Breast Cancer with Brain Metastases: the Role and Treatment Consideration of Radiotherapy Case Number: RT2009-127(M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor Purpose: to present a case with breast cancer with brain metastases; to discuss the role and treatment consideration of radiotherapy Scenario: You are radiotherapy (RT) Intent Doctor/Special Nurse/Resident Doctor, and you are assigned to evaluate the following patient before visiting of your RT attending physician. Please review the following description carefully; your RT attending physician will visit this patient later and discuss with you after your review. Case Presentation: This 49 year-old female patient, 李 OO, was referred to us for radiotherapy assessment of breast cancer (very local advanced stage at first) post neo-adjuvant chemotherapy (TP x1 in 2008/04) then MRM (2008/06, LMC), ypt3n2m0, stage IIIA, (2008/06, AJCC2006), then skin nodules and brain metastases were noted, rt0nxm1, r-stage IV. Hence, we need your help for whole brain radiotherapy of multiple brain metastases. Thanks a lot. S: 1. She is a case of histologically proven left breast cancer post neo-adjuvant chemotherapy and MRM at other hospital. Post-MRM radiotherapy for left chest wall and left SCF was done. RT dose fractionation was unknown. 2. In 2009/04, multiple brain mets with significant peri-focal edema were found by brain CT evidence. 3. On 2009/05/05, you visited this patient in the ward. Histories: NDKA; no major disease history. Review of systems: dizziness for days; right limbs weakness with ataxia also noted; memory partial impairment also noted. O: 1. General Condition: ECOG, 2-3; sitting on a wheelchair; speech, OK 2. PEs: erythematous skin lesions over the chest wall and forehead; LNs over the necks and the right axillary region; weakness over the right limbs; no edema on the limbs. 3. ***Pathology in 2008/06, other hospital, MRM (formal report not seen): infiltrating duct carcinoma. 4. Images: (1). Brain CT in 2009/04: multiple low-density regions over the bilateral hemisphere of the brain; a noted brain nodule over the left occipital lobe of the brain, suspect multiple brain metastases with significant peri-focal edema (2). CXR in 2009/05: right diaphragm elevation 5. Others: no available data of tumor makers
Key Image(s): Fig. 1. Fig. 2. Fig. 3.
Questions & Discussions: (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? Q4: What are your Oncology Diagnosis / Assessments for this case? Q5: What is your Oncology Plan for this case? Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.)
Questions & Discussions: (with potential answers) (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? A1: As described in the last attached page. Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? A2: initial ct4nxmx, stage III at least (2008/04, other hospital); rct4b(skin)n3c(left SCF)M1(brain), rc-stage IV (2009/04, AJCC 2006) Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? A3: ypt3n2m0, yp-stage IIIA (2008/06, AJCC 2006) Q4: What are your Oncology Diagnosis / Assessments for this case? A4: Oncology Diagnosis: Infiltrating duct carcinoma, Gx, of the left breast, initial ct4nxmx, stage III at least (2008/04, other hospital), post neo-adjuvant chemotherapy (TP x1 in 2008/04) then MRM (2008/06, other hospital), ypt3n2m0, yp-stage IIIA (2008/06, AJCC 2006), then chemotherapy and RT (dose fractionation unknown), with skin nodules and brain metastases, rct4b(skin)n3c(left SCF)M1(brain), rc-stage IV (2009/04, AJCC 2006) Q5: What is your Oncology Plan for this case? A5: Suggest: (1). Arrange Brain MRI if you agreed; (2). Keep chemotherapy; add palliative RT; (3). Arrange chest CT to further assess the lung mass that was revealed by CXR. Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.) A6: RT Plan may be designed as the following one: (1). Indication: Multiple brain metastases; metastatic skin nodules; may consider RT to the right lung hilar mass (2). Goal: palliative to potential prolong survival; symptoms alleviation and function preservation (3). Target & Volume: whole brain irradiation (4). Technique: 2DRT (5). Dose & Fractionation: 3060 cgy in 17 fractions with or without boost up to 5040-5940 cgy in 28-33 fractions, depending on patient s symptoms. Further Readings & References: NCCN 2009 & Perez 2008 & AJCC 2006 Radiation Oncologist Hon-Yi Lin 2009/05/06
Key Image(s): (with marked) Fig. 1. Fig. 1. A nodule with size about 1.5 cm over the left occipital lobe (as the short white arrow) with associated peri-focal edema of the adjacent brain tissue, c/w brain metastasis (as the long white arrow). Fig. 2. Fig. 2. Bilateral parietal lobes show significant peri-focal edema (as the white arrows). Fig. 3. Fig. 3. The CXR showed a right hilar mass (as the long white arrow) with associated RLL atelectasis (as the short white arrow); the portal-a in place was noted (as the white arrow head).