Powerpoint : Breast Cancer

BREAST CANCER

Epidemiology Breast cancer is the most prevalent cancer among women and affects

approximately one million women worldwide.

Prevalence ( epidemiology) is the total number of cases of a disease in a given

population at a specific time Prevalence is the number of all new and old cases of a disease during a particular period.

Incidence is the number of new cases of a disease diagnosed in one year.

Epidemiology Breast cancer accounts for 30% of all female

cancers (UK). Men can also develop breast cancer, accounting for 1% of cases diagnosed annually (UK). Breast cancer is the most common cause of cancer

in women (U.S.) The most common cause of death in women between the ages of 45 and 55 (U.S.)

RISK FACTORS Sex BC in men is rare (> 1% from all malignant tumors) Sex ratio, women / men = 100 : 1 Age Ageing is the most important RF

RISK FACTORS Geographical variation There is quite a difference in incidence rate of breast cancer between different countries. The biggest difference is between Eastern and Western countries - low to high

RISK FACTORS Reproductive factors - Women who start menstruating early in life or who have a late menopause have an increased risk of breast cancer. - Women who have natural menopause after the age of 55 are twice as likely to develop breast cancer then women who experience the menopause before the age of 45.

RISK FACTORS Age at first pregnancy Having no children and being older at the time of the first birth both increase the incidence of breast cancer. The risk of breast cancer in women who have their first child after the age of 30 is about twice that of women having their first child before the age of 20. The highest risk group are those who have their first child after the age of 35

RISK FACTORS Inherited risk Up to 10 % of breast cancer in Western countries is due to an inherited factor. It is not yet known how many breast cancer genes there are, but to date, two specific breast cancer genes have been identified (BRCA1 and BRCA2).

RISK FACTORS Previous breast disease Women with certain benign changes in their breasts severe atypical epithelial hyperplasia. Radiation Women who received radiation to the chest as a result of repeated X-rays for tuberculosis, age 10 and 14 years. Women with Hodgkin's disease who received radiation therapy to the chest have an excess risk of breast cancer.

RISK FACTORS Hormone replacement therapy

Among current users of hormone replacement therapy (HRT) and those who have stopped using it one to four years previously, there is an increased risk of breast cancer. This increased risk is very similar to the effect of a delay in the menopause by one year.

RISK FACTORS Weight

Being overweight is associated with a doubling of the risk of breast cancer in postmenopausal women whereas amongst premenopausal women obesity is associated with reduced breast cancer incidence. Alcohol intake

Some studies have shown a link between the amount of alcohol people drink and the incidence of breast cancer, but this relationship is not consistent and may be influenced by dietary factors other than alcohol.

RISK FACTORS Hormones

Women who take the contraceptive pill are at a slight increased risk while they take the Pill and they remain at risk for 10 years after stopping the drugs.

SYMPTOMS AND SIGNS Painless lump in the breast Change in the skin Dimpling Fixity Orange peel

Change in the nipple Retraction Eczema- ( Paget’s ) Painless lump in the axilla

INVESTIGATIONS Mammography Breast ultrasound FNAC Core biopsy Open biopsy MRI CXR Abdominal ultrasound Bone scintigraphy

MAMMOGRAPHY Mammograms are a good way of

identifying abnormalities in the breast. Used for women over the age of 35. In younger women the breast tissue is

more dense, which makes it difficult to detect any changes on the mammogram.

MAMMOGRAPHY However, mammograms are not perfect: A mammogram may miss some cancers. (The result

is called a "false negative.") A mammogram may show things that turn out not to

be cancer. (The result is called a "false positive.")  

Breast cancermammogram

BREAST ULTRASOUND SCAN An ultrasound uses sound waves to build up a

picture of the breast tissue. Ultrasound can often tell whether a lump is

solid (made of cells) or a fluid-filled cyst. It can also often gives the information

whether a solid lump is likely to be benign or malignant

FNAC Will show whether the lump is full of fluid or solid. Can allow a sample of cells to be removed for

examination under the microscope –cytology. This is a very accurate method of finding out whether

the lump is benign or malignant. A fine needle aspiration (FNA) is a quick, simple

procedure done in the outpatient clinic

NEEDLE CORE BIOPSY Can allow a breast tissue specimen for histological and

immunohistochemistry exam. Can obtain a preoperative diagnosis resulting in more

appropriate decision of therapy. Core biopsies are often done using ultrasound as guide to

the lump. Local anaesthetic is injected into the area first to numb it

OPEN BIOPSY A biopsy is the only way to tell for sure if cancer is

present. An incisional biopsy takes a sample of a lump or

abnormal area. An excisional biopsy takes the entire lump or area.  This procedure is done either under local

anaesthesia or general anaesthesia.

OTHER INVESTIGATIONS CHEST X RAY ABDOMINAL ULTRASOUND CT OF THE BRAIN BONE SCINTIGRAPHY

Types of breast cancer Early pathologists classified breast cancers

into 'invasive ductal' cancers and 'invasive lobular' cancers, believing that invasive ductal cancers arose in ducts and invasive lobular cancers in the lobules. A more logical classification divides tumours

into those of 'special' and 'no special' type.

Types of breast cancers Invasive carcinoma of no special type is also commonly referred

to as invasive ductal carcinoma. It is the most common type and accounts for up to 85 % of all breast cancers. Special types of tumour have particular microscopic features and

these include invasive lobular carcinoma, invasive tubular, cribriform, medullary and mucinous cancers. Many of the special-type cancers have a better prognosis - in other words the patient has a higher chance of survival.

Stage Information The American Joint Committee on Cancer (AJCC) staging system provides a strategy for grouping patients with respect to prognosis. Therapeutic decisions are formulated in part according to: - staging categories - lymph node status, - estrogen- and progesterone-receptor levels in the tumor tissue, - menopausal status, - the general health of the patient.

TNM AJCC/UICC 2002 - CLASSIFICATION  T (primary tumour)) Tx primary tumour cannot be assessed To without primary tumour Tis in situ (DCIS/ LCIS), Paget’s of the nipple T1 < 2 cm T1a ≤ 0.5 cm T1b 0.5-1 cm T1c > 1 cm T2 2 cm - 5 cm T3 > 5 cm T4 any size with invasion to the chest wall/skin T4a invasion to the chest wall T4b oedema, orange peel, satellite nodules T4c T4a + T4b T4d carcinomatous mastitis

Staging N (lymph nodes, LN) pN → ≥ 10 examined LN Nx cannot be assessed No no LN N1 mobile ipsilateral LN N2 fixed ipsilateral LN N3 subclavicular, internal mammary, supraclavicular LN

M (distant metastases, MTS ) M0 absent MTS M1 present MTS

TNM staging  Stage I

T1

No

Mo

 Stage IIA

To-1 T2 T2 T3

N1 No N1 No

Mo Mo Mo Mo

 Stage IIIB  Stage IIIC

To-2 T3 T4 any T

N2 N1-2 No-2 N3

Mo Mo Mo M0

 Stage IV

any T

any N

M1

 Stage IIB

 Stage IIIA

Staging of the breast malignant tumour  Stage 0 Ductal carcinoma in situ (DCIS) almost always completely curable.

The following stages of breast cancer are known as invasive breast cancer:  Stage 1 The tumour measures less than 2cm. The lymph nodes in the axilla are not affected and there are no signs that the cancer has spread elsewhere in the body.  Stage 2 The tumour measures between 2 and 5cm. or the lymph nodes in the

axilla are affected, or both. However, there are no signs that the cancer has spread further.  Stage 3 The tumour is larger than 5cm. and may be attached to surrounding

structures such as the muscle or skin. The lymph nodes are usually affected.  Stage 4 The tumour is of any size, but the lymph nodes are usually affected and

the cancer has spread to other parts of the body. This is metastatic breast cancer.

Tis – Paget,s of the nipple

Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New York: Springer, 2006: 219-233. ©American Joint Committee on Cancer.

T1mic – microinvasion ≤ 0.1 cm.

Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New York: Springer, 2006: 219-233. ©American Joint Committee on Cancer.

T1 - ≤ 2 cm. T1a – > 0.1 cm - 0.5 cm; T1b –> 0.5 cm - 1 cm; T1c – > 1 cm - 2 cm. Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New York: Springer, 2006: 219-233. ©American Joint Committee on Cancer.

T2 - > 2 cm - 5 cm T3 – > 5 cm. Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New York: Springer, 2006: 219-233. ©American Joint Committee on Cancer.

T4a - any size with direct invasion to the chest wall. Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New York: Springer, 2006: 219-233. ©American Joint Committee on Cancer.

T4b –any size with direct invasion to the skin, orange peel, skin ulcer, satellite nodule. Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New York: Springer, 2006: 219-233. ©American Joint Committee on Cancer.

T4c = T4a + T4b. Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New York: Springer, 2006: 219-233. ©American Joint Committee on Cancer.

T4d – inflammatory carcinoma

Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New York: Springer, 2006: 219-233. ©American Joint Committee on Cancer.

pN0 – no lymph node MTS. Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New York: Springer, 2006: 219-233. ©American Joint Committee on Cancer.

pN1mi - > 0.2 - 2.0 mm, pN1a – meta in 1-3 LN pN1b – meta int. mammary LN pN1c – N1a+N1b

Credit line: Breast. In: Greene, F.L., Compton, C.C., Fritz, A.G., et al., editors. AJCC Cancer Staging Atlas. New York: Springer, 2006: 219-233. ©American Joint Committee on Cancer.

pN2 – meta 4-9 LN

Hormone receptors Many breast cancers have receptors for the hormone

oestrogen. When oestrogen attaches to these receptors, it causes the cancer cells to grow. If a breast cancer has a significant number of oestrogen receptors it is known as being oestrogen-receptor positive ER+ If it doesn’t it is known as oestrogen-receptor negative ERKnowing whether the tumour has oestrogen receptors or not helps the doctors to decide on the best treatment.

Hormone receptors A tumour that is ER+ is likely to respond to hormonal treatments|,

whereas a tumour that is ER- will not respond. Some breast cancers have progesterone receptors and are

known as progesterone-receptor positive (PR-positive). Usually, cancers that are ER+ will also be PR+.  Progesterone receptors are less important than oestrogen

receptors in predicting the likely response to hormone treatment.

HER2 receptors Some cancers have receptors for a protein known as HER2|. Tumours that have high levels of these receptors are known

as HER2-positive and may respond to treatment with drugs such as trastuzumab (Herceptin®)|. HER2 is a protein found on the surface of certain cancer cells.  Some breast cancers have a lot more HER2 receptors than others.  In this case, the tumour is described as being HER2-positive.

HER2 receptors Tumours that are HER2-positive tend to grow more

quickly than other types of breast cancer. Knowing if a cancer is HER2-positive can sometimes affect

the choice of treatment.  Women with HER2-positive breast cancer can benefit

from a drug called trastuzumab (Herceptin®). Herceptin only works in people who have high levels of

the HER2 protein.

MANAGEMENT Multidisciplinary  Pacient  GP  Surgeon  Radiologist  Patologist  Oncologist  Radiotherapist

Systematic  Symptoms, history  Physical examination  Imaging investigations  Biopsy  (type, grading, markers)

Economic Work together.

Treatment overview The treatment of breast cancer is individual for

each woman. The treatment depends on many factors, including:  the stage and grade of the cancer  age  whether the cancer cells have receptors for certain hormones (such as oestrogen) or particular proteins (such as HER2).

 

Treatment overview Most primary breast cancers will be treated with 

surgery. All or part of the breast tissue may be removed.  If the whole breast is removed (mastectomy), Breast reconstruction may be carried out, either

at the same time as the initial surgery or later.

Treatment overview Sometimes chemotherapy| or hormonal therapy| may be

given to shrink a cancer before surgery -this is known as neoadjuvant therapy. After surgery, radiotherapy| will be given to any remaining

breast tissue, and may be given to the chest wall if the breast has been removed. This is to make sure that any cancer cells that may be left in the area are destroyed. Further treatment includes hormonal therapies,

chemotherapy and/or a drug called Herceptin|®.

Factors which affect the chance of the cancer coming back the size of the tumour lymph nodes status the grade of the tumour Receptor status for oestrogen or particular proteins (such

as HER2) Cancers with oestrogen receptors are less likely to recur in the short term, whereas those with HER2 receptors are more likely to come back unless Herceptin is given.

Surgery Segmental excision (breast-conserving

surgery or breast-sparing surgery)  Followed by radiotherapy aimed to destroy cancer

cells that may remain in the breast.

Mastectomy – excision of the whole

mammary gland  Studies have found equal survival rates for breast-

sparing surgery (with radiation therapy) and mastectomy for Stage I and Stage II breast cancer.

Breast-conserving surgery  Segmental excision – excision of a quadrant till MP muscle  This is usually followed by radiotherapy, treatment to the

remaining breast tissue.  The pathologist looks to see whether there is an area of healthy

cells all around the cancer – this is known as a clear margin.  If there are cancerous or precancerous (DCIS) cells at the edge of

the area of breast tissue that has been removed, there is a higher chance that the cancer will come back in the breast.   In this case, more breast tissue will need to be removed or even a

mastectomy.

 STAINING WITH CHINA INK TO ASSESS THE MARGINS OF

RESECTION  FREE OF TUMOUR CELLS / PRESENT TUMOUR CELLS

Radical surgery Removal of the whole breast (mastectomy) may be necessary if: The breast lump is large in proportion to the rest of the breast tissue. There are several areas of cancer cells in different parts of the breastmulticentricity of the tumour. The lump is just behind the nipple

Mastectomy  Simple mastectomy and sentinel node biopsy or node sampling

removes the breast tissue and the lower lymph nodes, within the axilla. Sentinel lymph node biopsy is a new method of checking for cancer cells in the lymph nodes. A surgeon removes fewer lymph nodes, which causes fewer side effects. (If there are cancer cells in the sentinel lymph node, an axillary lymph node dissection usually is done.)  Modified radical mastectomy removes all the breast tissue and all

of the lymph nodes in the axilla. It may also be referred to as a total mastectomy and axillary clearance.  Radical mastectomy removes all the breast tissue and the lymph

nodes in the axilla, together with the muscles behind the breast tissue. This is only done if the cancer invaded the pectoralis muscles.

Surgical complications Local pain and tenderness- pain relief with

painkillers Wound infection Bleeding wound Numbness and tingling of the shoulder and upper

arm due to nerve damage during axillary dissection Lymphedema of the arm due to impaired lymph

drainage following axillary dissection.

Radiotherapy for breast cancer Radiotherapy treats cancer by using high-energy rays to destroy

the cancer cells. The treatment is often used after surgery for breast cancer, most commonly after segmental excision.  It may occasionally be used before, or instead of, surgery.   Radiotherapy can cause side effects such as: skin soreness and tiredness,

but most will improve once the treatment has finished. 

Radiotherapy for breast cancer After a mastectomy, radiotherapy to the chest wall

may be given if there is a risk that any cancer cells have been left behind. If a few lymph nodes have been removed and these contained cancer cells, or if no lymph nodes have been removed, radiotherapy may be given to the axilla to treat the remaining lymph nodes. If all the nodes have been removed from the axilla, radiotherapy to this area is not usually needed.

Chemotherapy for breast cancer Chemotherapy is the use of anti-cancer (cytotoxic) drugs

to destroy cancer cells. The aim of chemotherapy is to do the maximum damage to cancer cells while causing the minimum damage to healthy tissue. Indications: Before surgery to shrink the cancer. This is known as neo-adjuvant chemotherapy. After surgery if doctors think there is a risk of the cancer coming back. This is known as adjuvant chemotherapy.

Chemotherapy  There are many different chemotherapy drugs used to treat

breast cancer, and they are often used in combinations (called a chemotherapy regimen).  The commonly used chemotherapy drugs include:  cyclophosphamide  epirubicin  fluorouracil (5FU)  methotrexate  paclitaxel (Taxol)  doxorubicin (Adriamycin®)  docetaxel (Taxotere®).

Hormonal therapies for breast cancer Hormonal therapies are treatments to reduce the levels

of hormones in the body or block their effects on cancer cells. They are often given after surgery, radiotherapy, and chemotherapy for breast cancer, to reduce the chance of recurrence. Hormonal therapies are only effective in women whose cancer cells have receptors for oestrogen and/or progesterone on their surface. This is known as being oestrogen-receptor positive (ER+) or progesterone-receptor positive (PR+).

Hormonal therapy for postmenopausal women Postmenopausal women may be offered hormonal treatment

with either an anti-oestrogen (such as tamoxifen) or an aromatase inhibitor (such as Arimidex®). Tamoxifen has been the most widely used hormonal therapy

for breast cancer and has been shown to be highly effective in reducing the chance of the cancer coming back.  Research has shown that for some women, giving aromatase

inhibitors instead of tamoxifen, or after a period of tamoxifen treatment, can further reduce the chance of the cancer coming back.

Hormonal therapy for premenopausal women Premenopausal women may be offered hormonal

treatment with:  an anti-oestrogen drug (such as tamoxifen)  Treatment to stop the ovaries from producing oestrogen

(ovarian ablation). This can be done using surgery, radiotherapy, or a drug called goserelin (Zoladex® ).

Unfortunately, ovarian ablation by surgery or radiotherapy

brings on an early menopause, which can be very upsetting, especially for women who were hoping to have children. The effects of medicines are usually temporary.

Biological therapy - Herceptin® (trastuzumab) for breast cancer Trastuzumab| ( Herceptin®) is a monoclonal antibody. It works by attaching to HER2 receptors (proteins) on the surface of

breast cancer cells. This stops the cancer cells from dividing and growing. Herceptin can reduce the chance of breast cancer to recur after initial treatment for early breast cancer. However, it is only effective for women whose breast cancer cells have a large number of the HER2 receptors on their surface. This is known as being HER2-positive. Around 1 in 5 women (20%) with breast cancer are HER2-positive.

Biological therapy - Herceptin® Side effects are usually mild, but some women may have: flu-like symptoms, diarrhoea , headaches , allergic reaction.

In some women, Herceptin may cause damage to the heart

muscle, which could lead to heart failure. If this happens the Herceptin® will be stopped. Usually, the effect on the heart is mild and reversible.

Therapeutical categories According to the first treatment: Surgical/non-surgical cancer Surgical breast cancer Stages - 0, I, II, partial IIIA (T3 N1) 

Initial therapeutic step - surgery



Post-operatively: treatment according to type/grade and tumoral receptors

Therapeutic categories Inoperabile cancer Stages IIIA (T0-3 N2), IIIB (T4 N0-2) şi IIIC (T0-3 N3) 

Therapeutic goal – palliation, improve QOL



Initial step – systemic therapy (CHT/HT/biological)  Good

response → surgery-mastectomy→ radioterapie

(RT)  Bad

response → RT (DT = 50 Gy)

Therapeutic categories  Metastatic or recurrent cancer  Stage IV (T0-4 N1-3 M1)

 Therapeutic goal:  Palliation  Cure- Local recurrence  Initial step:  Systemic therapy or  RTE, after surgical removal of local recurence if possible

LOCALLY ADVANCED BREAST CANCER ESMO 2008 Recommandations Systemic neo-adjuvant therapy Radiotherapy Surgery Post-op. systemic therapy

Breast cancer- Case report P.A., female, aged 50, Iasi

PRESENT COMPLAINT- upper outer quadrant painless lump in the right breast with enlarged axillary lymph nodes - december 2001. HISTORY  no family history of cancers  first period: age 12, last period: may 2002;  pregnancies: 2 (age 28, 31),  abortions: 2  no personal history of relevant diseases/ hospital admissions

DIAGNOSIS May 2002 Surgery Unit admission/ clinical evaluation: 3.5/4 cm mass in the upper outer quadrant of the right breast, slightly adherent to skin associated fixed, matted right axillary lymph nodes Fine-needle aspiration biopsy: malignant cytology

TREATMENT (I)

August 2002 Surgery – quadrantectomy + axillary clearance Pathology report: invasive ductal carcinoma, pT1 N1a M0 G2 L1 V1 - 1/1 cm tumor, negative resection limits - 3 out of 10 axillary lymph nodes with large metastasis - invasion of the subcutaneous tissue, vascular emboli, no perineural invasion  Immunehistochemistry report:  ER positive (35%), PR positive (50%)  HER 2 neu negative (1+)

Postoperative treatment September 2002 Oncology admission/ clinical evaluation:  Biologic work-up – normal  Postoperative thoracic scar – normal aspect  Abdominal ultrasound, chest X-ray – no apparent secondary lesions

QUESTION 1 HOW WOULD YOU TREAT? A. Start adjuvant chemotherapy (anthracycline-based regimen) + radiation therapy + hormone therapy B. Start adjuvant chemotherapy (CMF regimen) + hormone therapy C. Start adjuvant radiation therapy + hormone therapy D. Initiate adjuvant hormone therapy: tamoxifen E. Initiate adjuvant hormone therapy: aromatase inhibitors

TREATMENT (II)

October-December 2002 Adjuvant chemotherapy  CA protocol – cyclophosphamide 600 mg/m2 + adriamycin 60 mg/m2, 3-weekly schedule, 4 cycles January-March 2003 Adjuvant radiation therapy  conventional irradiation, TD 44 Gy/22 fr., tumor bed + axillary field March 2003 Adjuvant hormone therapy  tamoxifen 60 mg/day 2003-2005 3-monthly evaluations (clinical, biologic and imagistic)  no signs of disease progression

February 2005 Clinical evaluation:

progressively worsening  low-back and right leg pain. 

Lumbar spine X-ray:

dorso-lumbar scoliosis  reduction of the L3-L4 intervertebral space  no aspects suggestive of bone metastases 

QUESTION 2 WHICH ARE THE APPROPRIATE STEPS? A. Order a bone scan B. Recommend lumbar magnetic resonance imaging (MRI) to exclude spinal cord compression C. Prescribe nonsteroidal anti-inflammatory medication (NSAIDs) D. Evaluate serum and urine protein electrophoresis E. Perform a CT-guided biopsy

February-July 2005 NSAID treatment  Pain

diminished in intensity, still not controlled

July 2005 Bone scan:  Multiple

sites of pathologic increased uptake: skull, vertebral spine, bone pelvis, clavicle, right humerus, left femur, left tibia – bone metastases

QUESTION 3

HOW WOULD YOU TREAT? A. Start 2nd line hormone therapy (aromatase inhibitors) B. Initiate 2nd line chemotherapy (taxanes) + bisphosphonates C. Start 2nd line chemotherapy + 2nd line hormone therapy + bisphosphonates + palliative radiation therapy D. Recommend orthopedic surgery for internal fixation E. Initiate palliative radiation therapy

TREATMENT (III)

July 2005 Palliative radiation therapy  conventional irradiation, TD 20 Gy/4 fr., anterior femoral field

! during irradiation – pathologic fracture: left femur, medium third Orthopedic surgery – osteosynthesis by metallic

rigid nail

Starts 2nd line hormone therapy  letrozol 2.5 mg/day Starts bisphosphonates  pamidronat 60 mg/day I.V., on a monthly basis Continues pain therapy  NSAIDs  tramadolum P.O. 50 mg bid

September 2005 Clinical evaluation: 

pain controlled

Liver work-up – modified: 

γGT = 204 UI/l

Abdominal ultrasound: 

Liver – hipoechogenic nodules, segment 6 = 3.4 cm; segment 8 = 2 cm; segment 2 = 1.8 cm (metastases)

QUESTION 4

WHAT IS THE NEXT TREATMENT STEP? A. Start 2nd line chemotherapy (capecitabine/ docetaxel/ liposomal doxorubicin) B. Start 3rd line hormone therapy C. Consider transarterial hepatic chemoembolization (CHEAT) D. Consider surgical resection of hepatic lesions E. Best supportive care

 TREATMENT (IV)

October 2005  Starts 2nd line chemotherapy  capecitabine 1250 mg/m2 x 2 P.O., D1-14, 3-weekly schedule  Continues 2nd line hormone therapy (letrozol)  bisphosphonates (pamidronat), unchanged dosage and schedule. December 2005  Clinical evaluation:  ECOG PS 1, lumbar pain relatively controlled  Liver work-up – normal:  γGT = 33 UI/l  Abdominal ultrasound:  Liver metastases – segment 6 = 2.7 cm, segment 8 = 2.9 cm, segment 2 = 2.0 cm (stable disease)

January 2006 Left femur X-ray: 

Median osteoblastic cortical bone lesion (posttraumatic pathological bone lesion?)

Lumbar spine X-ray: 

Osteoblastic bone lesions of the L1 vertebral body (slightly collapsed) and the L2 right vertebral pedicle

Bone pelvis X-ray: 

Osteoblastic bone lesions of the right ramus ischium (2 cm) and of the lateral aspect of the left sacro-iliac articulation (diffuse)

QUESTION 5

HOW WOULD YOU TREAT? A. Palliative radiotherapy B. Start 3rd line chemotherapy C. Consider an orthopedic intervention D. Continue hormone therapy E. Consider all the above mentioned options

TREATMENT (V)

February 2006 Palliative radiation therapy 

conventional irradiation, TD 20 Gy/5 fr., dorsolumbar vertebral field

Continues 2nd line chemotherapy

(capecitabine), 2nd line hormone therapy (letrozol) and bisphosphonates (pamidronat), unchanged dosage and schedule Continues pain therapy

NSAIDs  tramadolum P.O. 50 mg tid 

May 2006  Clinical evaluation:  pain controlled  Abdominal ultrasound:  Liver metastases – segment 6 = 2.8 cm; segment 8 = 1.8 cm; segment 2 = 1.9 cm (stable disease) September 2007  Clinical evaluation:  ECOG PS 1, pain controlled  Abdominal ultrasound:  Liver metastases – stable disease  Dorso-lumbar spine X-ray:  Multiple osteoblastic bone lesions (D7-D12, L1-L2, iliac bones, sacrum)  Left femur X-ray:  Osteosynthesis nail overpasses the femoral head by approximately 2 cm

March 2008  Clinical evaluation:  pain controlled  Abdominal ultrasound:  Liver – stable disease  Bone X-rays:  stable disease  TREATMENT (present)  Continues 2nd line chemotherapy (capecitabine), 2nd

line hormone therapy (letrozol) and bisphosphonates (pamidronat), unchanged dosage and schedule  Continues pain therapy  NSAIDs  tramadolum 100 mg bid