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Chemotherapy And Radiation Done For Recurring Breast Cancer. Reason For Pain And Swelling On Back?

Posted on Tue, 12 Mar 2013

Question: My Aunt has been suffering from breast cancer and she had undergone Chemotherapy and radiation for the same in 2007. But it recurred again in 2011 and we had to repeat the radiation and chemotherapy. Things have been good for the past one year. But she started developing severe back pain. We are suspecting, it could be because of the fact that she was taking the lestrozole medicine post cancer. We tried the Bone Density check and found out that it is normal. We are planning to do a Bone biopsy check next week. But I would still want to know what is your expert opinion on this. She has severe back pain and swelling on her back. But I have learnt that one is supposed to lose weight and bone density must reduce in case of bone cancer. In my aunt's case her weight has increased and bone density is normal. Kindly give your opinion on this.

Answered by Dr. Dipanjan Majumder (1 hour later)

Hi,
Thanks for posting your query.
Breast cancer are of different types.
commonly found sub type is infiltrating duct carcinoma.
Other types like lobular carcinoma, sarcoma lymphoma can also be found.
ductal carcinoma can be classified on the basis of hormone receptor status (ER/PR/HER2.neu).

From the treatment history some inference can be drawn.
-Probably she had ductal carcinoma.
-the disease was hormone receptor positive (ER/PR+). [ as she is on letrozole]

To predict the outcome initial staging information is necessary.

As you have mentioned she has been treated with chemotherapy and radiotherapy, I would like to know exact drugs and modality of radiotherapy.

Another treatment is surgery, non-metastatic breast cancer treated by surgery combined with chemoradiotherapy.

Bone mineral density may be reduced on chronic use of letrozole ( class of drug : aromatase inhibitor). This should be reflected on routine bone density check. As this report came to be normal so this symptoms unlikely to be related to letrozole.

Breast cancer has high chance to metastasize to the bone. symptoms will be local tenderness.

This possibilities to be ruled out by doing a bone scan followed by X-ray if any suspicious lesion found .

Increase in body weight may be related to sedentary life style and dietary style ( specially increased fat, carbohydrate and decreased dietary fiber in food)

Breast cancer has a relationship with obesity. NCI study suggests obesity increases chance of recurrence in breast cancer.
NCCN 12 guideline also suggest BMI to be kept between 20-25 for best results.

Now, in case of your aunt, total metastatic work up to be done. If disease found to be progressed then systemic treatment to be instituted. change of hormonal treatment to be Considered.

Hope I have answered your queries, keep me posted for further follow up.

Above answer was peer-reviewed by : Dr. Mohammed Kappan

Follow up: Dr. Dipanjan Majumder (50 minutes later)

Thanks for the response Doctor. We have already done the X XXXXXXX and the results have come out to be normal, just like the Bone Density Scan. I will attach the results of the Bone Density Scan here in the reports section for your reference. I have just a few queries here on the basis of the information you provided me with

a) Can it happen that the X XXXXXXX Test is normal and the Bone Density Scan shows everything fine and the person can still suffer from Bone Cancer?

b) I have learnt that X Rays can help detect the presence of Bone Cancer in most of the cases. So does it mean that the person will be suffering from Bone Cancer which is at a pretty initial stage?

c) What could be the seriousness of the Bone Cancer which has meta sized into the same from Breast Cancer? We were told that this can be treated with an injection which is to be taken once in 6 Months for approximately 15 minutes every time.

Awaiting your response on this?

Regards
XXXXXXX

Answered by Dr. Dipanjan Majumder (26 minutes later)

Hi,

Thanks for follow up.

a) Let me give some clarification.
Bone mineral density scan and bone scan is different.
Bone mineral density scan is done by DEXA (Dual energy X - XXXXXXX absorbsiometry)
scan. It is used to detect osteoporosis. As your aunt is on letrozole so this
investigation may be routinely done.

Bone scan is different, it is used to detect bone metastasis by radioactive material.

In case of negative result in X-ray and bone scan it is unlikely to be a metastatic deposit. If there is strong clinical suspicion, MRI can be done.

b) Bone cancer is very unlikely at this age. Probably you wanted to mention bone metastasis. yes, that is common specially in hormone receptor positive breast cancer.

Further investigation which can be helpful is
serum alkaline phosphatase,
serum calcium,
serum albumin level.

c)Yes, you have been informed correctly regarding the treatment option.

That injection is called bisphosphonates. Mainly Inj. Zoledronic acid.

After getting the normal kidney function report this can be safely administered and has proven role to decrease skeletal related events (SRE) in malignancy.

For your information, bone metastasis from breast has relatively good prognosis. It responds to treatment very much. But, regular follow up is necessary to detect early visceral metastasis.

Hope I have answered your queries. Keep me posted for follow up.

Regards

Above answer was peer-reviewed by : Dr. Mohammed Kappan

Follow up: Dr. Dipanjan Majumder (2 hours later)

Hello Doctor,

Thanks a lot for your response. I would like to clarify just one more concern with you. Is bone metastasis and Bone Cancer the same? We have done only Bone Density Scan and X XXXXXXX for which results have been negative. We are hoping that this is not cancer again. In case it is not cancerous, what could be the probable reasons behind the pain when we have found that X XXXXXXX and Bone Density tests are negative?

Thanks for your support.

Answered by Dr. Dipanjan Majumder (1 hour later)

Hi,

Thanks for follow up.

Metastatic deposit in bone and primary malignant bone tumor are different.

Metastatic bone deposit can be identified on bone scan (not bone density scan), X-ray, also in CT scan.

Primary bone tumors ( malignant) also can be diagnosed by X-ray but diagnosis has to be confirmed by pathology report.

Pain in back, may be due to some sort of injury causing muscle spasm, this will not be evident on imaging. Other causes like disc prolapse, compression fracture are the possibilities often missed in early cases but clinical examination can guide to get a clue.

In a breast cancer patient, in my opinion, bone scan should be done in case of an unexplained back pain, as your bone density scan report supplied by you is normal.

Hope I have answered your queries.

Above answer was peer-reviewed by : Dr. Mohammed Kappan

Follow up: Dr. Dipanjan Majumder (2 hours later)

Thanks for your time doctor. One Last query. Since the X XXXXXXX reports are normal (& even the bone density scan report is normal), the chances of having bone cancer would be minimal, I believe?. Please give your opinion on this. Anyways, we are going ahead with the Bone Scan as well.

Regards

Answered by Dr. Dipanjan Majumder (17 minutes later)

Hi,
Thanks for posting your query.

Primary bone tumor generally detected by X-ray.
In case of any suspicion, CT scan advised and for better understanding of underlying soft tissue involvement and neurovascular structure involvement MRI can be beneficial.

But the appropriate modality should be chosen after detailed clinical examination.

As your aunt has normal X-ray primary bone tumor diagnosis is unlikely.

Anyway, bone scans will definitely help to find out any metastatic deposit if present at all.

Hope my reply has satisfied you. Wish you a good health.

Above answer was peer-reviewed by : Dr. Shanthi.E

Follow up: Dr. Dipanjan Majumder (2 days later)

Hello Doctor,

We have done the Bone scan and found out that there are metastatic deposits in right shoulder and knee area. Will it be serious? Is this common for Breast Cancer patients? We were told that an injection would suffice for 15 minutes, with 6 months gap. How long should the treatment be done in this case?.

Awaiting your response on this.

Answered by Dr. Dipanjan Majumder (43 minutes later)

Hi,
Thanks for providing the report of bone scan.

I am trying to answer your specific queries.

1. "metastatic deposits in right shoulder and knee area." Will it be serious?

Presence of bone metastasis signifies stage IV disease.
The disease is at advanced stage now. But, at this stage also the disease can be
treated. Better quality of life and longer survival are expected.

2. Is this common for Breast Cancer patients?

Hormone receptor positive breast cancer has a propensity to metastasize to
bone.

3. We were told that an injection would suffice for 15 minutes, with 6 months gap.
How long should the treatment be done in this case?.

You are correctly informed about injection zoledronic acid.
This injection can be given after renal function assessment.
This treatment can be continued until any side effects will be reported.

Specific precaution like regular check up by a dental surgeon ( at least at 6
months interval) should be encouraged.

Regular monitoring of serum creatinine, and Ca ++ should be done.

Consult your oncologist, he/she can guide you better.

Above answer was peer-reviewed by : Dr. Aparna Kohli

Follow up: Dr. Dipanjan Majumder (13 minutes later)

Thanks for the information doctor. Can you please let us know what could be the average life expectancy in this case?

Also please find below some info I got from different sources:

"Most breast cancer systemic recurrences (meaning the kinds that spread to the rest of the body) happen in the next two years after the first time the cancer is diagnosed. The next plateau is within five years. After that, it's very rare to have recurrences. Typically metastatic cancer spreads to bone, lungs, liver, and brain. If it's contained within the bone -- which is the case with the majority of patients -- they can do very well. "

Does this mean that she can do good with a good treatment and continuous check up?

Answered by Dr. Dipanjan Majumder (16 minutes later)

Hi,
For your information I want to assure you that visceral metastasis ( cancer spreads to other organs except bone) carries a bad prognosis but that is not true for bone only metastatic disease.

With proper treatment she can have better quality of life and long term survival.

Our clinical experience also support that fact. Average life expectancy has got subjective variation so it should not be commented upon right now.

Hope your aunt will respond to treatment very well. Take care.

Note: For further queries related to kidney problems Click here.

Above answer was peer-reviewed by : Dr. Aparna Kohli