorough diagnostic evaluation with endoscopy and imaging, followed by early initiation of systemic therapy, may improve outcomes in cases of esophageal metastasis from breast cancer. Multidisciplinary care and awareness of atypical metastatic patterns are key to timely diagnosis and management.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://aoe.amegroups.com/article/view/10.21037/aoe-25-25/rc

Peer Review File: Available at https://aoe.amegroups.com/article/view/10.21037/aoe-25-25/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://aoe.amegroups.com/article/view/10.21037/aoe-25-25/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Publication of this case report and accompanying images was waived from patient consent according to the University of Miami ethics committee/institutional review board. The nature of the incident being reported does not make it possible for the subject to be identified and does not include any photographs or images, nor does it involve a rare disease. Furthermore, the patient’s details were kept anonymous.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. McLemore EC, Pockaj BA, Reynolds C, et al. Breast cancer: presentation and intervention in women with gastrointestinal metastasis and carcinomatosis. Ann Surg Oncol 2005;12:886-94. [Crossref] [PubMed]
2. Jin L, Han B, Siegel E, et al. Breast cancer lung metastasis: Molecular biology and therapeutic implications. Cancer Biol Ther 2018;19:858-68. [Crossref] [PubMed]
3. Ding Q, Huo L, Peng Y, et al. Immunohistochemical Markers for Distinguishing Metastatic Breast Carcinoma from Other Common Malignancies: Update and Revisit. Semin Diagn Pathol 2022;39:313-21. [Crossref] [PubMed]
4. Washington K, McDonagh D. Secondary tumors of the gastrointestinal tract: surgical pathologic findings and comparison with autopsy survey. Mod Pathol 1995;8:427-33.
5. Sato Y, Horiguchi H, Yoshida M, et al. Four cases of esophageal metastasis from breast cancer. Nihon Shokakibyo Gakkai Zasshi 2012;109:921-8.
6. Montagna E, Pirola S, Maisonneuve P, et al. Lobular Metastatic Breast Cancer Patients With Gastrointestinal Involvement: Features and Outcomes. Clin Breast Cancer 2018;18:e401-5. [Crossref] [PubMed]
7. Su H, Wu J, Liu H, et al. Review of esophageal metastasis from breast cancer. Gland Surg 2020;9:417-22. [Crossref] [PubMed]
8. Da Cunha T, Restrepo D, Abi-Saleh S, et al. Breast cancer metastasizing to the upper gastrointestinal tract (the esophagus and the stomach): A comprehensive review of the literature. World J Gastrointest Oncol 2023;15:1332-41. [Crossref] [PubMed]
9. Alsaleem M, Toss MS, Joseph C, et al. The molecular mechanisms underlying reduced E-cadherin expression in invasive ductal carcinoma of the breast: high throughput analysis of large cohorts. Mod Pathol 2019;32:967-76. [Crossref] [PubMed]
10. Al Joudi FS. Human mammaglobin in breast cancer: a brief review of its clinical utility. Indian J Med Res 2014;139:675-85.
11. Liu A, Feng Y, Chen B, et al. A case report of metastatic breast cancer initially presenting with esophageal dysphagia. Medicine (Baltimore) 2018;97:e13184. [Crossref] [PubMed]
12. Sunada F, Yamamoto H, Kita H, et al. A case of esophageal stricture due to metastatic breast cancer diagnosed by endoscopic mucosal resection. Jpn J Clin Oncol 2005;35:483-6. [Crossref] [PubMed]