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.
GENERAL DATA
JG
42 years old
Female
chief complaint : low back pain
Previously diagnosed with invasive
ductal carcinoma stage 3B
HISTORY OF PRESENT ILLNESS
2 yrs. PTA
6 mo. PTA
5 mo. PTA
1 wk. PTA
Diagnosed
low
Pain
Consulted
back
increased
pain
at
with
PGH-OPD
in
Invasive
intensity
and
Ductal
and
a metastatic
was no longer
work-up
relieved
(CXR,
UTZ
by and
Mefenamic
Bone
Scan)
Acidwas done
-mostly
in the
evening
Carcinoma
Stage
III-B
-prescribed
unrecalled
pain medications
-temporarilywith
relieved
by Mefenamic
Acid
which offered slight relief
PATIENT HISTORY PROFILE
• Diagnosed with Invasive
(+) weight loss
Ductal
Carcinoma Stage III-B 2
(+)
anorexia
of breast
cancer:
• history
Nonsmoker
Menarche
at
14
y/o
years
PTCon
(+)
dyspnea
maternal
aunt
Nonalcoholic
exertionwithMRM,
G2P2
regular
menses
•• Underwent
radiation
and
• therapy
Worked
as6acycles
bankofteller
(-)chemotherapy
bowel changes
(-) seizure
(-) urination
(-) headache
• No hormal treatment
changes
• (-)(-)cough
HTN, (-)DM, (-)asthma, ((-))allergy
headache
PHYSICAL EXAMINATION
ORGAN
FINDINGS
SYSTEM
General conscious, coherent, non-ambulatory,
Survey not in cardiorespiratory distress
pale palpebral conjunctivae, anicteric
HEENT
sclerae,
Distinct heart sounds, (-) murmurs, (-)
Heart
heaves, (-) thrills
Symmetrical chest expansion, (-) crackles,
Chest
(-) wheezes;
and
Healed surgical scar on the right breast area,
Lungs
normal left breast, no masses / LAD
PHYSICAL EXAMINATION
ORGAN
SYSTEM
FINDINGS
Normoactive bowel sounds;
Abdomen soft palpable liver with a liver span of 10
cm
Skin,
Extremities are grossly normal
Extremitie (-) edmea
sNails
Full pulses
Neurologic unremarkable
Exam
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 nonspinal 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 IIIB
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
LABORATORY FINDINGS
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
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
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
Radionuclide Bone Scanning
INTERPRETATION
Normal: 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
tracer
uptake here
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 Diagnostics
CT Scan
Optimal for the visualization of bone over soft tissue
Higher sensitivity than X-ray
12000 php (VRPMC) and 9000 (The Medical City)
MRI
Optimal 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 Scan
Using 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.
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
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Epidemiology: Global Burden
• Breast cancer is
the 3rd most
common tumor in
the world
• Incidence Rates
among races:
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
Source: US National Cancer Institute, Surveillance Epidemiology and End Result(SEER, 2009)
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
Hormonal
• Estrogen
exposure
Genetic
• Tumor suppressor
genes
• Li-Fraumeni
syndrome (p53
mutation)
• PTEN gene
• DNA Repair genes
• BRCA-1 and
BRCA-2 genes
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
Invasive Ductal Carcinoma
Also called invasive
carcinoma of no special
type (NST)
Accounts for about 7080% of breast CA
Carcinomas that cannot
be classified as any
other subtype
Histologically display a
wide spectrum of
appearances
Source: Geneva Foundation for Medical
Research and Education
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 SDF1/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/10/1/101
Psailaa, B, Kaplana, RN, Port, ER, Lydena, D. (2006-2007). Priming the ‘soil’ for breast cancer metastasis: The pre-metastatic niche. Breast Disease 26, 6574, 65.
Rose AA, Siegel PM. Breast cancer-derived factors facilitate osteolytic bone metastasis. Bull Cancer. 2006;93:931-943.
Seed and Soil Hypothesis
CXCR-4 (receptor)
RANK (receptor)
SDF-1/CXCL-12(ligand)
RANK (ligand)
VEGDR-1+HPC
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-cancerresearch.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.
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.
Osteolytic Bone Metastasis
Tumor produces substances that can lead to resorption (ex. Vit Dlike 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
hydroxyprobecontaining peptide
Serve as
tumor
survival
factors
Release of
parathyroid
hormone-related
peptide, IL-6, TGF
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
Osteoblastic Bone metastasis
Tumor produces cytokines that activate osteoblasts
Increased alkaline phosphatase, hypocalcemia
Patient’s problem list
Low back pain
Weight loss and anorexia
Dyspnea on exertion
Pallor
Anemia
Leukocytosis, neutrophilia
Hypercalcemia
Increased alkaline phosphatase
LEUKOCYTOSIS
INFECTION
(PNEUMONIA)
IMMUNOCOMPROMISE
BREAST CA
BONE METASTASIS
OSTEOLYTIC
HYPERCALCEMIA
OSTEOBLASTIC
HIGH ALKALINE
PHOSPHATASE
DYSPNEA ON
EXERTION
LOW BACK PAIN
+ ANOREXIA
= WEIGHT LOSS
ANEMIA OF CHRONIC
DISEASE
ANEMIA
PALLOR
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
complications
tumor cells can directly
activate the bloodclotting 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 fractures
o From bone
metastasis
o From hormonal
changes due to
primary tumor
Screening by DEXA
Systemic Therapy
Bisphosphonate drugs
MoA: inhibit
osteoclasts and
induce apoptosis
prevent loss of bone,
reduce the risk of
fractures, decrease
pain
calcium and vitamin D,
weight-bearing exercises
cessation of smoking
reduction in alcohol intake
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
+ Biphosphonate
Ovarian Ablation
Endocrine Therapy
Visceral symptoms or
Completed 3 cycles of consecutive endocrine therapy
No
Yes
Chemotherapy
ECOG 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
+ Biphosphonate
Ovarian Ablation
Endocrine Therapy
Visceral symptoms or
Completed 3 cycles of consecutive endocrine therapy
No
Yes
Chemotherapy
ECOG performance status >= 3
No further improvement/clinical benefit
Completed 3 cycles of consecutive endocrine therapy
Bone metastasis
+ Biphosphonate
Ovarian Ablation
Endocrine Therapy
Visceral symptoms or
Completed 3 cycles of consecutive endocrine therapy
No
Yes
Chemotherapy
ECOG performance status >= 3
No further improvement/clinical benefit
Completed 3 cycles of consecutive endocrine therapy
Endocrine/Hormone therapy
Bone Metastasis
Non steroidal aromatase
inhibitor(anastrozole
or lestrozole)
Anastrazole
Tamoxifen
Steroidal aromatase inactivator
+ Biphosphonate
Tamoxifen
currently used for the
treatment of both early
and advanced ER+
(estrogen receptor
positive) breast cancer
in pre- and postmenopausal 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:
Bone
Endometrial cancer
Lipid profile
CNS
libido
Tamoxifen
SIDE EFFECTS:
Bone
Endometrial cancer
Lipid profile
CNS
libido
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
experiencing dyspnea
hypotension.
interrupted for patients
or clinically significant
• should be discontinued for infusion reactions
manifesting as anaphylaxis, angioedema, interstitial
pneumonitis, or acute respiratory distress syndrome
Control
Bone metastasis
+ Biphosphonate
Ovarian Ablation
Endocrine Therapy
Visceral symptoms or
Completed 3 cycles of consecutive endocrine therapy
No
Yes
Chemotherapy
ECOG performance status >= 3
No further improvement/clinical benefit
Completed 3 cycles of consecutive endocrine therapy
Treatment Complications
Chemotherapy
• 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 Complications
Chemotherapy
• Diarrhea
• Oral mucositis
• Fluid intake, diet, drugs:
Loperaamide, Atropine,
Octreotide
• Soft bland diet,
comprehensive dental
examination, drugs:
sucralfate, vitamins,
antibiotics and antifungals
Treatment Complications
Chemotherapy
• Myelosuppression resullting
in infection, bleeding,
anemia
• Primary ovarian failure
resulting in sterility and low
estrogen levels leading to
osteopenia
• Erythropoietin or
blood transfusion, GCSF
• Counseling
• Screening and
prevention of bone
loss
Treatment Complications
Chemotherapy
• 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 Complications
Radiotherapy
• 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 Complications
Radiotherapy
• 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 longterm complications
Treatment Complications
Endocrine 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
Spiritual
Emotional
Physical support
Pain
Treatment of Infections
Difficulty breathing
Nutritional Support
Loss of appetite
Fatigue, Weakness
Sleeping disorders
Emotional
Psychiatric consult
Depression
anxiety
Confusion
Family counseling/Group Therapy
End of life management
Genetic couseling
Financial counseling
Spiritual
Community support
Cancer support groups/network
Visualization techniques and meditation
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
QuickTime™ and a
decompressor
are needed to see this picture.
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 Variables
Estrogen 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 Variables
Histologic 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
Follow-Up
Survival is not influenced by early
diagnosis of relapse.
QuickTime™ and a
decompressor
are needed to see this picture.
Follow-Up
Survival is not influenced by early diagnosis
of relapse.
TEST
FREQUENCY
History; eliciting symptoms;
physical examination
Q3-6 months x 3 years; q612 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/PIIS14702045(09)70029-4/fulltext
http://clincancerres.aacrjournals.org/cgi/content/full/12/20/6
309s
http://www.biomedexperts.com/Abstract.bme/14534872/Co
agulopathic_complications_in_breast_cancer
references
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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 17th ed.
Robbins and Cotran Pathological Basis of Disease 7th ed.
Geneva Foundation for Medical Research and Education
http://images.google.com.ph/imgres?imgurl=http://tgmouse.compmed.ucdavis.edu/JENSEN-MAMM2000/BRCA1/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&st
art=13&tbnid=FzCMbQKO6gVaM:&tbnh=100&tbnw=150&prev=/images%3Fq%3Dinvasive%2Bductal%2Bcarcinoma%26gbv%3D2%2
6hl%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-cancerresearch.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.
Kang, Y. New tricks agains an old foe: Molecular dissection of metastasis tissue tropism in breast cancer. Breast Disease 26
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Reference
Gonzalez-Angulo AM et al. Factors Predictive of Distant Metastases in
Patients With Breast Cancer Who Have a Pathologic Complete
Response After Neoadjuvant Chemotherapy. 2005. Journal of
Clinical Oncology Vol. 23, No. 28