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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 67-70

Breast to bone: Acral metastasis


1 Department of Surgical Oncology, R. L. Jalappa Institute of Oncology, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, Karnataka, India
2 Department of Radiation Oncology, R. L. Jalappa Institute of Oncology, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, Karnataka, India
3 Department of Surgery, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, Karnataka, India

Date of Submission16-Jun-2022
Date of Decision03-Jul-2022
Date of Acceptance12-Jul-2022
Date of Web Publication02-Sep-2022

Correspondence Address:
Dr. Abhay K Kattepur
Department of Surgical Oncology, R. L. Jalappa Institute of Oncology, Sri Devaraj Urs Academy of Higher Education and Research, Tamaka, Kolar, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jco.jco_10_22

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  Abstract 

Metastasis of the acral bones is a rare phenomenon in breast cancer. Fibular metastasis is extremely uncommon and is usually associated with disseminated disease. We herein describe an elderly woman who presented with a metachronous fibular metastasis as a sign of oligo-recurrent metastatic breast cancer. The patient was treated with palliative radiotherapy with satisfactory outcomes. A brief review of the literature follows.

Keywords: Breast cancer, fibula, metachronous, metastases, radiotherapy


How to cite this article:
Kattepur AK, Manjunath G N, Nadipanna SP, Raj K, Aswathappa D. Breast to bone: Acral metastasis. J Curr Oncol 2022;5:67-70

How to cite this URL:
Kattepur AK, Manjunath G N, Nadipanna SP, Raj K, Aswathappa D. Breast to bone: Acral metastasis. J Curr Oncol [serial online] 2022 [cited 2022 Oct 3];5:67-70. Available from: http://www.https://journalofcurrentoncology.org//text.asp?2022/5/1/67/355580


  Introduction Top


Breast cancer is a common malignancy worldwide.[1] With ever-improving diagnostic and therapeutic modalities, the survival rates have improved. This has also led to early detection and treatment for metastatic disease during the follow-up period. Axial skeleton followed by viscera (lung, liver, and brain) are the most common sites of distant failures,[2] with treatment depending on the location and extent of metastatic disease, the type and receptor status of cancer, disease-free interval, prior treatment received, and performance status of the patient.

Breast cancer metastasizing to the appendicular skeleton is rare and those to the distal extremities are extremely rare. Only few cases of acral metastases from breast cancer have been described in the literature.[3],[4],[5] We herein describe a rare site of bony metastases from breast cancer in a 60-year-old woman. A brief review follows.


  Case Report Top


A 60-year-old woman with no comorbidities presented with a painful swelling over the lower end of the right leg of 2 months’ duration following trivial trauma. The patient was a breast cancer survivor since the beginning of 2019, having undergone modified radical mastectomy (histopathology report being infiltrating ductal carcinoma grade III stage pT3N1a ER [estrogen receptor]: negative PR [progesterone receptor]: negative and Her/2-neu: positive) followed by adjuvant chemotherapy and radiotherapy to the chest wall (treatment completed in February 2019), and was on regular follow-up since then. The patient had not received Trastuzumab therapy in view of cost constraints.

On clinical examination, a tender, globular bony hard swelling was noted at the distal end of the right leg overlying the fibula. Distal neurovascular examination was normal. There was no inguinal lymphadenopathy. Rest of the systemic examination, including the mastectomy scar and ipsilateral axilla, was normal. The opposite breast was unremarkable. There was no supraclavicular lymphadenopathy. However, mild tenderness in the acromion process of the right scapula was elicited.

The patient was evaluated with plain X-rays of the right ankle joint which showed a lytic, destructive lesion in the distal end of the right fibula with cortical thinning [Figure 1]. The tibia and rest of the foot bones were radiologically normal. In view of the past history of breast cancer, a clinical suspicion of metastasis was made. Fine-needle aspiration cytology (FNAC) revealed metastatic adenocarcinoma. Tc99-MDP (methylene diphosphate) bone scan showed osteoblastic activity in the lower end of the right fibula and acromion process of the right scapula, with no other sites of skeletal uptake [Figure 2] suggesting two skeletal lesions. Rest of the staging workup showed no evidence of disease elsewhere.
Figure 1: Pretreatment X ray of fibula AP (A) and lateral view (B) showing a lytic lesion involving the distal part of right fibula with thinning of the posterior cortex

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Figure 2: Tc-99 bone scan showing uptake in the lower end of the right fibula (red arrow) and scapula (black arrow)

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The patient underwent radiotherapy (20 Gy/5#) to the affected bony areas on telecobalt machine. Right fibular lesion was treated using a single right lateral beam with patient in supine position and right scapular lesion was treated using a single posteroanterior beam with the patient in a prone position. The patient tolerated treatment well with no reported adverse events. Posttreatment X-rays showed a marginal increase in the size of the lesion. However, there was a subjective improvement in pain scores and a reduction in the size of the swelling. Currently, the patient is undergoing systemic chemotherapy.


  Discussion Top


This study reported a rare site of bony spread (i.e., fibula) from breast cancer. Fibular metastasis is most commonly encountered in the setting of advanced lung cancer,[6],[7],[8] although various reports of spread from cancers of the endometrium,[9] cervix,[10] vagina,[11] stomach,[12] cholangiocarcinoma,[13] bladder,[14] kidney,[15] and prostate[16] have all been documented.

Breast cancer metastases to bones commonly occur in the axial skeleton, namely the thoracolumbar vertebrae, pelvic bones, and proximal femur. Bone-limited disease spread as the metastatic signature is frequently encountered with hormone-receptor-positive tumors, whereas Her-2/neu-positive and triple-negative tumors commonly spread to the viscera.[17] In our case, the first site of recurrent disease was in the appendicular skeleton.

Bone metastases can be either synchronous or metachronous, the latter being more common. Treatment must be individualized depending on the extent and sites of metastatic disease, prior therapy received, and patient’s symptomatology. Notwithstanding, they could lead to spinal cord compression, pathological fractures, and hypercalcemia due to bone loss or as a paraneoplastic syndrome.[18] Radiation to painful or at-risk bony areas along with bone-strengthening agents and systemic therapy is the standard of care in most instances. Surgery is reserved for palliative fixation of pathological fractures or as curative treatment in the oligometastatic setting.

Fibular metastasis from breast cancer is very rare with few cases reported in the literature [Table 1] to date.[3],[4],[5] In the majority of cases, they are associated with the disease either in the tibia or other bones of the feet. However, in our case, the patient had an additional disease in the scapula. Fibula involvement can be either unilateral (as in our case) or bilateral and commonly involves the ends of the bone. A painful swelling associated with a limp is the most common presentation. Most cases are in the metachronous setting with a long disease-free interval from the treatment of the index cancer. Lytic destruction of the affected area leading to pathological fractures is the most common radiological finding. Once metastasis is suspected, additional cross-sectional and bone-directed imaging is needed to confirm the extent of metastatic disease.
Table 1: Various studies on breast cancer metastasis to fibula

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Other causes of pain must be kept in mind. Ryder and Deyle[19] reported a case of a stress fracture in a breast cancer survivor who presented with foot pain and stressed the need for a dedicated magnetic resonance imaging scan for problem-solving.

Most cases have been treated with radiotherapy considering the fact that other bony lesions may be present simultaneously. Radiotherapy is associated with a reduction in the pain and allows healing of the affected area. Surgical resection of the fibula with or without the use of bone grafts is indicated in isolated setting, especially when the shaft/ ankle mortis is involved.[20],[21] Systemic therapy is indicated in widely metastatic disease, those with additional visceral involvement with impending crisis and progression on hormonal therapy. The outcomes of these patients are generally poor. The biology of the cancer is dictated by the receptor status at metastatic recurrence.


  Conclusion Top


Metastasis to the fibula is rare in breast cancer and is commonly associated with other sites of bony or visceral metastases. A high index of suspicion is needed for diagnosis. Treatment is based on the current disease burden and receptor status of the index cancer and can include a combination of local and systemic therapy. Overall prognosis is generally poor despite treatment.

Financial support and sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of interest

All authors declare no conflict of interest



 
  References Top

1.
Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2021;71:209-49.  Back to cited text no. 1
    
2.
Chen MT, Sun HF, Zhao Y, Fu WY, Yang LP, Gao SP, et al. Comparison of patterns and prognosis among distant metastatic breast cancer patients by age groups: A SEER population-based analysis. Sci Rep 2017;7:9254.  Back to cited text no. 2
    
3.
Osterhouse MD, Guebert GM Bilateral acrometastasis secondary to breast cancer. J Manipulative Physiol Ther 2004;27:275-9.  Back to cited text no. 3
    
4.
Choi M, Probyn L, Rowbottom L, McDonald R, Bobrowski A, Chan S, et al. Clinical presentations of below knee bone metastases: A case series. Ann Palliat Med 2017;6:85-9.  Back to cited text no. 4
    
5.
Jacox RF, Tristan TA Carcinoma of the breast metastatic to the bones of the foot: A case report. Arthritis Rheum 1960;3:170-7.  Back to cited text no. 5
    
6.
Akram M, Zaheer S, Hussain A, Siddiqui SA, Afrose R, Khalid S Solitary fibular metastasis from nonsmall cell lung carcinoma. J Cytol 2017;34:113-5.  Back to cited text no. 6
    
7.
Hsu CC, Chuang YW, Lin CY, Huang YF Solitary fibular metastasis from lung cancer mimicking stress fracture. Clin Nucl Med 2006;31:269-71.  Back to cited text no. 7
    
8.
Miller SD Metastatic adenocarcinoma to distal fibula. Foot and Ankle Surgery 2002;8:119-23.  Back to cited text no. 8
    
9.
Chen CY, Huang KG, Abdullah NA, Ueng SH, Lee CL Successful treatment of isolated fibular bone metastasis in a uterine endometrial cancer of clear cell carcinoma. Eur J Gynaecol Oncol 2013;34:347-9.  Back to cited text no. 9
    
10.
Ulery RM, Ivins JC, Hunter JS Carcinoma of the cervix with metastasis to the tibia and fibula: Report of case. Proc Staff Meet Mayo Clin 1954;29:9-12.  Back to cited text no. 10
    
11.
Tjalma WA, Somville J Fibula metastasis as the presenting feature of vaginal cancer. Eur J Gynaecol Oncol 2011;32:114-6.  Back to cited text no. 11
    
12.
Hekmat S, Ghaedian T, Barati H, Movahed M Solitary metastasis of gastric cancer to fibula: A case report. Iran J Radiol 2012;9:161-4.  Back to cited text no. 12
    
13.
Karanjia H, Abraham JA, O’Hara B, Shallop B, Daniel J, Taweel N, et al. Distal fibula metastasis of cholangiocarcinoma. J Foot Ankle Surg 2013;52:659-62.  Back to cited text no. 13
    
14.
Mughal TI, Phillips RH, Robinson WA Bladder carcinoma presenting as a solitary bony metastasis. J Urol 1983;130:973.  Back to cited text no. 14
    
15.
Rajan P, Warner A, Quick CR Fibular metastasis from renal cell carcinoma masquerading as deep vein thrombosis. BJU Int 1999;84:735-6.  Back to cited text no. 15
    
16.
Rashid N, Javed MM, Hassan A Fibular findings in carcinoma prostate; a challenging situation for reporting physician. J Pak Med Assoc 2019;69:1572-3.  Back to cited text no. 16
    
17.
Yamamura J, Kamigaki S, Fujita J, Osato H, Manabe H, Tanaka Y, et al. New insights into patterns of first metastatic sites influencing survival of patients with hormone receptor-positive, HER2-negative breast cancer: A multicenter study of 271 patients. BMC Cancer 2021;21:476.  Back to cited text no. 17
    
18.
Tsuzuki S, Park SH, Eber MR, Peters CM, Shiozawa Y Skeletal complications in cancer patients with bone metastases. Int J Urol 2016;23:825-32.  Back to cited text no. 18
    
19.
Ryder M, Deyle GD Differential diagnosis of fibular pain in a patient with a history of breast cancer. J Orthop Sports Phys Ther 2009;39:230.  Back to cited text no. 19
    
20.
Sebghati J, Khalili P, Tsagkozis P Surgical treatment of metastatic bone disease of the distal extremities. World J Orthop 2021;12:743-50.  Back to cited text no. 20
    
21.
Perisano C, Marzetti E, Spinelli MS, Graci C, Fabbriciani C, Maffulli N, et al. Clinical management and surgical treatment of distal fibular tumours: A case series and review of the literature. Int Orthop 2012;36:1907-13.  Back to cited text no. 21
    


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