for UG level

1. METASTATIC CARCINOMA
OF BREAST

2. • It is the spread of tumour into different places like bone, lungs
and pleura, liver, soft tissues , brain and adrenals
Modes of spread :
1. Local spread : As the tumour grows in size it infiltrates skin
causing ulceration, fungation, bleeding, foul smelling
discharge
2. Lymphatic spread : Central group, pectoral, lateral,
subscapular and supraclavicular nodes
Inner medial quadrant of the breast, penetrate the
rectus sheath and join intraperitoneal lymphatics, thus producing
ascites, Krukenberg’s tumours, seconadries in liver.
3. Blood spread :
a. Secondaries in flat bones are common
b. Secondaries in brain results in headache, vomiting and
blurring of vision
c. Malignant plueral effusion is common cause of death

3. Tumour

4. Bone
• It is the most common site of
metastasis via blood spread
• Spread to vertebra is through
posterior intercostal vein and Batson’s
venous plexus
• Vertebrae, ribs, upper end of humerus
and femur, pelvis are commonly
involved
• Pain – stretching of periosteum
• Pathological fractures
• Spinal compression, quadriplegia and
paraplegia
• Radiotherapy , internal fixation, spinal
compression is required

5. Lungs and pleura
• Spread to them causes ‘cannon ball’
secondaries, effusion, consolidation,
chest wall secondaries.
• It signifies terminal event
• Poor prognosis
• Respiratory distress and failure
• HRCT is ideal diagnostic tool

6. Brain
• Secondaries presents with headache, vomiting,
convulsions, raised intracranial pressure and
papilloedema
Liver
• Secondaries may develop either by
haematogenous or via lymphatics across
diaphragm
Soft tissue secondaries got better prognosis;
visceral secondaries got worst prognosis.
Medial survival time for metastatic breast
cancer is 24 months

7. Examination for distant metastasis
1. Opposite axilla and opposite breast
2. Abdominal examination for secondaries in the liver , ascites and
Krukenberg’s tumour
3. Rectal examination – deposits in rectouterine pouch
4. Respiratory system – effusion
5. Bony tenderness – spine, long bones, skull, etc
Evaluation
FNAC/incisional biopsy, Chest CT, LFT, USG Abdomen, CT abdomen, whole
body scanning, CT brain, tissue study for ER/PR/HER-2 neu receptor status

8. Treatment concept
• To improve quality of life
• To relieve pain of secondaries like bone, lungs
• To relieve neurological problems like convulsions, space occupying
cranial problems
• Other symptomatic relief
Treatment strategy
• Chemotherapy
• Radiotherapy
• Hormone therapy
• Trastuzumab
• Supportive treatment

9. Chemoptherapy
• CMF, CAF, Taxanes in combination.
• High dose of chemotherapy using cyclophosphamide, cisplastine,
carmustine, melphalan are tried to get high response rate. But toxic effects
are life threatning
• Haemopoietic growth factor is also used along with chemotherapy to
enhance cell kill with less marrow toxicity
Radiotherapy
• Used in bone metastasis, brain secondaries, to prevent paraplegia in spine
involvement and advanced axillary nodes.
• It is also used in painful bone secondaries, chest wall secondaries

10. Harmone therapy
• Tamoxifen, androgens, progestogens, oophorectomy, adrenalectomy,
aminoglutethimide, are used
• It is useful in slow growing soft tissue or bone secondaries
Trastuzumab
• It is a monoclonal antibody that interferes with the HER-2 neu receptor
• Patients who have overexpression of HER-2 receptor, may also receive trastuzumab
in addition to above
Supportive treatment
Malignant plueral effusion : once effusion is confirmed by aspiration and cytology,
an intercostal drain is left in place
talc insufflation is done to achieve pleurodesis, talc is most effective agent
followed by tetracyclin or bleomycin, etc
Cerebral metastasis : corticosteroids and cranial radiotherapy

11. Bone metastasis :
Localised bone lesions are treated by palliative radiotherapy or
decompression as in quadriplegia, etc.
Bisphosphonates – oral clodronates have been found to arrest
progression of bone disease , dose – 1600 mg/day
Causes of death
• Malignant plueral effusion
• Spine involvement – quadriplegia
• Bony metastasis
• Secondaries in brain
• Cancer cachexia