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BMJ Case Rep. 2010; 2010: bcr10.2009.2388.
Published online 2010 January 13. doi:  10.1136/bcr.10.2009.2388
PMCID: PMC3029533
Reminder of important clinical lesson

Metastatic breast disease: an all too common cause of back pain

Abstract

A 50-year-old multiparous woman presented with a 3 month history of back pain. She was initially treated for non-mechanical back pain by her primary care physician, but was subsequently discovered to have a right sided clinical breast cancer and palpable axillary lymphadenopathy. An oestrogen/progesterone receptor positive invasive ductal carcinoma with axillary metastatic disease was confirmed on breast clinic triple assessment. Magnetic resonance imaging of the spine revealed an L1 vertebral body metastatic fracture with cord compression and other axial and non-axial stable skeletal metastases. The patient underwent immediate orthopaedic spinal stabilisation with full resolution of her back pain, and began primary endocrine breast cancer therapy with outpatient spinal radiotherapy planned.

Background

While breast cancer commonly presents with signs or symptoms related to the primary tumour, the manifestation of back pain and neuropathy, due to metastases, as a primary presentation is rare.

We feel this case highlights the need for primary care physicians and hospital doctors to consider the presentation of back pain as a spectrum of other diseases, including breast cancer, rather than treat symptomatically in isolation. This case also highlights the need for breast examination in women at population or increased breast cancer risk

Case presentation

A previously healthy, 50-year-old multiparous woman was referred by her general practitioner with a 3 month history of lower back pain radiating to the posterior aspect of her left hip. She had been diagnosed clinically as suffering from pelvic instability and had been initially treated with physiotherapy and analgesia. She had repeated primary care visits requiring increasing analgesia and physiotherapy culminating with cessation of work and referral to outpatients for investigation of back pain. Examination demonstrated a right breast mass with associated skin tethering and palpable axillary nodes clinically consistent with a breast cancer and axillary lymphadenopathy. Locomotor examination demonstrated tenderness over the L1–L3 vertebrae, but normal lower limb dermatomal and myotomal examination.

Investigations

She underwent breast clinic triple assessment including mammography, ultrasound, breast core biopsy and axillary node fine needle aspiration, which demonstrated an oestrogen/progesterone receptor positive invasive ductal carcinoma with axillary metastatic disease.

Plain spinal radiograph, isotope bone scan and spinal magnetic resonance imaging (MRI) demonstrated a metastatic comminuted pathological L1 vertebral body fracture resulting in 50% body height loss, extending to the base of the pedicles and partial fragment retropulsion into the spinal cord (fig 1). In addition she had multifocal stable bony metastases in the adjacent thoracic (T1–6 and T11–12) and lumbar (L2–4) vertebrae and throughout her non-axial skeleton.

Figure 1
Spinal magnetic resonance image. Comminuted pathological L1 vertebral body fracture resulting in 50% body height loss, extending to the base of the pedicles and partial fragment retropulsion into the spinal cord.

Differential diagnosis

  • Metastatic cancer (breast, kidney, lung, thyroid)
  • Prolapsed disc
  • Musculoskeletal pain.

Treatment

Following orthopaedic review and calculation of her Tokuhashi spinal score as 14, she underwent successful posterior spinal stabilisation with full resolution of her back pain.

Outcome and follow-up

The patient was reviewed by medical and radiation oncologists who started her on primary endocrine therapy for her breast cancer and planned outpatient spinal radiotherapy in the postoperative period.

Discussion

Back pain due to axial skeletal metastases is an uncommon presentation of symptomatic breast cancer. Symptomatic patients most commonly present with a palpable breast primary (43%) and/or secondary axillary metastases (0.3–1%). However, >30% may ultimately develop skeletal bony metastases.1 While the most common cause of back pain is a benign one (95%), few cases of primary breast cancer presentation with metastatic disease have been described.2 It is therefore important to include a detailed breast risk factory history and physical examination to exclude metastatic breast disease as a primary cause. With regard to the role of surgery in the management of spinal metastases, direct decompressive surgical resection is the most frequently used treatment.

Studies have shown that surgical fixation has an improved, more durable functional outcome versus radiotherapy alone in many studies3 and intervention in our case was based on the Tokuhashi spinal score. This score determines general health, number of spinal, extraspinal and organ bony metastases, primary cancer site, and neurological deficit. Each parameter is rated 0–2, zero signifying the worst prognosis. Spinal stabilisation is not indicated in those with a score [less-than-or-eq, slant]8 points as [less-than-or-eq, slant]12 month survival is forecast.4

Learning points

  • It is important to consider the possibility of metastatic breast disease presenting as back pain.
  • Careful breast risk factor history taking and physical examination is important.
  • Where appropriate, surgical spinal fixation has an improved outcome over radiotherapy alone.

Footnotes

Competing interests: None.

Patient consent: Patient/guardian consent was obtained for publication.

REFERENCES

1. Cuccurullo SJ. Physical medicine and rehabilitation board review, 2nd edn Demos Medical Publishing, 2009: 635
2. Oterdoom DL, Klaase JM, Jobsen J, et al. Diagnosis and treatment of patients with spinal epidural metastases. Ned Tijdschr Geneeskd 2008; 152: 1129–35 [PubMed]
3. Patchell R, Tibbs PA, Regine WF, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet 2005; 366: 643–8 [PubMed]
4. Tokuhashi Y, Matsuzaki H, Toriyama S, et al. Scoring system for the preoperative evaluation of metastatic spine tumor prognosis. Spine 1990; 15: 1110–3 [PubMed]

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