September 17, 2024. 5:03 pm
General information about the patient Diagnosis: Caused by the tumor itself Family history: High blood pressure, Diabetes Mellitus Weight in kg: 84 Height: 163 Age: 73 Years of evolution: 1 Alcohol: Moderate consumption Drugs: No use Exercise: Sedentary Gender: Female Smoker: No Title Chronic pain as a debut…
General patient data
Diagnosis: Caused by the tumor itself Family history: High blood pressure, Diabetes Mellitus Weight in kg.: 84 Height: 163 Age: 73 Years of evolution: 1 Alcohol: Moderate consumption Drugs: Does not consume Exercise: Sedentary Gender: Female Smoker: No
Title
Chronic pain as a debut of metastatic breast cancer Medical history and main reason for consultation Patient who is referred from Primary Care to Traumatology at our center in November 2021 due to pain in the left hip of at least 6 months’ duration.
Physical examination
AP: MVC. AC: rhythmic, no murmurs. Abdomen: soft, depressible, not painful, normal RHA. Neurological: no neurological focality. Breasts: no palpable tumors.
Complementary tests
MRI hip (05/11/2022): aggressive bone tumor of the right anterior superior iliac spine. Metastasis to be ruled out. Coxa vara and bilateral acetabular protrusion. CT body (05/24/2022): 10 mm pseudonodular image in CIE of the right breast, with nonspecific characteristics to be characterized with a directed study (mammography and ultrasound) if not known. Aggressive-looking lesion in the left anterior superior iliac spine, already described in MRI. Ultrasound and mammography (05/26/2022): nodule suspicious for malignancy in offspring related to finding described on CT in the inferoexternal quadrant of the right breast. BI-RADS category 4C. Biopsy (05/26/2022): INFILTRATING DUCTAL CARCINOMA ER+ PR+ Her2- Ki67: 10%. Biopsy of a bone lesion in the left iliac crest (06/21/2022): metastasis due to a carcinoma of glandular architecture and intermediate grade, consistent with breast origin. ER+ PR+ Her2- Ki67: 3%.
Diagnosis
INFILTRATING DUCTAL CARCINOMA OF THE LEFT BREAST T1 N0 M1 due to de novo bone metastases (at diagnosis) ER+ PR+ Her2- Ki67: 3%.
Treatment
Radiotherapy, transdermal fentanyl, sublingual fentanyl. Oncologic: letrozole + abemaciclib.
Evolution
Patient who, after months of follow-up in Traumatology with infiltrations, first and second level analgesics, simple hip and spine X-rays, finally underwent an MRI of the hips as described above, and after study the proposed diagnosis was confirmed. She started the third level with transdermal and sublingual fentanyl for the additional breakthrough pain (VAS 8), in addition to being referred to Radiation Oncology for analgesic treatment of the lesion on her left hip. Currently on active antineoplastic treatment with letrozole and abemaciclib, with good control of pain and breakthrough pain.
Discussion and conclusions
Despite advances in diagnosis and treatment, the lack of suspicion of a risk case (such as in this 72-year-old woman with chronic pain) is still the most common diagnosis of de novo metastatic breast cancer. It is essential to know which patients can benefit from a more exhaustive diagnostic approach. Likewise, pain management can be minimized in the absence of suspicion of a more serious pathology, as in this patient, in whom the pain was managed for several months as a mechanical pain. Third-step analgesia with complementary analgesic procedures (radiotherapy, in this case) and the correct management of breakthrough pain can help us to provide quality of life to patients with this type of pathology.
Bibliography 1
-Daily K, Douglas E, Romitti PA, Thomas A. Epidemiology of de novo metastatic breast cancer. Clin Breast Cancer. 2021;21(4):302-8.
