The role of fulvestrant in the management of intestinal obstruction associated with lobular carcinoma has not been specifically described.
Case presentation
Herein we present two cases where fulvestrant, as the only available parenteral endocrine agent for postmenopausal advanced breast cancer has the opportunity to provide a means to initiate treatment in those patients who present with varying degrees of intestinal obstruction.
Conclusion
Fulvestrant may obviate the use of chemotherapy while achieving sustained clinical benefit with less toxicity, in appropriately selected patients.
The online version of this article (doi:10.1186/1477-7819-6-128) contains supplementary material, which is available to authorized users.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
JYMT wrote the report, revised and submitted the manuscript for publication. KLC and RS helped with editing the report. All authors read and approved the final manuscript.
Background
Fulvestrant (Faslodex) is a relatively new oestrogen receptor (ER) antagonist with a novel mode of action; it binds, blocks, and increases degradation of ER [1].
Fulvestrant is licensed for treatment of postmenopausal women with hormone receptor-positive advanced breast cancer (HR(+) ABC) progressing or recurring on anti-oestrogen therapy. However, it is also active in the first-line setting in patients with HR(+) tumours [1]. It is currently the only parenteral endocrine agent licensed for use in postmenopausal breast cancer, given as 250 mg intramuscularly every 4 weeks.
Anzeige
The role of fulvestrant in the management of intestinal obstruction associated with lobular carcinoma has not been specifically described. Herein we present two cases – both highlighting the use of fulvestrant in this context.
Case presentation
Case 1
An 82 year old lady presented as an emergency with small bowel obstruction but no history of abdominal surgery. Her chest X-ray revealed a small pleural effusion at the right base. Concomitantly, she was found to have a highly suspicious, palpable mass on her right breast.
CT scan findings revealed obstruction at the distal ileum (Figure 1), bilateral hydronephroses, widespread sclerotic bony metastases and a pulmonary embolus (PE). The right-sided breast mass was biopsied and this confirmed an invasive lobular adenocarcinoma (Grade 2), that was both strongly ER and progesterone receptor (PR) positive, with a H-score of 280 and 220 respectively.
Figure 1
CT scan demonstrating mechanical small bowel obstruction.
×
She was deemed high risk for surgery due to her recent PE and she also did not wish to have surgery. In view of the circumstances, she was commenced on fulvestrant injections as a primary endocrine therapy.
Anzeige
This lady's intestinal obstruction eventually settled with non-operative management. When she was reviewed in the outpatient clinic two months after commencing fulvestrant, her tumour marker (CA15.3) had decreased from 57 to 38 kU/L. Follow-up CT scan at 6 months showed no evidence of progression of metastases with resolution of the small bowel obstruction.
At one year of fulvestrant, the overall assessment was that of a partial response with complete resolution of the palpable breast tumour.
Case 2
With a background history of ER+ lobular breast carcinoma metastasizing to the lungs and bones for a few years, a 64 year old lady presented recently with symptoms of gastric outlet obstruction and changes in bowel habit.
This patient was first diagnosed with ER+ lobular breast carcinoma and was treated with wide local excision and post-operative radiotherapy. She then developed recurrences in her lymph node which progressed to her lungs and bones over the years.
CT scan revealed thickening in the duodenum and in both the ascending and descending colon with narrowing of the lumen (Figure 2). Biopsy results from both the duodenum and colon were consistent with metastases from a breast primary. Her symptoms of gastric outlet obstruction resolved after an uneventful gastrojejunostomy but her bowel symptoms remained. She was commenced on fulvestrant as systemic therapy following prior treatments with tamoxifen, then an aromatase inhibitor.
Figure 2
CT scan demonstrating thickening of colonic wall with narrowing of lumen.
×
A repeat CT done 2 months later showed stable disease. She felt very well in herself with resolution of her bowel symptoms.
Discussion
Lobular breast carcinoma accounts for about 8% to 14% of all breast cancers [2]. Several studies have demonstrated higher prevalence of spread of metastatic disease to the gastrointestinal tract, peritoneum and retroperitoneum, and ovaries in patients when compared to patients with ductal carcinoma [3, 4]. Loss of expression of the cell-cell adhesion molecule E-cadherin in infiltrating lobular carcinoma may have contributed to these differences [5].
In hormone-responsive patients, endocrine therapy represents the mainstay of effective, well-tolerated treatment for advanced breast cancer before cytotoxic chemotherapy is required. A proviso for the success of any new endocrine therapy must be a lack of cross-resistance with prior treatments [6]. It is found that women who respond well to endocrine treatment for sustained periods tend to respond well to subsequent endocrine therapy. In Case 2, there was a decrease in the time lag between each endocrine therapy prior to starting fulvestrant. However, as noted, the patient responded well to treatment, obviating the need to commence chemotherapy.
Anzeige
This case report highlights not only the unusual presentation (ie intestinal obstruction) known to be associated with lobular carcinomas [2, 5] but also the challenges this specific type poses to initiating therapy. In the presence of gastric metastasis, it is found that endocrine therapy (tamoxifen as a first line agent) is used as often as chemotherapy [7]. The chemotherapy schemes most frequently used were cyclophosphamide, methotrexate and 5 fluorouracil or cytoxan, doxorubicin and 5 fluorouracil. Initiating tamoxifen was not an option in Case 1 and fulvestrant proved to be an efficacious alternative.
A recent study demonstrated that fulvestrant was active in patients with multiple sites of metastases, visceral metastases, human epidermal growth factor receptor 2-positive disease and after heavy endocrine pre-treatment [8]. Another study comparing fulvestrant with anastrozole appears to show that patients with visceral metastases may have a longer duration of response with fulvestrant [9].
Two large randomized trials have previously shown that fulvestrant is at least as effective as anastrozole against breast cancer in postmenopausal women who failed on prior endocrine therapy [10, 11]. However, fulvestrant showed neither superiority nor noninferiority in comparison to tamoxifen for the treatment of postmenopausal women who have received no prior hormonal or cytotoxic therapy for advanced breast cancer [12].
Conclusion
Fulvestrant, is the only available parenteral endocrine agent for postmenopausal advanced breast cancer, and has the opportunity to provide a means to initiate treatment in patients who present with varying degrees of intestinal obstruction. This may obviate the use of chemotherapy while achieving sustained clinical benefit, with less toxicity, in appropriately selected patients.
Anzeige
Consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Acknowledgements
Keith (Medical Photography Nottingham University Hospitals) – formatting the images for this case report.
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
JYMT wrote the report, revised and submitted the manuscript for publication. KLC and RS helped with editing the report. All authors read and approved the final manuscript.
Nach der Katheterablation von Vorhofflimmern kommt es bei etwa einem Drittel der Patienten zu Rezidiven, meist binnen eines Jahres. Wie sich spätere Rückfälle auf die Erfolgschancen einer erneuten Ablation auswirken, haben Schweizer Kardiologen erforscht.
Schmerzen im Unterbauch, aber sonst nicht viel, was auf eine Appendizitis hindeutete: Ein junger Mann hatte Glück, dass trotzdem eine Laparoskopie mit Appendektomie durchgeführt und der Wurmfortsatz histologisch untersucht wurde.
Derzeit wird empfohlen, eine Therapie mit GLP-1-Rezeptoragonisten präoperativ zu unterbrechen. Eine neue Studie nährt jedoch Zweifel an der Notwendigkeit der Maßnahme.
Die Ureterstriktur ist eine relativ seltene Komplikation, trotzdem bedarf sie einer differenzierten Versorgung. In komplexen Fällen wird dies durch die roboterassistierte OP-Technik gewährleistet. Erste Resultate ermutigen.
Update Chirurgie
Bestellen Sie unseren Fach-Newsletterund bleiben Sie gut informiert.
Das Karpaltunnelsyndrom ist die häufigste Kompressionsneuropathie peripherer Nerven. Obwohl die Anamnese mit dem nächtlichen Einschlafen der Hand (Brachialgia parästhetica nocturna) sehr typisch ist, ist eine klinisch-neurologische Untersuchung und Elektroneurografie in manchen Fällen auch eine Neurosonografie erforderlich. Im Anfangsstadium sind konservative Maßnahmen (Handgelenksschiene, Ergotherapie) empfehlenswert. Bei nicht Ansprechen der konservativen Therapie oder Auftreten von neurologischen Ausfällen ist eine Dekompression des N. medianus am Karpaltunnel indiziert.
Das Webinar beschäftigt sich mit Fragen und Antworten zu Diagnostik und Klassifikation sowie Möglichkeiten des Ausschlusses von Zusatzverletzungen. Die Referenten erläutern, welche Frakturen konservativ behandelt werden können und wie. Das Webinar beantwortet die Frage nach aktuellen operativen Therapiekonzepten: Welcher Zugang, welches Osteosynthesematerial? Auf was muss bei der Nachbehandlung der distalen Radiusfraktur geachtet werden?
Inhalte des Webinars zur S1-Leitlinie „Empfehlungen zur Therapie der akuten Appendizitis bei Erwachsenen“ sind die Darstellung des Projektes und des Erstellungswegs zur S1-Leitlinie, die Erläuterung der klinischen Relevanz der Klassifikation EAES 2015, die wissenschaftliche Begründung der wichtigsten Empfehlungen und die Darstellung stadiengerechter Therapieoptionen.
