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Recurrent Metastatic Breast Cancer with Placental Metastasis: A Case Report
Abstract Number: F2D-5
Abstract Type: Case Report/Case Series
Case: A 28-year-old African American female at 33 weeks of gestation presented to the emergency department for worsening her upper back pain and a mass on her left upper back. She had a history of stage IIIA left breast cancer diagnosed almost one year ago and underwent surgical resection, chemotherapy, and radiation. The CT scan revealed a soft tissue mass, arising from the posterior left fifth rib, most consistent with a metastatic lesion. Her medical history was significant for chemotherapy-induced cardiomyopathy and chronic hypertension. Her current pregnancy was complicated by incompetent cervix required cerclage placement at 21 weeks of gestation. Spine MRI revealed multiple metastatic lesions throughout the cervical, thoracic and lumbar vertebral bodies without intradural lesion. After the multidisciplinary team discussion, a decision made to deliver to expedite the cancer treatment. For her labor analgesia, an epidural catheter was placed which was accidentally pulled out in 7 hours. Almost after 12 hours of the induction process, the decision was made to proceed a cesarean delivery secondary to the failure of progress of labor. She underwent a cesarean section with spinal anesthesia which revealed inadequate surgical anesthesia, converted by general anesthesia. Throughout the extensive workup for staging, she had metastasis to vertebral bodies, right breast, left ovary, and placenta. She was discharged home postop day 7.
Discussion: Spine is one of the common metastatic sites from breast cancer. Neuraxial procedures carried a significant risk of paraplegia in the presence of spinal cord compression. Systemic analgesia with remifentanil PCA was optional for labor, however, if a cesarean delivery is indicated, general anesthesia with a considerable risk of neonatal depression and its related complications is required. After the multidisciplinary team discussion, she was considered to be a candidate for labor epidural analgesia for vaginal delivery because there was no evidence of intradural or spinal canal involvement of metastasis despite there were scattered metastatic lesions throughout the cervical, thoracic and lumbar vertebral bodies. When cesarean delivery was indicated, spinal anesthesia was attempted which failed to achieve a surgical level of anesthesia. The possible mechanisms of the failed block would include partially misplaced local anesthetic or restricted spread of local anesthetic solution from any anatomical abnormality. Interestingly, there are a few cases describing failed spinal anesthesia for cesarean section caused by a spinal mass or vertebral metastases. In our case, there was no evidence of a mass in the spinal canal or intradural space. Recurred metastatic breast cancer in pregnancy is a rare occasion but a clinically challenging situation for patients and their physicians. A multi-disciplinary approach is recommended for optimal decision making for labor and delivery.