Multilevel stenting of malignant colonic obstructions from multilevel breast cancer colonic metastases. Primary author Andrew Alabd. Co-author Schaefer R. S. Mock. These are our disclosures. Stenting has been used for colonic obstruction over the past years. Colonic metastases from breast cancer is rare, with only few cases reported to date. Furthermore, the ability to palliate a patient with multilevel metastases via endoscopy is yet to be described. In this case, we demonstrate the use of multilevel self-expanding metallic stents for colonic obstructions in a patient with multilevel breast cancer colonic metastases. A 54-year-old woman with known stage 4 breast cancer presented with colonic obstruction. MR entrography showed three distinct colonic obstructions, and colonoscopy showed strictures and irregular dark mucosa from 22-28 cm, 40-45 cm, and 50-53 cm, proven to be metastases from breast biopsy. An adult endoscope was introduced into the colon to the distal two sigmoid malignant structures. The endoscope was advanced up to the third structure, marking each of the three structures with endoclips, fluoroscopically. Then, a 0.035x450 long guide wire was introduced through the endoscope past the oral end of the proximal structure and coiled into the proximal colon. The endoscope was then exchanged for an adult colonoscope, which was then advanced over the guide wire to the distal most structure. Each of the distal most structures were then dilated using a wire-guided CRE balloon starting at 10, 11.5, and 12 mm and held for one minute, allowing for colonoscope advancement to the proximal most structure. Using a 12 mm biliary balloon, contrast was injected under fluoroscopy, revealing a tight 60 mm stenosis. Next, a 22 mm x 90 mm uncovered self-expanding metallic stent bridged across the structure and deployed under endoscopic and fluoroscopic guidance. A 12 mm balloon was again advanced over the wire, and the scope was slowly withdrawn to the mid-structure. Contrast was again injected under fluoroscopic guidance, demonstrating a 20 mm mid-structure, 10 mm normal bridge, and 40 mm distal structure. The scope was slowly withdrawn to the mid-structure, measuring 20 mm, and then 10 mm proximal, to reach the oral end of the distal most structure. Next, a 22 mm x 120 mm uncovered self-expanding metal stent was again advanced over the guide wire, past both stenoses. Fluoroscopic guidance was also being used. Next, a 22 mm x 120 mm uncovered self-expanding metal stent was again advanced over the guide wire, past both stenoses. Fluoroscopic guidance was also being used for stent deployment. As we can see here, the stent is being fully deployed, and the wire is being removed. After the stent was fully deployed, a tiny bit of CO2 was insufflated and easily traversed the stents into the descending column. After the stent was fully deployed, a tiny bit of CO2 was insufflated and easily traversed the stents into the descending column. The procedure was performed with only water injection, and under fluoroscopic guidance. Finally, as we see, contrast was injected through the stent, demonstrating intraluminal contrast into both stents, and no extravasation. The adult colonoscope was then withdrawn through the anus out of the patient, and the procedure concluded. Post-procedural radiograph was stents in place in the colon, and post-procedural physical examination showed soft abdomen with no tenderness. Our case demonstrates the successful use of multilevel self-expanding metallic stents for multilevel colonic obstructions from breast metastases. We show that dilating the distal structure using a wire-guided CRE balloon allowed for colonoscope passage, and facilitated the deployment of the stent, and that the same technique can be repeated for other obstructions. In conclusion, stenting of multilevel colonic obstructions via endoscopy to palliate a patient with multilevel metastases is safe and effective when done under fluoroscopic and endoscopic guidance.

case study

breast cancer

colonic obstruction

self-expanding metallic stents

multilevel stenting