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Description
Palliative care is an integral component of comprehensive cancer care that offers reasonable symptom control and a decent quality of life beyond the chance for cure.1 A 50-year-old postmenopausal woman was seen in the oncology clinic with a progressive lump in the right breast and ulceration over the right chest wall and axilla for one year with associated pain and bleeding. She had no comorbidities and a WHO performance score of 1. A 3×2 cm non-tender lump was palpable over the right breast in the upper outer quadrant with nipple retraction, fixed to the breast tissue but not to the chest wall. A small satellite nodule was present at 10 o’clock. An approximately 8×6 cm area of ulceration with bleeding points and everted edges was present just above the lump from the mid-clavicular line to the anterior axillary fold, which extended into the axillary tail (figure 1). The ipsilateral supraclavicular (SCF) lymph node was palpable.
Ulceration in the anterior chest wall and axilla at the baseline.
A core biopsy from the lump revealed an infiltrating ductal carcinoma (ER+/PR+/Her2neu−/Ki67 30%), and a fine-needle aspiration from the SCF lump showed metastatic carcinoma. Additional workup revealed metastatic lesions in bilateral lung and liver and increased uptake in multiple ribs. She was diagnosed as a case of metastatic breast cancer (MBC) (UICC TNM cT4bN3cM1).
She received palliative radiotherapy to the chest wall by a single anterior field using a telecobalt receiving a dose of 20 Gray in five fractions over one week, the prescription point being at the depth of maximum dose (Dmax) with 0.5 cm wet cotton bolus (figure 2). She was also started on zoledronic acid and oral letrozole, and further planned for CDK4/6 inhibitor therapy. At six weeks after radiotherapy, she had a good subjective and objective response, with relief in pain and bleeding and a reduction in the size of the ulcer with overlying crusting (figure 3). At three months after radiotherapy, the lesion had healed by secondary intention (figure 4). The patient was still alive at 12 months and receiving systemic therapy.
Radiotherapy field.
Good clinical response at six weeks after palliative radiotherapy.
Clinical picture at three months after radiotherapy showing the lesion has healed by secondary intention.
Palliative radiotherapy for advanced breast cancer is an effective intervention that helps reduce discharge or bleeding, and reduces offensive odour associated with the condition.2 With the growing incidence and mortality of breast cancer globally, more women will stand to require palliative radiotherapy. International programmes have been developed to provide rapid access to palliative care,3 and efforts need to be streamlined in low-income and middle-income countries.4 While the use of telecobalts has declined in the Western world in the last few years, they help in resource optimisation and find utility in developing countries that often have long waitlists and a high volume of patients, and is particularly useful in palliation. For ER+/Her− MBC, while our patient received sequential therapy, the concomitant use of CDK4/6 inhibitors during radiotherapy seems safe.5
Patient’s perspective
I was diagnosed with advanced breast cancer that had spread to other parts of my body, which was partially due to my neglect and seeking medical advice late. My breast ulcer had become extensive with foul odour and discharge, and I would find it difficult in social or family situations. The one-week radiotherapy schedule helped me reduce some amount of mental distress associated with my condition and helped me gain some confidence.
Learning points
Palliative radiotherapy for advanced or ulcerated breast cancers is useful to reduce bleeding, discharge and offensive odour.
It helps improve quality of life where cure cannot be achieved.
Palliative radiotherapy seems safe to be combined with systemic agents.
Ethics statements
Footnotes
DC and MV are joint first authors.
Twitter @DeepOnco
DC and MV contributed equally.
Contributors DK was involved in patient management, manuscript writing and image acquisition. DC was involved in image acquisition, manuscript writing and patient management. MS was involved in patient management. MV was involved in clinical oversight and manuscript review. All authors agree to the final version of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.