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Multilevel stenting of malignant colonic obstructions from multilevel breast cancer colonic metastasis

Open AccessPublished:January 25, 2022DOI:https://doi.org/10.1016/j.vgie.2021.12.012

      Video

      (mp4, (72.24 MB)

      A video depicting the enclosed case, procedure, and discussion.

      Abbreviation:

      SEMS (self-expanding metallic stent)
      Breast cancer frequently metastasizes to the bones, lungs, brain, and liver, whereas colonic metastasis from breast cancer is rare, with only a few cases reported to date.
      • Schwarz R.E.
      • Klimstra D.S.
      • Turnbull A.D.
      Metastatic breast cancer masquerading as gastrointestinal primary.
      Colonic obstruction causes electrolyte and fluid imbalances and increases the risk of bowel necrosis and perforation, which can be life-threatening.
      • Bonin E.A.
      • Baron T.H.
      Update on the indications and use of colonic stents.
      The use of self-expanding metallic stents (SEMSs) was first reported in 1991, and SEMSs have been used in recent years for the palliation of malignant colonic obstruction.
      • Cetinkaya E.
      • Dogrul A.B.
      • Tirnaksiz M.B.
      Role of self expandable stents in management of colorectal cancers.
      Studies have identified variations in the outcomes of SEMS placement when comparing patients with colorectal cancer and those with extracolonic malignancies.
      • Kim J.Y.
      • Kim S.G.
      • Im J.P.
      • et al.
      Comparison of treatment outcomes of endoscopic stenting for colonic and extracolonic malignant obstruction.
      • Keswani R.N.
      • Azar R.R.
      • Edmundowicz S.A.
      • et al.
      Stenting for malignant colonic obstruction: a comparison of efficacy and complications in colonic versus extracolonic malignancy.
      • Moon S.J.
      • Kim S.W.
      • Lee B.-I.
      • et al.
      Palliative stent for malignant colonic obstruction by extracolonic malignancy: a comparison with colorectal cancer.
      Although stent placement has been used for colonic obstruction, the ability to palliate a patient with multilevel metastases, via endoscopy, has yet to be described. In this case, we demonstrate the use of multilevel SEMSs for colonic obstructions in a patient with metastatic breast cancer to the colon.
      A 54-year-old woman with known stage IV breast cancer presented with colonic obstruction. Magnetic resonance enterography showed 3 distinct colonic obstructions, and colonoscopy showed proximal, middle, and distal strictures that were all biopsied and revealed metastatic breast cancer.
      An upper endoscope (Olympus America, Chelmsford, Mass, USA) was introduced into the colon to the distal and middle strictures. The upper endoscope was advanced up to the proximal stricture, marking each of the 3 strictures with endoclips fluoroscopically. 0.035-inch × 450-cm long guidewire was then introduced through the endoscope, past the oral end of the proximal stricture, and coiled into the proximal colon. The upper endoscope was exchanged for an adult colonoscope, which was then advanced over the guidewire to the distal stricture. The middle and distal strictures were dilated using a wire-guided controlled radial expansion 10- to 12-mm balloon (Fig. 1), allowing for colonoscope advancement to the proximal stricture.
      Figure thumbnail gr1
      Figure 1Endoscopic view showing balloon dilation of the distal stricture.
      A 12-mm biliary balloon was used to inject contrast under fluoroscopy, revealing a tight 60-mm stenosis. Next, a 22-mm × 90-mm uncovered SEMS (Boston Scientific, Marlborough, Mass, USA) was bridged across the stricture and deployed under endoscopic and fluoroscopic guidance. A 12-mm balloon was again advanced over the wire. The endoscope was slowly withdrawn to the middle stricture, and another 22-mm × 120-mm uncovered SEMS was deployed in the same fashion, covering middle and distal strictures.
      Carbon dioxide insufflation was used, and the colonoscopy easily traversed the stents into the descending colon (Fig. 2). Contrast was injected through the stent, demonstrating stents in place (Fig. 3). The colonoscope was withdrawn, and the procedure was concluded. The postprocedural radiograph showed stents in place, and an examination showed a soft abdomen with no tenderness. The colonic obstructions were successfully palliated. After 1 year of follow-up, the patient had no complaints or adverse events.
      Figure thumbnail gr3
      Figure 3Fluoroscopic view after contrast injection, demonstrating stent in place.
      Our case demonstrates the successful use of multilevel SEMSs for colonic obstructions from breast cancer metastases. The procedure was performed with only water insufflation and under fluoroscopic guidance. We show that dilating the distal stricture using a wire-guided controlled radial expansion balloon allowed for colonoscope passage and facilitated the deployment of the stent; the same technique can be repeated for other obstructions.
      Stent placement of multilevel colonic obstructions via endoscopy to palliate a patient with multilevel metastases is safe and effective when done under fluoroscopic and endoscopic guidance (Video 1, available online at www.VideoGIE.org).

      Disclosure

      Dr Mok is a consultant for Medtronic and ConMed. All other authors disclosed no financial relationships.

      Supplementary data

      References

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