Palliation of specific problems associated with breast cancer

Bone metastases:

• 73% of patients who die from breast cancer have skeletal metastases
• However, less than 50% of these patients experience symptoms and these lesions should only be managed when recognised as a source of trouble
• The exception is a lesion that threatens pathological fracture, such as one in a weight-bearing bone which should be fixed internally and followed by radiotherapy
• Pain can be controlled with:
• Radiotherapy
• NSAIDs
• Opiates

Bisphosphonates have been shown to reduce the progression and morbidity associated with bony metastases, even if they are not associated with hypercalcaemia

Transient hypercalcaemia occurs in almost 50% of those with bone metastases. Levels >3mmol/L are often associated with distressing gastrointestinal and neurological symptoms

Pleural and lung metastases:

• Up to 37% of all malignant pleural effusions are associated with metastatic breast cancer and are nearly always the result of haematogenous metastasis but, in some locally advanced tumours, spread may be directly through the chest wall
• Bilateral effusions occur in 15% of cases
• Malignant pleural effusions are managed by aspiration followed by pleurodesis (to prevent an inevitable reaccumulation of the effusion)
• Individual lung metastases do not generally cause problems
• However, diffuse infiltration of the pulmonary lymphatics produces a stiff lung – often with bronchospasm and dyspnoea
• Median survival is 6-15 months

CNS metastases:

• On autopsy, 30% of the victims of breast cancer have CNS metastases
• Of these, only 35% are symptomatic – it is rare for a brain metastasis to be the cause of death
• The most common site is the dura, with the cerebellum next
• Symptoms are either due to raised ICP or focal neurological problems, depending on the site of the metastasis
• Untreated, survival is <6 weeks
• With aggressive therapy, 50% are still alive after 1 year

Spinal cord compression:

• After lung cancer, breast cancer is the second most common cause of symptomatic spinal cord compression
• Once it has occurred, ~35% develop irreversible hemiparalysis, therefore, early diagnosis and treatment are essential

• The metastases reach the epidural space either by:
• Direct local extension from invasion of a vertebral body
• Haematogenous spread
• For diagnosis, a plain X-ray is ideal and can detect the presence or absence of metastasis in 80% of cases
• Nevertheless, in a patient with breast cancer and back pain, who has both a normal neurological examination and a normal plain film, spinal metastasis is very unlikely
• CT and MRI provide the diagnostic information necessary for planning treatment
• As mentioned above, treatment is a matter of urgency:
• Dexamethasone (to reduce oedema)
• Radiotherapy

• Approximately 50% respond to the above measures

Indications for surgical decompression include:

Posteriorly placed lesion

Continued progression of disease in spite of radiotherapy

Recurrent compression after initial response to radiotherapy

Vertebral instability

Radiotherapy is the best therapeutic option and should be given to all those treated surgically if they have not been previously irradiated at the site of compression