Download oncology 2002 - Pass the FracP

ONCOLOGY 2002
QUESTION 7: A 56-year old woman presented with pleuritic chest pain and
SOB. She has a past history of breast cancer. Her CT of her chest is shown:
interpreted as small right pleural effusion with large pericardial effusion. What
is the next best step in her management?
a) drain the pleural effusion
b) drain the pericardial effusion
c) insertion of pleurocath
d) give chemo
e) start tamoxifen
Metastatic breast cancer
Nearly half of patients treated for apparently localized breast cancer develop
metastatic disease. Although some of these patients can be salvaged by combinations
of systemic and local therapy, most eventually succumb. Soft tissue, bony, and
visceral (lung and liver) metastases each account for approximately one-third of sites
of initial relapses. However, by the time of death, most patients will have bony
involvement. Recurrences can appear at any time after primary therapy. Half of all
initial cancer recurrences occur more than 5 years following initial therapy.
Because this diagnosis of metastatic disease alters the outlook for the patient so
drastically, it should not be made without biopsy. Every oncologist has seen
patients with tuberculosis, gallstones, primary hyperparathyroidism, or other
nonmalignant diseases misdiagnosed and treated as though they had metastatic breast
cancer. This is a catastrophic mistake and justifies biopsy for every patient at the time
of initial suspicion of metastatic disease.
Once metastatic breast cancer becomes evident, it is appropriate to determine the
extent and location of metastases. An overall therapeutic strategy is then developed on
the basis of age, disease-free interval, hormone-receptor status, and extent of disease.
Because therapy of systemic disease is palliative, the potential toxicities of therapies
should be balanced against the response rates.
Several variables influence the response to systemic therapy. For example, the
presence of estrogen and progesterone receptors is a strong indication for endocrine
therapy. On the other hand, patients with short disease-free intervals, rapidly
progressive visceral disease, lymphangitic pulmonary disease, or intracranial disease
are unlikely to respond to endocrine therapy.
For women with limited and non–life-threatening disease, especially those who have
no symptoms, are elderly, or have estrogen-receptor–positive tumors, hormonal
therapy is the initial treatment of choice.
Eventually, in most women, metastatic breast cancer becomes refractory to hormonal
treatment, at which time the women should receive chemotherapy (CMF or FAC).
The approach to metastatic breast cancer that progresses after hormonal therapy
followed by first-line chemotherapy is changing rapidly. Today, the taxanes and
vinorelbine are the second-line and third-line treatments of choice, respectively, and
we know that taxane-containing salvage regimens improve overall survival. Another
area of progress has been the treatment of anthracycline-resistant breast cancer,
defined as disease that progresses during treatment with a regimen containing an
anthracycline (doxorubicin or a related drug). Before taxanes became available, the
response rates in women with tumors resistant to anthracyclines (as second-line or
third-line treatment) were less than 10 percent, and their overall survival was less than
six months. Now, with the availability of taxanes, the response rates in these women
range from 30 percent to 40 percent and survival for 10 to 12 months is customary.
In many cases, systemic therapy can be withheld while the patient is managed with
appropriate local therapy. Radiation therapy and occasionally surgery are effective at
relieving the symptoms of metastatic disease, particularly when bony sites are
involved. Many patients with bone-only or bone-dominant disease have a relatively
indolent course. Under such circumstances, systemic chemotherapy has a modest
effect, whereas radiation therapy may be effective for long periods. Other systemic
treatments, such as strontium 89 and/or bisphosphonates, may provide a palliative
benefit without inducing objective responses. Since the goal of therapy is to maintain
well-being for as long as possible, emphasis should be placed on avoiding the most
hazardous complications of metastatic disease, including pathologic fracture of the
axial skeleton and spinal cord compression. New back pain in patients with cancer
should be explored aggressively on an emergent basis; to wait for neurologic
symptoms is a potentially catastrophic error. Metastatic involvement of endocrine
organs can cause profound dysfunction, including adrenal insufficiency and
hypopituitarism. Similarly, obstruction of the biliary tree or other impaired organ
function may be better managed with a local therapy than with a systemic approach.
With this in mind:
-we are not given any information regarding the pt’s previous diagnosis of breast ca
-obviously the most important thing to do is to establish whether her symptoms and
signs are due to metastatic disease
-giving tamoxifen without knowing her oestrogen receptor status doesn’t make sense
-giving chemo without even knowing whether it’s metastatic disease would be rash,
not to say negligent!
-the pleural effusion is only small, and unlikely to be contributing greatly to her
symptoms, so inserting a pleurocath would probably make her feel even worse
-draining either effusion and analysing the aspirate would lead to a diagnosis, but the
pericardial effusion is the biggest and potentially life threatening problem for her in
the short term, so I think the best option here is B.