Breast  Joint  Clinic  ( Tumor Board )  6 AUG , 2016

Case presentation : Breast cancer metastasis to scalp bone and ovary

 35yrs female, FH negative  with chief complain of headache

 PE & Imaging : Lt Calvarium masses in temporal  bone  ( 3 iso-intense masses ) with epidural extention & suggestive of lytic metastasis                        

1st operation : Temporal craniectomy & cranioplasty with titanium

Pathology : Adenocarcinoma with breast origin, ER + , PR + , HER2 - , Ki67 10%,                  

Breast Imaging  : US : Rt 9 O’C cyctic mass with thick cortex & internal septa

                               MG : No discrete mass, B 0                            

Mets W/U : Rt adnexal mass with central necrosis ( Rt ovary origin ? ) & Gestational  sac 6 week in uterus                  

                                  Whole body bone scan : no metastasis          

(Chemotherapy : 4 course TAC ( Abortion in 8 W

Joint recommendation: TVS – Breast MRI & Targeted US and CNBx –
                                    CA125J                                     


2nd Operation : Rt MRM & Bilateral salpingo-oophorectomy & Omentectomy

2nd pathology: Rt breast : Tiny post-neoadjuvant  residue of Intraductal and Invasive atypical cells                                         

Rt ovary : Metastatic carcinoma -Ductal-breast origin                                         

 

                       Lt ovary & Omentum : No malignancy                                         

Discussion:

Metastatic (stage IV) breast cancer is defined by tumor spread beyond the breast, chest wall, and ipsilateral regional lymph nodes. The most common sites for breast cancer metastasis include the bone, lung, liver, lymph nodes, chest wall, and brain. However, case reports have documented breast cancer dissemination to almost every organ in the body(1).

 Hormone receptor–positive tumors are more likely to spread to bone as the initial site of metastasis; hormone receptor–negative and/or HER2+ tumors are more likely to recur initially in viscera. Lobular (as opposed to ductal) cancers are more often associated with serosal metastases to the pleura and abdomen. Most women with metastatic disease will have been initially diagnosed with early-stage breast cancer, treated with curative intent, and then experience metastatic recurrence. Only about 10% of patients with newly diagnosed breast cancer in the United States have metastatic disease at presentation; this proportion is far higher in areas where screening programs are not available(1).

Limited data suggest ovarian breast cancer metastases can appear many years following the initial diagnosis of breast cancer and tend to be hormone receptor-positive. Surgical evaluation of an adnexal mass may be required to discriminate metastatic breast cancer from a primary ovarian cancer(2).

One cannot assume that the primary tumor will respond to systemic therapy in parallel with metastatic sites of disease, and progressive local disease may lead to impaired quality of

life and the need for palliation. The true frequency with which unresected local disease becomes a “local control” problem or “symptom control” problem requiring surgery in the modern era is difficult to ascertain without prospective collection of patient information. Single-institution data range from a low of 9% (7 of 82 patients) undergoing palliation in the University of Texas MD Anderson Cancer Center (MDACC) series , to 36% in both the MSKCC dataset and the Northwestern series , to 53% reported in the Washington University series (3).

A Translational Breast Cancer Research Consortium prospective, multi-institutional registry study TBCRC 013 examining the role of surgery for the primary tumor in de novo stage IV disease has recently completed accrual and data presented at the 2013 San Antonio Breast Cancer Symposium demonstrated that the need for true surgical palliation of symptoms is infrequent in the modern era (3).

Additional support for the rationale of optimizing local control includes the identification of a larger population of patients with oligometastatic or low-volume metastatic disease, many of whom would have been treated aggressively for cure in the era before widespread magnetic resonance imaging (MRI) and positron emission tomography (PET)(3).

The natural history of this category of stage IV breast cancer is largely unknown, yet conceptually, they may not be very different from patients with earlier-stage disease who

are found to harbor occult bone marrow micrometastases. Studies suggest that bone marrow micrometastases are present in up to 30% of stages I to III patients at the time of diagnosis and are associated with a poor OS and breast cancer disease-free survival, yet surgical treatment and adjuvant therapy are routinely performed in these patients, resulting in a significant number of long-term survivors(3).

Hortobagyi  has also suggested that an aggressive multimodal approach that includes surgery produces long-term, disease-free survival or cure in a subset of patients with limited metastatic breast cancer. These long-term survivors with stage IV disease are typically young, with limited metastatic disease and excellent performance status(3).

A review by Singletary et al. demonstrates that surgery combined with adjuvant therapy, compared with radiation or systemic therapy alone, can result in significantly better survival in select patients with metastatic disease to the lung, liver, brain, or sternum.

References:


1-DeVita et al,Cancer: Principles & Practice of Oncology, 10th ed. 2015.


2-UpToDate  Guideline , 2016.


3-Jay R Harris,Monica Moro.”Diseases of the breast”. 5th ed. ,2014.


 

 

 






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