Q. How to treat breathlessness in a metastatic breast cancer patient?

Hello,

Welcome to icliniq.com.

I have read all the reports (attachment removed to protect the patient's identity) including your CT (computed tomography) scan. It is very sad to be in such a situation with multiple problems. Metastatic breast cancer with underlying lung comorbidities is the cause of her breathlessness. Overall the distress is a result of all lung problems happening at the same time. First thing, having malignant pleural effusion compresses both the lungs and compromises oxygen dissociation in blood. Pleurodesis (procedure to adhere the pleura - outer layer of lungs) is performed again because of fibrosis around the lungs which again limits oxygenation. At the same time, she has lung consolidation, interstitial disease, and residual effusion. In such a complicated situation, oxygenation is affected very much. So supplemental oxygen has to be continued to keep oxygen saturation above 95 %. If only oxygen is not enough to maintain saturation, she may require long-term noninvasive ventilation. So, we are dealing with too many lung problems at the moment. As and when the parameters improve, her distress will be reduced to some extent. Management of such cases should ideally be in ICU (intensive care unit) with monitoring. Steroids are the mainstay of treatment for pleural inflammation, interstitial problem, and ALI (acute limb ischemia). She is already receiving the tablet Medrol (Methylprednisolone) 16 mg thrice daily. Appropriate antibiotics according to sensitivity tests should be used to treat lung consolidation. It takes time for healing pleural inflammation, especially after talc pleurodesis and underlying lung disease. Recurrent effusions are making the situation worse for which guided aspirations are required to evacuate the pleural space for faster healing. Treatment of the underlying breast cancer simultaneously is very important as effusions will be recurring because of uncontrolled malignancy. Good nutritional and protein supplements are a must. Proper nursing, care, and prevention of bed sores should be looked for. In total, in my experience, her respiratory distress is multifactorial as we discussed above and she will need time to improve with all supports. At present, she is on the best treatment for a lung problem. But, you should remember that any cancer especially metastatic is a progressive disease and we can only treat the symptoms but not the disease permanently. I hope she will respond to this maximum treatment and come out of this complex disease.

Thank you.

Hi,

Welcome back to icliniq.com.

At this moment, I will not recommend the tablet Pirfenex (Pirfenidone) as I do not think this case is idiopathic pulmonary fibrosis unless she has some collagen vascular disorder. Tablet Pirfenex is not recommended for any fibrosis. But, the final decision should be taken by the treating physician with appropriate evidence like HRCT (high-resolution computed tomography) thorax or lung biopsy in favor of IPF (idiopathic pulmonary fibrosis). So, I do not think tablet Pirfenex will help her at the moment. Tablet Medrol can be continued in tapering doses. Also, regarding antibiotics, if there is no fever or any laboratory evidence of infection or sepsis, they should not be used for the long term. So, what she needs now is steroids in tapering doses and oxygen support. The outcome depends totally on her response to the current appropriate treatment.

I hope I have addressed your concerns. Feel free to reach out if you have any further questions.

Same symptoms doesn’t mean you have the same problem. Consult a doctor now!

Dr. Amol Kumar Wasudeorao Diwan

Experience: 20 + Yrs

Allergy Specialist

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