Diagnosis and surgical management of breast cancer metastatic to the spine

Abstract

Breast cancer is the most common malignancy and the second leading cause of death in Western women. Breast cancer most commonly metastasizes to the bone and has a particular affinity with the spine, accounting for 2/3 of osseous metastases discovered. With significant improvements in cancer therapies, the number of patients at risk for symptomatic spinal metastases is likely to increase. Patients may suffer from intractable pain and neurological dysfunction, negatively influencing their quality of life. Timely diagnosis of patients is crucial and has been aided by several breakthrough advances in imaging techniques which aid in detection, staging, and follow-up of bone metastases. Breast metastases are usually responsive to hormonal therapy and pharmacologic interventions, but skeletal metastases often require surgical intervention. The treatments are palliative but goals include the preserving or restoring neurologic function, ensuring spinal stability, and relieving pain. Advances in surgical techniques and instrumentation have allowed more effective decompression and stabilization of the spine, and with the support of recent evidence the trend has shifted towards using more advanced surgical options in appropriately selected patients. In this review, the clinical presentation, diagnosis, patient selection, and surgical management of breast cancer metastatic to the spine are discussed. Key words: Breast cancer; Spine; Metastasis; Surgery; Outcomes; Decompression Core tip: Breast cancer most commonly metastasizes to the bone and has a particular affinity for the spine. The treatment for symptomatic spinal metastases remains palliative and is not intended to prolong survival. Surgical advances in the last few decades have allowed improved spinal cord decompression and tumor resection. With the support of recent literature, the trend has shifted towards using more advanced surgical options in appropriately selected patients. Goals of treatment include restoration of and preservation of neurological function, maintaining spinal stability, and pain relief in an effort to achieve a better quality of life.Ju DG, Yurter A, Gokaslan ZL, Sciubba DM. Diagnosis and surgical management of breast cancer metastatic to the spine. World

Case series of 21 patients with extrahepatic metastatic lobular breast carcinoma to the gastrointestinal tract

“…However, due to this study's small sample size, significant conclusions are limited. Palliative therapy for metastatic breast cancer is supported by the literature and is generally associated with a survival benefit [19][20][21]. Localization of extrahepatic GI metastasis to the stomach and omentum are observed to be associated with more favorable outcomes, although not statistically significant.…”

Which red flags aid the early detection of metastatic bone disease in back pain?

“…The second most common serious pathology to affect the spine after fracture, is metastatic bone disease (MBD) as a consequence of primary cancers [2]. The spine is one of the earliest sites affected especially in those with a history of breast and prostate cancer [4,5,6]. Metastases can affect any region of the spine: Cervical 20%;…”

“…The spread of MBD is not fully understood but its affinity to the spine is thought to be the result of hematogenous spread via venous or arterial routes. The complex spinal venous system, causes a slower venous flow allowing for deposits of tumour cells to occur and highly perfused vertebral bodies allow effective delivery of tumour cells [5,6].…”

“…Pain is prevalent in the early stages of MBD with 70% of patients describing pain associated with the disease [4]. Three distinct types of MBD pain are described; [a] local pain, which patients describe as a persistent gnawing, aching pain; [b] mechanical pain, which is aggravated by movement and [c] radicular pain described as sharp shooting, stabbing and burning [3,5,16]. Ju et al [5] state the importance of understanding the type of pain a patient experiences as this may help to give clues to its etiology.…”

“…Three distinct types of MBD pain are described; [a] local pain, which patients describe as a persistent gnawing, aching pain; [b] mechanical pain, which is aggravated by movement and [c] radicular pain described as sharp shooting, stabbing and burning [3,5,16]. Ju et al [5] state the importance of understanding the type of pain a patient experiences as this may help to give clues to its etiology. However, these descriptors are not helpful in differentiating between those patients who have MBD and those who have benign back pain as they are common descriptors used by both groups.…”