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