Surgical treatment of hepatic metastases from breast cancer

Is liver resection justified for patients with hepatic metastases from breast cancer?

OBJECTIVE

The purpose of this study was to examine our experience with hepatic resection (HR) in a relatively unselected group of patients with breast cancer liver metastases (BCLM).

BACKGROUND

Although medical therapies provide limited survival benefit (median survival, 3-15 months), inclusion of HR into the multimodality treatment of patients with BCLM remains controversial. Our approach has been to offer HR to all patients with BCLM, provided that curative hepatic resection was feasible and extrahepatic disease was controlled with medical and/or surgical therapy.

METHODS

Outcomes for 85 consecutive patients (all female, median age, 47 years) with BCLM treated with HR from 1984 to 2004 were reviewed. Extrahepatic metastases had been treated prior to HR or were synchronously present in 27 patients (32%). BCLM were solitary in 32 patients (38%) and numbered more than 3 in 26 patients (31%). The prognostic value of each study variable was assessed with log rank tests for univariate analysis and Cox proportional hazard models for multivariate analysis.

RESULTS

Within 60 days of major hepatectomy (> or =3 segments, 54 patients) or minor hepatectomy (<3 segments, 31 patients), there was no mortality. The median hospital stay was 9 days with complications occurring in 26% of patients. Microscopically and macroscopically positive margins were present in 18% (R1) and 17% (R2) of patients. Following HR, 28 patients (33%) developed isolated hepatic recurrences, 12 of whom were treated with repeat hepatectomy. At a median follow-up interval of 38 months, 32 patients were alive, yielding median and 5-year overall survivals of 32 months and 37%. Median and 5-year disease-free survivals were 20 months and 21%. Study variables independently associated with poor survival were failure to respond to preoperative chemotherapy (P = 0.008), an R2 resection (P = 0.0001), and the absence of repeat hepatectomy (P = 0.01).

CONCLUSIONS

For patients with BCLM, HR is safe and may provide a significant survival benefit over medical therapy alone. Response to preoperative chemotherapy, resection margin, and rehepatectomy for intrahepatic recurrence are key prognostic factors. Importantly, favorable outcomes can be achieved even in patients with medically controlled or surgically resectable extrahepatic disease, indicating that surgery should be considered more frequently in the multidisciplinary care of patients with BCLM.

Radiofrequency ablation (RFA) as a cytoreductive strategy for hepatic metastasis from breast cancer

INTRODUCTION

Patients with liver metastasis from breast cancer have a poor prognosis, although this may be improved by hepatectomy in a selected group with disease confined to the liver. We evaluate the effectiveness of radiofrequency ablation (RFA) as a cytoreductive strategy in the management of liver metastasis from primary breast cancer.

PATIENTS AND METHODS

Nineteen patients with hepatic metastasis from primary breast cancer underwent RFA of their liver lesions between April 1998 and August 2004.

RESULTS

The median age of the patients was 52 years (range, 32-69 years), 8 had disease confined to the liver, with 11 having stable extrahepatic disease in addition. Seven patients with disease confined to the liver at presentation are alive, as are 6 with extrahepatic disease, median follow-up after RFA was 15 months (range, 0-77 months). Survival at 30 months was 41.6%. In addition, 7 patients followed up for a median of 14 months (range, 2-29 months) remain alive and disease-free. RFA failed to control hepatic disease in 3 patients. RFA was not associated with any mortality or major morbidity.

CONCLUSIONS

Control of hepatic metastasis from breast cancer is possible using RFA and may lead to a survival benefit, particularly in those patients with disease confined to the liver.

Hepatectomy for metastatic noncolorectal gastrointestinal, breast and testicular tumours

BACKGROUND

The indications for hepatectomy for colorectal or neuroendocrine metastases are becoming clear with increasing experience reported. For other primary diseases, however, the overall number of cases is relatively small, and it is more difficult to derive clear guidelines. This paper reviews the reported experience of hepatectomy for metastases from non-colorectal gastrointestinal primary cancers, breast cancer and testicular teratoma. The aim is to determine for each whether and under what circumstances hepatectomy is indicated.

METHODS

A Medline search was used to identify papers reporting hepatectomy for metastases from non-colorectal gastrointestinal carcinomas, breast carcinomas and testicular teratomas. The data collected included the primary disease, the number of cases reported, the survival post-hepatectomy and any prognostic factors associated with outcome.

RESULTS

Of the gastrointestinal malignancies, hepatectomy for gastric metastases yields a 5-year survival, roughly half that reported for colorectal disease, and further elucidation of prognostic factors would be desirable. Results were poor for other gastrointestinal malignancies. Good results were reported for breast and testicular teratoma.

CONCLUSION

Of the non-colorectal gastrointestinal primaries, at present only hepatectomy for gastric metastases can be cautiously recommended. For nongastrointestinal primaries, hepatic metastases probably represent widespread dissemination even if occult, and therefore, hepatectomy may only be of use when effective adjuvant treatments are available.

Magnetic resonance-guided percutaneous microwave coagulation therapy for liver metastases of breast cancer in a case

Real-time magnetic resonance (MR) imaging enables the application of percutaneous microwave coagulation for high-risk patients with metastatic liver tumours. The tumours, local vessels and bile ducts can be observed clearly in three-dimensional sections and a sufficient surgical margin can be confirmed on the MR image even during the coagulation procedure. MR-guided percutaneous microwave coagulation therapy is effective for treatment of not only primary liver tumours but also metastatic breast cancers in the liver, which are not diffuse but discrete, and difficult to treat with only chemo-and endocrine therapy. We report a 44-year-old Japanese woman who underwent modified radical mastectomy for right breast cancer (T1c N0 M0 Stage I). Three years after the operation, she developed two metastatic liver tumours and was treated by MR-guided percutaneous microwave coagulation, achieving a complete response (CR) without any recurrence for 15 months as of the present. The most beneficial aspect of MR-guided percutaneous microwave coagulation is its safety. It is only minimally invasive and can be repeated. This therapy, therefore promises to prolong the disease free period. Additional clinical trials will be valuable to delineate the effectiveness and safety of MR-guided percutaneous microwave coagulation therapy for controlling the liver metastases of breast cancer.

[Surgical treatment of liver metastases from breast cancer]

INTRODUCTION

A small number of patients with breast cancer develop liver metastases (LM) as the sole site of regional dissemination. In these patients, surgical resection seems to be the best therapeutic option. We present our experience of LM from breast cancer and discuss the indications for resection.

MATERIAL AND METHODS

Between July 2003 and March 2005, we performed five hepatectomies for LM from breast cancer. The mean age was 51 years (range: 38-66). Patients received diverse combinations of chemotherapy, hormone therapy and radiotherapy after mastectomy. The disease-free interval between mastectomy and diagnosis of LM was 61 months (range: 36-80). The number of LM was 1.83 (range: 1-6) with a median of one LM. The mean size was 4.1 cm (range: 1.5-6).

RESULTS

Surgery consisted of segmentectomy (three patients), bisegmentectomy (one patient), right hepatectomy associated with isolated metasectomies of the left lobe and hilar lymphadenectomy (one patient). Operative mortality was 0%. Morbidity was 20% (one patient). The mean length of hospital stay was 8 days. The mean length of follow-up was 11.4 months (range: 3-21). The mean survival was 11.4 months (range: 3-21). Disease-free survival was 9.6 months (range: 3-21). Two patients have had recurrence (one local and one regional).

CONCLUSIONS

Given its characteristics, LM from breast cancer is an infrequent indication for liver resection and should be performed whenever technically feasible, whenever R0 resection can be achieved, and when there is low operative risk. Postoperative survival is better with resection than with any other therapeutic modality, even though the period of disease-free survival is short.

MR-Guided Laser Ablation

MR-guided LITT is a safe and effective treatment modality that improves survival in well-selected patients who have liver metastases. A major advantage of MR-guided LITT is that it can be easily performed under local anesthesia in an outpatient setting with a low complication rate.

The oligometastatic state in breast cancer: hypothesis or reality

The term 'oligometastasis' was initially used to describe a restricted locoregional tumour load, but the term has now become synonymous with isolated distant metastases. The existence of an oligometastatic state is still not widely recognised in the management of breast cancer patients. However, there are a number of patients who do develop isolated metastases and in whom long term survival can be achieved following appropriately targeted treatment. This review article discusses the possible biological mechanisms behind the development of an oligometastatic state and the findings from different trials which describe results following radical therapy for isolated metastatic disease. Although no large scale trials in this area have yet been undertaken, there is evidence to support the existence of an oligometastatic state in patients with breast cancer and we discuss the appropriate management for this clinical scenario.

The role of liver resections for noncolorectal, nonneuroendocrine metastases: experience with 142 observed cases

BACKGROUND

To evaluate the role of liver resection for noncolorectal, nonneuroendocrine metastases, indications and results were retrospectively reviewed in 142 observed patients.

METHODS

A curative liver resection was performed in 83 cases (58.5%), and the remaining 59 patients received palliative treatments. The primary tumor site was gastrointestinal in 18, breast in 21, genitourinary in 15, leiomyosarcoma in 10, and other in 19. The mean number of metastases was 1.4. The mean diameter of the nodules was 5.7 cm. Liver metastases were synchronous in 11 (13.3%) cases and metachronous in the remaining 72 (86.7%).

RESULTS

There was no operative mortality. Postoperative morbidity was 20.5%. The median postoperative stay was 9.5 days. The 3- and 5-year actuarial survival rate was 49.5% and 34.3% in resected cases, respectively, whereas there were almost no survivors 3 years after diagnosis in unresected cases (P < .05). The 3- and 5-year disease-free survival was 41.4% and 23.8%, respectively. Among the 83 resected cases, the 3- and 5-year actuarial survival was 17.3% and 8.6% for metastases from gastrointestinal tumors, 53.9% and 24.6% from breast cancer, 63.7% and 36.4% from leiomyosarcoma, 50.4% and 37.8% from genitourinary neoplasms, and 55.6% and 42.4% from other sites, respectively. Fifteen patients (18.1%) survived longer than 5 years.

CONCLUSIONS

Liver resection is an effective treatment for noncolorectal, nonneuroendocrine metastases; it allows satisfactory long-term survival with an acceptable operative risk in selected patients. Hepatic metastases from gastrointestinal carcinoma have the worst prognosis; those from genitourinary tumors show a better outcome. Patient selection is the key to achieving encouraging results.

Hepatic Resection for Metastatic Breast Cancer: Prognostic Analysis of 34 Patients

Liver metastasis of breast cancer is considered a generalized disease, and surgical treatment is rarely discussed. Thirty-four patients who underwent 35 hepatectomies for liver metastases of breast cancer between 1985 and 2003 were analyzed. The median interval between the breast surgery and relapse in the liver was 1.9 years (0-20 years). The liver was the first site of recurrence in 25 patients. Fifteen clinicopathologic factors were evaluated using univariate and multivariate analyses to predict survival after hepatic resection. No patients died because of the surgery. The median survival was 36 months (1 month to 20 years). The overall and disease-free 5-year survival rates after hepatectomy for breast metastases were 21% and 16%, respectively. Four patients survived more than 5 years. The presence of extrahepatic recurrence prior to hepatectomy was the only significant prognostic factor according to the analyses, and the 5-year survival rate of patients without extrahepatic disease was 31%. No patient who had hilar lymph node metastasis survived more than 5 years. In the absence of extrahepatic recurrence, surgical resection of liver metastasis from breast cancer can offer an acceptable prognosis and should not be avoided in selected patients.

Inhibition of hepatocellular carcinomas in vitro and hepatic metastases in vivo in mice by the histone deacetylase inhibitor HA-But

PURPOSE

The purpose is to evaluate the CD44-mediated cellular targeting of HA-But, a hyaluronic acid esterified with butyric acid (But) residues, to hepatocellular carcinoma cell lines in vitro and to hepatic tumor metastases in vivo.

EXPERIMENTAL DESIGN

In vitro, the CD44-dependent cytotoxicity in two human hepatocellular carcinoma cell lines (HepB3 and HepG2) with high and low CD44 expression was investigated; in vivo, the effect on liver metastases originating from intrasplenic implants of Lewis lung carcinoma (LL3) or B16-F10 melanoma in mice was compared with the pharmacokinetics of organ and tissue distribution using different routes of administration.

RESULTS

HepB3 and HepG2 cell lines showed different expression of CD44 (78 and 18%, respectively), which resulted in a CD44-dependent HA-But inhibitory effect as demonstrated also by the uptake analysis performed using radiolabeled HA-But ((99m)Tc-HA-But). Pharmacokinetic studies showed different rates of (99m)Tc-HA-But distribution according to the route of administration (i.v., i.p., or s.c.): very fast (a few minutes) after i.v. treatment, with substantial accumulation in the liver and spleen; relatively slow after i.p. or s.c. treatment, with marked persistence of the drug at the site of injection. The effect of s.c. and i.p. treatment with HA-But on liver metastases originating from intrasplenic implants of LL3 carcinoma or B16-F10 melanoma (both CD44-positive: 68 and 87%, respectively), resulted in 87 and 100% metastases-free animals, respectively (regardless of the route of administration), and a significant prolongation of the life expectancy compared with control groups.

CONCLUSIONS

HA-But tends to concentrate in the liver and spleen and appears to be a promising new drug for the treatment of intrahepatic tumor lesions.

Breast cancer metastases in liver: laser-induced interstitial thermotherapy--local tumor control rate and survival data

PURPOSE

To evaluate the local tumor control rate and survival data for magnetic resonance (MR) imaging-guided laser ablation of breast cancer liver metastases by using laser-induced interstitial thermotherapy (LITT).

MATERIALS AND METHODS

MR-guided LITT was performed in 232 female patients with 578 liver metastases from breast cancer. Survival rates were calculated with the Kaplan-Meier method. Indications for the procedure were defined for patients with no more than five metastases, none of which were larger than 5 cm in diameter, as follows: recurrent liver metastases after partial liver resection (8.2%), metastases in both liver lobes (45.2%), locally nonresectable tumors (19%), general contraindications for surgery (2.6%), or refusal to undergo surgical resection (25%).

RESULTS

Local recurrence rate at 6-month follow-up after LITT was 2.3% (five of 213) for metastases up to 2 cm in diameter, 4.3% (seven of 162) for metastases 2-3 cm in diameter, 3.2% (two of 63) for metastases 3-4 cm in diameter, and 1.9% (one of 52) for metastases larger than 4 cm in diameter. No additional local tumor progression was observed beyond 6 months. The mean survival rate for all treated patients, with calculation started on the date of diagnosis of the metastases treated with LITT, was 4.9 years (95% confidence interval: 4.3, 5.4). The median survival was 4.3 years; 1-year survival, 96%; 2-year survival, 80%; 3-year survival, 63%; and 5-year survival, 41%. The mean survival after the first LITT treatment was 4.2 years (95% confidence interval: 3.6, 4.8).

CONCLUSION

MR-guided LITT yields high local tumor control and survival rates in patients with liver metastases from breast cancer.

Hepatic resection in breast cancer metastases: should it be considered standard treatment?

A 34-year-old woman was diagnosed in October 1994 with a stage I breast cancer and treated with conservative surgery, locoregional radiotherapy and adjuvant chemotherapy. Nonetheless, 47 months after the initial diagnosis, an isolated liver metastasis was diagnosed in segments VII and VIII. A subsegmentectomy was performed, and chemotherapy with doxorubicin and paclitaxel was given for five cycles. High-dose chemotherapy with peripheral stem cell rescue was then administered and tamoxifen hormonal therapy was begun. Now, 54 months after the liver recurrence, the patient remains free of disease. Isolated liver metastases from breast cancer are rare and should be treated with surgical resection if possible, in the context of multimodality programs with hormonal and chemotherapy. According to the small series published in the literature, an improvement of 27-57 months in median survival rates can be expected when such treatment replaces standard therapies, although a selection bias cannot be excluded.

A role for curative surgery in the treatment of selected patients with metastatic breast cancer

Although metastatic breast cancer is widely believed to carry a grim prognosis, treatment developments over the past 25 years have greatly improved survival outcomes in these patients. In selected cases, aggressive treatment approaches may occasionally result in long-term survival of 15 years or more. This review considers the role of surgery in the treatment of single or multiple metastatic lesions restricted to one site. For each site, available literature from 1992-2002 was assessed to determine the role of surgery on survival outcomes and to determine appropriate criteria for selecting the best candidates for surgery. For lung, liver, brain, and sternum metastases, the use of surgery with or without adjuvant therapy resulted in greater median survival times and 5-year survival rates. The best candidate for surgery had no evidence of additional metastatic disease, good performance status, and a long disease-free interval after treatment of the primary tumor. Current treatment standards for breast cancer follow-up do not include imaging studies other than mammography. The addition of chest x-rays as part of routine follow-up should be considered as a cost-effective approach for early assessment of metastases to the lung or sternum that may be appropriate for surgical excision.

Surgical treatment of hepatic and pulmonary metastases from non-colorectal and non-neuroendocrine carcinoma

BACKGROUND

Surgical resection is standard treatment for colorectal and neuroendocrine liver metases provided the tumor can be removed completely. The same is true for isolated pulmonary metastases. To date, only few reports have addressed the value of surgical resection of organ metastases from other solid tumors.

METHODS

The literature was searched by Medline, conference proceedings and cross-referencing of published articles for information pertaining to the long-term results of surgical treatment of non-colorectal and non-neuroendocrine (NCNN) liver or lung metastases.

RESULTS

Resection of hepatic and pulmonary metastases is increasingly performed in non-colorectal and non-neuroendocrine malignancies. Mortality and morbidity of hepatic and pulmonary resection are low and 5 year survival can be expected to reach some 20-30 percent, irrespective of the histological type of the primary tumor.

CONCLUSION

Resection of hepatic or pulmonary metastasis should be considered in all patients with low operative risk provided that complete resection is possible.

[Hepatic resection for breast cancer metastases: results and prognosis (65 cases)]

STUDY AIM

To report results of liver resections for breast cancer liver metastasis (BCLM) and to evaluate the rate of survival and the prognostic factors.

PATIENTS AND METHOD

Between 1988 and 1999, 69 patients were operated on for BCLM and 65 who had liver resection were analyzed. The selection criteria for surgery were: normal performance status and liver function test; radiological objective response to chemotherapy (and/or hormonotherapy); in cases of non-isolated BCLM, complete response of associated metastatic site (usually bone) and no brain metastases. The mean age of the 65 patients was 47 (30-70) years. BCLM was diagnosed an average of 60 (0-205) months after the initial cancer. The BCLM was more frequently solitary (n = 44). The mean diameter was 3.8 (0-12) cm. The mean number of cycles of chemotherapy before surgery was 7.5 (3-24). Liver resections included major hepatectomy (n = 31): right n = 19, extended left n = 4, left n = 8, minor hepatectomy (n = 25) and limited resection (n = 9).

RESULTS

There was no postoperative mortality. The 18% morbidity rate included a majority of pleural effusions with two reoperations. The median follow-up was 41 months (6-100 months). The survival rate after surgery was 90% at 1 year, 71% at 3 and 46% at 4 years. Thirteen patients are alive at 4 years. The 36-month survival rate differed according to the time to onset of BCLM: 55% before versus 86% after 48 months (p = 0.01). The other studied factors were not statistically associated with survival. The recurrence rate in the remaining liver at 36 months differed according to the lymph node status of the initial breast cancer: 40% for N0-N1 versus 81% for N1b-N2 (p = 0.01) and according to the type of liver resection: 45% for minor liver resection versus 73% for major (p = 0.02).

CONCLUSION

Adjuvant liver surgery should be included in multicenter treatment protocols for medically-controlled breast cancer liver metastasis.