Hard nodular lesions over the chest wall
Thirteen years after undergoing a mastectomy for breast cancer, this patient developed lesions near the scar.
Treatment includes systemic therapy and possibly surgery
The main goal of treatment for patients with metastatic breast cancer is to relieve symptoms and prolong the patient’s life, while ensuring minimal treatment-related adverse effects. The mainstay of treatment is systemic therapy, and in certain circumstances, surgery and/or radiation. Systemic therapy includes endocrine therapy, chemotherapy, and/or biologic agents depending upon the patient’s hormonal receptor status and expression of HER2.
Combination chemotherapy is preferred because it is associated with higher response rates, longer progression-free survival, and a modest improvement in overall survival compared with sequential single-agent chemotherapy.4 According to numerous trials conducted by The French Epirubicin Study Group, the FEC (fluorouracil, epirubicin, and cyclophosphamide) regimen for metastatic breast cancer has been demonstrated to be more effective in terms of response rate, time to progression (TTP), and overall survival compared to the FAC (fluorouracil, doxorubicin, and cyclophosphamide) regimen.5 The FEC regimen also has fewer hematologic, gastrointestinal, and cardiac adverse effects.5 Four initial cycles of FEC should be administered with identical retreatment based on disease progression.5 The duration of chemotherapy is based on how well the patient can tolerate adverse effects and the patient’s informed opinion.
Zoledronic acid has been shown to directly inhibit cell proliferation and induce apoptosis of metastatic/highly tumorigenic cancer cells.6 It also interferes with osteoclast function, slows bone resorption, and thus prevents future skeletal morbidity from the bone lesion.6 Zoledronic acid is administered along with chemotherapy for one year. It is administered continuously for 3 weeks, followed by a one-week break before the next cycle.
Our patient was ER, PR, and HER2 negative, and that limited our treatment options. Based on the National Comprehensive Cancer Network guidelines and our patient’s financial status, we decided on a course of treatment that included 6 cycles of FEC with zoledronic acid, followed by external beam radiotherapy.7
Fifteen days after the third cycle, our patient developed pleural effusion and a pigtail catheter was placed for drainage. Fluid cytology revealed no evidence of malignant cells. We resumed and completed the 6 cycles of chemotherapy. The patient did not receive radiation therapy and was lost to follow-up.
CORRESPONDENCE
Raghunath Prabhu, MD, Department of Surgery, Kasturba Medical College, Manipal University, Manipal, Karnataka, India 576104; drraghu81@yahoo.co.in.
