Asian Journal of Surgery 43 (2020) 1008e1009
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Asian Journal of Surgery
journal homepage: www.e-asianjournalsurgery.com
Letter to Editor
Long-term survival with eribulin monotherapy after whole brain
radiation therapy in a patient with brain metastasis from breast cancer
Keywords:
Breast cancer
Brain metastasis
Palliative chemotherapy
Eribulin
Whole brain radiation therapy
To the editor,
Brain metastasis (BM) from breast cancer has a very poor prog-
nosis, with a one-year survival rate of only 20%. The cytotoxic
agents may not cross the bloodebrain barrier (BBB), so their effec-
tiveness is limited.1 Eribulin is a non-taxane microtubule dynamic
inhibitor with proven therapeutic effects in metastatic breast can-
cer, which has been shown to improve overall survival, but is
controversial in BM.2 We report a case of long-term benefit
achieved through eribulin therapy after the whole brain radiation
in a patient with brain metastasis of breast cancer.
In March 2015, a 61-year-old woman was diagnosed with inva-
sive ductal carcinoma of 2.5 cm. Ipsilateral axillary lymph node me-
tastases and multiple bone metastases were detected. The clinical
stage of her disease was determined to be T2N1M1. The histological
grade was moderate, positive for estrogen receptor and progester-
one receptor, negative for HER2, and Ki-67 labeling index <4%.
The patient underwent primary systemic chemotherapy from
March 2015 to July 2015, comprising of six cycles of docetaxel
(75 mg/m2, every 3 weeks, intravenously) with doxorubicin
Fig. 1. Magnetic resonance imaging of the patient. A heterogeneous enhancing brain parenchymal mass (2.5  1.6 cm) was identified in the right frontal region of the cerebrum in
March 2018.
https://doi.org/10.1016/j.asjsur.2020.05.002
1015-9584/© 2020 Asian Surgical Association and Taiwan Robotic Surgery Association. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
(60 mg/m2, every 3weeks, intravenously). Thereafter a salvage mas-
tectomy with axillary node dissection was performed. And a resid-
ual mass of 5 cm was found. The patient refused to continue
chemotherapy after surgery and switched to hormone therapy
(tamoxifen 20 mg daily). The patient developed multiple bone me-
tastases and liver metastasis as observed on PET CT scan performed
in May 2017. The patient was consequently started on third-line
systemic chemotherapy from May 2017, comprising of gemcitabine
(1250 mg/m2 on days 1 and 8, every 3 weeks, intravenously) with
paclitaxel (175 mg/m2, every 3 weeks, intravenously). The PET CT
performed 10 months later revealed exacerbation of the liver
metastasis, while a BM (2.8  1.6 cm) was observed in the frontal
lobe on the brain MRI (Fig. 1). In March 2018, the patient underwent
WBRT (total 3000 cGy: 300 cGy/day for 10 days) and was started on
eribulin monotherapy (1.4 g/m2 on days 1 and 8, every 3weeks,
intravenously) in April 2018. The brain MRI performed six months
later showed a decrease in the metastatic lesions, and a further
decrease after continued therapy. The recent MRI study performed
in December 2019 showed stable brain metastatic lesions (Fig. 2).
The chemotherapy schedule was delayed due to leukopenia and
was discontinued from September 2019 to December 2019 due to
the patient’s personal situation. However the patient was reiniti-
ated into the therapy at the same dose in December 2019. 28th Eri-
bulin monotherapy was completed on April 28, and is being
considered for continued administration.
Eribulin may exert effect after passing through the BBB: the
WBRT may increase the BBB permeability.3 The BBB in metastatic
brain tumors tends to be relatively permeable compared to the pri-
mary brain tumors.4 Incidentally, when the brain metastases grow
larger than 0.2 cm, it results in capillary angiogenesis. These newly
formed capillaries exhibit abnormal BBB function. The P-sugar
 Letter to Editor / Asian Journal of Surgery 43 (2020) 1008e1009
Fig. 2. Magnetic resonance imaging of the patient. In December 2019, eribulin was sustained and brain metastatic lesions remained small.
protein (P-gp) which is involved in resistance to cytotoxic agent, is
reduced expression in the angiogenesis iafter WBRT.3,5
Conclusion
Eribulin monotherapy after WBRT may be an effective treatment
for brain metastasis from breast cancer and further study is needed.
Declaration of competing interest
The authors declare that they have no competing interests.
Acknowledgments
This work was supported by the National Research Foundation
of Korea (NRF) grant funded by the Korea government (MEST)
(No. 2019M3E5D1A02070865). And we would like to thank Editage
(www.editage.co.kr) for English language editing.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.asjsur.2020.05.002.
1009
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Sung Ui Jung, Chang Wan Jeon, Jin Hyuk Choi*
Division of Breast Surgery, Department of Surgery, University of Kosin
College of Medicine, Kosin Univ. Gospel Hospital, Busan, South Korea
*
Correspinding author. Division of Breast Surgery, Department of
Surgery, University of Kosin College of Medicine, Kosin Univ.
Gospel Hospital, 262, Gamcheon-ro, Seo-gu, Busan, Republic of
Korea.
E-mail address: drchoijinhyuk@gmail.com (J.H. Choi).
3 May 2020
Available online 4 July 2020