Issues in clinical research for metastatic breast cancer

Superior divisional third nerve palsy due to breast cancer metastasis to the orbital apex

PURPOSE

To report a case of breast cancer with metastasis to the orbital apex with manifestation of superior divisional third nerve palsy.

CASE DESCRIPTION

A 40-year-old female, a known case of breast cancer diagnosed 3 years ago, referred to our neuro-ophthalmology clinic with chief complaint of ptosis and diplopia. In ophthalmic examination, visual acuities of both eyes were 20/20 and there was no significant finding in the anterior and posterior segment ophthalmic examination. There was left eye ptosis with MRD1 of 2 mm. In ocular movement examination, there was limitation of motion in supraduction (-2 to -3) of the left eye. Orbital MRI with contrast was requested for the patient which demonstrated a lesion in the orbital apex of the left eye. At the end, the patient was diagnosed as having superior divisional third nerve palsy. Orbital radiotherapy was recommended for the patient.

CONCLUSION

In a patient with breast cancer who presents with diplopia, metastasis to the orbital apex with manifestation of divisional third nerve palsy should be kept in mind, and appropriate orbital imaging should be considered.

Nodular Scleritis Revealing Metastasis of Breast Cancer: Diagnosis Not to Be Neglected

We report the case of ocular metastasis in a 48-year-old woman presenting left eye redness and pain. The patient was followed in another health institution for nodular scleritis and received systemic corticosteroids with moderate improvement. Medical history revealed that she was diagnosed three years ago with invasive ductal carcinoma of the left breast treated by tumorectomy with ganglion dissection. An ophthalmological examination found a hard scleral nodule with vascular architectural disorganization. A biopsy was performed, and the histopathological study revealed the presence of secondary tumor proliferation of poorly differentiated carcinoma of mammary cancer. This case report shows the fact that any unusual ocular presentation, even one simulating anterior scleritis, in a patient with a history of breast cancer should raise suspicion of metastasis.

How to emerge from the conservatism in clinical research methodology?

PURPOSE OF REVIEW

Despite recent changes in clinical research methodology, many challenges remain in drug development methodology.

RECENT FINDINGS

Advances in molecular biology and cancer treatments have changed the clinical research landscape. Thus, we moved from empirical clinical oncology to molecular and immunological therapeutic approaches. Along with this move, adapted dose-limiting toxicities definitions, endpoints, and dose escalation methods have been proposed. Moreover, the classical frontier between phase I, phase II, and phase III has become unclear in particular for immunological approaches. So, investigators are facing major challenges in drug development methodology.

SUMMARY

We propose to individualize clinical research using innovative approaches to significantly improve patient outcomes and targeting what is considered unmet need. Integrating high level of translational research and performing well designed biomarker studies with great potential for clinical practice are of utmost importance. This could be performed within new models of clinical research networks and by building a strong collaboration between academic, cooperative groups, on-site investigators, and pharma.

Ophthalmic Metastasis of Breast Cancer and Ocular Side Effects from Breast Cancer Treatment and Management: Mini Review

Breast cancer is one of the most common malignant diseases occurring in women, and its incidence increases over the years. It is the main site of origin in ocular metastatic disease in women, and, due to its hematogenous nature of metastatic spread, it affects mainly the uveal tissue. The purpose of this paper is to summarize the clinical manifestations of the breast cancer ocular metastatic disease, alongside the side effects of the available treatment options for the management and regression of the systematic and ophthalmic disease.

The horizon of precision medicine in breast cancer: fragmentation, alliance, or reunification?

Genomic studies have shown that breast cancer includes a large number of targetable genomic alterations. Most of these genomic alterations are rare and can evolve during the natural history of the disease. Three paths are being followed to develop precision medicine in metastatic breast cancer. First, the conventional path will consist of fragmenting the disease and developing drugs in each rare genomic segment. This will require screening large numbers of patients for genomic alterations to run the therapeutic trials, especially the registration trials. The second path will consist in clustering rare genomic alterations in more frequent segments defined by an altered pathway. Finally, one possible path for precision medicine will be to test genomic algorithms for the whole patient population with metastatic breast cancer. This latter scenario would reunify breast cancer into a single entity and test whether the use of genomics would improve outcomes in this population of patients. Challenges and perspective in the field of precision medicine will include the prediction of resistance, the integration of immunology, and DNA repair in the genomic algorithms and the transfer of concepts to early-stage breast cancers.