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Ca breast with chronic subdural hematoma
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Ca breast with chronic subdural hematoma

My mother is a breast cancer patient since July 2005. She underwent MRM, chemotherapy and RT treatment, developed osseous mets in October 2007; since then in view of only bony metastasis she was on Femara and Zometa. Last week after suspicious findings in the chest x- ray she underwent PET scan. Report concluded multiple new lesions in the liver, lymphnodes and bones. At the same time a new problem was incidentally discovered Bilateral subdural collection was seen right (thickness 2.7cm)> left (thickness 1.4 cm) likely to be subdural hematoma. Mid line shift was seen (.04cm) towards left effacement of bilateral ventricles. A follow up CT brain was performed which suggested bilateral frontoparietal and temporal (right > left) chronic subdural hematoma seen. No midline shift was seen. Basal ganglia, thalamus and brainstem are normal. In view of her health our neurologist suggested a follow up CT brain scan after 2 weeks and prescribed 2Tabs Eptoin 100mg daily.  She is apparently showing no major symptoms except for occasional headaches. Is this related to cancer or side effect of any cancer drug? She might start second line chemotherapy shortly. Does she require any brain surgery for this? cancer has already invaded the cranial vault. Is this a life threatening condition? Any advice would be greatly appreciated. Thanks.
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10 Comments Post a Comment
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Avatar_dr_m_tn
Hi.  If the cancer has invaded the cranial vault, it might have started to erode on some of the veins running along the inside of the vault, causing some bleeding and formation of the subdural hematoma.  Chemotherapy could theoretically, also cause subdural hematoma by decreasing the platelet count and increasing the risk of intracranial bleeding, but from what you've told me, your mother has not had chemotherapy since 2-3 years ago.  Femara or Zometa don't usually cause severe derangement of either the platelet count or clotting factors, so the subdural hematoma is more likely due to the cancer itself.  

Your mother would require brain surgery if the subdural hematoma is shown to be progressively increasing in size on consecutive CT scans.  If the hematoma is stable and is not causing symptoms other than the occasional headache, brain surgery is not urgent.  If the cause of the hematoma is the cancer eroding on the blood vessels in the cranial vault, then chemotherapy will certainly help to control this complication.  Cancer which is actively metastasizing to multiple areas in the body is a life-threatening situation, and should be dealt with at the soonest possible time.
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Avatar_f_tn
Thanks you Dr. Roque. I profoundly appreciate your valuable and prompt advice. Subsequent to your opinion I have following concerns.

Summary of Chemotherapy treatment received from Aug 2005 to Feb 2006.
1) 2 Cycles of TAC. LVEF was reduced from 72% to 50 % protocol was changed.
2) 4 cycles of CMF
3) 2 Cycles of Taxotere only, with increased dose.

Summary of hormonal treatment
1) Tab tamoxifen 20mg from 25/03/06 to 04/08/07 (led to profound increase in Endrometrial thickness18.3mm hence changed)
2) Tab Aromasin 25mg from 04/08/07 to 22/11/07 (bony mets occurred)
3) Inj faslodex 250mg 6 cycles till 19/05/08 bony disease progressed
4) Tab femara2.5mg 19/05/08 to date.

Summary of radiation treatment
1) EBRT to chest flap, and axilla
2) Palliative radiotherapy to dorsal spine and right femur (26/10/07 to 08/11/07)
3) Palliative radiotherapy to right shoulder and left femur (22/04/08 to 08/05/2008
4) Palliative radiotherapy to right hemipelvis(19/07/2008 to 02/08/2008)

12 Zometa IV shots so far.

She is HER 2 neu negative through fish test.

CT Scan of the liver shows multiple ill defined round hypodense lesion of variable sies in both lobes. IHBR are not dilated. Right hepatic lesion measures 2.1 x 1.9 cm FNAC report awaited. Her LFT is in perfect range. Though she is experiencing indigestion and poor appetite these days

PET Scan: Extensive skeletal mets.  Both lungs show few subcm nodular lesions with patchy infiltration in middle lobe. FNAC –Chest wall nodule shows blood only.

Metabolically active enlarged lymphnodes were seen in right suraclavicular, right pectoral, right paratracheal, prevascular, aortopulmonary, subcarinal, bilateral hilar, paraesophageal, periportal, left paraaortic and right subcrural region.

In view of above disease and treatment received so far what further treatment protocol she would require. How can chemotherapy be safely administered, at the same time preventing low platelets that can cause serious bleeding? What precautions do we need to keep in mind.

Once again Thanks a ton Dr. Roque
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Avatar_dr_m_tn
Hi.  From your description, your mother seems to have widespread breast cancer which is resistant to both chemotherapy and hormonal therapy.  The disease has progressed in spite of extensive treatment.  At this point, the cancer is at an advanced stage and is not curable.  The best we can hope for is for the treatment to control further spread of the cancer and prevent complications.  Furthermore, your mother already has additional medical conditions such as heart disease and subdural hematoma.  

Given all these facts, I think the question which should be asked is:  should your  mother receive additional cycles of chemotherapy?  Or should she opt to just receive supportive care and preserve her quality of life?  There are still chemotherapy options available to treat breast cancer which is resistant to Taxotere and hormonal therapy.  One such option is Ixabepilone (Ixempra), which is really used in this situation.  However, this drug is quite toxic and has a lot of side effects.  If your mother's body is already weak and debilitated, I would have second thoughts about recommending Ixempra or any further chemotherapy.
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Avatar_f_tn
Thanks Dr. Roque for replying back. Yesterday we had an appointment with our medical oncologist. evaluating her present condition and previous treatments. following decision has been taken
1. we will wait for 2 weeks to get a follow up CT brain scan done.
2. if hematoma found stable. she will be scheduled for "weekly" chemo. considering that she had 1-1/2 yrs of disease free time after her initial chemo of taxotere. she has been advised "taxol". which i am given to understand has fewer blood complications than some of the second line chemo drugs.
3.Till then femara and zometa will continue.
WHAT IS YOUR OPINION ON THIS?
Yes she has lost weight and got frail in recent time. i understand your concern of revaluating the chemo option and will re-discuss with my oncologist. thanks Dr. Roque. At times second opinion gives altogether a new perspective to the enitre situation.
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Avatar_dr_m_tn
Hi.  Taxol comes from the same family of drugs as Taxotere and will likely cause the same adverse reactions (e.g. numbing of the arms and legs, hair loss, body pains).  Taxol will also cause the same degree of blood complications as other second line chemotherapy drugs (usually decreased red and white cell counts).  I cannot comment on the appropriateness of Taxol for your mother, as I have not closely examined her, nor do I know all the facts about her case.  But you should discuss with her oncologist to see how much benefit additional chemotherapy will give her.  If additional chemotherapy will not improve her survival, then maybe you should reconsider your options.
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Avatar_f_tn
Thank you Dr. Roque. I will discuss with my oncologist as advised. honestly speaking we just feel like captive listeners in the OPD. Any kind of discussion here is taken as an offence/ advice to a doctor!! Thats why am just groping for answers outside. am very devastated by the fact that despite monthly check ups..my oncologist neither could detect bone mets last year nor could detect hematoma and viceral mets this time. Its me who proactively got the investigations done and bought to their notice. This has shaken my faith in them.
I extend my heartfelt thanks to you for all your worthy advise.

Since she has been advised to avoid pain killers, sedatives and vigil on the bleeding factors. in this case how can we expect the disease to progress and distress my mother if NO FURTHER TREATMENT IS GIVEN.
Regards.
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Avatar_dr_m_tn
Hi.  I can understand the doctor's advise to avoid sedatives for now.  This is to better monitor if the subdural hematoma is progressing.  Progression of the subdural hematoma will cause your mother to be less responsive and to be more drowsy.  Taking sedatives at this time will mask the appearance of these "alarm" symptoms.  However, I don't agree that she should avoid taking pain killers.  Pain from the cancer may be severe, and every measure should be taken to ensure the patient's quality of life.  If the doctors cannot cure your mother, the very least they could do is make her comfortable.
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Avatar_f_tn
My mother is having cough for the past 1 month! Her oncologist gave her ciplox 500 BD for 5 days but it hasn't helped her at all. its difficult for her to sleep at night, do people with lungs mets have to tolerate the discomfort all the time or is there any treament!! TB test came out negative.
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Avatar_dr_m_tn
Hi.  Your mother's difficulty in breathing and cough may be due to infection (pneumonia).  If this is the case, then taking antibiotics will help relieve her symptoms.  If the pneumonia is not getting better with the Ciplox, then maybe she should be given another antibiotic.  The other possible cause of your mother's respiratory symptoms is extensive cancer metastases in her lungs.  As the cancer replaces normal lung tissue, your mother's capacity to take in air is also decreased, hence the respiratory symptoms.  If this is the case, the only treatment would be to give chemotherapy or hormonal treatment to try and contain the spread of the cancer in the lungs.
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Avatar_f_tn
Thanks Dr Roque, it seems the mets in the chest lymph nodes is leading to hacking cough. oncologist have ruled out the possibility of pneumonia as if now. I want to share a news with you on subdural Haemotoma. since 17thoct we did 3 CT brain scans.They have confirmed that haemotoma is shrinking in size.. i wish i could show you the gradual progress report! we have been advised another scan on 15th Nov which will give us the final picture. we might start palliative chemotherapy (single drug taxol) on weekly basis under strict vigil keeping in mind that it will have least efffect on the platelets and not disturb the haemotoma. plus it will control the further cancer spread. how she would tolerate remains to be seen.
Regards.
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