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  Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 53  |  Issue : 3  |  Page : 360-362
 

Incidence and pattern of bone metastases at presentation in Indian carcinoma breast patients


1 Department of Nuclear Medicine, MNJ Institute of Oncology and Regional Cancer Centre, Hyderabad, Telangana, India
2 Department of Radiation Oncology, MNJ Institute of Oncology and Regional Cancer Centre, Hyderabad, Telangana, India

Date of Web Publication24-Feb-2017

Correspondence Address:
A Suryadevara
Department of Radiation Oncology, MNJ Institute of Oncology and Regional Cancer Centre, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.200655

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 » Abstract 

BACKGROUND: Breast cancer (BC) is the most common female cancer and frequently metastases to the bones. Breast cancer among Indian women occurs a decade earlier and more aggressive than the western population. Screening guidelines are based on western studies. The aim of our study is to assess the role of Technitium99m bone scan (TBS) in screening Indian EBC patients at presentation. We also looked at the pattern of BM in all stages of BC. METHODS: Patients with BC who had TBS at presentation from January 2012 to September 2015 were included in the study. RESULTS: Bone metastases were seen in 23.42% (241/1029). Of these, 10.06% (31/308) EBC, 25.60% (169/660) locally advanced BC (LABC) and 63.93% (39/61) of metastatic BC (MBC) patients had BM. Most common sites of BM were spine and pelvis. In long bone and sternum, proximal part was commonly involved. CONCLUSION: The incidence of BM in Indian BC patients at presentation is higher than western population. The incidence of BM per stage is similar to west. So TBS should be done in LABC and symptomatic EBC. There is high incidence of BM to spine and pelvis. In pelvis, SI joints and ilium and in long bones and sternum, proximal parts were commonly involved.


Keywords: At presentation, bone metastases, breast cancer, India, technetium-99m bone scan


How to cite this article:
Doddala S, Suryadevara A, Chinta S, Madisetty A. Incidence and pattern of bone metastases at presentation in Indian carcinoma breast patients. Indian J Cancer 2016;53:360-2

How to cite this URL:
Doddala S, Suryadevara A, Chinta S, Madisetty A. Incidence and pattern of bone metastases at presentation in Indian carcinoma breast patients. Indian J Cancer [serial online] 2016 [cited 2017 Jul 27];53:360-2. Available from: http://www.indianjcancer.com/text.asp?2016/53/3/360/200655



 » Introduction Top


The data on bone metastases (BM) in Indian breast cancer (BC) patients at presentation is sparse. Screening for BM at presentation is based on studies done on Western BC patients.[1] It is seen that BC among Indian women occurs a decade earlier and is more aggressive than in the West. The aim of our study is to assess the need of technetium-99m bone scan (TBS) in screening early BC (EBC) at presentation in Indian BC patients. We also looked at the pattern of BM in all stages of BC.


 » Materials and Methods Top


This is a single institute retrospective observational study. All BC patients, who were screened for BM by TBS at presentation, were included in the study. A total of 1029 patients were included in the study, from January 2012 to September 2015. Patients' age, sex, and clinical stage were noted. All patients undergoing TBS were given 20 mCi of technetium-99m and 3 h later whole body scan was done. Suspicious scans were confirmed with repeat imaging, clinical examination, and correlated with the computed tomography scan and magnetic resonance imaging scan when available.


 » Results Top


The median age at presentation was 48 years. BMs were seen in 23.42% (241/1029) patients. A total of 69.9% (711/1029) and 7.48% (77/1029) had negative and inconclusive scans, respectively. Results are summarized in [Figure 1],[Figure 2],[Figure 3],[Figure 4] and [Table 1]. No BMs were seen in Stage I. In Stage IIa, one patient had metastases in sternum and ribs, one had isolated thoracic spine metastasis, other two had metastases in pelvis, and one had metastasis in femur.
Figure 1: The clinical stage at presentation and bone metastases

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Figure 2: The percentage of patients with bone metastases at presentation

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Figure 3: The early breast cancer patients with bone metastases

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Figure 4: The pattern of bone metastases among different stages of breast cancer

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Table 1: The distribution of bone metastases in Indian breast cancer patients at disease presentation

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 » Discussion Top


Carcinoma breast patients frequently have BM.[2] Based on the Western studies, TBS is done in locally advanced BC (LABC) and metastatic BC (MBC). Bone scan in EBC is done if the patient has bone pain or elevated alkaline phosphatase at disease presentation.[1],[3] At diagnosis, 5–6% of BC patients present with metastases mostly BM.[4],[5],[6] In our study, BMs were seen in 23.42% patients at presentation.

In a large study (1985–1995) on 5407 BC patients, the incidence of BM at presentation was 0.5%, 2.4%, and 8.3% in Stage I, II, and III, respectively. In a study done on 1307 patients (1972–1980), BM was 6.8%, 8.8%, and 24% in Stage I, II, and III, respectively. In a study done on 412 patients, BM was 14% at presentation on TBS.[7] In a study done on 107 BC patients, BM was 32.7%. Among these, spine metastases were commonly followed by ribs and sternum. The extremities, distal portions, are rare sites for BM.[8] These studies were done on breast patients in the West.

There is no large study on the pattern and incidence of BM in Indian BC patients. Our study showed a high incidence of metastases to spine and pelvis. Other common sites were ribs and sternum followed by skull. In Stage IIb and IIIa, the most common site of BM was spine and pelvis followed by skull and ribs. Long bones, clavicle, sternum, and scapula are rarely involved. In Stage IIIb and IV, most common site of BM was spine and pelvis.

In our study, 10.06% EBC patients had a positive TBS. None of the Stage I patients had BM. In West, the incidence of BM in Stage I ranged from 0.5% to 6.8%.[7] We had very few patients in Stage I and needed a larger sample to confirm these findings. There were 9.09% patients with Stage II disease and BM versus 2.4–8.8% in the literature.[7] There were 23.75% Stage III patients with BM and 8.3–24% in the Western studies.[7] Among MBC, BM was seen in 63.93%.

Hence, compared to West, our study showed a lower rate of BM in Stage I. In Stage II and III, the incidence of BM at presentation was slightly higher but comparable to the West. In our study, the incidence of BM at presentation is higher but stagewise incidence is similar to the Western BC patients. This is because the most common stage at presentation was stage IIIB (LABC). Hence, in Indian women with BC, we should consider the same guidelines used in the West when screening for BM.

Spinal metastases were common in all the stages. Thoracic vertebra metastases (50.89%) were common than the lumbar vertebra (42.41%). Cervical spine metastases (6.69%) were seen in Stage IIIa and beyond. In pelvis, iliac bone and sacroiliac joints (SIJ) are commonly involved. Metastases to long bones are rare, if involved it is the proximal part and manubrium in sternal metastases. Patients with skull metastases commonly had metastases to other bones.


 » Conclusion Top


TBS for screening in BC should be done in all LABC and symptomatic EBC at disease presentation like in the Western population. Metastases should be suspected in the spine and pelvis in EBC. Parts of bone to focus are thoracic and lumbar spine in all stages, cervical spine in Stage III and IV, SIJ, ilium in pelvis, and proximal part of long bones and manubrium sterni.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 » References Top

1.
Samant R, Ganguly P. Staging Investigations in Patients With Breast Cancer: The Role of Bone Scans and Liver Imaging. Arch Surg 1999;134:551-4.  Back to cited text no. 1
    
2.
Adewuyi SA, Chom ND, Humera M, Samaila MO. Pattern of skeletal metastases from breast cancer in an Asian population. Niger J Surg Res 2006;8:128-31.  Back to cited text no. 2
    
3.
Goyal S, Buchholz TA, Haffty BC. Breast Cancer: Early Stage. Perez and Brady's Principles and Practice of Radiation Oncology. 6th ed., Ch. 56. Philadelphia, USA: Wolters Kluwer;2013. p. 1060.  Back to cited text no. 3
    
4.
Jensen AØ, Jacobsen JB, Nørgaard M, Yong M, Fryzek JP, Sørensen HT. Incidence of bone metastases and skeletal-related events in breast cancer patients: A population-based cohort study in Denmark. BMC Cancer 2011;11:29.  Back to cited text no. 4
    
5.
Søgaard KK, Cronin-Fenton DP, Pedersen L, Sørensen HT, Lash TL. Survival in Danish patients with breast cancer and inflammatory bowel disease: A nationwide cohort study. Inflamm Bowel Dis 2008;14:519-25.  Back to cited text no. 5
    
6.
Louwman WJ, Voogd AC, van Dijck JA, Nieuwenhuijzen GA, Ribot J, Pruijt JF, et al. On the rising trends of incidence and prognosis for breast cancer patients diagnosed 1975-2004: A long-term population-based study in southeastern Netherlands. Cancer Causes Control 2008;19:97-106.  Back to cited text no. 6
    
7.
Baseline Staging Tests in Primary Breast Cancer. Evidence-based Guideline 1-14 Version 2 – Education and Information 2015. A Quality Initiative of the Program in Evidence-Based Care (PEBC), Cancer Care Ontario (CCO); 2015.  Back to cited text no. 7
    
8.
Kakhki VR, Anvari K, Sadeghi R, Mahmoudian AS, Torabian-Kakhki M. Pattern and distribution of bone metastases in common malignant tumors. Nucl Med Rev 2013;16:66-9.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]



 

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