Decide on the Spot: Benign or malignant disease?

May 12, 2015 By: B. Rembacken

Benign or malignant disease?

The photo shows the findings in a 65 year-old woman.

The photo shows the findings in a 65 year-old woman.

The photograph shows the findings in a 65-year-old woman undergoing investigations for anaemia. Her only medications are ibuprofen for backache and tamoxifen, which was started 7 years previously.


a) NSAID-induced gastric ulceration

b) CMV gastritis

c) Gastric lymphoma

d) Linitis plastica

e) Gastric metastates




The ulcers are too thickened and indurated for CMV gastritis or benign ulceration. Linitis plastica rarely causes ulceration. A gastric lymphoma may appear similar and would be the main differential diagnosis. However, the gastric wall is studded with discrete nodules whilst the intervening mucosa appears normal. There are numerous distinct deposits with a normal intervening mucosa, making metastasis the most likely diagnosis. In this patient taking tamoxifen, metastatic breast cancer would be the first diagnosis.

Infiltrating lobular carcinoma of the breast is particularly associated with peritoneal disease. In a retrospective analysis by McLemore et al., the mean interval between primary diagnosis and metastatic presentation was 7 years.1 In view of the long interval, it is particularly important to highlight the endoscopic diagnosis of gastric metastasis to your histopathology colleagues; this should prompt them to obtain the original histology slides of the primary breast cancer to compare the microscopic appearance with that of the endoscopic biopsy samples. Gastric metastasis from breast cancer is, of course, terrible news; the mean survival was reported as 28 months in the study by McLemore and colleagues.



  1. McLemore EC, et al. Breast cancer: presentation and intervention in women with gastrointestinal metastasis and carcinomatosis. Ann Surg Onc 2005; 12: 886–894.


Correct answer: e.



About the author

Bjorn Rembacken is at Leeds Teaching Hospitals NHS Trust, Leeds, UK. He was born in Sweden and qualified from Leicester University in 1987. He undertook his postgraduate education in Leicester and in Leeds. His MD was dedicated to inflammatory bowel disease. Dr Rembacken was appointed Consultant Gastroenterologist, Honorary Lecturer at Leeds University and Endoscopy Training Lead in 2005. Follow Bjorn on Twitter @Bjorn_Rembacken



Waleed Mahrous, June 26, 2015 13:06
e) Gastric metastates

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