|Year : 2019 | Volume
| Issue : 2 | Page : 31-34
Pattern of visceral metastasis from breast cancer patients in Ahmadu Bello University Teaching Hospital, Zaria, North Western Nigeria
Peter Pase Abur1, Lazarus M Yusufu1, Vincent I Odigie2
1 Department of Surgery, Breast and Endocrine Unit, ABUTH, Zaria, Nigeria
2 Department of Surgery, University of Benin Teaching Hospital, Benin, Edo State, Nigeria
|Date of Submission||24-Apr-2019|
|Date of Decision||26-May-2019|
|Date of Acceptance||10-Oct-2019|
|Date of Web Publication||20-Jan-2020|
Peter Pase Abur
Department of Surgery, Breast and Endocrine Unit, ABUTH, Zaria
Source of Support: None, Conflict of Interest: None
Background: Visceral metastasis from breast cancer usually results in high tumor burden with poor prognosis. Aim: This study aimed to document the pattern, treatment, and outcome of breast cancer patients with visceral metastasis in our hospital. Patients and Methods: This is a 5-year prospective study of breast cancer patients with visceral metastasis from January 2011 to December 2015. All patients had tru-cut biopsy to establish diagnosis. Chest X-ray, abdominopelvic ultrasound, and computed tomography of the thoracoabdominal region were done to establish the extent of visceral organ involvement. Information documented included patients' biodata, histology, site of visceral metastasis, treatment, and outcome. Results: Two hundred and fourteen out of 1087 patients with breast cancer had visceral metastasis (19.7%). Their age ranged 15–83 years. Eighty-four (39.4%) patients had metastasis to the lungs. Thirty-nine (18.3%) patients had metastasis to the liver. Fifty-eight (27%) patients had metastasis to two or more visceral organs. One hundred and eighty-one (84.6%) patients had chemotherapy, 158 (73.8%) had hormonal therapy, whereas 103 (49.1%) had surgery. The mortality at 3-year follow-up was 58.4%. Conclusion: The lungs were the most common organ of visceral metastasis followed by the liver in this study. A significant percentage had metastasis to two or more visceral organs. Early presentation will reduce the incidence of visceral metastasis and the high mortality associated with it.
Keywords: Advanced breast cancer, management, outcome, pattern of metastasis
|How to cite this article:|
Abur PP, Yusufu LM, Odigie VI. Pattern of visceral metastasis from breast cancer patients in Ahmadu Bello University Teaching Hospital, Zaria, North Western Nigeria. Arch Med Surg 2019;4:31-4
|How to cite this URL:|
Abur PP, Yusufu LM, Odigie VI. Pattern of visceral metastasis from breast cancer patients in Ahmadu Bello University Teaching Hospital, Zaria, North Western Nigeria. Arch Med Surg [serial online] 2019 [cited 2020 Feb 23];4:31-4. Available from: http://www.archms.org/text.asp?2019/4/2/31/276180
| Introduction|| |
Visceral metastases are metastases to internal organs including the liver, lungs, and body cavities such as the pleura and peritoneum., Site of metastasis depends not only on the primary tumor but also on the individual tumor subtype and genetic profile.,, Patients with visceral metastasis often have a poor prognosis.,, Visceral metastasis from breast cancer usually results in high tumor burden with poor outcome.,,,,, The site (s) and degree of metastatic dissemination are among the principal prognostic factors for patients with metastatic breast cancer.,,,,, Patients with visceral metastases to the liver and/or lung have a very poor prognosis.,,,,,
Patients with breast cancer in our hospital often present late with locally advanced or metastatic breast cancer. In the course of treatment, some of the patients with locally advanced breast cancer develop visceral metastasis, and even some patients who presented with early breast cancer do develop visceral metastasis during treatment or follow-up. Despite this significant number of patients with visceral metastasis from breast cancer in this hospital, there is no documentation on the subject from this center. The aim of the study was to document the pattern, treatment, and outcome of breast cancer patients with visceral metastasis in our hospital.
| Patients and Methods|| |
The study was a 5-year prospective study of breast cancer patients with visceral metastasis from January 2011 to December 2015 at ABUTH, Zaria.
The patients studied gave their consent for the study, and ethical clearance was obtained from the ethical clearance committee of the hospital. All patients had tru-cut biopsy to establish diagnosis. Chest X-ray, abdominopelvic ultrasound, and computed tomography (CT) of the thoracoabdominal region were done to establish the extent of visceral organ involvement.
Once the diagnosis of visceral metastasis was made, patients were then followed up for 3 years, and information of health outcomes was recorded once they occurred.
Information documented included patients' bio data, histology, receptor status, site of visceral metastasis, treatment, and outcome.
Data were analyzed using SPSS version 19.0 manufactured by IBM in 2010 in Armonk, New York, USA, and the results were presented as simple percentages and charts.
| Results|| |
Two hundred and fourteen out of 1087 patients diagnosed of breast cancer during the study period had visceral metastasis (19.7%), with 202 females and 12 males, and female-to-male ratio was 17:1. Patients' age ranged 15–83 years. [Table 1] summarizes the age–sex distribution. Histological types were invasive ductal carcinoma (138 [64.5%]), invasive lobular (26 [12.20%]), malignant phylloides (16 [7.5%]), medullary carcinoma (14 [6.5%]), papillary carcinoma (11 [5.10%]), and inflammatory carcinoma (9 [4.20%]). The receptor status was done on 127 patients: estrogen receptor/progesterone receptor (ER/PR) positive in 71 (56.0%), ER/PR negative in 18 (14.0%), Her2 positive in 9 (7.0%), and triple negative in 29 (23.0%) patients. The pattern of visceral metastases was lungs in 84 (39.4%); liver in 39 (18.3%); pleural in 24 (11.3%); peritoneum in 9 (4.0%); lungs and liver in 18 (8.2%); lungs and pleural in 20 (9.4%); lungs, liver, and peritoneum in 7 (3.3%); lungs, peritoneum, and ovary in 2 (0.9%); liver, peritoneum, and kidney in 1 (0.5%); and more than three visceral organs in 10 (4.7%) patients. The lungs were the most frequent visceral organ involved in 119 (55.6%) patients. [Table 2] summarizes the frequency of visceral organ metastasis. As the Manchester staging increases, the frequency of visceral metastasis increases. [Figure 1] depicts the frequency of visceral metastasis according to stage. The frequency of visceral metastasis increases with increase in tumor size. [Table 3] summarizes the frequency distribution of visceral metastasis according to tumor size. One hundred and fifty-nine (74.3%) patients had visceral metastasis at the first presentation, whereas 55 (25.7%) patients had visceral metastasis after initial treatment. For treatment, hormonal therapy (tamoxifen or anastrozole or letrozole) was giving to 158 (73.8%), chemotherapy – cyclophosphamide, adriamycin and paclitaxel (CAP), docetaxel + capecitabine in 181 (84.6%), surgery – breast-conserving surgery in 5 (2.3%), simple mastectomy in 16 (7.5%), Auchincloss mastectomy in 55 (25.7%) and toileting mastectomy in 27 (12.6%) inoperable patients 111 (51.9%). Radiotherapy was done for 75 (35.1%) patients and trastuzumab was administered in 4 (1.9%) patients.
|Figure 1: Frequency distribution of visceral metastasis according to stage|
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|Table 3: Frequency distribution of visceral metastasis according to tumor size|
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Only 16 (7.5%) patients who presented with early breast cancer (Manchester 1 and 2) had visceral metastasis after 3 years of follow-up.
Only 56 (35.2%) patients who had visceral metastasis at presentation were alive at 3-year follow-up.
Thirty-three patients (60%) who developed visceral metastasis after surgery were alive after 3 years of follow-up. [Table 4] for outcome following treatment of patients with visceral metastasis.
| Discussion|| |
A significant number of patients in our hospital had developed visceral metastasis from breast cancer, with more than half had developed metastasis at the time of presentation. This is similar to report elsewhere  in the country. This is largely as a result of late presentation to the hospital. In Nigeria, as indeed in many developing countries, a combination of poor health education, poverty, and a high patronage of nonorthodox healing practices among the populace contribute to the late presentation of breast cancer in many hospitals with attendant high number of metastatic disease and poor disease survival. In some countries, distant metastasis is now found in <10% of patients at initial presentation. This is because of increased efforts on routine screening toward early detection of the disease over the past two decades, resulting in marked reduction in late presentation and the incidence of metastatic disease in many centers in the Western communities. However, in some developing countries such as Nigeria, routine screening for breast cancer is not yet commonly practiced, and a large number of patients still present late. This is compounded by the limitation of the resources necessary for the care of these patients. There is a need for increased breast cancer awareness and advocacy programs aimed at encouraging our women to participate in breast cancer screening programs and also encourage them to present early so that the incidence of visceral metastasis at presentation would reduce. A significant percentage (56.0%) of patients who had immunohistochemistry were positive for ER/PR receptors; this is slightly higher than 39.1% reported in the southern part of the country. Only 24% of patients were ER positive in a study conducted in Eastern Nigeria, whereas 25% of those tested in a study from Northern Nigeria were ER positive., In a similar report from East Africa, Nalwoga et al. reported 34% basal-like tumors among breast cancer specimen. The observed difference may be as a result of learning curve in reporting immunohistochemistry at our center at the time. Twenty-three percent of the patients were tipple negative. This is similar to reports elsewhere, but slightly lower than 46% reported by Adisa et al. in South Western Nigeria. The above reason may also explain the observed difference. This significant number of triple-negative disease with a younger age at presentation coupled with late presentation may explain the high incidence of visceral metastasis at our center. The most common visceral organs involved were lungs alone (39.4%) and liver alone (18.3%); this finding is similar to other reports., However, in this study, the lungs were the most common organ involved followed by the liver. This is in contrast with the report of Adisa et al. in the southern part of Nigeria where the liver was the most common organ involved followed by the lungs. Fifty-eight patients (27%) had metastasis to two or more visceral sites. This study reaffirm the fact that the higher the Manchester staging, the higher the chances of visceral organ metastasis. The same is applicable to tumor size. Majority of the patients received chemotherapy using standard doses of cycloposphomide, adriamycin, and paclitaxel. The dosage was, however, adjusted based on patient's performance status and hematological and biochemical indices. Docetaxel and capacitabine were used for patients who had initial treatment with CAP and later developed visceral metastasis. Tamoxifen was given to ER/PR-positive premenopausal patients and patients of unknown receptor status. This unknown receptor status was as a result of nonavailability of reagents at that time. Anastazole or letrozole was given to postmenopausal patients with ER/PR-positive status. A major constraint in the management of the patients was the limitation of resources. Our patients bear the burden of paying for cancer treatment in a low-resource country. Although the National Health Insurance Scheme has recently covered some aspects of treatment of breast cancer, only a small number of patients are currently covered by the scheme. There is a need to extend the insurance to cover local and state government employees. However, the best option is to make breast cancer treatment free for all patients in our country. The mortality was high for patients that presented with visceral metastasis at initial presentation. Only 56 (35.2%) patients who had visceral metastasis at presentation were alive at 3-year follow-up. The prognosis was better for those that developed visceral metastasis after initial treatment, with 60% still alive after 3 years of follow-up.
The study had the following limitations. First, different radiologists with different levels of experience performed abdominopelvic ultrasound and reported the chest X-ray and the CT scan of the thoracoabdominal region. Although majority of the reports were done by consultant radiologists, observer biasness could not be eliminated. Second, the diagnosis of visceral metastasis was based on radiological investigation report. There was no histological confirmation of the visceral metastasis. Lastly, our patients bore the costs of investigations and treatment, making the choice of drugs used to depend heavily on affordability by patients.
| Conclusion|| |
Visceral metastasis following breast cancer is not uncommon at our center. Majority of the visceral metastasis occurred at the time of diagnosis of breast cancer. The most common visceral organs involved were lungs and liver. Majority of the patients received chemotherapy and hormonal therapy. The mortality was high especially for patients that presented with visceral metastasis at the time of diagnosis. Early presentation will reduce the incidence of visceral metastasis and the high mortality associated with it.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Adisa AO, Arowolo OA, Akinkuolie AA, Titiloye NA, Alatise OI, Lawal OO, et al.
Metastatic breast cancer in a Nigerian tertiary hospital. Afr Health Sci 2011;11:279-84.
Papoola AO, Igwilo AI, Sowunmi A, Ketiku KK, Duncan KJ, Hou N, et al
. Pattern of bone metastasis in breast cancer patients at a radiotherapy facility in Lagos British. J Med Med Res 2013;4:843-51.
Falkson G, Holcroft C, Gelman RS, Tormey DC, Wolter JM, Cummings FJ. Ten-year follow-up study of premenopausal women with metastatic breast cancer: An eastern cooperative oncology group study. J Clin Oncol 1995;13:1453-8.
Chung CT, Carlson RW. Goals and objectives in the management of metastatic breast cancer. Oncologist 2003;8:514-20.
Cardoso F, Di LA, Lohrisch C, Bernard C, Ferreira F, Piccart MJ. Second and subsequent lines of chemotherapy for metastatic breast cancer: What did we learn in the last two decades? Ann Oncol 2002;13:197-207.
Bernard-Marty C, Cardoso F, Piccart MJ. Facts and controversies in systemic treatment of metastatic breast cancer. Oncologist 2004;9:617-32.
Adebamowo CA, Ajayi OO. Breast cancer in Nigeria. West Afr J Med 2000;19:179-91.
Ikpatt OF, Ndoma-Egba R. Oestrogen and progesterone receptors in Nigerian breast cancer: Relationship to tumour histopathology and survival of patients. Cent Afr J Med 2003;49:122-6.
Gukas ID, Jennings BA, Mandong BM, Igun GO, Girling AC, Manasseh AN, et al.
Clinicopathological features and molecular markers of breast cancer in Jos, Nigeria. West Afr J Med 2005;24:209-13.
Nalwoga H, Arnes JB, Wabinga H, Akslen LA. Frequency of the basal-like phenotype in African breast cancer. APMIS 2007;115:1391-9.
Perou CM. Molecular stratification of triple-negative breast cancers. Oncologist 2011;16 Suppl 1:61-70.
Berman AT, Thukral AD, Hwang WT, Solin LJ, Vapiwala N. Incidence and patterns of distant metastases for patients with early-stage breast cancer after breast conservation treatment. Clin Breast Cancer 2013;13:88-94.
[Table 1], [Table 2], [Table 3], [Table 4]