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BREAST CANCER

Epidemiology
Breast cancer is the most prevalent cancer among women and affects
approximately one million women worldwide.

Prevalence ( epidemiology) is the total number of cases of a disease in a given


population at a specific time
Prevalence is the number of all new and old cases of a disease during a
particular period.

Incidence is the number of new cases of a disease diagnosed in one year.


Epidemiology
Breast cancer accounts for 30% of all female
cancers (UK).
Men can also develop breast cancer, accounting
for 1% of cases diagnosed annually (UK).

Breast cancer is the most common cause of cancer


in women (U.S.)
The most common cause of death in women
between the ages of 45 and 55 (U.S.)
RISK FACTORS

Sex
BC in men is rare (> 1% from all malignant
tumors)
Sex ratio, women / men = 100 : 1

Age
Ageing is the most important RF
RISK FACTORS

Geographical variation

There is quite a difference in incidence rate of


breast cancer between different countries.

The biggest difference is between Eastern and


Western countries - low to high
RISK FACTORS
Reproductive factors
- Women who start menstruating early in life or
who have a late menopause have an increased
risk of breast cancer.

- Women who have natural menopause after the


age of 55 are twice as likely to develop breast
cancer then women who experience the
menopause before the age of 45.
RISK FACTORS
Age at first pregnancy
Having no children and being older at the time of
the first birth both increase the incidence of breast
cancer.
The risk of breast cancer in women who have their
first child after the age of 30 is about twice that of
women having their first child before the age of 20.
The highest risk group are those who have their first
child after the age of 35
RISK FACTORS

Inherited risk
Up to 10 % of breast cancer in Western
countries is due to an inherited factor.
It is not yet known how many breast cancer
genes there are, but to date, two specific
breast cancer genes have been identified
(BRCA1 and BRCA2).
RISK FACTORS
Previous breast disease
Women with certain benign changes in their breasts -
severe atypical epithelial hyperplasia.
Radiation
Women who received radiation to the chest as a result of
repeated X-rays for tuberculosis, age 10 and 14 years.
Women with Hodgkin's disease who received radiation
therapy to the chest have an excess risk of breast
cancer.
RISK FACTORS
Hormone replacement therapy
Among current users of
hormone replacement therapy (HRT) and
those who have stopped using it one to four
years previously, there is an increased risk of
breast cancer.
This increased risk is very similar to the effect
of a delay in the menopause by one year.
RISK FACTORS
Weight
Being overweight is associated with a doubling of the risk
of breast cancer in postmenopausal women whereas
amongst premenopausal women obesity is associated
with reduced breast cancer incidence.

Alcohol intake
Some studies have shown a link between the amount of
alcohol people drink and the incidence of breast cancer,
but this relationship is not consistent and may be
influenced by dietary factors other than alcohol.
RISK FACTORS
Hormones
Women who take the contraceptive pill are
at a slight increased risk while they take
the Pill and they remain at risk for 10 years
after stopping the drugs.
SYMPTOMS AND SIGNS
Painless lump in the breast
Change in the skin
Dimpling
Fixity
Orange peel
Change in the nipple
Retraction
Eczema- ( Paget’s )
Painless lump in the axilla
INVESTIGATIONS
Mammography
Breast ultrasound
FNAC
Core biopsy
Open biopsy
MRI
CXR
Abdominal ultrasound
Bone scintigraphy
MAMMOGRAPHY
Mammograms are a good way of
identifying abnormalities in the breast.

Used for women over the age of 35.

In younger women the breast tissue is


more dense, which makes it difficult to
detect any changes on the mammogram.
MAMMOGRAPHY
However, mammograms are not perfect:

A mammogram may miss some cancers. (The result


is called a "false negative.")

A mammogram may show things that turn out not to


be cancer. (The result is called a "false positive.")
 
Breast cancer-
mammogram
BREAST ULTRASOUND SCAN
An ultrasound uses sound waves to build up a
picture of the breast tissue.

Ultrasound can often tell whether a lump is


solid (made of cells) or a fluid-filled cyst.

It can also often gives the information


whether a solid lump is likely to be benign or
malignant
FNAC
Will show whether the lump is full of fluid or solid.

Can allow a sample of cells to be removed for


examination under the microscope –cytology.

This is a very accurate method of finding out whether


the lump is benign or malignant.

A fine needle aspiration (FNA) is a quick, simple


procedure done in the outpatient clinic
NEEDLE CORE BIOPSY
Can allow a breast tissue specimen for histological and
immunohistochemistry exam.

Can obtain a preoperative diagnosis resulting in more


appropriate decision of therapy.

Core biopsies are often done using ultrasound as guide to


the lump.

Local anaesthetic is injected into the area first to numb it


OPEN BIOPSY
A biopsy is the only way to tell for sure if cancer is
present.

An incisional biopsy takes a sample of a lump or


abnormal area.

An excisional biopsy takes the entire lump or area.

 This procedure is done either under local


anaesthesia or general anaesthesia.
OTHER INVESTIGATIONS
CHEST X RAY

ABDOMINAL ULTRASOUND

CT OF THE BRAIN

BONE SCINTIGRAPHY
Types of breast cancer

Early pathologists classified breast cancers


into 'invasive ductal' cancers and 'invasive
lobular' cancers, believing that invasive
ductal cancers arose in ducts and invasive
lobular cancers in the lobules.

A more logical classification divides tumours


into those of 'special' and 'no special' type.
Types of breast cancers
Invasive carcinoma of no special type is also commonly referred
to as invasive ductal carcinoma.
It is the most common type and accounts for up to 85 % of all
breast cancers.

Special types of tumour have particular microscopic features and


these include invasive lobular carcinoma, invasive tubular,
cribriform, medullary and mucinous cancers.
Many of the special-type cancers have a better prognosis - in
other words the patient has a higher chance of survival.
Stage Information

The American Joint Committee on Cancer (AJCC) staging


system provides a strategy for grouping patients with
respect to prognosis.

Therapeutic decisions are formulated in part according to:


- staging categories
- lymph node status,
- estrogen- and progesterone-receptor levels in the tumor
tissue,
- menopausal status,
- the general health of the patient.
TNM AJCC/UICC 2002 - CLASSIFICATION
 T (primary tumour))
Tx primary tumour cannot be assessed
To without primary tumour
Tis in situ (DCIS/ LCIS), Paget’s of the nipple
T1 < 2 cm
T1a ≤ 0.5 cm
T1b 0.5-1 cm
T1c > 1 cm
T2 2 cm - 5 cm
T3 > 5 cm
T4 any size with invasion to the chest wall/skin
T4a invasion to the chest wall
T4b oedema, orange peel, satellite nodules
T4c T4a + T4b
T4d carcinomatous mastitis
Staging
N (lymph nodes, LN)
pN → ≥ 10 examined LN
Nx cannot be assessed
No no LN
N1 mobile ipsilateral LN
N2 fixed ipsilateral LN
N3 subclavicular, internal mammary, supraclavicular LN

M (distant metastases, MTS )


M0 absent MTS
M1 present MTS
TNM staging
 Stage I T1 No Mo

 Stage IIA To-1 N1 Mo


T2 No Mo
 Stage IIB T2 N1 Mo
T3 No Mo

 Stage IIIA To-2 N2 Mo


T3 N1-2 Mo
 Stage IIIB T4 No-2 Mo
 Stage IIIC any T N3 M0

 Stage IV any T any N M1


Staging of the breast
malignant tumour
 Stage 0 Ductal carcinoma in situ (DCIS) almost always completely curable.

The following stages of breast cancer are known as invasive breast cancer:
 Stage 1 The tumour measures less than 2cm. The lymph nodes in the axilla are not
affected and there are no signs that the cancer has spread elsewhere in the body.

 Stage 2 The tumour measures between 2 and 5cm. or the lymph nodes in the
axilla are affected, or both. However, there are no signs that the cancer has spread
further.

 Stage 3 The tumour is larger than 5cm. and may be attached to surrounding
structures such as the muscle or skin. The lymph nodes are usually affected.

 Stage 4 The tumour is of any size, but the lymph nodes are usually affected and
the cancer has spread to other parts of the body. This is metastatic breast cancer.
Tis – Paget,s of the nipple

Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New York:
Springer, 2006: 219-233.
©American Joint Committee on Cancer.
T1mic – microinvasion ≤ 0.1 cm.

Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New York:
Springer, 2006: 219-233.
©American Joint Committee on Cancer.
T1 - ≤ 2 cm.
T1a – > 0.1 cm - 0.5 cm;
T1b –> 0.5 cm - 1 cm;
T1c – > 1 cm - 2 cm.
Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New York:
Springer, 2006: 219-233.
©American Joint Committee on Cancer.
T2 - > 2 cm - 5 cm
T3 – > 5 cm.
Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New
York: Springer, 2006: 219-233.
©American Joint Committee on Cancer.
T4a - any size with direct invasion to the chest wall.

Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas.
New York: Springer, 2006: 219-233.
©American Joint Committee on Cancer.
T4b –any size with direct invasion to the skin, orange peel,
skin ulcer, satellite nodule.

Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging
Atlas. New York: Springer, 2006: 219-233.
©American Joint Committee on Cancer.
T4c = T4a + T4b.

Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer
Staging Atlas. New York: Springer, 2006: 219-233.
©American Joint Committee on Cancer.
T4d – inflammatory carcinoma

Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas.
New York: Springer, 2006: 219-233.
©American Joint Committee on Cancer.
pN0 – no lymph node MTS.

Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New
York: Springer, 2006: 219-233.
©American Joint Committee on Cancer.
pN1mi - > 0.2 - 2.0 mm,

pN1a – meta in 1-3 LN

pN1b – meta int. mammary LN

pN1c – N1a+N1b

Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New York: Springer,
2006: 219-233.
©American Joint Committee on Cancer.
pN2 – meta 4-9 LN
Hormone receptors

Many breast cancers have receptors for the hormone


oestrogen.
When oestrogen attaches to these receptors, it causes the
cancer cells to grow.
If a breast cancer has a significant number of oestrogen
receptors it is known as being oestrogen-receptor positive
ER+
If it doesn’t it is known as oestrogen-receptor negative ER-
Knowing whether the tumour has oestrogen receptors or not
helps the doctors to decide on the best treatment.
Hormone receptors

A tumour that is ER+ is likely to respond to hormonal treatments|,


whereas a tumour that is ER- will not respond.

Some breast cancers have progesterone receptors and are


known as progesterone-receptor positive (PR-positive).

Usually, cancers that are ER+ will also be PR+.

 Progesterone receptors are less important than oestrogen


receptors in predicting the likely response to hormone treatment.
HER2 receptors

Some cancers have receptors for a protein known as HER2|.


Tumours that have high levels of these receptors are known
as HER2-positive and may respond to treatment with drugs
such as trastuzumab (Herceptin®)|.
HER2 is a protein found on the surface of certain cancer
cells.
 Some breast cancers have a lot more HER2 receptors than
others.
 In this case, the tumour is described as being HER2-positive.
HER2 receptors

Tumours that are HER2-positive tend to grow more


quickly than other types of breast cancer.

Knowing if a cancer is HER2-positive can sometimes affect


the choice of treatment.

 Women with HER2-positive breast cancer can benefit


from a drug called trastuzumab (Herceptin®).

Herceptin only works in people who have high levels of


the HER2 protein.
MANAGEMENT
Multidisciplinary
 Pacient
 GP
 Surgeon
 Radiologist
 Patologist
 Oncologist
 Radiotherapist
Systematic
 Symptoms, history
 Physical examination
 Imaging investigations
 Biopsy
 (type, grading, markers)

Economic
Work
together.
Treatment overview

The treatment of breast cancer is individual for


each woman.

The treatment depends on many factors, including:


 the stage and grade of the cancer
 age
 whether the cancer cells have receptors for certain
hormones (such as oestrogen) or particular proteins
(such as HER2).
 
Treatment overview
Most primary breast cancers will be treated with 
surgery.

All or part of the breast tissue may be removed.

 If the whole breast is removed (mastectomy),

Breast reconstruction may be carried out, either


at the same time as the initial surgery or later.
Treatment overview
Sometimes chemotherapy| or hormonal therapy| may be
given to shrink a cancer before surgery -this is known as neo-
adjuvant therapy.

After surgery, radiotherapy| will be given to any remaining


breast tissue, and may be given to the chest wall if the breast
has been removed. This is to make sure that any cancer cells
that may be left in the area are destroyed.

Further treatment includes hormonal therapies,


chemotherapy and/or a drug called Herceptin|®.
Factors which affect the chance of
the cancer coming back
the size of the tumour

lymph nodes status

the grade of the tumour

Receptor status for oestrogen or particular proteins (such


as HER2) Cancers with oestrogen receptors are less likely
to recur in the short term, whereas those with HER2
receptors are more likely to come back unless Herceptin
is given.
Surgery
Segmental excision (breast-conserving
surgery or breast-sparing surgery)
 Followed by radiotherapy aimed to destroy cancer
cells that may remain in the breast.

Mastectomy – excision of the whole


mammary gland
 Studies have found equal survival rates for breast-
sparing surgery (with radiation therapy) and
mastectomy for Stage I and Stage II breast cancer.
Breast-conserving surgery

 Segmental excision – excision of a quadrant till MP muscle


 This is usually followed by radiotherapy, treatment to the
remaining breast tissue.

 The pathologist looks to see whether there is an area of healthy


cells all around the cancer – this is known as a clear margin.

 If there are cancerous or precancerous (DCIS) cells at the edge of


the area of breast tissue that has been removed, there is a higher
chance that the cancer will come back in the breast. 

 In this case, more breast tissue will need to be removed or even a


mastectomy.
 STAINING WITH CHINA INK TO ASSESS THE MARGINS OF
RESECTION
 FREE OF TUMOUR CELLS / PRESENT TUMOUR CELLS
Radical surgery
Removal of the whole breast (mastectomy)
may be necessary if:
The breast lump is large in proportion to
the rest of the breast tissue.
There are several areas of cancer cells in
different parts of the breast-
multicentricity of the tumour.
The lump is just behind the nipple
Mastectomy

 Simple mastectomy and sentinel node biopsy or node sampling


removes the breast tissue and the lower lymph nodes, within the axilla.
Sentinel lymph node biopsy is a new method of checking for cancer
cells in the lymph nodes. A surgeon removes fewer lymph nodes, which
causes fewer side effects. (If there are cancer cells in the sentinel
lymph node, an axillary lymph node dissection usually is done.)

 Modified radical mastectomy removes all the breast tissue and all
of the lymph nodes in the axilla. It may also be referred to as a total
mastectomy and axillary clearance.

 Radical mastectomy removes all the breast tissue and the lymph
nodes in the axilla, together with the muscles behind the breast tissue.
This is only done if the cancer invaded the pectoralis muscles.
Surgical complications
Local pain and tenderness- pain relief with
painkillers
Wound infection
Bleeding wound

Numbness and tingling of the shoulder and upper


arm due to nerve damage during axillary dissection

Lymphedema of the arm due to impaired lymph


drainage following axillary dissection.
Radiotherapy for breast
cancer

Radiotherapy treats cancer by using high-energy rays to destroy


the cancer cells.
The treatment is often used after surgery for breast cancer,
most commonly after segmental excision.
 It may occasionally be used before, or instead of, surgery.  
Radiotherapy can cause side effects such as:
skin soreness and
tiredness,
but most will improve once the treatment has finished. 
Radiotherapy for breast
cancer

After a mastectomy, radiotherapy to the chest wall


may be given if there is a risk that any cancer cells
have been left behind.
If a few lymph nodes have been removed and these
contained cancer cells, or if no lymph nodes have been
removed, radiotherapy may be given to the axilla to
treat the remaining lymph nodes.
If all the nodes have been removed from the axilla,
radiotherapy to this area is not usually needed.
Chemotherapy for breast
cancer

Chemotherapy is the use of anti-cancer (cytotoxic) drugs


to destroy cancer cells.
The aim of chemotherapy is to do the maximum damage
to cancer cells while causing the minimum damage to
healthy tissue.
Indications:
Before surgery to shrink the cancer. This is known as
neo-adjuvant chemotherapy.
After surgery if doctors think there is a risk of the
cancer coming back. This is known as adjuvant
chemotherapy.
Chemotherapy
 There are many different chemotherapy drugs used to treat
breast cancer, and they are often used in combinations
(called a chemotherapy regimen).
 The commonly used chemotherapy drugs include:
 cyclophosphamide
 epirubicin
 fluorouracil (5FU)
 methotrexate
 paclitaxel (Taxol)
 doxorubicin (Adriamycin®)
 docetaxel (Taxotere®).
Hormonal therapies for
breast cancer

Hormonal therapies are treatments to reduce the levels


of hormones in the body or block their effects on
cancer cells.
They are often given after surgery, radiotherapy, and
chemotherapy for breast cancer, to reduce the chance
of recurrence.
Hormonal therapies are only effective in women whose
cancer cells have receptors for oestrogen and/or
progesterone on their surface.
This is known as being oestrogen-receptor positive
(ER+) or progesterone-receptor positive (PR+).
Hormonal therapy for
postmenopausal women
Postmenopausal women may be offered hormonal treatment
with either an anti-oestrogen (such as tamoxifen) or an
aromatase inhibitor (such as Arimidex®).

Tamoxifen has been the most widely used hormonal therapy


for breast cancer and has been shown to be highly effective in
reducing the chance of the cancer coming back.

 Research has shown that for some women, giving aromatase


inhibitors instead of tamoxifen, or after a period of tamoxifen
treatment, can further reduce the chance of the cancer coming
back.
Hormonal therapy for
premenopausal women

Premenopausal women may be offered hormonal


treatment with:
 an anti-oestrogen drug (such as tamoxifen)
 Treatment to stop the ovaries from producing oestrogen
(ovarian ablation). This can be done using surgery,
radiotherapy, or a drug called goserelin (Zoladex® ).
Unfortunately, ovarian ablation by surgery or radiotherapy
brings on an early menopause, which can be very
upsetting, especially for women who were hoping to have
children. The effects of medicines are usually temporary.
Biological therapy - Herceptin®
(trastuzumab) for breast cancer
Trastuzumab| ( Herceptin®) is a monoclonal antibody.
It works by attaching to HER2 receptors (proteins) on the surface of
breast cancer cells.
This stops the cancer cells from dividing and growing.
Herceptin can reduce the chance of breast cancer to recur after
initial treatment for early breast cancer.
However, it is only effective for women whose breast cancer cells
have a large number of the HER2 receptors on their surface. This is
known as being HER2-positive. Around 1 in 5 women (20%) with
breast cancer are HER2-positive.
Biological therapy - Herceptin®
Side effects are usually mild, but some women may have:
flu-like symptoms,
diarrhoea ,
headaches ,
allergic reaction.

In some women, Herceptin may cause damage to the heart


muscle, which could lead to heart failure.
If this happens the Herceptin® will be stopped.
Usually, the effect on the heart is mild and reversible.
Therapeutical
categories
According to the first treatment:
Surgical/non-surgical cancer

Surgical breast cancer


Stages - 0, I, II, partial IIIA (T3 N1)
 Initial therapeutic step - surgery
 Post-operatively: treatment according to type/grade
and tumoral receptors
Therapeutic
categories
Inoperabile cancer
Stages IIIA (T0-3 N2), IIIB (T4 N0-2) şi IIIC (T0-3 N3)
 Therapeutic goal – palliation, improve QOL
 Initial step – systemic therapy (CHT/HT/biological)
 Good response → surgery-mastectomy→ radioterapie
(RT)
 Bad response → RT (DT = 50 Gy)
Therapeutic
categories
 Metastatic or recurrent cancer
 Stage IV (T0-4 N1-3 M1)

 Therapeutic goal:
 Palliation
 Cure- Local recurrence

 Initial step:
 Systemic therapy or
 RTE, after surgical removal of local recurence if possible
LOCALLY ADVANCED BREAST CANCER
ESMO 2008 Recommandations

Systemic neo-adjuvant therapy

Radiotherapy

Surgery

Post-op. systemic therapy


Breast cancer- Case report

P.A., female, aged 50, Iasi

PRESENT COMPLAINT- upper outer quadrant painless lump in the


right breast with enlarged axillary lymph nodes - december 2001.

HISTORY
 no family history of cancers
 first period: age 12, last period: may 2002;
 pregnancies: 2 (age 28, 31),
 abortions: 2
 no personal history of relevant diseases/ hospital admissions
DIAGNOSIS

May 2002
Surgery Unit admission/ clinical evaluation:
3.5/4 cm mass in the upper outer quadrant
of the right breast, slightly adherent to skin
associated fixed, matted right axillary
lymph nodes
Fine-needle aspiration biopsy:
malignant cytology
TREATMENT (I)

August 2002
Surgery – quadrantectomy + axillary clearance
Pathology report: invasive ductal carcinoma, pT1
N1a M0 G2 L1 V1
- 1/1 cm tumor, negative resection limits
- 3 out of 10 axillary lymph nodes with large
metastasis
- invasion of the subcutaneous tissue, vascular
emboli, no perineural invasion
 Immunehistochemistry report:
 ER positive (35%), PR positive (50%)
 HER 2 neu negative (1+)
Postoperative treatment

September 2002
Oncology admission/ clinical evaluation:
 Biologic work-up – normal
 Postoperative thoracic scar – normal aspect
 Abdominal ultrasound, chest X-ray – no apparent
secondary lesions
QUESTION 1

HOW WOULD YOU TREAT?

A. Start adjuvant chemotherapy (anthracycline-based


regimen) + radiation therapy + hormone therapy

B. Start adjuvant chemotherapy (CMF regimen) + hormone


therapy

C. Start adjuvant radiation therapy + hormone therapy

D. Initiate adjuvant hormone therapy: tamoxifen

E. Initiate adjuvant hormone therapy: aromatase inhibitors


TREATMENT (II)
October-December 2002
Adjuvant chemotherapy
 CA protocol – cyclophosphamide 600 mg/m2 +
adriamycin 60 mg/m2, 3-weekly schedule, 4 cycles

January-March 2003
Adjuvant radiation therapy
 conventional irradiation, TD 44 Gy/22 fr., tumor bed
+ axillary field

March 2003
Adjuvant hormone therapy
 tamoxifen 60 mg/day

2003-2005
3-monthly evaluations (clinical, biologic and imagistic)
 no signs of disease progression
February 2005
Clinical evaluation:
 progressively worsening
 low-back and right leg pain.

Lumbar spine X-ray:


 dorso-lumbar scoliosis
 reduction of the L3-L4 intervertebral space

 no aspects suggestive of bone metastases


QUESTION 2

WHICH ARE THE APPROPRIATE STEPS?

A. Order a bone scan

B. Recommend lumbar magnetic resonance imaging


(MRI) to exclude spinal cord compression

C. Prescribe nonsteroidal anti-inflammatory medication


(NSAIDs)

D. Evaluate serum and urine protein electrophoresis

E. Perform a CT-guided biopsy


February-July 2005
NSAID treatment
 Pain diminished in intensity, still not controlled

July 2005
Bone scan:
 Multiple sites of pathologic increased uptake:
skull, vertebral spine, bone pelvis, clavicle,
right humerus, left femur, left tibia
– bone metastases
QUESTION 3

HOW WOULD YOU TREAT?

A. Start 2nd line hormone therapy (aromatase inhibitors)

B. Initiate 2nd line chemotherapy (taxanes) +


bisphosphonates

C. Start 2nd line chemotherapy + 2nd line hormone therapy +


bisphosphonates + palliative radiation therapy

D. Recommend orthopedic surgery for internal fixation

E. Initiate palliative radiation therapy


TREATMENT (III)
July 2005
Palliative radiation therapy
 conventional irradiation, TD 20 Gy/4 fr., anterior femoral field

! during irradiation – pathologic fracture: left


femur, medium third
Orthopedic surgery – osteosynthesis by metallic
rigid nail

Starts 2nd line hormone therapy


 letrozol 2.5 mg/day

Starts bisphosphonates
 pamidronat 60 mg/day I.V., on a monthly basis

Continues pain therapy


 NSAIDs
 tramadolum P.O. 50 mg bid
September 2005
Clinical evaluation:
 pain controlled

Liver work-up – modified:


 γGT = 204 UI/l

Abdominal ultrasound:
 Liver – hipoechogenic nodules, segment 6 = 3.4 cm;
segment 8 = 2 cm; segment 2 = 1.8 cm
(metastases)
QUESTION 4

WHAT IS THE NEXT TREATMENT STEP?

A. Start 2nd line chemotherapy (capecitabine/


docetaxel/ liposomal doxorubicin)

B. Start 3rd line hormone therapy

C. Consider transarterial hepatic


chemoembolization (CHEAT)

D. Consider surgical resection of hepatic lesions

E. Best supportive care


 TREATMENT (IV)
October 2005
 Starts 2nd line chemotherapy
 capecitabine 1250 mg/m2 x 2 P.O., D1-14, 3-weekly
schedule
 Continues 2nd line hormone therapy (letrozol)
 bisphosphonates (pamidronat), unchanged dosage and
schedule.

December 2005
 Clinical evaluation:
 ECOG PS 1, lumbar pain relatively controlled
 Liver work-up – normal:
 γGT = 33 UI/l
 Abdominal ultrasound:
 Liver metastases – segment 6 = 2.7 cm, segment 8 = 2.9
cm, segment 2 = 2.0 cm (stable disease)
January 2006
Left femur X-ray:
 Median osteoblastic cortical bone lesion
(posttraumatic pathological bone lesion?)

Lumbar spine X-ray:


 Osteoblastic bone lesions of the L1 vertebral body
(slightly collapsed) and the L2 right vertebral pedicle

Bone pelvis X-ray:


 Osteoblastic bone lesions of the right ramus ischium
(2 cm) and of the lateral aspect of the left sacro-iliac
articulation (diffuse)
QUESTION 5

HOW WOULD YOU TREAT?

A. Palliative radiotherapy

B. Start 3rd line chemotherapy

C. Consider an orthopedic intervention

D. Continue hormone therapy

E. Consider all the above mentioned options


TREATMENT (V)
February 2006
Palliative radiation therapy
 conventional irradiation, TD 20 Gy/5 fr., dorso-
lumbar vertebral field

Continues 2nd line chemotherapy


(capecitabine), 2nd line hormone therapy
(letrozol) and bisphosphonates (pamidronat),
unchanged dosage and schedule

Continues pain therapy


 NSAIDs
 tramadolum P.O. 50 mg tid
May 2006
 Clinical evaluation:
 pain controlled

 Abdominal ultrasound:
 Liver metastases – segment 6 = 2.8 cm; segment 8 = 1.8 cm;
segment 2 = 1.9 cm (stable disease)

September 2007
 Clinical evaluation:
 ECOG PS 1, pain controlled
 Abdominal ultrasound:
 Liver metastases – stable disease
 Dorso-lumbar spine X-ray:
 Multiple osteoblastic bone lesions (D7-D12, L1-L2, iliac bones,
sacrum)
 Left femur X-ray:
 Osteosynthesis nail overpasses the femoral head by
approximately 2 cm
March 2008
 Clinical evaluation:
 pain controlled
 Abdominal ultrasound:
 Liver – stable disease
 Bone X-rays:
 stable disease

 TREATMENT (present)
 Continues 2nd line chemotherapy (capecitabine), 2nd
line hormone therapy (letrozol) and
bisphosphonates (pamidronat), unchanged dosage and
schedule
 Continues pain therapy
 NSAIDs

 tramadolum 100 mg bid