Bony Metastases 6 Years After Mastectomy and Chemotherapy?
Bony Metastases 6 Years After Mastectomy and Chemotherapy?
A 60-year-old patient is 6 years post treatment for a node-negative, Her2/neu-negative, 5-cm tumor. She underwent mastectomy, node dissection, and standard chemotherapy with cyclophosphamide/methotrexate/5-fluorouracil (CMF). She now presents with bony metastases to the T1 and T2 vertebrae. What would you recommend at this point? What is the likelihood of prolonged survival?
The choice of treatment for metastatic breast cancer is based upon both disease-specific factors and patient-specific factors. Disease-specific factors include the biology of the disease (ie, ER/PR and Her2/neu status) and tumor burden (ie, visceral sites of disease). Patient-specific factors include prior treatment history, age, performance status, and comorbid conditions. Treatment is palliative, and there is no evidence that initiation of cytotoxic therapy as the initial therapy improves survival.
Having said that, a critical piece of missing information is the ER/PR status. I would presume that the tumor was ER/PR-negative, since the patient did not receive adjuvant tamoxifen. If that is true, then the treatment option here is limited to cytotoxic therapy, since the tumor is also Her2/neu-negative. Note that if Her2/neu status was not determined by fluorescence in situ hybridization (FISH) analysis for gene amplification, it should be done in order to provide the highest level of assurance that the disease is truly Her2/neu-negative.
Yamamoto and colleagues reported a prognostic factor analysis for metastatic breast cancer in Japanese women. Features associated with a worse outcome included history of prior adjuvant chemotherapy, distant lymph node metastases, hepatic metastases, elevated serum lactate dehydrogenase, and short disease-free interval (< 24 months). The median survival was best for patients with 0-1 factor (49.6 months), intermediate for those with 2-3 factors (22.8 months), and poorest for those with 4-5 factors (10.0 months). All patients in this series received doxorubicin-based therapy for metastatic disease.
Although all of the relevant factors are not provided in this case, it appears that this patient has at least 1 factor (ie, prior adjuvant chemotherapy), indicating that she could fall into the most favorable group. A doxorubicin-based combination would therefore be a reasonable choice. Other agents such as docetaxel, capecitabine, vinorelbine, gemcitabine, may be held in reserve. Pamidronate (or another potent bisphosphonate such as zoledronate) would also be useful, as these agents have been shown to reduce the skeletal-related event rate (ie, bone fractures, radiation therapy, spinal cord compression) by about 30% in patients with lytic bone metastasis receiving chemotherapy.
A 60-year-old patient is 6 years post treatment for a node-negative, Her2/neu-negative, 5-cm tumor. She underwent mastectomy, node dissection, and standard chemotherapy with cyclophosphamide/methotrexate/5-fluorouracil (CMF). She now presents with bony metastases to the T1 and T2 vertebrae. What would you recommend at this point? What is the likelihood of prolonged survival?
The choice of treatment for metastatic breast cancer is based upon both disease-specific factors and patient-specific factors. Disease-specific factors include the biology of the disease (ie, ER/PR and Her2/neu status) and tumor burden (ie, visceral sites of disease). Patient-specific factors include prior treatment history, age, performance status, and comorbid conditions. Treatment is palliative, and there is no evidence that initiation of cytotoxic therapy as the initial therapy improves survival.
Having said that, a critical piece of missing information is the ER/PR status. I would presume that the tumor was ER/PR-negative, since the patient did not receive adjuvant tamoxifen. If that is true, then the treatment option here is limited to cytotoxic therapy, since the tumor is also Her2/neu-negative. Note that if Her2/neu status was not determined by fluorescence in situ hybridization (FISH) analysis for gene amplification, it should be done in order to provide the highest level of assurance that the disease is truly Her2/neu-negative.
Yamamoto and colleagues reported a prognostic factor analysis for metastatic breast cancer in Japanese women. Features associated with a worse outcome included history of prior adjuvant chemotherapy, distant lymph node metastases, hepatic metastases, elevated serum lactate dehydrogenase, and short disease-free interval (< 24 months). The median survival was best for patients with 0-1 factor (49.6 months), intermediate for those with 2-3 factors (22.8 months), and poorest for those with 4-5 factors (10.0 months). All patients in this series received doxorubicin-based therapy for metastatic disease.
Although all of the relevant factors are not provided in this case, it appears that this patient has at least 1 factor (ie, prior adjuvant chemotherapy), indicating that she could fall into the most favorable group. A doxorubicin-based combination would therefore be a reasonable choice. Other agents such as docetaxel, capecitabine, vinorelbine, gemcitabine, may be held in reserve. Pamidronate (or another potent bisphosphonate such as zoledronate) would also be useful, as these agents have been shown to reduce the skeletal-related event rate (ie, bone fractures, radiation therapy, spinal cord compression) by about 30% in patients with lytic bone metastasis receiving chemotherapy.
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