SACDALAN, D.B., SALES, M.C., SALONGA, A.E., SALVADOR, D.S., SAQUITAN, A.T., SARANZA, G.R., SEÑA, L.C., SEÑGA, I.R.,
SERRANO, G.K., SESE, D.G., SIMBULAN, J.C., SOBRIO, M.C., SUAREZ, F.L., SUGUITAN, A., SUMALAPAO, D.E., SY, P.L., SY.
S.M., TALADUA, K.M., TAN, C.S.
G r a n d R o u n d s
GENERAL DATA
JG 42 years oldFemalechief complaint : low back pain
Previously diagnosed with invasive ductal carcinoma stage 3B
2 yrs. PTA 6 mo. PTA 5 mo. PTA 1 wk. PTA
low back pain
-mostly in the evening
-temporarily relieved by Mefenamic Acid
Pain increased in intensity and was no longer relieved by Mefenamic Acid
-prescribed with unrecalled pain medications which offered slight relief
Consulted at PGH-OPD and a metastatic work-up (CXR, UTZ and Bone Scan) was done
HISTORY OF PRESENT ILLNESS
Diagnosed with Invasive Ductal
Carcinoma Stage III-B
PATIENT HISTORY PROFILE
Review of Systems
Past Medical History
Family History
Personal Social History
Obstetrics History
(+) weight loss(+) anorexia(+) dyspnea on exertion
(-) bowel changes
(-) urination changes(-) cough(-) headache
(-) seizure (-)
headache
• Diagnosed with Invasive Ductal Carcinoma Stage III-B 2 years PTC
• Underwent MRM, radiation therapy and 6 cycles of chemotherapy
• No hormal treatment• (-) HTN, (-)DM, (-)asthma,
(-)allergy
history of breast cancer: maternal aunt
• Nonsmoker• Nonalcoholic• Worked as a bank
teller
• Menarche at 14 y/o• G2P2 with regular
menses
PHYSICAL EXAMINATION
ORGAN SYSTEM
FINDINGS
General Survey
conscious, coherent, non-ambulatory, not in cardiorespiratory distress
HEENTpale palpebral conjunctivae, anicteric sclerae,
HeartDistinct heart sounds, (-) murmurs, (-) heaves, (-) thrills
Chest and
Lungs
Symmetrical chest expansion, (-) crackles, (-) wheezes;Healed surgical scar on the right breast area, normal left breast, no masses / LAD
PHYSICAL EXAMINATION
ORGAN SYSTEM
FINDINGS
AbdomenNormoactive bowel sounds; soft palpable liver with a liver span of 10 cm
Skin, ExtremitiesNails
Extremities are grossly normal(-) edmeaFull pulses
Neurologic Exam
unremarkable
I. Symptom: Low back pain, 42 y/o
Consider: • Metabolic x• Infection• Autoimmune/Inflammatory• Neoplasm• Degenerative• Trauma• Congenital x• Vascular x
Infection
1. UTI- ask for other GU symptoms, dysuria, discharge
2. Pelvic Inflammatory Disease- ask for sexual history, other GU symptoms, vaginal discharge
3. Endometriosis - ask for timing of pain, history of heavy menstrual bleeding, other symptoms fatigue, pain with intercourse, diarrhea, constipation, painful bowel movements during the menstrual period, rectal bleeding or blood in urine only during the menstrual period, and irregular bleeding or spotting between periods
4. Osteomyelitis - ask for tenderness, swelling and warmth in the affected area; avoidance of use in the affected part; malaise, loss of appetite, fever, nausea, fatigue, irritability
5. spinal infection- ask for fever, night sweats, and recent weight loss; check for elevated erythrocyte sedimentation rate and, spinous tenderness on percussion.
Degenerative
1. Osteoporosis- patient its over 40 years of age; ask thoroughly focusing on risk factors
2. Lumbar disc herniation- a slowly progressive degenerative process; ask for distribution of pain in the body
3. Acquired spinal stenosis- a consequence of degenerative joint disease that has been present for many years; ask for insidious pain at lower back and buttocks radiating to the legs; burning sensation in the buttocks and posterior thighs; pain typically increases with walking and
is relieved by rest. The patient may also feel better when he or she bends at the waist, because the diameter of the spinal canal is increased with flexion and decreased with extension; patient with spinal stenosis feels worse with hyperextension.
4. Spondylolisthesis- ask for progressive neurological deficit, cauda equina syndrome, or unremitting leg pain; affects women more than men
Inflammatory
1. Ankylosing Spondylitis- ask for pattern of pain (usually worse in the morning and improving through the day) and stiffness experienced over 3 months; ask for pain in sacrum, lumbar spine and thoracic spine and other peripheral joints; family history
2. Rheumatoid Arthritis- consider the criteria (presence of four of the following):
(1) morning stiffness in and around joints that lasts for longer than one hour
(2) arthritis (pain and inflammation) with swelling of three or more joints simultaneously
(3) at least one of the joints referred to in (2) must be in the hand
(4) symmetric arthritis with simultaneous involvement of the same joint bilaterally
(5) rheumatoid nodules over bony prominences or near joints
(6) positive serum rheumatoid factor (RF)
(7) x-ray changes typical of RA.
Neoplasm
1. spinal tumor (Primary)- severe and progressive pain, which commonly occurs during the night; slow and progressive neurological loss
2. Osteoid Osteoma- back pain that becomes worse at night, but is relieved by taking aspirin; look for visible bone loss on x-ray studies.
3. Metastatic spinal tumors- history of breast ca; unexplained weight loss; ask for other non- spinal symptom; ask for relief of pain: Degenerative Joint Disease is typically relieved by rest while metastatic bone pain is not
4. Multiple Myeloma
Trauma
1. Spinal Fracture- ask for any history of major and minor trauma e.g. falls; ask for neurologic deficits and paralysis
2. Cauda Equina syndrome- ask for bilateral leg pain, numbness, and/or weakness, as well as bowel and bladder incontinence, saddle anesthesia around the anus and buttocks; may be due to spinal stenosis, a spinal cord lesion, a very large posterior disc herniation, an inflammatory reaction, or a combination of all of these pathologies
II. Signs and Symptoms : low back pain mostly in the evening for 6 mos., temporarily relieved by Mefenamic acid; progression of pain slightly relieved by another pain killer (unrecalled); weight loss; previously
diagnosed to have Invasive Ductal Carcinoma Stage III-B
(-) hx of trauma
(-) signs of infection, fever
(-) asthma, allergy
(-) Cardiorespiratory symptoms except for dyspnea on exertion
(-) GU symptoms
(-) Abdominal symptoms
(-) Neurologic problems
II. Symptoms: low back pain mostly in the evening for 6 mos., temporarily relieved by Mefenamic acid; progression of pain
slightly relieved by another pain killer (unrecalled); weight loss; previously diagnosed to have Invasive Ductal Carcinoma Stage III-
B
Consider:
Neoplastic
1. Spinal tumor (Primary)- (+) severe and progressive pain, which commonly occurs during the night; ask if there is slow and progressive neurological loss
2. Osteoid Osteoma- (+) back pain that becomes worse at night, but should be relieved by taking aspirin; look for visible bone loss on x-ray studies.
3. Metastatic spinal tumors- (+) history of breast cancer, weight loss; soft palpable liver, 10 cm liver span which may indicate metastasis to the liver;
ask for relief of pain: Degenerative Joint Disease is typically relieved by rest while metastatic bone pain is not
Parameter Px Results Normal Values Interpretation
Hgb 100 g/L 120-180 g/L Low (Anemic)
Hct .35 0.370-0.540 Low (Anemia and Bone Marrow
problems)
WBC 15 x 109/L 4.0-11.0 x 109/L High (leukocytosis probably due to
an infection)
Neut 80% 50-70% High ( due to an infection)
Platelet 400 x 109/L 150-450 x 109/L Normal
AST 20 U/L 15-37 U/L Normal
ALT 30 U/L 30-65 U/L Normal
BUN 3 mmol/L 2.8-6.4 mmol/L Normal
Crea 72 mmol/L 53-115 mmol/L Normal
Alk phos 300 U/L 50-136 U/L High ( may indicate liver or bone
mets)
Ca 2.9 mmol/L 2.2-2.62 mmol/L High ( may indicate bone mets)
Alb 35 g/L 34-50 g/L Normal
LABORATORY FINDINGS
III. Symptoms: above signs and symptoms plus labs
Hypercalcemia- may indicate cancer especially in the ff cases:
• Multiple myeloma• Breast cancer• Squamous Cell Lung cancer• Renal cancer
These have high propensity to spread to the bones and release calcium into the blood. Some tumors secrete parathyroid-related peptide which acts like PTH.
III. Symptoms, PE + labs
Consider:
Neoplasm- Metastatic spinal tumor
D i a g n o s t i c s
Chest X-ray• Straight PA position with
clavicle equidistant with each other.
• There is a veil of haziness on the right lower lung with the right lateral sulcus, not defined.
– Veil of haziness in the RLL may suggest a pneumonic process with associated pleural effusion.
• The right hemi-diaphragm is slightly elevated laterally and the lateral elevation of the right hemi-diaphragm may suggest the presence of a sub-pulmonic effusion.
– A right lateral decubitus may be indicated for confirmation.
• The delineated osseus structures of the chest appears unremarkable.
Radionuclide Bone Scanning
Utilizes a radioactive tracer, a radionuclide to visualize various bone conditions on a scanner
Radionuclide emits γ radiation which accumulates at regions called “hot spots”
“Hot spots” correspond to areas of interest as these could point towards a tumor or focus of inflammation
INTERPRETATIONNormal: A scan result
is normal if bone uptake is equal throughout the body that is, there are no “hot” or “cold” spots seen
It is important to note the symmetric nature of traceruptake here
Radionuclide Bone Scanning
Radionuclide Bone Scanning
Abnormal: A scan result is abnormal by virtue of the presence of areas of increased or decreased uptake in the bone imaged.o Increased uptake may indicate
inflammation, bone infection, a malignant process, or a metabolic bone dyscrasia such as Paget’s disease
o Decreased uptake may indicate bone ischemia/infarction or malignancies such as multiple myeloma
Sample Bone Scan: J.G.
Sample Bone Scan: J.G.
Bone scan of J.G. presents hot spots at various sites: ribs, skull, femur, and lumbar spine
However taken alone this image is suggestive but not diagnostic of metastasis Sources estimate that bone scanning has an
excellent sensitivity of about 95% but a specificity of only 70% for malignancy; and only a 64% positive predictive value for metastasis in patients with a known extra osseous malignancy
Good as a screening but not as a diagnostic tool
Correlation with clinical findings and other laboratories may be beneficial
Abdominal UTZ
No significant findings
Other DiagnosticsCT Scan
Optimal for the visualization of bone over soft tissue
Higher sensitivity than X-ray
12000 php (VRPMC) and 9000 (The Medical City)
MRIOptimal for the visualization of soft tissue pathologies
Some sources note Sensitivity and Specificity to be as high as 95%
Capable of detecting bone marrow involvement which precedes cortical or trabecular bone changes seen in RBS and CT
17,261 php (St. Luke’s) 19,000 php (The Medical City)
PET ScanUsing a radioactive glucose analog, PET scanning can detect areas of increased
metabolic demand such as malignant tumors
Low sensitivity for malignancy, negative result of limited value in work-up
Lower sensitivity and specificity than MRI
3000-700 USD in the US and 890 USD in S.Kor.
C a n c e r S t a g i n g
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PRIMARY TUMOR (T)
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REGIONAL LYMPH NODES (N)
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DISTANT METASTASIS (M)
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STAGE GROUPING
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STAGE GROUPING
Ethnicity Females w/ breast CA per 100,000 women
All races 123.8
White 127.8
Black 117.7
Asian/Pacific Islander 89.5
American indian 74.4
Hispanic 88.3
Epidemiology: Global Burden
Source: US National Cancer Institute, Surveillance Epidemiology and End Result(SEER, 2009)
• Breast cancer is the 3rd most common tumor in the world
• Incidence Rates among races:
Breast CA in the Philippines
One of the top 10 leading cancers in both sexes
It is also one of the top 10 leading causes of cancer deaths in both sexes
#1 site of cancer and cancer deaths in Filipino women
Risk Factors
Genetic• Tumor
suppressor genes• Li-Fraumeni
syndrome (p53 mutation)
• PTEN gene
• DNA Repair genes• BRCA-1 and
BRCA-2 genes
Hormonal• Estrogen
exposure
HER2• also called HER2/neu, and HER-2 or human epidermal growth factor receptor 2• a gene that sends control signals to cells telling them to grow, divide, and make repairs. • A healthy breast cell has 2 copies of the HER2 gene. Breast cancer gets started when a breast cell has more than 2 copies of that gene due to overproduction of HER2 protein. This causes the cells to grow and divide much too quickly. This problem is not genetic but is more likely caused by aging, and wear and tear of the body.
HER2• Breast cancer gets started when a breast cell has more than 2 copies of that gene due to overproduction of HER2 protein. This causes the cells to grow and divide much too quickly. This problem is not genetic but is more likely caused by aging, and wear and tear of the body.
HER2• If breast cancer’s HER2 status is positive then the HER2 genes are over producing and creating the cancer.
–HER2 positive type of breast cancer is associated with more aggressive disease, greater likelihood of recurrence, poorer prognosis, and decreased survival.
• If it is negative, HER2 protein is not causing the cancer.
HER2• Immunohistochemistry or IHC measures the production of the HER2 protein by the tumor. Fluorescence In Situ Hybridization or FISH uses fluorescent probes to look at the number of HER2 gene copies in a tumor cell. If there are more than 2 copies of the HER2 gene, then the cancer is HER2 positive.
Other Risk Factors
Sex
Age
Early age at menarche
Later age at first full-term pregnancy
Late age at Menopause
No/short duration of Breastfeeding
First-degree relatives w/ breast CA
Radiation exposure
Endometrial carcinoma
Geographic influence
Diet
Classification of Breast CA
Almost all breast malignancies are adenocarcinomas, with other types (squamous cell, phyloodes, sarcomas, and lymphomas) making up <5%
Classified as either carcinoma in situ, or invasive carcinoma
Source: Geneva Foundation for Medical Research and Education
Invasive Ductal Carcinoma
Also called invasive carcinoma of no special type (NST)
Accounts for about 70-80% of breast CA
Carcinomas that cannot be classified as any other subtype
Histologically display a wide spectrum of appearances
Breast Cancer Metastasis Prognostic Factors
Breast Cancer Metastasis
The most common areas of breast cancer metastasis are: soft tissues, lung/liver and bone (1/3 of cases each)
5 leading site of metastatic breast CA are: lung, bone, lymph nodes, liver and pleura.
Spread of breast cancer to bone primarily involves the hematogenous route
HPIM
Kang, Y. New tricks agains an old foe: Molecular dissection of metastasis tissue tropism in breast cancer. Breast Disease 26 (2006,2007) 129–138 129.
Why bone?• Seed and Soil Hypothesis• Some proposed mechanisms:
– RANK (receptors) are abundant in the breast cancer cells, they preferentially migrate to bone where RANKL (ligand) is abundant
– Chemokine receptor CXCR-4 is abundant in breast cancer cells, goes to bone marrow, lungs and liver abundant in SDF-1/CXCL-12, its natural ligand.
– Involvement of VEGFR-1+ HPC in areas of metastasis– Breast cancer cell signals, including osteoblast-mediated signals acting
on osteoclasts, promote the formation of bone metastases.
Hofbauer, LC, Rachner, T, Singh, SK. (2008). Fatal attraction: why breast cancer cells home to bone. Breast Cancer Research 2008, 10:101 Retrieved online at http://breast-cancer-research.com/content/10/1/101Psailaa, B, Kaplana, RN, Port, ER, Lydena, D. (2006-2007). Priming the ‘soil’ for breast cancer metastasis: The pre-metastatic niche. Breast Disease 26, 65-74, 65.Rose AA, Siegel PM. Breast cancer-derived factors facilitate osteolytic bone metastasis. Bull Cancer. 2006;93:931-943.
Hofbauer, LC, Rachner, T, Singh, SK. (2008). Fatal attraction: why breast cancer cells home to bone. Breast Cancer Research 2008, 10:101 Retrieved online at http://breast-cancer-research.com/content/10/1/101Psailaa, B, Kaplana, RN, Port, ER, Lydena, D. (2006-2007). Priming the ‘soil’ for breast cancer metastasis: The pre-metastatic niche. Breast Disease 26, 65-74, 65.Rose AA, Siegel PM. Breast cancer-derived factors facilitate osteolytic bone metastasis. Bull Cancer. 2006;93:931-943.
Seed and Soil HypothesisRANK (receptor)
RANK (ligand)
CXCR-4 (receptor)
SDF-1/CXCL-12(ligand)
VEGDR-1+HPC
Bone Metastasis
Primary sites: vertebrae, proximal femur, pelvis, ribs,
sternum, proximal humerus, skull
Clinical manifestation: PAIN!PAIN is the most frequent complaint, it is
present over weeks, localized, more severe at night
Other manifestations include swelling, nerve root/ spinal cord compression, pathologic fracture, myelophthisis
Can also be asymptomatic
Bone metastasis
Can be either osteolytic, osteoblastic or both.
In most metastasis, there are stages where osteolytic or osteoblastic tendency predominates.
HPIM,Hofbauer, LC, Rachner, T, Singh, SK. (2008). Fatal attraction: why breast cancer cells home to bone. Breast Cancer Research 2008, 10:101 Retrieved online at http://breast-cancer-research.com/content/10/1/101
Osteolytic Bone Metastasis
Tumor produces substances that can lead to resorption (ex. Vit D-like steroid, prostaglanding, PTH-related peptide) or the tumor produces cytokines that induce osteoclast formation (ex. IL-1, TNF, receptor activator of NF-êB ligand (RANKL) )
Bone destruction
Hypercalcemia, excretion of hydroxyprobe-containing peptide
Release of parathyroid hormone-related peptide, IL-6, TGF
Serve as tumor survival factors
Tumor produces cytokines that activate osteoblasts
Increased alkaline phosphatase, hypocalcemia
Osteoblastic Bone metastasis
Patient’s problem list
Low back painWeight loss and anorexiaDyspnea on exertionPallorAnemiaLeukocytosis, neutrophiliaHypercalcemiaIncreased alkaline phosphatase
BREAST CA BONE METASTASIS
LOW BACK PAIN
+ ANOREXIA= WEIGHT LOSS
IMMUNOCOMPROMISE
INFECTION (PNEUMONIA)
LEUKOCYTOSIS
DYSPNEA ON EXERTION
OSTEOLYTIC OSTEOBLASTIC
HIGH ALKALINE PHOSPHATASE
HYPERCALCEMIA
ANEMIA OF CHRONIC DISEASE
ANEMIAPALLOR
Complications
Liver Metastasis
Lung Metastasis
Early detection: Ultrasound / CT scan:
liver metastasis
Chest X-ray / sputum cytology: lung metastasis
Systemic therapy:-chemotherapy, radiotherapy, hormone therapy
Complications
Thromboembolic complicationstumor cells can directly
activate the blood-clotting cascade
Tumor cells can induce procoagulant properties of vascular endothelial cells, platelets, monocytes and macrophages.
Early detection of symptoms through patient education (edema, warmth, tenderness)
Low molecular weight heparin
Complications
Bone loss and fractureso From bone
metastasiso From hormonal
changes due to primary tumor
Screening by DEXASystemic TherapyBisphosphonate drugs
MoA: inhibit osteoclasts and induce apoptosis
prevent loss of bone, reduce the risk of fractures, decrease pain
calcium and vitamin D,weight-bearing exercisescessation of smokingreduction in alcohol intake
Tr e a t m e n t
Stage IV Invasive Ductal Carcinoma with systemic disease
4 Goals of Therapy in Cancer
1 Prevention
2 Curative
3 Control
4 Palliation
Curative
1 Hormone/Endocrine Therapy
2 Chemotherapy
Bone metastasis
Ovarian Ablation+ Biphosphonate
Endocrine Therapy
Visceral symptoms or
Completed 3 cycles of consecutive endocrine therapy
Yes
No
ChemotherapyECOG performance status >= 3
No further improvement/clinical benefit
Completed 3 cycles of consecutive endocrine therapy
Biphosphonate
Bone metastasis complications:
pathologic fractures
nerve root compression
hypercalcemia
Pain
bone marrow infiltration
MOA: inhibits bone resorption and disrupt the metabolism and adhesive abilities of tumor cells
Bone metastasis
Ovarian Ablation
+ Biphosphonate
Endocrine Therapy
Visceral symptoms or
Completed 3 cycles of consecutive endocrine therapy
Yes
No
ChemotherapyECOG performance status >= 3
No further improvement/clinical benefit
Completed 3 cycles of consecutive endocrine therapy
Bone metastasis
Ovarian Ablation
+ Biphosphonate
Endocrine Therapy
Visceral symptoms or
Completed 3 cycles of consecutive endocrine therapy
Yes
No
Chemotherapy
ECOG performance status >= 3
No further improvement/clinical benefit
Completed 3 cycles of consecutive endocrine therapy
Endocrine/Hormone therapy
Bone Metastasis
Anastrazole
Tamoxifen
+ BiphosphonateNon steroidal
aromatase inhibitor(anastrozol
e or lestrozole)
Steroidal aromatase inactivator
Tamoxifen
currently used for the treatment of both early and advanced ER+ (estrogen receptor positive) breast cancer in pre- and post-menopausal women
binds to estrogen receptors on tumors and other tissue targets, producing a nuclear complex that decreases DNA synthesis and inhibits estrogen effects.
SIDE EFFECTS:BoneEndometrial cancerLipid profileCNSlibido
Tamoxifen
SIDE EFFECTS:BoneEndometrial cancerLipid profileCNSlibido
HERCEPTIN• (a.k.a. trastuzumab) is a monoclonal antibody drug that is used to treat HER2 positive breast cancer.• It is a targeted therapy and is referred to as an immune treatment. It is given intravenously, once every 2-3 weeks. • It targets HER2 protein production to stop the growth of HER2 positive cancer cells.• It shrinks positive tumors before surgery, it gets rid of HER2 positive cancer cells that have spread beyond the original tumor and it helps prevent recurrence of the HER2 positive cancer if it was a 2cm or larger tumor or if the cancer had spread to the lymph nodes.
HERCEPTIN• This treatment is most helpful with combination with chemotherapy. • Caution should be observed in using this drug as it may cause cardiac failure manifesting as congestive heart failure (CHF) and decreased left ventricular ejection fraction (LVEF). • Infusion should be interrupted for patients experiencing dyspnea or clinically significant hypotension. • should be discontinued for infusion reactions manifesting as anaphylaxis, angioedema, interstitial pneumonitis, or acute respiratory distress syndrome
Control
Bone metastasis
Ovarian Ablation
+ Biphosphonate
Endocrine Therapy
Visceral symptoms or
Completed 3 cycles of consecutive endocrine therapy
Yes
No
Chemotherapy
ECOG performance status >= 3
No further improvement/clinical benefit
Completed 3 cycles of consecutive endocrine therapy
Treatment ComplicationsChemotherapy
• Aches or pains from time to time in the treated breast or the muscles around the breast even years after treatment
• Nausea and vomiting
• Pain control
• Pre-medication with anti-emetics (ondansetron, serotonin receptor antagonists, dopamine agonists)
Treatment ComplicationsChemotherapy
• Diarrhea
• Oral mucositis
• Fluid intake, diet, drugs: Loperaamide, Atropine, Octreotide
• Soft bland diet, comprehensive dental examination, drugs: sucralfate, vitamins, antibiotics and antifungals
Treatment ComplicationsChemotherapy
• Myelosuppression resullting in infection, bleeding, anemia
• Primary ovarian failure resulting in sterility and low estrogen levels leading to osteopenia
• Erythropoietin or blood transfusion, G-CSF
• Counseling • Screening and prevention of bone loss
Treatment ComplicationsChemotherapy
• Pulmonary toxicity– Pulmonary fibrosis– Pulmonary edema– Acute
hypersensitivity pneumonitis
• Cardiotoxicity, nephrotoxicity, hepatotoxicity, neurotoxicity
• Supportive therapy (O2)
• Monitoring cumulative dose of drugs• Frequent monitoring for signs of organ
damage
Treatment ComplicationsRadiotherapy
• mild fatigue that builds up gradually over the course of therapy
• reddening, dryness and itching of the skin
• slowly goes away 1-2 months following the radiation therapy
• usually heal completely within a few weeks • Skin moisturizers may be applied
Treatment ComplicationsRadiotherapy
• Slight swelling of the breast
• radiation pneumonitis– cough, shortness of
breath and fevers three to nine months after
• goes away within 6-12 months
• usually mild so no specific treatment is needed• goes away within two to four weeks with no long-term
complications
Treatment ComplicationsEndocrine Therapy
Tamoxifen
Hot flashes (80%)
Vaginal discharge (50%)
Water retention (32%)
Nausea (26%)
Irregular menstrual periods (25%)
Weight loss (23%)
Vaginal bleeding (23%)
Patient counseling
Aromatase Inhibitors
joint stiffness and joint pain
bone problems
Pain management
Regular exercise
Screening and preventive measures for bone complications
ECOG PERFORMANCE STATUS*
Grade ECOG
0 Fully active, able to carry on all pre-disease performance without restriction
1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
2 Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours
3 Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours
4 Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair
5 Dead
• As published in Am. J. Clin. Oncol.:Oken, M.M., Creech, R.H., Tormey, D.C., Horton, J., Davis, T.E., McFadden, E.T., Carbone, P.P.: Toxicity And
• Response Criteria Of The Eastern Cooperative Oncology Group. Am J Clin Oncol 5:649-655, 1982. The ECOG Performance Status is in the public domain therefore available for public use. To duplicate the scale, please cite the reference above and credit the Eastern Cooperative Oncology Group, Robert Comis M.D., Group Chair.
Palliation
Physical
Emotional
Spiritual
Physical support
PainTreatment of InfectionsDifficulty breathingNutritional SupportLoss of appetiteFatigue, WeaknessSleeping disorders
Psychiatric consultDepression anxiety Confusion
Family counseling/Group TherapyEnd of life managementGenetic couselingFinancial counseling
Emotional
Community support
Cancer support groups/network
Visualization techniques and meditation
Spiritual
Alternative Therapy (CAM)
Relaxation techniques
Acupunture
Yoga and tai chi
Herbal medications for pain and relaxation
Prognosis: 5-year Survival Rate for Breast Cancer by Stage
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Prognostic Variables
Tumor Staging-tumor size -status of axillary lymph nodes-involvement of microvessels (capillary or lymphatic channels)
Detection of breast cancer cells -in the circulation/bone marrow-use of gene expression arrays
Prognostic VariablesEstrogen and Progesterone Receptor
Status- tumors that lack either or both has greater chances for relapse.
Measures of Tumor Growth Rate-tumors with high proportion (more than the median) of cells in S-phase pose greater risk of relapse.
DNA content/form- (+) nondiploid tumors have somewhat worse prognosis
Prognostic VariablesHistologic of Classification
-Elston Score: tumors with poor nuclear grade have higher risk recurrence than those with good nuclear grade.
Molecular Changes in the Tumor-tumor overexpresses erbB2 (HER -2/neu) or have a mutated p53 gene- worse prognosis
Presence of microvessels-worse prognosis
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Follow-Up
Survival is not influenced by early diagnosis of relapse.
Follow-Up Survival is not influenced by early diagnosis
of relapse.TEST FREQUENCY
History; eliciting symptoms; physical examination
Q3-6 months x 3 years; q6-12 months x 2 years; then
annually
Breast self-exam monthly
mammography annually
Pelvic exam annually
Patients education about symptoms of recurrence
ongoing
Coordination of care ongoing
Source HPIM 17th ed
Reference
http://www.radiologyinfo.org/en/info.cfm?pg=breastcancer&bhcp=1#4
http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(09)70029-4/fulltext
http://clincancerres.aacrjournals.org/cgi/content/full/12/20/6309s
http://www.biomedexperts.com/Abstract.bme/14534872/Coagulopathic_complications_in_breast_cancer
references• P53 pathway in breast cancer http://breast-cancer-research.com/content/4/2/70• Tp53 website http://p53.free.fr/our_work/breast.html• Mayoclinic risk factors http://www.mayoclinic.com/health/breast-cancer/DS00328/DSECTION=risk-factors• Ngelangel, Wang. 2002. Cancer and the philippines http://jjco.oxfordjournals.org/cgi/reprint/32/suppl_1/S52• Fauci et. al. Harrison’s Principles of Internal Medicine 17 th ed.• Robbins and Cotran Pathological Basis of Disease 7 th ed.• Geneva Foundation for Medical Research and Education •
http://images.google.com.ph/imgres?imgurl=http://tgmouse.compmed.ucdavis.edu/JENSEN-MAMM2000/BRCA-1/slide160.jpg&imgrefurl=http://www.gfmer.ch/selected_images_v2/detail_list.php%3Foffset%3D45%26cat1%3D2%26cat3%3D32%26stype%3Dd&usg=__W9Ntx_VhEgdcgh7e7Ldk84kks8A=&h=1205&w=1800&sz=813&hl=tl&start=13&tbnid=FzCM-bQKO6gVaM:&tbnh=100&tbnw=150&prev=/images%3Fq%3Dinvasive%2Bductal%2Bcarcinoma%26gbv%3D2%26hl%3Dtl
HPIM,
Hofbauer, LC, Rachner, T, Singh, SK. (2008). Fatal attraction: why breast cancer cells home to bone. Breast Cancer Research 2008, 10:101 Retrieved online at http://breast-cancer-research.com/content/10/1/101
Psailaa, B, Kaplana, RN, Port, ER, Lydena, D. (2006-2007). Priming the ‘soil’ for breast cancer metastasis: The pre-metastatic niche. Breast Disease 26, 65-74, 65.
Rose AA, Siegel PM. Breast cancer-derived factors facilitate osteolytic bone metastasis. Bull Cancer. 2006;93:931-943.
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