Patient's Query
Hello, doctor,
My mother had breast cancer 13 years ago, and this year again she has been diagnosed with bone-only metastasis, as per the report. She has been on Letrozole and Ibrance for the last five months.
Initially, there was bone pain near pelvic, and so did the ultrasound, in that it showed minimal ascites. Following that, we did CA 125 at 104 and CEA at 47 five months back, followed by a CT and PET CT scan and biopsy (the biopsy was done from bone and not from mental, which came back positive for breast cancer origin and negative for colon and intestine CA. In both, there were two observations. Non-FDG avid bone and generalized haziness.
What is a non-FDG avidity that is described in a PET scan?
What is a generalized haziness, omental metastasis from breast cancer?
What can be the cause?
Two months ago, we repeated CA 125, which came to 33 from 104 at the initial diagnosis, and 2 CEA at 29, 47 at the initial diagnosis.
Kindly guide.
Hello,
Welcome to icliniq.com.
I can understand your concern regarding the new findings on the PET CT (Positron Emission Tomography-Computed Tomography) scan of your mother. She is having multiple bony metastases proven radiologically and pathologically. The generalized mesenteric and omental haziness with raised tumor markers, CA 125 / CEA, raises suspicion of peritoneal involvement. However, no clear nodule or mass was found in the abdominal cavity. Therefore, she requires a close follow-up and further investigation.
She has proven bone metastasis as confirmed pathologically and radiologically (CT scan) without uptake of FDG. Non-FDG avid means that some of her bone metastases have not taken up FDG. Usually, the tumor and the metastatic site take up FDG, but here, bone metastasis has been confirmed already by CT scan and biopsy.
At this stage, I would suggest you discuss with your oncologist for a possible laparoscopic evaluation of the abdomen (peritoneum, omentum, and mesentery). It will show any visible suspected lesion in the abdomen, and biopsies can be taken from any suspicious lesions, or she can be put on close follow-up, and a PET CT and tumor markers can be repeated after two months. They should also drain the abdominal fluid and send it for analysis (cytology for malignant cells).
Also, she may need a transvaginal ultrasound, which is very sensitive to detect any ovarian tumor because the ovary is one of the common causes of peritoneal and omental involvement. She may also need to do an MRI of the whole spine, as there are multiple vertebral metastases. There is a risk of spinal cord compression, and an MRI can detect it early.
Did she have a previous surgery of the uterus, ovaries, or any abdominal surgery?
Revert with the answer to assist further.
I read your query and can understand your concern.
I hope this information helps you.
Feel free to ask further queries.Thank you.
Patient's Query
Hello doctor,
The uterus was removed many years ago.
If it is non-avid, is it an indolent, low-grade, or slow CA?
According to current reports, do you think omental involvement is 100 % there, or is it suspicious?
The oncologist has told us to do an ultrasound to check the progress, and he does not think the ovaries or other organs are involved. He told us that the CA had omental involvement, and moreover, the treatment will be the same.
What is the prognosis of such a CA?
We repeated the test of CA-125 every two months, which came back 33, and at the time of the diagnosis, it was 104, after five months. Does this indicate anything?
Hello,
Welcome to icliniq.com.
I read your query and can understand your concern.
Yes, non-FDG avid usually means low-grade tumor. But here it does not apply because bones are her metastatic sites, and metastatic tumors follow the same grade and pathology as the primary tumor. Regarding omental involvement, it is highly suspicious and not confirmed yet.
In case the omentum is involved, then the malignancy is advanced, and the prognosis is poor. The peritoneum and omentum are usually involved if a primary tumor is a lobular carcinoma rather than a ductal carcinoma.
Tumor markers are not very high. In case they are doubling in the short period, then there is definitely pathology in the peritoneum or ovarian regions.
I hope this information helps you.
Feel free to ask further queries.
Thank you.
Patient's Query
Hi doctor,
Thank you, doctor,
In case the omentum is involved, can it be resolved with the current medication?
Is it possible in the near future to develop better treatments for such a condition?
In the last four to five months, since it was diagnosed, the patient's weight increased from 75 to 79, and the tumor marker is down. I am wondering if the omentum was involved by this time; it would have been detected or had symptoms?
I am wondering if our oncologist believed it was very serious, then why has he kept us on the first-line therapy, Letrozole and Ibrance, and monthly injections?
According to the report from 13 years back, the carcinoma was mixed lobular and ductal. Basically, how much time does it take for a tumor to grow if it is not detected clearly in a PET/CT scan?
I have read that early omental disease shows as diffuse haziness on the CT scan. Is it true?
Hello,
Welcome to icliniq.com.
I read your query and can understand your concern.
If the omentum is involved, the disease is incurable, and the chances of complete resolution are slim. But with cancer medicine, it can be controlled, and the progression can be delayed. For a patient with omental disease from breast cancer, the average survival is 18 months.
But in her case, the omental and peritoneal involvement is highly suspicious but not confirmed. Only 15 % of patients with omental or peritoneal involvement can survive for five years. Many clinical trials are going on, and in the coming years, better and revolutionary treatment is expected.
The weight gain, good appetite, decreased tumor markers, and pain control without medicine or with occasional analgesics are good clinical signs and indicate a good clinical response to the treatment. So that is the reason in her case, that her oncologist is continuing with the same medicine.
In case there was a microperitoneal or omental disease, and the medicine she took was not working, in that case, the disease could have become visible and palpable with worsening symptoms in a few months. Letrozole and Ibrance are the best treatments for post-menopausal women with metastatic breast cancer, ER-positive and HER2-negative.
In case there is a micro or small omental and peritoneal disease, and the patient is not responding to the treatment, it will become visible on radiological imaging in three months' time. The gold standard to diagnose a peritoneal or omental disease is through laparoscopy. By other techniques like PET CT, ultrasound, MRI, etc. It can be missed if there is micro disease or a small metastasis.
Patient's Query
Hi doctor,
We had an ultrasound, and it came back normal, though it says minimal free fluid in the pelvis in the intrabowel space. At the time of diagnosis, it said minimal ascites. This time, the radiologist checked for omental as it was written on the doctor's prescription, and she said there was nothing abnormal. What is the minimal free fluid in the pelvis in the intrabowel space?
Hello,
Welcome to icliniq.com.
I read your query and can understand your concern.
The ultrasound report is showing no peritoneal or omental pathology (no masses or nodules). Minimal free fluid in the pelvis in the intrabowel space is a non-specific finding. Anything that causes inflammation of the organs in the pelvis can be associated with minimal to moderate free fluid in the pelvis. Most of them are benign conditions.
So, I would suggest repeating the ultrasound after 45 days and comparing it with the previous one. It looks like there is no gross pathology in the abdomen (omentum or peritoneal cavity).
I hope this information helps you.
Feel free to ask further queries.
Thank you.
Patient's Query
Hi doctor,
Thank you for the reply.
The recent CBC report and USG are normal. There are a couple of things I want to ask.
We do not know whether the omentum has been involved for the last six months. However, whenever I see a doctor's prescription on the top, it is written as CA - Omentum or bone, or is that an assumption, or are they sure that omentum is involved? One way is that bone, omental, and mesenteric haziness were found at the same time in a PET-CT scan. Have they assumed that the omentum is involved too?
I am just wondering, in our case, has the disease been overdiagnosed?
What is another cause of generalized omental and mesenteric haziness as seen on PET/CT at the time of diagnosis?
In the coming time, can we see more effective treatments than today?
What is the chance of the omentum being involved?
Hello,
Welcome to icliniq.com.
I read your query and can understand your concern.
In case the findings are unchanged in the peritoneum and omentum, it is good news that there are two possibilities here. Either the patient is responding to the current treatment, so there is no disease progression. Or the lesions in the peritoneum or omentum are just suspicious or benign.
Omental and peritoneal haziness can also be due to fibrosis, old abdominal infection, or previous abdominal surgery. But the main cause is malignant infiltration.
Many new medicines for breast cancer, including immunotherapy, are in the pipeline. Treatment choice will depend mainly upon molecular genomic profile and many other factors.
I hope I have answered your question.
I hope this information helps you.
Feel free to ask further queries.
Thank you.
Patient's Query
Hello doctor,
I have attached the doctor's prescription. It always says MBC omental with a sign above it, but it never mentioned bone when it was discovered in a CT scan.
In layman's terms, is haziness in a CT scan associated with small metastasis or an initial stage or small-grade tumor, which can be resolved with current medication?
I have attached the initial biopsy report, which says mucin vacuole of breast origin.
Is there any medicine coming in the near future if there is resistance to the current medication?
Hello,
Welcome to icliniq.com.
I read your query and can understand your concern.
It looks like a biopsy was taken from the left iliac bone and shows metastasis. But full details of the biopsy report are lacking. I could not find any biopsy report from the omentum or peritoneum.
Yes, the haziness in the peritoneum can be due to low-grade metastatic tumors or very small peritoneal metastases. The only way to confirm this peritoneal haziness is through laparoscopic evaluation and biopsy. If it is confirmed through biopsy, it can be well controlled by medicine, but the complete resolution of this metastasis with medicine is difficult.
Metastatic adenocarcinoma with mucin vacuole means confirmed metastasis pathologically (mucin-containing adenocarcinoma is usually aggressive).
There are more options available if there is resistance or progression due to current medications. One of the options is Ribociclib.
I hope this information helps you.
Feel free to ask further queries.
Thank you.
Patient's Query
Hello doctor,
Thank you for the reply,
Please find enclosed the complete report of the biopsy.
At the time of diagnosis, the operating doctor wrote to do a biopsy of the omentum, though the doctor who took the biopsy confirmed that the omentum biopsy was not needed. Only the bone was needed.
I read on the net about oligometastatic breast cancer metastasis, which says a few lesions less than 1.9 inches in one or two sites. Does it make any sense in our case, as the lesions' size or quantity is not mentioned in PET CT or biopsy?
Is our overall case a low-volume or high-volume metastasis?
Does it change the prognosis?
Recently, we did a monthly CBC, in which all the other parameters of white blood cells came to normal range after six months. Does it indicate anything? Kindly guide.
Hello,
Welcome to icliniq.com.
I read your query and can understand your concern.
I have reviewed the reports (attachment removed to protect the patient's identity).
1. The biopsy was taken from the bone rather than the omentum. It was better to take the biopsy from both areas. But it is easier to take a sample from bone than to take a sample from an omental area.
2. Oligometastasis, or low-volume metastasis, can be managed and controlled through anticancer medications and, in some cases, can be resected completely through surgery. High-volume metastasis is difficult to control and spreads to other parts quickly.
3. CBC (complete blood count) report is normal. It is good news. If CBC is deranged, it raises suspicion towards certain points.
Is there any toxicity to bone marrow from anticancer medications?
Whether there is any bone marrow infiltration of cancer cells.
Nutrition and vitamin deficiency.
Any microbleeding inside the body.
I hope this information helps you.
Feel free to ask further queries.
Thank you.
Patient's Query
Hi doctor,
Thank you for the reply,
We just did a CT scan, CA 125, and monthly CBC, and it all seems to be normal (attached reports).
In the CT scan, it says mild generalized haziness, and at the bottom, it says hernia with 10 mm. Can the haziness be related to a hernia or its CA, which has mild symptoms? It has been eight months since the diagnosis, but still, we do not know what the haziness is all about. I have attached the CT scan files. In the initial time, it was general, without the mention of the word mild or what exactly mild is in medical terms.
CA 125 came to 17.9. Originally, it was 104 eight months ago. I am wondering if it is in the normal range. Can it still be metastasis to the omentum?
In the current report, the scan was for the abdomen, so we do not know whether pelvic bones were checked, as the report mentions only what was mentioned in the report eight months ago. It looks like cut, copy, and paste. Kindly let us know whether the bone scan was done from the CT scan images (attached). If it is only bone metastasis and CA 125 is normal, can it be possible that the metastasis is not in the bone? As I have come across, it is mentioned that if it's only bone metastasis, patients are doing well beyond 10 to 15 years.
From the scan, can we find out what exactly the cause of the haziness is?
Hello,
Welcome to icliniq.com.
I read your query and can understand your concern.
I have reviewed the reports (attachments removed to protect the patient's identity) and understand your concern. There is not much to worry about regarding omental lesions. As they have been under control for a long time, there is no increase in haziness or new lesions in the omentum or peritoneum. Clinically and radiologically, the abdomen's (omentum and peritoneum) suspicious lesions are well under control.
The main concern is the bony metastasis, which is at multiple sites and can increase the risk of pathological fracture, but I want to see the comparison report (that is not attached) to see whether the bony lesions have increased, decreased, or are static. In case the bony lesions are the same, she should continue the same medications, and she is currently responding well. Bisphosphonates or Denosumab can be added to the treatment.
Non-FDG avid lesions and omental haziness can be due to low-grade tumors, benign lesions, or fibrosis.
Tumor markers are low, and bone pain is decreased; appetite is preserved. These are all good signs and responses to the treatment.
I would recommend doing a DEXA (dual-energy X-ray absorptiometry) bone scan so that if there is any risk of fracture anywhere, some prophylactic procedures can be recommended.
I hope this information helps you.
Feel free to ask further queries.
Thank you.
Patient's Query
Hi doctor,
Thank you for the reply.
Can the CT scan tell whether the bony metastasis contains cancer cells? As other reports are in the normal range, it is possible that the lesions are still there as previously, eight months ago, though it does not have cancer cells. As I read somewhere that even with effective therapy, bone lesions hardly heal. Is it even free from CA cells?
At the moment, can we say that it is a bone-only metastasis from breast cancer?
Can it also be possible that a CT scan can detect very small metastases too? That is why they have not mentioned any difference in the CT scan report regarding bone metastasis (earlier it was bigger, but now it can shrink, though it is still there).
What are the limitations of CT scans when assessing response for bone metastasis?
Hello,
Welcome to icliniq.com.
I read your query and can understand your concern.
All the reports attached are old (attachments removed to protect the patient's identity), and I could not find any of the latest assessment reports.
Many tumors are non-FDG avid, which means they are not sensitive to the FDG (Fluorodeoxyglucose) tracer or the tumor cells have low or no uptake of the FDG tracer.
Examples of non-FDG avid tumors are when the tumor size is small, usually less than 0.3 inches, or low-grade tumors. Some other examples include kidney and carcinoid tumors. But currently, there is a new tracer called C 11 acetate tracer, which may detect non-FDG avid tumors, but it is still not approved.
Regarding omental and mesenteric (abdominal) haziness. That means there is a suspicion of metastasis in this area, possibly from the breast. But not confirmed. But if haziness increases on subsequent scans, the patient may need a laparoscopic evaluation of the omentum and peritoneum and a biopsy from the suspicious area.
CA 125 and CEA were under control, but I do not have any latest reports available for comparison.
Suppose she is eating well, with no pain, and doing some work and some activities. That means she has a good response to the treatment, and she should continue her treatment.
I wish her a long life and a complete cure.
I hope this information helps you.
Feel free to ask further queries.
Thank you.
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Answered byDr. Arshad Hussain Shah
Medically reviewed byiCliniq medical review team
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