Local Treatment for Metastases

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Surgery to remove metastatic breast cancer isn't common, but a small study suggests that some women can benefit from surgery to remove breast cancer that has metastasized to the liver if the cancer has certain characteristics:

  • hormone-receptor-positive
  • responded to chemotherapy before surgery
  • didn't grow in the time between metastatic diagnosis and surgery

Right now, we don't know if women who have surgery to remove metastatic breast cancer in the liver have better outcomes than women who don't have surgery. Still, if you have liver metastases, you may want to ask your doctor about the benefits and risks of surgery in your unique situation.

Cryoablation may be an option to treat small, isolated metastatic breast cancer tumors in women who aren’t good candidates for surgery. Guided by imaging (ultrasound, CT scan, or MRI), cryoablation inserts a special freezing probe (a type of catheter) through the skin and to the tumor to be treated. Once the tip of the probe is in the right spot inside the tumor core, pressurized argon gas is injected through the probe into the tumor, freezing and destroying the cancerous tissue. Cryoablation techniques may vary from one cancer treatment facility to another. Cryoablation is more common in cases where the breast cancer is being well controlled by systemic treatments.

Problems Requiring Local Treatment

You may have signs (medical findings) or symptoms of a cancer spread that is causing or threatens to cause an immediate problem. Your doctor will consider using a local form of treatment to relieve the symptoms and to control the disease at that spot. Here are some of the most common "hot spots" of metastatic breast cancer that need immediate attention:

Spinal cord compression means the cancer is putting pressure on, or squeezing, your spinal cord—the large bundle of nerves in the middle of your backbone that connects the brain to the body. Cancer growing in the backbone can put pressure on the spinal cord that damages the nerves, resulting in back pain, weakness, and even paralysis, as well as altered bowel and bladder habits. Rarely, cancer damages the nerves by growing right around the spinal cord (and not in the backbone).

Treatment should start quickly to avoid permanent damage to your nerves. To shrink swelling around the problem, first you will be given a steroid in either pill form or sometimes as an injection. One of the most commonly used steroids is Decadron (chemical name: dexamethasone). Then radiation therapy is delivered to kill the cancer cells in the problem spot. Occasionally, you may need surgery to reduce pressure around the spinal cord.

Brain metastases causing symptoms also require immediate treatment. Your doctor will prescribe steroids first, followed by other treatments, such as surgery, chemotherapy, and/or radiation.

  • Your doctor may use surgery to remove one small spot of cancer that shows up a long time after you were first diagnosed with breast cancer if the cancer is in an area that's safe to operate. You may also need surgery if a single metastasis causing severe pressure in the brain does not respond to other treatments. But if several areas of cancer are in the brain, or in other parts of the body, surgery is not usually a good option. Occasionally, if cancer is blocking the fluid drainage system in and around the brain, a tube might be placed to bypass the blockage. This tube is called a shunt.
  • When cancer cells get into the fluid that normally surrounds the brain and spinal cord, cancer may grow on individual nerves. This can cause you to lose feeling or movement in certain parts of your body. Symptoms may improve with steroids. But your doctor may also want to inject chemotherapy drugs directly into the fluid bathing the nerves. This is called intrathecal chemotherapy therapy. This type of chemotherapy may reduce the number of cancer cells in the spinal fluid so they are less likely to cause new problems. But it's unlikely for this treatment to reverse problems already caused by the cancer.
  • Radiation is aimed at the whole brain or specific nerves. It is rarely aimed at the entire spinal cord. Radiation to too large an area would lower the number of important infection-fighting cells, which can delay the start and continuation of chemotherapy.

Bleeding problems can be helped by radiation. Sometimes you may bleed from cancer growing in the skin of or near the breast, or from a tumor in an air passageway to the lung. This bleeding can respond quickly to radiation.

Cancer in the bones of the legs, hips, or arms can weaken and destroy their structure and strength. This makes these bones more likely to break, even without a fall or other injury.

If a bone in the leg or arm is seriously weakened and is at risk for fracture at any moment, an orthopedic surgeon may recommend placing a metal rod in the weak area. This will give the bone strength and reduce the chance of it breaking. If a weight-bearing bone, such as a hip or leg bone, has already broken, then a stabilizing device is usually surgically placed. Then your doctor will treat the area with radiation. This radiation will destroy the cancer so the bone can heal. Bone cannot rebuild and strengthen itself if cancer cells are in the way.

If you have bone tumors, a bone-strengthening medicine can help prevent bone breaks and relieve pain. Your doctor may prescribe either Aredia (chemical name: pamidronate disodium) or Zometa (chemical name: zolendroic acid). Both are put into your blood with a needle drip (intravenously) into the arm. It takes 15 minutes to get a dose of Zometa, and about two hours to get a dose of Aredia. These drugs can:

  • relieve your bone pain
  • help strengthen your bones
  • lower the risk of breaking a bone weakened by the tumor
  • reduce the number of new bone tumors developing
  • lower high levels of calcium in the blood

One study found that Zometa works as well as Aredia. But your doctor may have had more experience with Aredia, because Zometa is a newer drug.

These medications are associated with a rare side effect called osteonecrosis of the jaw, which might cause problems for people having dental work. If you have dental problems while taking one of these medicines, be sure to let your dentist know that you're taking this kind of medicine. It's also important for your dentist to know about special care considerations.

Aredia or Zometa can reduce how well the kidney functions over time, but these changes are reversible. If you are taking these drugs your doctor will check your kidney function frequently.

A newer oral drug, Bonefos (chemical name: clodronate), has shown to be effective as well. One study of women with advanced cancer showed that taking this medication for two years significantly increased bone mineral density of the hip and spine.

Some women develop scattered, painful bone tumors that don't respond to chemotherapy. These tumors can't be easily treated with localized radiation because the area needing treatment is too big. Another type of radiation can be given to reduce the multiple sites of pain. The radioactive chemical strontium-89 can be given intravenously (injected into one of your veins) as a one-time dose. The bone-making cells and the cancer cells in the bone take up the radiation given off by these chemicals. The treatment generally reduces pain, but just like chemotherapy, it can make you more prone to infection, anemia, and bleeding problems.

Hypercalcemia is a condition in which you have too much calcium in your blood. The tumor itself can cause it, or the tumor's effect on the bone can cause it. Hypercalcemia can also be a side effect of cancer treatment. Too much blood calcium can cause serious medical problems. It has to be treated immediately with:

  • extra fluids
  • other medications, depending on the cause and degree of the high calcium level
  • Aredia or Zometa, which stops calcium from coming out of the bone and getting into the bloodstream

Fluid AROUND the lung (called "pleural effusion") is different from fluid IN the lung, which happens with heart problems or pneumonia. Fluid around the lung can keep the lung from expanding normally, which makes it hard to breathe. Your doctor can remove the fluid by inserting a needle between your ribs into the fluid buildup. This procedure is called "thoracentesis." The needle will not go into the lung. If fluid keeps building up, a surgeon can put a tube into the fluid-filled space within your chest to drain it.

To prevent fluid from coming back to the same area, your doctor may put an irritating substance (Sterile Talc Powder or antibiotic) within the chest cavity. This will cause scar tissue to form and make the lung stick to the chest wall, so there's no space left for fluid buildup. You need to be in the hospital for several days for this treatment, which is called "pleurodesis." It may be quite uncomfortable or sometimes painful. But strong pain medications can greatly ease the pain and make breathing easier. Be sure to ask your doctor to order pain medication so it's ready and waiting in case you need it. If the procedure is successful, the improvement in your breathing will be noticeable, long-lasting, and probably worth the temporary pain.

Liver pain is caused by the tumor growing inside the liver and stretching the surface of the liver. This pain is best treated with chemotherapy and managed with pain medications. But if no chemotherapy or pain medication seems to be working, radiation to the liver can be useful for reducing pain.

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