Breast Cancer (Mammary Carcinoma): Therapy of Metastatic Breast Carcinoma

General: Cure is the exception for distant metastases (daughter tumors that form near the primary tumor).

Therapeutic Objective

Achieve:

• As high a quality of life as possible
• Freedom from pain and symptoms

Therapy

Adjusts according to

• The individual wishes of the patient
• The type of metastases
• The symptoms
• The age
• The concomitant diseases
• The hormone receptor status
• The HER2 status
• The menopause status
• The pretreatment

Metastases during primary therapy (“initial therapy”)

If metastases are already detectable during primary therapy in staging, the therapeutic principles of adjuvant or neoadjuvant therapy (treatment that occurs before tumor surgery; see above) apply.

Removal of the intact primary tumor after chemotherapy does not improve the prognosis of women with newly diagnosed metastatic breast cancer.

Metastases after primary therapy

When possible, histology should be obtained for secondary metastases to redetermine hormone receptor status and HER 2 status, because metastases often have alterations from primary status.

Therapy should be administered on an individual basis in trials if possible. There is no single strategy. The following may be used (see above):

• Antiestrogens,
• Progestins
• VEGF inhibitors
• Various chemotherapeutic agents

Therapy of special metastases

• Skeletal metastasesTherapy of skeletal metastases (bone metastases) includes:
  • Radiotherapy (see above).
  • + bisposphonates
  • Alternatively + rank ligand inhibitor (e.g. denosumab); Cave: necrosis of the jaw.
• Brain metastases
  • Isolated brain metastases are treated by:
    • Surgery
    • Or stereotactic single time irradiation (RC: radiosurgery).
    • Or fractionated irradiation (SFRT: stereotactic fractionated radiotherapy).
  • Multiple brain metastases are treated by:
    • Percutaneous whole brain irradiation (radiotherapy delivered externally through the skin).
    • + Steroid medication for prophylaxis of perifocal edema to control neurologic symptoms, if any.
• Visceral metastases
  • Visceral metastases (e.g., liver, lung) may be treated in individual cases by local therapy under the following conditions:
  • Metastases only in one lobe of the lung or liver.
  • Metastases not disseminated
  • Occurrence of metastasis not before one year after primary treatment
• Malignant pleural effusionIf effusion is due to pleural carcinomatosis ( involvement of the pleura with metastases of a malignant tumor), pleurodesis is indicated with:
  • Bleomycin
  • Talc
• Skin and soft tissue metastasesTherapy by:
  • Excision (surgical removal) in the healthy.
  • Percutaneous irradiation (radiation therapy from the outside through the skin).
  • Excision + irradiation
  • Topically (“locally”) acting cytostatic drug e.g. miltefosine.
  • Electrochemotherapy of skin lesions, i.e. electroporation triggered by electrical pulses (method of making cell membranes temporarily permeable) to facilitate the penetration of the active substance (in this case: bleomycin) into the cells.