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Case History

image A previously fit 80-year old woman presents with a self-detected 4.5 cm mass in the upper outer quadrant of the left breast. The skin is red, thickened and puckered but there is no ulceration. On full history she complains of pain in her right leg over the past 3 weeks. A plain radiograph shows a large lytic lesion in the proximal third of the right femur. An isotope bone scan suggests several other rib lesions and a large hot spot in the right femur. The chest radiograph is clear of metastases although it shows slight cardiomegaly. Liver ultrasound shows no abnormality.

What steps would you consider in the management of this patient?

Which other specialties will you involve in her care?

Discuss how you will arrive at a decision about systemic management of this patient.


What steps would you consider in the management of this patient?

image This woman has a clinical and radiological diagnosis of metastatic breast cancer. Although this is an incurable condition with a quoted median life expectancy in the order of 20 months, survival may be considerably longer in the absence of visceral metastases.1 The priorities in this setting should be palliation of symptoms and extension of survival while maintaining quality of life. A history should be sought of current symptoms, general health and past medical problems. At this age a social history, taking into account any impairment in activities of daily living and instrumental activities of daily living, will be particularly important as these sensitive measures of functional status are useful in guiding treatment (see Chapter 9). Examination should seek to identify other possible sites of disease (e.g. axillary lymphadenopathy) and comorbidities.

To confirm the diagnosis, a needle core biopsy of the breast mass should be done (Figure 38.1). This should be tested for hormone receptor expression and HER-2/neu overexpression, to guide systemic treatment and give prognostic information. Further staging investigations, i.e. a computed tomography (CT) scan of chest and abdomen, could be done to identify possible unidentified lung, liver or nodal metastases, but it may not lead to a change in current management. Routine haematological and biochemical tests also guide treatment and exclude major bone marrow or liver dysfunction, which would alter management.

Figure 38.1

Algorithm for management of advanced breast cancer in the case study patient. CGA, comprehensive geriatric assessment; RT, radiotherapy; ER, oestrogen receptor; PR, progesterone receptor.

Symptomatic management of the bone pain should be a priority. Administration of analgesics should follow the World Health Organization (WHO) ladder. The addition of a bisphosphonate may add to pain control, and will reduce the risk of bone complications.2


Which other specialties will you involve in her care?


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