CASE REPORT
cancer, comorbidity, infratentorial lesion, primary breast cancer
BRAIN METASTASIS, HYPERCHOLESTEROLEMIA, CANCER, DISEASE, ONCOLOGY
A 75-yr-old woman with a diagnosis of mBC (ER+, PR-, HER2-; Ki-67 10%) participated in the EFFECT study (The woman was diagnosed with primary breast cancer in 2014, which had disseminated to the liver in 2016, to the bone in 2017 and to lymph nodes and the kidney in 2020. She had undergone chemotherapy, radiotherapy to the pelvis, endocrine therapy, immunotherapy, and bisphosphonate treatment. At the time of randomization to the intervention group of the EFFECT study (August 2020), she was on her third line of mBC treatment receiving Palbociclib and Fulvestrant. The only known comorbidity was hypercholesterolemia, since 2017, for which she was treated with simvastatin.The patient attended the training sessions regularly (86%, 43 of 50 sessions). She was supervised by the same exercise trainer throughout the exercise program. In month 7 of the intervention, the patient’s performance declined unexpectedly. During the training session, the trainer recognized some changes and symptoms that were not in line with her previous performance and included failure to complete walking on a line, one leg stand or dual-tasking exercises during the balance component, requiring longer resting intervals or a decrease in intensity (i.e., workload) while performing the high intensity interval protocol during aerobic training. In addition, the patient seemed a little sleepier and her eye movements seemed slower than usual, especially when she was lying down. She also shared a complaint that sometimes her legs did not “listen to her” when she wanted to start walking and that she felt a “bit groggy,” but she did not seem to be overly concerned by it. Initially, the patient attributed these insidious changes to the fluctuations inherent to the disease and its treatments; however, the trainer advised her to talk to her oncologist.Four weeks later, during a training session, the patient began to make slight superfluous movements with her arms during the bench press exercise. Hence, the trainer encouraged the patient again to speak with her oncologist about these symptoms during the appointment she had that same day, but she did not do so. The patient did not seem to care and was not fully aware of the changes that were happening to her. Hence, these symptoms remained unrecognized by the medical team and the patient’s cancer treatment remained unchanged. Suspecting BM based on the signs that indicated the patient’s neurological functioning was deteriorating, the trainer sought approval from the patient 3 d later, to contact the oncologist and discuss her concerns. The oncologist responded immediately by ordering a brain MRI.Five days after the communication between the trainer and the oncologist, the MRI confirmed BM (Fig. (A) Axial T1 weighted image without gadolinium. (B) Coronal T1 weighted image without gadolinium. (C) Axial T1 weighted image after gadolinium. (D) Coronal T1-weighted image after gadolinium showing an infratentorial lesion suspected for brain metastasis.The new treatment plan included radiotherapy and chemotherapy. At the start of whole brain radiation, 4 wk after the MRI was performed, regular physical examination still showed no obvious signs of CNS involvement. Neither the patient nor her husband believed that there has been a marked deterioration over time. The patient died 5 months after diagnosis of BM. Following the CARE case reports guidelines, a timeline is provided in Figure Timeline of the case report. ECOG, Eastern Cooperative Oncology Group.