Adjuvant therapy

1. ADJUVANT TREATMENT FOR BREAST
CARCINOMA(INCLUDING METASTATIC BREAST
CANCER ITS CLINICAL EXAMINATION WORK UP,
MANAGEMENT
Under the guidance of
DR . P NARESH KUMAR PROFESSOR
DR. SIREESHA ASSITANT PROFESSOR
DR. ABHILASH ASSISTANT PROFESSOR
BY
Dr. K.HEMANTH KUMAR
S3 UNIT

2. • The treatment of breast cancer is multimodal which includes
1. Surgery
2. Systemic treatment
Chemotherapy
Targeted therapy
Hormonal therapy
3. Radiotherapy

3. When to give radiotherapy
• Post bcs
• Post mastectomy
• Palliative
• Neoadjuvant

4. TECHNIQUE FOR RADIOTHERPY
• Positioning
• immobilization
• simulation
• target volumer
• treatment planning
• dose & fractionation
• set up verification and treatment delivery

5. POSITIONING AND IMMOBILIZATION
• Supine or prone position
• Arms abducted and externally rotated to 90 or 120 degree
• Prone position is suitable for pendulous breasts, where breast only
radiotherapy is required
• Results is significantly better coverage of breast and significant
reduction of dose to the ipsilateral lung and heart
• decrease the skin toxicity due to loss of skin folding

7. IMMOBILISATION DEVICES
• Breast board
• wing board
• prone breast board

10. IMMOBILISATION DEVICES
• Thermoplastic shells
• adhesive tapes
• vac lock
• alpha cradle
• breast ring
• breast cup
• stocking

12. RADIOTHERAPY
• Radiotherapy is shown to decrease the risk of locoregional and systemic
recurrence and improve survival.
• The indications include the following:
1. Patients with locally advanced breast cancers T3, T4, N1, N2, N3 disease
2. Following BCS.
3. Positive or close margins
4. After mastectomy if:
Tumour size ≥5 cm; skin or chest wall involvement; lymphovascular
invasion (LVI), grade 3; triple negative receptor status, inadequate nodal dissection,
Axillary lymph node positive for metastasis.

13. • Women with metastatic disease involving four or more axillary lymph nodes and
• premenopausal women with metastatic disease involving one to three lymph
nodes also are at increased risk for recurrence and are candidates for the use of
chest wall and supraclavicular lymph node radiation therapy.

14. • In advanced local-regional breast cancer (stage IIIA or IIIB), women are at high risk
for recurrent disease after surgical therapy, and adjuvant radiation therapy is used to
reduce the risk of recurrence.
• Current recommendations for stages IIIA and IIIB breast cancer are
• (a) adjuvant radiation therapy to the breast and supraclavicular lymph nodes after
neoadjuvant chemotherapy and segmental mastectomy with or without axillary
lymph node dissection,
• (b) adjuvant radiation therapy to the chest wall and supraclavicular lymph nodes
after neoadjuvant chemotherapy and mastectomy with or without axillary lymph
node dissection,
• (c) adjuvant radiation therapy to the chest wall and supraclavicular lymph nodes
after segmental mastectomy or mastectomy with axillary lymph node dissection and
adjuvant chemotherapy

15. • Many patients with early stage breast cancer will be candidates for breast
conservation including adjuvant radiotherapy. In this setting, whole breast
radiotherapy
• (WBRT) is the most commonly utilized approach. This can be accomplished with
the patient in the supine or prone position
• Treatment course can range from 3 to 7 weeks in duration, depending on patient
and tumor characteristics.
• Generally, 3–6 weeks elapse following lumpectomy before initiation of WBRT to
allow postsurgical healing.

16. INDICATION FOR AXILLARY NODE IRRADIATION
• N+ with extensive ece
• SLN+ with no dissection
• Inadequte axillary dissection
• High risk with no dissection

17. INDICATIONS OF SCLN IRRADIATION
• clinical N2 or N3 disease
• >4+LN after axillary dissection
• 1-3+LN with high risk feature
• high risk no dissection

18. Target volume
• After BCS
• Whole breast rt + lumpectomy boost
• Regional nodes
• After mastectomy
• Chest wall
• Mastectomy scar
• Ragional nodes

19. Field borders
• INFERIOR - 1 cm margin inferiorly to inframammilary fold
• SUPERIOR - inferior edge of the sternoclavicular junction
• LATERAL - include all breast tiossue with a 1cm margin; this
usually places this border at the posterior to midaxillary line
• MEDIAL -at the midline in the most patients
• ANTERIOR -2 cm margin of light is given above the highest poiunt
of the breast
• POSTERIOR -the deep edges of the tangents shouyld be coincident

24. DOSE OF RADIATION
• Whole breast radiotherapy/chest wall irradiation
Conventional dose
50 Gy in 25 daily fractions given of 1.8–2 Gy in 3 weeks
Hypofractionated dose schedule
40 Gy in 25 daily fractions of 2.67Gy given in 3 weeks
42.5 Gy in 16 daily fractions of 2.66Gy given in 3.5 weeks
• Breast boost dose irradiation to tumor bed
16Gy in 8 daily fractions given in 1.5 weeks
10Gy in 5 daily fractions given in 1 week
• Lymph node irradiation
50Gy in 25 daily fractions given in 5 weeks
40 Gy in 15 daily fractions of 2.67Gy given in 3 weeks

25. ROLE OF BOOST
• Boost to tumor site after WBRT in bcs
• Rationale
• Local recurrence tend to be primarily in and around the primary
tumor site
• Boost decreases risk of marginal recurrence
• More advantageous when margins unknown and young women less
than 40 yrs but benefit seen in all age group

26. • Accelerated partial breast irradiation (APBI) is a modality of radiotherapy for
selected patients meeting the followingcriteria (American Society for Radiation
Oncology ABPI guidelines, 2016):
1. women 50 years or older with T1 disease and negative resected margins with a
margin width of ≥2 mm, invasive ductal carcinoma, no LVI, ER positive, BRCA
negative and sentinel node negative
2. women 50 years or older with low-risk DCIS (screen detected,
low/intermediate nuclear grade, tumour size ≤2.5 cm, negative resected margin
widths ≥3 mm).
• The tumour bed is irradiated along with a narrow rim of surrounding tissue so as
to avoid the potentially harmful efects of irradiation on healthy tissue. It is
delivered twice daily for 5 days.

27. Neoadjuvant systemic therapy (NAST)
• Neoadjuvant chemotherapy (nact), targeted therapy or hormonal therapy prior to surgery.
• It aims to downsize the disease and enable clinicians to know the in vivo response of the tumour
to therapy.
• The indications for nact are as follows:
1 locally advanced breast cancer t3, t4/n2, n3 disease: to downsize the tumour.
2 select cases of early breast cancer:
a to downsize the tumour to facilitate breast conservation surgery (bcs);
b her2/neu-positive tumours;
c triple-negative breast cancer (tnbc);
d premenopausal women (age <50 years);
e patients with axillary node metastasis.

28. ● Neoadjuvant targeted therapy (trastuzumab, pertuzumab) is administered for
HER2/neu-positive tumours >5 mm in diameter.
● Neoadjuvant hormonal therapy is ofered to elderly or frail women (with ER
and/or -, PR-positive advanced tumours) who are deemed unfit to receive systemic
chemotherapy.
Neoadjuvant hormonal treatment takes longer (around 3–6 months) for the
response to become clinically evident.

29. Response assessment and timing of surgery:
• The patient is examined 3 weeks after administration of the second cycle of nact.
• Response evaluation criteria in solid tumours (recist) are used for reporting the
response to nast.
• The four recist categories are:
• Complete response (cr) (lesion not detectable on clinical palpation and imaging);
• Partial response (pr) (≥30% reduction in the maximal diameter);
• Stable disease (sd) (<30% reduction in maximal diameter);
• Progressive disease (pd) (≥20% increase in the maximal diameter).

30. • For patients with CR and PR, the entire chemotherapy regimen may be delivered
prior to surgery
• If the patient is being planned for BCS, a radio-opaque clip or magnetic marker
such as magseed® is placed under image guidance in the epicentre of the tumour
to allow identifcation at the time of surgery should there be a complete response
to NACT.
• This catheter tip remains palpable even after complete regression of the tumour
and helps the surgeon in performing removal of the index area for bcs, excising
2 cm of tissue all around this catheter.
• For patients showing stable or progressive disease, after the initial two cycles of
chemotherapy, the patient should undergo surgery and be given second-line
chemotherapy after surgery.

31. ADJUVANT SYSTEMIC THERAPY
• The purpose of adjuvant systemic therapy is to control
putative micrometastases, delay relapse and prolong
survival.
• Chemotherapy
• Targeted therapy
• Hormonal therapy

32. • The goal of adjuvant therapy is to prevent the recurrence opf breast cancer by
eradicating occult, micrometastatic deposits of tumor present at the time of
diagnosis.
• In the early stages of breast cancer development, tumor cells are disseminated
through out the body
• Systemic therapy can control microscopic tumor dissemination, the locoregional
therapies to treat clinically apparent or high risk areas may be effective in
achieving a multimpdal cure

33. • Three systemic treatment modalities are widely used as adjuvant thearapy for
early stage breast cancer
1. Endocrine treatments such as tamoxifen, ais or ovarian supression
2. Anti -HER2 therapy with targeted therapies such as humanized monoclonal
antibody trastuzumab
3. Chemotherapy

34. • Patients with tumors that are hormone receptor positive are candidates for
adjuvant endocrine therapy
• Patients with tumors that are her2 overexpressing are candiadtes for anti her2
treatments
• Chemotherapy is a used for tumors that are hormone receptor negative,
alongside trastuzumab in her2 positive tumors, and in addition to endocrine
therapy in erpositive patients

36. TYPES OF ADJUVANT ENDOCRINE THERAPY
• Tamoxifen is the historic standard for adjuvant endocrine therapy for breast
cancer
• Tamoxifen admisnistered for 5 years results in 41% reduction in the annual rate of
breast cancer recurrence and 34% reducation in annual death rate for women
with er positive breast cancer
• Tamoxifen works by binding to the er, ais function through inhibition of
aromatase enzyme that converts androgen into esrogen,results in profound
estrogen depletion

38. TAMOXIFEN
• It is an antioestrogen.
• It blocks cytosolic oestrogen receptors.
• Dose is 10 mg bid or 20 mg od for 5 years.
• Half life of tamoxifen is 7 days; it takes 4 weeks to show its benefits.
• It reduces the cholesterol and also cardiovascular morbidity.
• Adverse effects:
• Tamoxifen flare—flushing, tachycardia, sweating, genital itching, vaginal atrophy and dryness
(premenopausal), vaginal discharge (postmenopausal), fluid retention, weight gain.
• Occasionally it causes bone pain which should be differentiated from pain due to bone metastasis. It is due to
loss of bone density in premenopausal women.
• It increases the incidence of endometrial cancer.
• Dvt (3%), pulmonary embolism, cva, tia, cataract, fractures.

39. • Advantages:
• It reduces the recurrence rate by 25%.
• It improves the prognosis.
• It is used presently in all age group, ER +ve patients.
• Preservation of bone density in postmenopausal women. But it causes bone loss in
premenopausal women.
• Cheap, easily available, less toxic effects, very effective.
• It is equally effective in carcinoma male breast.
• It is presently also under trial for certain benign diseases of breast (ANDI, cyclical mastalgia).
• Selective oestrogen antagonists
• Do not cause endometrial hyperplasia or endometrial carcinoma.
• Drugs include droloxifen, toremifen, raloxifene.

40. LETROZOLE
• It is a nonsteroidal competitive inhibitor of the enzyme ‘aromatase’.
• This enzyme converts adrenal androgens to oestrogen (aromatization). So it is an
aromatase inhibitor.
• Other aromatase inhibitors are anastrozole and exemestane(in postmenopausal).
• It is expensive but more effective than tamoxifen.
• It is also used in recurrent disease.
• Letrozole is used as an adjuvant endocrine therapy in postmenopausal women with
hormone sensitive breast cancer (in premenopausal women this will cause rise in
gonadotrophins and ovarian aromatase is not well suppressed).

41. • It can alsobe used in metastatic and recurrent cases.
• It slows down and stops the growth of oestrogen sensitive breast tumours.
• It reduces oestrogen level by 98%. Its half life is 45 hours.
• It decreases the bone density.
• Dosage of letrozole is 2.5 mg once daily.
• It is given for 5 years or for 2 years following 3 years of tamoxifen.
• Side effects of letrozole are vaginal dryness, night sweats, hot flushes, vaginal
bleeding, cardiovascular problems and osteoporosis.

42. TARGETED THERAPY: TRASTUZUMAB(HERCEPTIN)
• It is a monoclonal antibody that blocks HER-2/neu receptors thereby preventing
growth of cancer cells.
• It is c-erbb2 (growth factor receptor) inhibitor.
• Her 2/neu receptor is tyrosine kinase receptor.
• It has very little effect on her-2/neu negative cancers. It is useful only in HER-
2/neu positive cancers.
• It is used along with pertuzumab to treat her2/neu-positive tumors along with
chemotherapy
• The cytotoxic agent t-dm1 is used in her2/neu-positive disease: a chemotherapy
agent, emtansine, is conjugated to trastuzumab to allow targeted delivery of the
chemotherapy to her2-positive cells.

43. • It is currently approved by FDA for use only in metastatic disease. It is given as
intravenous infusion.
• Studies have shown substantiate improvement in disease free and overall
survival rate.
• Pertuzumab is another similar agent. But both do not cross the blood-brain
barrier.
• Dose is 4 mg/kg as loading; 2 mg/kg as maintenance for 1 year.
• It has got cardiac side effects.

45. CHEMOTHERAPY
• Adjuvant chemotherapy :refers to administration of cytotoxic drugs to women after breast cancer
surgery in the hope of eliminating clinically undetectable distant spread. Reduced recurrence rate
and improved survival rate is observed in all women with invasive breast cancer.
• Neoadjuvant chemotherapy: refers to administration of cytotoxic drugs in a large operable
tumour to reduce the loco-regional tumour burden to make it better amenable for surgical
resection, usually after 3 doses. It downstages the disease; may achieve breast conservative
surgery in selected patients (only); early systemic control is achieved.
• Palliative chemotherapy is used in advanced and metastatic carcinoma breast.

46. • Indications:
• All node positive patients.
• Primary tumour more than 1 cm in size.
• Presence of poor prognostic signs of any tumour—vascular and lymphatic invasion; high nuclear and
histologic grade; Her 2/Neu overexpression; negative hormone receptor status.
• In advanced carcinoma breast as a palliative procedure.
• In postoperative period after simple mastectomy in stage III carcinoma breast with fixed axillary
nodes.
• In inflammatory carcinoma of breast.
• In stage IV carcinoma breast with secondaries in bone, lungs, liver.
• In premenopausal age group with poorly differentiated tumours.

47. Chemotherapy.
• Adjuvant chemotherapy is of minimal benefit to women with negative nodes and
cancers ≤0.5 cm in size and is not recommended.
• Women with negative nodes and cancers 0.6 to 1.0 cm are divided into those with
a low risk of recurrence and those with unfavorable prognostic features that
portend a higher risk of recurrence and a need for adjuvant chemotherapy.
• Adverse prognostic factors include blood vessel or lymph vessel invasion, high
nuclear grade, high histologic grade, HER2/neu overexpression, and negative
hormone receptor status.

48. • American Society of Clinical Oncology guidelines suggest that adjuvant
chemotherapy should be considered for patients with
positive lymph nodes
HER2-positive disease
grade 3 lymph node negative tumors >5 mm
triple-negative tumors
lympho-vascular invasion or
estimated distant relapse risk of greater than 15% at 10 years based on
21 gene recurrence score.

49. CMF REGIME(NON-ANTHRACYCLINE REGIME);
• Cyclophosphamide, methotrexate and 5 flurouracil is good old regime
• It is cheaper and easy to administer
• Side effects
Alopecia
Bone marrow supression
Meggaloblastic anemia
Cystitis
Git disturbances
Nephritis

50. ANTHRACYCLINES
• First anthracycline extracted is daunorubicin from streptomyces: later doxorubicin
• Adriamycin is the most commonly used anthracycline
• It s used often with other chemotherapeutic agents and also with trastuzumab
• These are first line drugs

51. TAXANES
• They are newer chemotherapeutic drugs which act by G2/M phase of cell cycle.
• It is commonly used in metastatic carcinoma of breast.
• Drugs are paclitaxel and docetaxel.
• Taxanes have no cross-resistance with anthracyclines and so can be used
sequentially or concurrently with anthracyclines.
• These are second line drugs

52. GEMCITABINE
• Synthetic pyrimidine nucleoside prodrug-anti cancer drug
• It is used often in selecyted cases of metastatic breast cancer and
locally advanced breast cancer for better results
• 3rd line of drug

53. Frequently used chemotherapy agents

54. • For women with hormone receptor-negative cancers that are >1 cm in size, adjuvant
chemotherapy is appropriate.
• Women with node-negative hormone receptor–positive cancers and t1 tumors are candidates for
antiestrogen therapy with or without chemotherapy.
• Assessment of overall risk using known prognostic factors or additional testing such as the 21-
gene recurrence score assay can help to guide decision making regarding chemotherapy in
patients with node negative, er-positive breast cancer.
• Special-type cancers (tubular, mucinous, medullary, etc), which are usually strongly estrogen
receptor positive, adjuvant antiestrogen therapy should be advised for cancers >1 cm. For women
with node-positive tumors or with a special-type cancer that is >3 cm
• The use of chemotherapy is appropriate; those with hormone receptor positive tumors should
receive antiestrogen therapy

55. • For stage IIIA breast cancer, preoperative chemotherapy with an anthracycline and taxane-
containing regimen followed by either a modified radical mastectomy or segmental mastectomy
with axillary dissection followed by adjuvant radiation therapy should be considered, especially for
estrogen receptor negative disease.
• While the same regimen may be considered for estrogen receptor positive disease, it is known that
these tumors respond less well to chemotherapy with <10% pCR rate overall and <3% pCR rate for
lobular cancers.
• Other options such as neoadjuvant endocrine therapy followed by local regional treatment or in
some cases primary endocrine therapy may be considered depending on other tumor
characteristics and the patient’s comorbid conditions and preference.

56. METASTATIC DISEASE
• Metastatic disease(stage 4 )breast cancer is defined by tumor spreade beyond the
breast,chestwall,ipsilateral regional lymph nodes
• Most common sites for breast cancer metastasis include thge bone,lung,liver,lymph
nodes,chestwall ,brain.
• Hormone receptor positive tumors are more likely to spread to bone as the initial
site of metastasis
• Hormone receptor negative/HER2 positive tumors are more likely to recur initially
in the viscera
• Most women with metastatic disease will have been initially diagnosed witrh early
stage breast cancer, treated wuth curative intent, and then experience metastatic
recurrence

57. • Symptoms of metastatic breast cancer relate to the location and extent of the
tumorCommon symptoms or physical examination findings include bone
discomfort,lymphadenopathy, skin changes,cough or sob and fatigue
• The treatment goals in women with advanced breast cancer include prolongation
of life, control of tumor burden, reduction in cancer related symptoms or
complications
• Maintanence of quality of life and function

58. • Patients with endocrine sensitive tumors,particularly those with minimal
symptoms and limited visceral involvement are candiadtes for initil treatment with
endocrine therapy alone
• Patients with hormone receptor negative tumors or tghose with hormone receptor
positive tumors progessing despite the use of endocrine therapy are candidates
for chemotherapy
• If the tumor is HER2 positive , then the anti-her2 treatment is employed with
chemotherapy
• The art of treating patients with metastatic breast cancer involves careful,
thoughtful repetition of process of treatment initiation

59. ENDOCRINE THERAPY FOR METASTATIC
BREAST CANCER
• Endocrine treatment is a key intervention for women with
hormone receptor positive, metastatic breast cancer
• Single agent therapy is the standard approach

60. • Tamoxifen was the historic standard as treatment for ER positive metastatic breast cancer,
associated with 50% response rate and median duration of response of 12-18 months among
treatment naive patients
• A tamoxifen flare reaction, typically charecterized by intensification of bone pain, transient tumor
progression, and hypercalcemia, can arise in 5-10% of patients within first days or weeks of
tamoxifen treatment
• Flare reactions are not frequently seen with other endocrine therapies such as ais or fulvestrant
• In premenopausal women with metastatic breast cancer, combined endocrine therapy with ovarian
suppression and tamoxifen can improve survival compared with either alone
• Premenopausal women with metastatic tumor despite tamoxifen usea are candidates for ovarian
supression or ablation and AI therapy

61. • Post menopausal women are candidates for tamoxifen, ais, fulvestrant or
progestational agents as palliation for metastatic breast cancer
• Ais appears to be the preferred initial agents for women who received prior
tamoxifen treatment in the adjuvant settings

62. • Bone is the most common site of metastasis. Spread to vertebra is through
posterior intercostal vein and Batson’s venous plexus (valveless). Vertebrae, ribs,
upper end of humerus and femur are common bones involved.
• Lungs and pleural spread causes ‘cannon ball’ secondaries, effusion, consolidation,
chest wall secondaries.
• Liver secondaries may develop either by haematogenous or through lymphatics
across diaphragm from lower inner quadrant of breast.
• Brain secondaries present with headache, vomiting, convulsions, localising
features.
• Soft tissue secondaries has got better prognosis; visceral secondaries has got worst
prognosis.

63. • It is evaluated by
FNAC/incision biopsy
LFT
USG abdomen
CT ,MRI
whole body bone scanning,
PET SCAN
tissue study for ER/PR/HER-2 Neu receptor status.

64. PLANAR BONE SCINTIGRAPHY
• Planar BS is clinically easy to read, widely available and cost effective , and has
been recommended as the primary technique to detect bone metastases in
asymptomatic high-risk breast cancer women
• Abnormal accumulation of 99mTc-labelled diphosphonates is connected to
increased local blood flow and osteoblastic activity which occur consequently to
metastatic growth within bone marrow
• The sensitivities of planar BS reportedly range between 62 and 100%

65. SPECT bone scan
• BS was augmented using single-photon emission computerised
tomography (SPECT) in the lower thoracic and lumbar spine, or across
the entire axial skeleton (whole-bodySPECT) .
• On a per-patient basis in breast cancer, SPECT showed a high
specificity of 94% compared with 74% using BS

67. • CT which shows a good specificity although a poorsensitivity (95% and 73% respectively)
• Metastases appear on CT as areas of lucency or sclerosis, and rarely as well-defined radiodensity
within the bone marrow
• Sensitivity and specificity for detecting liver metastases were reported 73–75% and 94–96%,
respectively
• Generally, HER2-expressing breast cancers tend to metastasise to the liver more frequently than
ER/PR positive breast cancers .
• Portal venous phase of CT shows liver metastases as irregular hypodense lesions with peripheral
contrast enhancement .
• Nevertheless, liver metastases may appear isodense with the hepatic parenchyma and their
extent may beunderestimated or, when diffuse, entirely missed

70. Conventional MRI
• In metastatic breast cancer, malignant cells displace and replace normal bone
marrow fat cells causing a reduction in fat content, whereas successful
management is associated with return of healthy bone marrow fat
• Radiologist can discriminate bone metastases (which manifest with nodular focal
metastatic lesions or marrow infiltration/replacement) from benign marrow
alterations (such as marrow hyperplasia induced by chemotherapy)

71. • With an 80–82% and 96–98% reported ranges of sensitivity and specificity,
respectively MRI is an appropriate modality to detect hepatic metastases
• Breast cancer metastases in liver are typically hypo- to isointense on T1WI, iso- to
hyperintense on T2WI and,since breast metastases are frequently hypovascular,
they usually show perilesional enhancement in the arterial phase of contrast
enhancement.
• However, hypervascular metastases may also occur, which can be associated with
disease progression .
• In addition,DWI can aid the detection of small liver metastases easily overlooked
on other sequences

72. • For the detection of brain metastases, contrast enhanced MRI has higher
sensitivity than CT , due to its higher soft tissue resolution and its better
detection of parenchymal and leptomeningeal involvement
• Lesions are usually supratentorial, and they can be solitary or multiple, arising at
the grey-white matter junction and at watershed zones of major arterial
territories .
• Moreover, MRI showed higher sensitivity and specificity than PET-CT for brain
metastases

74. PET
• In oncological staging, 18F-fludeoxyglucose (18F-FDG) is the most widely used
radiotracer
• The net clearance of 18F-sodium fluoride (18F-NaF) in breast cancer bone
metastases is 3–10 times greater than that in healthy bone, conferring the capacity
to detect both osteolytic and osteosclerotic metastases
• 18F-NaF PET-CT has better diagnostic performance than 18F-NaF PET alone
without the CT component

75. TREATMENT FOR METASTATIC SITES
• Treatment of metastatic cancer is aimed at palliating symptoms, improving quality of
life, preventing potential disabling complications and attempting to prolong life.
• Endocrine therapy for hormone receptor-positive disease is preferred for patients
with bony metastasis and limited visceral metastasis.
• Systemic chemotherapy is preferred for patients with hormone receptor-negative
cancers, hormone-refractory metastases and patients with visceral crisis.
• Oral low-dose metronomic chemotherapy has cytostatic and antiangiogenic effects
and may help in improving quality of life.

76. • LYTIC BONE METASTASES
-Patients with bony metastasis should receive palliative radiotherapy to lesions
in weight-bearing areas (e.g. vertebra, femur) and to painful bony deposits,
- either iv bisphosphonate therapy such as pamidronate or zoledronic acid, or
RANK ligand inhibiotor denosumab
- these agents lessen the pain associated with bone lesions and prevent
complications of skeletal metastasis, including fractures and hypercalcemia
- treatment with zolendronic acid every 3 months is as effective as monthly
therapy
- extended therapy can be associated with osteonecrosis of jaw, so patients
should me monitored for atypical oreal lesions

77. • Therapy for brain metastasis remain inadequate but generally includes
radiotherapy, administered to the whole brain - diffuse involvement
• Surgical excision may also be an option for patients with isolated lesions or
dominant masses as well as those who experience recurrence after radiotherapy
• Patients with leptomeningeal disease may achieve symptomatic improvement
with wbi or intrathecal; chemotherapy with methotrexate or cytarabine
• Symptomatic pleural efusions are palliated by intercostal chest drainage and
pleurodesis.
• Surgical resection of metastatic lesions may be indicated in solitary visceral
metastasis in patients with good performance status and favourable tumour
biology

78. breast cancer - non metasatic - mrm + chemo/radiotherapy
oligometastatic: <5 metastases- surgery+radiotherapy
if the lesions are invovling single lobe of liver- resection
if the lesion invovling single lung or less than 2 lobes of lung - resection
along with radiotherapy to breast chest wall, lung fields and abdomen
polymetastatic: >5 metastases neoadjuvant followed by surgery
more than 2 lobes of lung/ diffuse lung involvement,b/l lungs, both lobes of liver
involved. peritoneal or omental deposits , multiple bone deposits
bones -radiotherapy and fixation for pathological fractures
visceral mets - chemo and radiotherapy followed by surgery

79. • REFERENCES
• schwartz’s principles of surgery
• bailey’s & love short practice of surgery
• devita, hellman, and rosenberg’s cancer principles and practice of
oncology
• SRB’S manual of surgery

80. THANK YOU