breast carcinoma metastasis
TRANSCRIPT
METASTATIC CARCINOMA OF
BREAST
• It is the spread of tumour into different places like bone, lungs and pleura, liver, soft tissues , brain and adrenals
Modes of spread :1. Local spread : As the tumour grows in size it infiltrates skin
causing ulceration, fungation, bleeding, foul smelling discharge 2. Lymphatic spread : Central group, pectoral, lateral,
subscapular and supraclavicular nodes Inner medial quadrant of the breast, penetrate the rectus sheath and join intraperitoneal lymphatics, thus producing ascites, Krukenberg’s tumours, seconadries in liver.3. Blood spread : a. Secondaries in flat bones are common b. Secondaries in brain results in headache, vomiting and blurring of vision c. Malignant plueral effusion is common cause of death
Tumour
Bone • It is the most common site of metastasis
via blood spread• Spread to vertebra is through posterior
intercostal vein and Batson’s venous plexus• Vertebrae, ribs, upper end of humerus
and femur, pelvis are commonly involved
• Pain – stretching of periosteum• Pathological fractures• Spinal compression, quadriplegia and
paraplegia• Radiotherapy , internal fixation, spinal
compression is required
Lungs and pleura
• Spread to them causes ‘cannon ball’ secondaries, effusion, consolidation, chest wall secondaries.• It signifies terminal event • Poor prognosis• Respiratory distress and failure• HRCT is ideal diagnostic tool
Brain • Secondaries presents with headache, vomiting,
convulsions, raised intracranial pressure and papilloedema
Liver• Secondaries may develop either by
haematogenous or via lymphatics across diaphragm
Soft tissue secondaries got better prognosis; visceral secondaries got worst prognosis.
Medial survival time for metastatic breast cancer is 24 months
Examination for distant metastasis1. Opposite axilla and opposite breast2. Abdominal examination for secondaries in the liver , ascites and
Krukenberg’s tumour3. Rectal examination – deposits in rectouterine pouch4. Respiratory system – effusion5. Bony tenderness – spine, long bones, skull, etc
Evaluation FNAC/incisional biopsy, Chest CT, LFT, USG Abdomen, CT abdomen, whole body scanning, CT brain, tissue study for ER/PR/HER-2 neu receptor status
Treatment concept • To improve quality of life• To relieve pain of secondaries like bone, lungs• To relieve neurological problems like convulsions, space occupying
cranial problems• Other symptomatic relief
Treatment strategy • Chemotherapy• Radiotherapy• Hormone therapy• Trastuzumab• Supportive treatment
Chemoptherapy• CMF, CAF, Taxanes in combination.• High dose of chemotherapy using cyclophosphamide, cisplastine,
carmustine, melphalan are tried to get high response rate. But toxic effects are life threatning• Haemopoietic growth factor is also used along with chemotherapy to
enhance cell kill with less marrow toxicity
Radiotherapy• Used in bone metastasis, brain secondaries, to prevent paraplegia in spine
involvement and advanced axillary nodes. • It is also used in painful bone secondaries, chest wall secondaries
Harmone therapy • Tamoxifen, androgens, progestogens, oophorectomy, adrenalectomy,
aminoglutethimide, are used• It is useful in slow growing soft tissue or bone secondaries
Trastuzumab• It is a monoclonal antibody that interferes with the HER-2 neu receptor• Patients who have overexpression of HER-2 receptor, may also receive trastuzumab
in addition to above
Supportive treatmentMalignant plueral effusion : once effusion is confirmed by aspiration and cytology,
an intercostal drain is left in place talc insufflation is done to achieve pleurodesis, talc is most effective agent followed by tetracyclin or bleomycin, etcCerebral metastasis : corticosteroids and cranial radiotherapy
Bone metastasis : Localised bone lesions are treated by palliative radiotherapy or decompression as in quadriplegia, etc. Bisphosphonates – oral clodronates have been found to arrest progression of bone disease , dose – 1600 mg/day
Causes of death • Malignant plueral effusion• Spine involvement – quadriplegia • Bony metastasis• Secondaries in brain • Cancer cachexia